AbstractBackground: There is evidence that the transfer of information on medication changes on patient’s discharge summaries is poor.  By considering the completion of an electronic discharge summary as a behaviour we can consider which components of behaviour we can target to improve their completion so that they consistently include information on medication changes.  Objectives:  Barriers and facilitators to completing information on medication changes on discharge summaries were identified.  These were then mapped to behavioural components within the COM-B model (Capability, Opportunity, Motivation) of the behaviour change wheel (BCW) to help design tailored interventions to affect change.Methods:  In this qualitative study 12 semi structured interviews were conducted with junior doctors.  An interview topic guide based around the COM-B model was used.  Transcripts of the interviews were analysed using framework analysis to identify key categories emerging from the data.Results:  Nine categories were identified that encompassed the identified barriers and facilitators.  The identified barriers and facilitators influenced all aspects of the COM-B model.Conclusions: Use of the BCW as a theoretical lens for this study enabled interventions to be identified that targeted specific components of behaviour.  It is the implementation of all these interventions that may be required to influence behaviour change and ensure all electronic discharge summaries contain information on medication changes.  All intervention functions were relevant but key functions were education, enablement and persusaion.  Other institutions can use the BCW and the COM-B model to develop their own tailored interventions to achieve these functions.

KeywordsElectronic discharge summary, junior doctor, electronic patient record, pharmacist, medication changes.

IntroductionIn the United Kingdom (UK) the discharge summary provides the primary means of communication between hospital services and primary care in the National Health Service (NHS).1 The document details a patient’s hospital stay and recommended follow up actions for the patient’s general practitioner (GP). The majority are written by foundation year (FY) junior doctors. FY1 and 2 junior doctors are one to two years post graduation from medical school, similar to a junior resident in the USA.2

Various studies advocate the need to include details of medication changes on discharge summaries3,4 such as medications stopped, started and dose changes. GPs have also highlighted the importance of receiving such information on medication changes.5–7 A lack of information on medication changes could lead GPs to believe a medication has been discontinued when it has not been or for a GP to inadvertently restart a medication that was intended to be stopped. Inclusion of the information also helps to promote continuity of care. 3,8,9 In addition to the patient safety risks, there is the potential for wasted staff time

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while attempts are made to establish if a change was intentioned.10

Professional bodies in the UK have issued guidance advocating the need to transfer information on medication changes.8,11,12 Despite this, there is evidence that this is not happening at the point of discharge - an issue which is not confined to the UK.13–15 Studies suggest from 29% to 72% of discharge summaries do not contain any information on medication changes.10,16–18 These results occurred in spite of the introduction of processes such as medicines reconciliation and the use of electronic discharge summaries. Medicines reconciliation is the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the prescribers admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patients at all transition points.19 Many hospitals in the UK conduct medicines reconciliation on admission and some may record this as part of the EPR record. It has been suggested the use of electronic templates which contain a section for medication changes, might improve the likelihood of adherence to recommended national standards.10 Both electronic templates and the medicines reconciliation process aimed to improve the transfer of information around medicines.1,10,20

Writing a discharge summary using an electronic patient record (EPR) can be thought of as an example of a behaviour. If we can change aspects of that behaviour, then we may be able to improve the completion of such electronic discharge summaries so they include information on medication changes. Various behaviour change theories exist and the Behaviour Change Wheel (BCW) is a synthesis of 19 frameworks of behaviour change and can be applied to any behaviour in any setting.21 At its core is a model of behaviour known as COM-B – Capability, Opportunity, Motivation and Behaviour. These components can be further divided into physical and psychological capability, physical and social opportunity and automatic and reflective motivation. The model recognises that behaviour is part of an interacting system involving all these components. Changing behaviour will involve changing one or more of the components. Surrounding these components, the BCW incorporates nine intervention functions aimed at targeting one or more of these components that requires changing. The nine interventions include modelling, environmental restructuring, and restrictions which impact on capability whilst education, persuasion and incentivisation impact on opportunity. Finally, coercion, training and enablement impact on motivation. If the components to be targeted can be identified, interventions can be tailored to change behaviour and potentially ensure that all electronic discharge summaries contain information on medication changes and thus contribute to maintaining patient safety.22 A detailed examination of such behaviour can determine the current barriers and facilitators to the inclusion of information on medication changes on electronic discharge summaries. Little research has been conducted which has explored barriers and facilitators in relation to the completion of discharge summaries.10,23,24 Those studies that have examined barriers and facilitators in relation to transfer of information of medication changes have focussed on the medicines reconciliation process rather than the process of completing discharge summaries.25–30

