Abstract

Risk and risk assessment are concepts that health and social care professionals engage with

daily. However, literature pertaining to how physiotherapists encounter risks in discharge

planning is scarce. This article addresses that gap by exploring how physiotherapists

experience and perceive risk in connection to discharging older people from acute hospitals.

Face-to-face interviews with individual physiotherapists were used to gather data on how

discharge planning is perceived and experienced. The methodology adopted is based on

interpretative phenomenological analysis (IPA). Participants were selected from a sub-group

of physiotherapists working in one acute hospital. Purposive sampling was used as per IPA

methodology, and five physiotherapists volunteered to participate.

Key findings of the study are that physiotherapists’ perspectives on autonomy strongly

influence discharge planning decision-making, with autonomist practitioners prioritising

service user wishes over risk. Furthermore, the physiotherapist’s discharge decision-making

philosophy is be related to their expressed anxiety over the process, with less anxiety

expressed by participants who adopted an autonomist approach in their discharge decisions.

Further research is needed into how physiotherapists perceive autonomy, how it influences

their discharge decision-making, and how this reflects their opinions on discharge planning.

Use of a decision making tool would be beneficial for physiotherapists when discharge

planning.

Keywords

acute hospital, discharge planning, older people, physiotherapy, risk assessment

Background

Discharge planning has been defined as an “interdisciplinary approach to continuity

of care” that links “hospital, community-based services…and carers” (Lin et al., 2012). In

recent years, there has been a greater emphasis on optimising service user flow through the

acute hospital, which includes improving the process of discharge planning. (“NEXT STEPS

ON THE NHS FIVE YEAR FORWARD VIEW”, 2017).

Preventable delays in discharging older people from hospitals exacerbate health

outcomes (Pellett, 2016), thus shorter hospital stays are motivated by a quality component

and are not merely financial. Discharge planning is widely discussed in the literature, though

often from a medical model perspective , focussing on quantifiable outcomes rather than the

service user or clinician experience of the process (Holland & Bowles, 2012).

Discharge planning is interdisciplinary in its approach and involves physiotherapists.

Smith et al. (2010) conducted a quantitative study to determine whether physiotherapists

make appropriate discharge recommendations. They found that when the therapist’s

discharge recommendation was not followed, the patient was 2.9 times to readmitted, thus

supporting the role of the physiotherapist in this process. However, little research has

focused on physiotherapists’ experiences of the process or how they clinically reason from a

decision-making perspective.

Within social work literature, risk and how it relates to rights and responsibilities is

extensively discussed. Kemshall and Wilkinson (2011) discuss risk from various angles,

including how it relates to the older person being discharged from the hospital.

Conversely, there is a paucity in the literature on risk and how it is experienced or

considered by physiotherapists when discharging older people from hospitals, despite

physiotherapists being key professionals in this process (Smith et al., 2010). The lack of
consideration of this topic within the physiotherapy profession suggests that physiotherapists

are poorly equipped to evaluate risk holistically in their daily practice.

Research suggests that older people often feel disempowered by the discharge

planning process in hospitals (Huby et al., 2004); however, it is likely that physiotherapists

are largely unaware of how older people are perceiving the experience despite aspiring to be

client centred. This study’s findings will help shed some light on how physiotherapists

perceive and experience risk and, when disseminated, this knowledge has the potential to

promote more client-centred care.

Methods

Design

This study aims to explore the lived experience of the physiotherapists involved in

discharge planning. We chose to use interpretative phenomenological analysis (IPA) as it

enables a deep exploration and interpretation of the individual’s lived experience (Smith,

2011). In this article we draw on data collected through semi-structured one-to-one

interviews. The interviews allowed the collection of rich and reflective data which relate to

exploring the perceptions of risk (Harper & Thompson, 2012).

Sampling

The inclusion criteria for the study were that the person is a qualified physiotherapist

working in an inpatient setting at the same acute hospital . A total of five physiotherapists

participated.

Ethics Approval

Ethical approval was obtained from the Faculty of Health and Social Care and from

the hospital trust where research was being undertaken.

Findings

Four superordinate themes emerged from the analysis, which were shared by all

participants. In these superordinate themes, there were clusters of subordinate themes, as

illustrated below.

Table 1

Superordinate Themes and Associated Subordinate Themes

Superordinate Theme Subordinate Theme

Discharge planning as a process “As systematically as possible”

“Documentation is crucial”

“It’s our bread and butter”

Service user at the centre “What do you want to do?”

