1. Discharge decision-making in the Acute Medical Unit for older people
Annabel Rule
Specialist Occupational Therapist – Elderly medicine
Imperial College Healthcare NHS Trust
NWL Research Symposium

2. This project; PhD research project Research Aim; Objectives;
Completed during a 4 year clinical academic studentship
Supervised by Professor Jo Adams and Professor Jackie Bridges
Research Aim;
To explore and understand the processes by which discharge decisions are made for older people returning to the community from an acute medical unit.
Objectives;
To understand the context within which discharge decisions are made
Explore the impact of the context of the acute medical unit on those involved in discharge decision-making (patients, staff and relatives).
Identify the characteristics of the process of discharge decision-making on the AMU
Explain the impact of the context of the acute medical unit on the practice of discharge decision-making
Explain the impact of this process on those involved in discharge decision- making (patients, staff and relatives)

3. Background to the project;
Discharge decision-making for older people
Societal context;
- Independence ideal
- Identity of ‘older people’
Policy context;
- Shared decision-making
- Involvement
- Choice
Research context;
- Poor experiences
- Lack of involvement
- Lack of acknowledgement of the older person in acute care
Clinical context
One 58 bed AMU in a large tertiary hospital in the South of England. Serves a large population from both urban and rural areas.
From Jan 2013 – Jan 2014 saw 11,976 admissions of people aged over 65.
Aims for length of stay of ≤ 48 hours.
Weicht (2010)
Cohen (1994)
BGS (2012)
DH (2010)
Bridges et al (2010)
Maben et al. (2012)

4. Methodology and Methods
Savage (2006)

5. Findings – the Context Key themes Pace-focussed Acute Medical Unit
Everyday battles
Disjointed processes
Impact;
Guilty patients – using resources, time, space
Patients self-efface and silence themselves – become “patient patients”
Relatives – try to negotiate confusing system and advocate for patients
Health professionals – low staff morale – negative culture – anti-change. Undervalued, disempowered

6. Findings – The Context
“they probably didn’t realise how I really felt because … they’re so busy, I wouldn’t have chatted to them about myself” Mrs Andrews
“But when it was in the paper how busy they were, not to go there if you can help it … go and see your GP … I never intended to go there at all” Mrs South

7. Findings – the practice of discharge decision-making
Behaviours and approaches in decision-making
Staff; bed-seeking, escalating, requiring back-up, categorising and re-categorising, discuss qualitative judgements as factual assertions – dichotomies – authoritative voice
Relatives; advocating, chasing
Patients; minimise their own opinions/preferences, ‘patient patients’, passive voice
Impact
Staff – reduced professionalism, element of guilt, allocate any blame to “the organisation”
Relatives – increase burden as assumptions made
Patients – experience = processed

8. Findings – decision-making processes
“They were looking for beds and uh I was only too pleased to help out there” Mr Gilo
“slung me out” – Mr Gilo
“got rid of me” – Mr Gilo
“Bundled me up” – Mrs Adams
“Shunted into another area” – Mrs Andrew’s daughter
“trying to get rid of everybody” – Mrs Delahey
“get rid of me” – Mrs Norway
“kicked out” – Nurse 1
“shoved out” – Mrs Adams

9. Discussion
Williams’ (2001) Pace – Complexity dynamic. AMU prioritises pace over complexity
Is it realistic to expect involvement and shared decision-making in a pace focussed environment?
Can we re-configure care to focus on complexity efficiently?
Do we need re-configure our policy rhetoric as a society?
Relational approach to ethics, autonomy and care
Or is involvement possible in NHS care?

10. Thank you for listening! Any questions?
References;
BGS (2012) Quality and Care for Older People with Urgent & Emergency Care Needs “Silver Book”. London: The British Geriatrics Society
Bridges et al. (2010) Older people's and relatives’ experiences in acute care settings: Systematic review and synthesis of qualitative studies. International journal of nursing studies 47(1):
Cohen (1994) Self Consciousness: An Alternative Anthropology of Identity. London: Routledge
DH (2012) Health and Social Care Act 2012: Chapter 7, Explanatory Notes. The Stationery Office
Maben et al. (2012) ‘Poppets and parcels’: the links between staff experience of work and acutely ill older peoples’ experience of hospital care. International journal of older people nursing 7(2): 83-94
Savage (2006) Ethnographic evidence the value of applied ethnography in healthcare. Journal of Research in Nursing 11(5):
Weicht (2010) Embracing dependency: rethinking (in) dependence in the discourse of care. The Sociological Review 58(s2):
Williams et al. (2009) Relational practice as the key to ensuring quality care for frail older people: discharge planning as a case example. Quality in Ageing and Older Adults 10(3): 44-55
With thanks to;
Professor Jo Adams
Professor Jackie Bridges
Contact:
Annabel Rule
Specialist Occupational Therapist
Elderly medicine
Imperial College Healthcare NHS Trust