“Doing what is right for the patient”

“Holistic approach”

Aspects of decision-making “Discharge planning is very subjective”

“Discharges are complex”

“It was a risk worth taking”

“Home is the ideal”

“With experience you get more confident in

your decision-making”

Interpersonal Interactions “You’ve won them over”

“Normally what stops the discharge is

family”

“Family often have a different opinion to

that which the patient has”

Discharge Planning as a Process

 Each participant described a common discharge planning process, with clear steps that

were similar for each participant.

“As Systematically as Possible”

Discharge planning is described as “logical” (PT2)and “systematic” (PT4). This

systematic approach was viewed by some respondents as something that can be fully

completed, which eases their anxieties regarding making decisions.

“Documentation is Crucial”

Documentation is only discussed by PT1 and PT2; however, they both consider it

vitally important, describing it as “crucial” (PT1) and “a huge thing” (PT2). In both cases, the

physiotherapists discuss the importance of documentation as an insurance in case of

complaints.

“It’s Our Bread and Butter”

PT4 uses the idiom “bread and butter” to describe how discharge planning is an

everyday part of the role . PT1 describes discharge planning as now being a “crucial part of

what we do” implying that the physiotherapy role has changed and that the discharge

planning aspect is a key part of it.

Service user at the Centre

All the physiotherapists repeatedly discussed the importance of the service user

remaining “at the centre”, although what this meant in terms of decision-making varied

across the participants.

“What Do You Want to Do?”

All participants talked about what the service user wanted and its importance for

them; however, the weight of this in terms of their decision-making, compared to other

factors such as safety, differed for each participant.

“Doing What is Right for the Patient”

The phrase “doing what is right” is used by PT1, PT3, and PT5; however, it appears

to have different meanings for each physiotherapist. For PT3, “doing what is right” includes

what the service user wants and meeting their needs.

For PT5, doing “the right things” is related to taking “the right measures to keep him

[the service user] safe at home”. PT5 appears to strongly believe in doing the “best thing”

even if this implies risking “getting a complaint or getting into trouble about it”.

“Holistic Approach”

All participants emphasise considering the broader picture (not just the service user’s

physical needs), with PT1, PT3, and PT4 using the term “holistic”.

Decision Making

“Discharge Planning is Very Subjective”

Assessments in hospital are described as “subjective” and this is partly related to the

person being assessed in what PT1 describes as an “alien environment” . PT2 goes as far as

to say that “you can’t” see a person’s true functional ability in hospital.. The inability to

replicate in hospital how a person manages at home leads to the element of “guessing” when

planning the person’s discharge.

“Discharges Are Complex”

The decision-making philosophy differed between physiotherapists and linked in with

the anxiety levels expressed by the clinicians.

PT1’s decision-making is based on an interplay between the service user being happy,

their family being happy, and the service user being safe (so the therapist themselves being

happy). PT1 expresses anxiety and frustration when either the service user, their family, or

themself are not happy. Unfortunately, during many discharge plans, keeping all parties

happy is impossible; for example, when a service user wants to go home, but the therapist
feels it is unsafe. In such situations, PT1 describes feeling “daunted”, “frustrated”, and

“fearful” since they allowed “ this to happen”. In this scenario, service users are

depersonalized and described as “these people”, anxiety affecting how the service user is

viewed.

PT2 appears to have a more straightforward view in terms of decision-making,

expressing a belief that home is better, and this belief drives decision-making. Unlike PT1,

PT2 does not talk about discharges in terms of the service user’s safety and states that “you

are never going to have a safe discharge. Safe isn’t a good word to use, as there is always

going to be a risk” . This belief appears to alleviate some of their anxiety surrounding

discharge plans.

PT3 and PT4 adopt a similar approach to their decision-making since both are driven

by what the service user wants, and a belief that home is the best option for the service user.

Descriptions of fear or frustration are not present in PT3’s transcript since they feel confident

that if they are following the service user’s wishes they are “doing what is right”.

“It Was a Risk Worth Taking”

Taking risks was mostly framed in positive terms by the respondents. Of the

participants, only PT5 commented that they felt they took “too many risks” , prioritising

hospital pressures at the time over the service user.

An interesting concept discussed by PT3 was whose perception of risk is the most

important, and the idea that perceptions of risk are specific to the person. The example they

gave was of a person who frequently falls but says “I don’t care, I just get myself up and

carry on” .This person does not consider the risk of falling as important despite it being

important to their family, who feel that they are not “safe”. PT3 advocates considering the

perception of risk that the person holds themselves.

 Ensuring that service users are “aware “of risks is crucial to the respondents and is

discussed in detail by each of them. PT1 emphasises this, stating being “really fully aware of

what the risks were” ; PT2 also links this explanation of risk to wanting to avoid blame or

complaint if the discharge does not go well.

“Home is the Ideal”

All the participants viewed home as the best place for the service user. It was

described in warm terms, using words such as “familiar” as opposed to the “alien

environment” of the hospital (PT 1). PT3 opines that people are “best placed at home” and

are “whole different people at home”. She describes how they are viewed by others and

perhaps viewed by themselves, stating that at home “their attitude is better, they are more

open, they are more confident usually. Whereas in the hospital you look at the frail person sat

in the chair” . This suggests that being in a hospital impacts a person’s identity and

behaviours, possibly due to their lack of control in the hospital environment.

“With Experience You Get More Confident You’re Your Decision-Making”

Confidence was a key word used by all participants, with each of them claiming they

felt more confident in making decisions and taking risks by accruing more experience. PT2

used to feel ill-equipped initially and suggests encouraging “more teaching about it at

university” .

Interpersonal Interactions

“You’ve Won Them Over”

The language used to describe the physiotherapist– service user and/or

physiotherapist–families interactions indicated how the physiotherapist viewed the

relationship. This differed significantly for each physiotherapist. PT1 talks about families
coming “round”, doing “the right thing”, and winning “them over” to their view about a

situation. PT1 appears to set the agenda and is keen that service users/families follow their

plan.

Contrarily, PT3 defines a more equal partnership with the service user, describing

listening “carefully to what the patient wants” and explaining their thoughts to the service

user as what they “think” rather than using absolute terms. PT3 appears to facilitate what the

service user wants rather than enforcing their own ideas. They also clearly advocate for the

service user in cases where there is disagreement between them and their families.

“Normally What Stops the Discharge Is Family”

Another common theme was disagreements with a service user’s family being the

greatest challenge to discharge planning. Strong phrases such as “emotionally charged” (PT1)

and “obstructive” (PT2) are used to describe families that are unhappy. The word “difficult”

is frequently linked with families by all participants.

“Family Often Have a Different Opinion to That Which the Patient Has “

The respondents claim that families often “have a different opinion to that which the

service user has”(PT3) and label this as “difficult” (PT1). This different opinion is that

“families do not want the patient home, but the patient wants to go home” (PT3). Within

these scenarios, both PT3 and PT4 spoke about acting as advocates and upholding the

autonomy of the service user – “it’s the person’s decision to make for themselves” (PT3).

The importance of speaking to the person’s family was reiterated by all. This was to

avoid “issues” (PT2), “act like a kind of liaison”(PT3,), and avoid “complaint” (PT3). PT5

cites “communication” as integral to an efficient discharge (PT5).

Discussion
 The discharge planning process was discussed by all participants, with documentation

being touted a “crucial” aspect since it “protects” the physiotherapist in case of complaints.

Documentation as a form of protection for the health care professional is advocated by the

Department of Health in a paper published in 2007 titled “Independence, Choice and Risk”.

The paper recommends using a “supported decision tool” to guide discussions and

documentation (Department of Health, 2007). No such tool was mentioned by participants in

this study, which aligns with the findings of Atwal et al. (2012), who recommend the use of

such a framework as a means of providing permission for the therapist to take risks that

would “facilitate person-centred care”. Use of such a tool would probably benefit

physiotherapists and service users since it will assist with clear decision-making,

comprehensive documentation and aid learning.

Within this study, the participants’ view of person-centred care together with their

view on safety and risk informed their decision-making philosophy. All participants spoke of

being “patient centred”. However, this holds different meanings for each of them. This aligns

with the paternalistic versus autonomist perspectives described by Sánchez-Izquierdo et al.

(2019). They describe paternalistic care as care in the person’s best interest but differing from

autonomist care since the “individual choice of the patient is not reinforced”.

Health practitioner anxiety pertaining to discharge planning was identified by Murphy

et al. (2018), who found that it reduces with experience. PT2, PT3, PT4 and PT5 focused

more on what the service user wanted, i.e. the service user’s autonomy, stating this as their

primary concern and commenting less on multiple factors influencing their decisions. They

also expressed less anxiety regarding the outcomes of their discharge decisions, appearing

surer of their reasoning processes.

 Governing principles such as those outlined by the Department of Health (2007) (e.g.

that “people have the right to live their lives to the full as long as this does not stop others

from doing the same”) were not directly referred to by any participant in this study. We

suggest that regular team discussions on clinical decision-making and ethical principles –

which can clarify physiotherapists’ thinking regarding their responsibilities – can help

decrease anxiety and clarify discharge planning decision-making.

Unlike Crennan & Macrae (2010) and Denson et al. (2012), this study views risk in

both physical and psychological terms. Physical risks such as falls are frequently cited but

also the risk to the person psychologically, for example, of remaining in hospital, were

acknowledged. Thus, “doing no harm” could involve discharging a person home, despite the

risk of falls, due to it being balanced against the risks associated with hospital stay, which

includes both physical (e.g. hospital-related functional decline) and psychological risks. (de

Vos (2012)). Murphy et al. (2018) acknowledge such risks, and the psychological risks of

hospital stay discussed by PT3 are clearly expounded by Jacelon (2004). The physiotherapist

benefits from citing such psychological risks when completing documentation using a

framework such as that already suggested.

Risk perceptions vary from therapist to therapist and between service user, their

family, and health care professional. This was discussed by PT3 and is highly significant. A

mixed method study by Verver et al. (2017) found that while professionals focus on the

health risks to older adults, the latter focus on threats to their independence and wellbeing.

Dissemination of such findings to physiotherapists working in discharge planning would

probably influence their perception of risk for the individual and impact discharge decisions.

Within this study, use of the word “safe” was generally ambiguous, in contrast to the

study by Macleod and Stadnyk (2015) in which risk is on a continuum, with “safe” meaning

low rather than “no” risk. Given the frequency of discussions with families in the acute
hospital setting whether a discharge is “safe”, we recommend teaching and team discussions

on the concept to attain a consistency in word usage.

Discharge planning with its associated principles has been recognised in this study’s

findings as being insufficiently taught in the undergraduate setting. This view was also

highlighted by physiotherapists in a 2014 study by Matmari et al. Mental capacity and its

impact on discharge decision-making was frequently mentioned by the participants in the

study but cited as having developed in their thinking following qualification. Placing

discharge planning with its associated ethical principles and considerations of mental

capacity in the undergraduate physiotherapy curriculum will assist newly qualified

physiotherapists in their decision-making philosophy and should assist in developing person-

centred care.

Participants repeatedly referred to the benefits of working in a team, asking

colleagues for advice, and the benefits of senior support. Murphy et al. (2018) also mention

the benefits of “utilising the multi-disciplinary team” for support, and the Department of

Health paper (2007) discussing “independence, choice and risk” recommends decision-

making in the team context and together with the client so that risk is shared and not “owned”

by one person.

Family difficulties and conflict emerged as key themes in this study and presented as

an area of stress for the participants. Like Murphy et al. (2018), participants stated that

families often want to eliminate risk and not discharge the service user home. This view of

younger relatives placing a higher significance on safety than on autonomy is also upheld by

Denson et al. (2012). The Department of Health (2007) states that “conflict of wishes should

aim to support the rights of all involved”. Supporting the rights of all was considered difficult

by the study participants. In such situations, the team’s support (mentioned as beneficial in

this study) and senior staff can assist with conflict management.
Conclusion

In this article we have identified that physiotherapist perspectives on autonomy

strongly influence discharge planning decision-making philosophy, with service user wishes

being more significant than risk in the autonomist practitioner’s thinking. Furthermore, this

perspective on autonomy appears to relate to the physiotherapist’s expressed anxiety relating

to the process, with less anxiety being expressed by participants who adopted an autonomist

approach to their discharge decisions.

We argue that further research into the philosophical ideas related to decision-making

and autonomy of service users, combined with use of discharge planning tools and regular

team reviews of complex cases, could lead to increased clarity of thought by physiotherapists

when discharge planning and improved service user experience.

As discussed, studies reveal that engagement by older service user discharge planning

is limited due to older people feeling “outsiders” and “poorly informed”. Local evaluation of

service user satisfaction in relation to discharge planning could lead to relevant action to

improve engagement and experience.

References

Atwal, A., McIntyre, A., & Wiggett, C. (2012). Risks with older adults in acute care settings:

UK occupational therapists’ and physiotherapists’ perceptions of risks associated with

discharge and professional practice. Scandinavian Journal of Caring Sciences, 26(2),

381–393. doi:10.1111/j.1471-6712.2011.00946.

Crennan & Macrae, M., & MacRae, A. (2010). Occupational therapy discharge assessment of

elderly patients from acute care hospitals. Physical & Occupational Therapy in

Geriatrics, 28(1), 33–43. doi:10.3109/02703180903381060

Denson, L. A., Winefield, H. R., & Beilby, J. J. (2013). Discharge‐planning for long‐term

care needs: The values and priorities of older people, their younger relatives and

health professionals. Scandinavian Journal of Caring Sciences, 27(1), 3–12.

doi:10.1111/j.1471-6712.2012.00987.x

Department of Health. (2007). Independence, choice and risk: A guide to best practice in

supported decision making. Department of Health.

de Vos, A. J., Asmus-Szepesi, K. J., Bakker, T. J., de Vreede, P. L., van Wijngaarden, J. D.,

Steyerberg, E. W., Mackenbach, J. P., & Nieboer, A. P. (2012). Integrated approach

to prevent functional decline in hospitalized elderly: the Prevention and Reactivation

Care Program (PReCaP). BMC geriatrics, 12, 7. https://doi.org/10.1186/1471-2318-

12-7

Harper, D., & Thompson, A. R. (2012;2011). Qualitative research methods in mental health

and psychotherapy: A guide for students and practitioners Wiley-Blackwell.

Holland, D. E., & Bowles, K. H. (2012). Standardized discharge planning assessments:

Impact on patient outcomes. Journal of Nursing Care Quality, 27(3), 200.

Huby, G., Stewart, J., Tierney, A., & Rogers, W. (2004;2006;). Planning older people’s

discharge from acute hospital care: Linking risk management and patient participation

in decision-making. Health, Risk & Society, 6(2), 115–132.

Jacelon, C. S. (2004). Older adults and autonomy in acute care: Increasing patients'

independence and control during hospitalization. Journal of Gerontological Nursing,

30(11), 29-36. doi:10.3928/0098-9134-20041101-10

Kemshall, H., & Wilkinson, B. (2011). Good practice in assessing risk: Current knowledge,

issues and approaches. Jessica Kingsley.

Lin, C.J., Cheng, S.J., Shih, S.C., Chu, C.H.& Tjung, J.J (2012). Discharge planning.

International Journal of Gerontology, 6(4), 237–240.

MacLeod, H., & Stadnyk, R. L. (2015). Risk: 'I know it when I see it': How health and social

practitioners defined and evaluated living at risk among community-dwelling older

adults. Health, Risk & Society, 17(1), 46–63. doi:10.1080/13698575.2014.999749

Matmari, L., Uyeno, J., & Heck, C. S. (2014). Physiotherapists’ perceptions of and

experiences with the discharge planning process in acute-care general internal

medicine units in Ontario. Physiotherapy Canada, 66(3), 254–263.

doi:10.3138/ptc.2013-12

Murphy, T., Butler, M., & Kidd, J. (2018). Losing something of value: An exploration of risk

in discharge planning with older people. New Zealand Journal of Occupational

Therapy, 65(2), 13–19.

NHS England. (2017, March 31). Next Steps on the NHS Five Year Forward View.

https://www.england.nhs.uk.

https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-

NHS-FIVE-YEAR-FORWARD-VIEW.pdf
Pellett, C. (2016). Discharge planning: Best practice in transitions of care. British Journal of

Community Nursing, 21(11), 542–548.

Sánchez-Izquierdo, M., Santacreu, M., Olmos, R., & Fernández-Ballesteros, R. (2019). A

training intervention to reduce paternalistic care and promote autonomy: A

preliminary study. Clinical Interventions in Aging, 14, 1515–1525.

doi:10.2147/CIA.S213644

Smith, J. A. (2011). Evaluating the contribution of interpretative phenomenological analysis.

Health Psychology Review, 5(1), 9–27. doi:10.1080/17437199.2010.510659

Smith, B. A., Fields, C. J., & Fernandez, N. (2010). Physical therapists make accurate and

appropriate discharge recommendations for patients who are acutely ill. Physical

Therapy, 90(5), 693–703.

Verver, D., Merten, H., Robben, P., & Wagner, C. (2017). Perspectives on the risks for older

adults living independently. British Journal of Community Nursing, 22(7), 338–345.

doi:10.12968/bjcn.2017.22.7.338