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This study aimed to identify and design interventions tailored to target specific elements of behaviour within the COM-B model. Study objectives were to identify the barriers and facilitators to junior doctors completing information on medication changes on electronic discharge summaries including why these occurred. The identified barriers and facilitators were then mapped to components of behaviour as described in the COM-B model contained within the BCW. This study focussed on use of the inner two rings of the BCW and did not consider policy interventions. The focus was to establish interventions that individual hospitals could implement to enforce change and an exploration of policy interventions were outside the scope of this study.

Methods

Study design and participantsA qualitative design allowed the researcher to interpret and understand motives, explore social interactions and the meaning of events31,32. Semi structured interviews captured in depth, individual views and experiences of junior doctors in a confidential and non-threatening environment33. The views and perspectives of junior doctors were sought as this staff group complete the majority of discharge summaries2 and little is reported in the literature about their perspectives. The study received ethical approval from the University Senate Ethics Committee.

The study was conducted at a large acute teaching hospital in the North West of England. Medicines reconciliation documents are routinely completed, by pharmacists, on a patient’s admission to hospital and all prescribing is via an electronic prescribing system. Discharge summaries are prepared by doctors using a standardised template built into the electronic prescribing system.

All 63 FY doctors were sent an email by the Consultant Medical Tutor about the research study, including an information sheet and consent form. The medical tutor was not part of the research team but acted as a gatekeeper to provide an efficient and expedient conduit for access to clinicians outside the researcher’s immediate professional group34. The researcher described the project and answered any questions at weekly training sessions which were open to all junior doctors. The researcher attended several weekly training sessions to capture doctors who may not have attended previous training sessions either due to being on annual leave or working night shifts. A poster highlighting the project was also displayed in the doctors’ common room. Doctors contacted the researcher in person or via email if they wished to take part in the study. Doctors were free to volunteer to participate and were requested to sign a consent form prior to taking part. Doctors were informed that non participation would have no bearing on their training programme. A homogenous purposive sample of six FY1s and six FY2s was selected from the 17 junior doctors who volunteered. Interviews were conducted with an equal mix of FY1 and FY2 doctors. A decision was made a priori to conduct 12 interviews. This was considered a manageable number given the timescale available for the research. This number was also selected based on the work by Guest et al35 who suggest a

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sample of twelve will likely be sufficient to achieve saturation, if the goal is to describe a shared perception, belief or behavior among a relatively homogenous group.

Doctors who had only ever worked in academia, accident and emergency, general practice or critical care were excluded as they would not have written any discharge summaries. Doctors who participated in interviews received a £10 ($15, €14) voucher as recognition of the time they gave up to participate in the interviews.

Data collectionSemi-structured interviews were arranged at a time convenient for the doctor and lasted between 40 and 78 minutes. They were recorded with consent. The interviews discussed the discharge process from hospital to the patient’s own home. Discussions regarding discharge to hospices or intermediate care facilities were excluded, as the discharge process differs for these patients.

A topic guide based around the COM-B model within the BCW was used to conduct the interviews (Appendix 1). The initial topics were selected to open discussion and explore aspects of their capability, opportunity and motivation to engage in the behaviour of including information about medication changes on the discharge summary. Follow up questions included probing, interpreting and specifying questions, as described by Kvale.36 The reflexive process meant the interviewer (SE) decided not to reveal her professional background as a pharmacist to the interviewees unless they specifically asked. This was to ensure the professional background of the researcher did not bias the interviews or present any power imbalances. Interviews were conducted with the aim of achieving saturation. This is defined as finding no new themes, concepts, knowledge or problems being evident in the data.36,37 Reflexive accounts were written after each interview and during the iterative analysis to reflect on themes and the researcher’s potential biases. This led to updates of the interview topic guide as interviews progressed.

Data AnalysisFramework analysis, as described by Ritchie and Lewis38 was used to analyse the transcripts. This approach is useful when the aim of the research is to generate recommendations39. It is also better adapted to research that has a specific question, limited time frame, pre-designed sample and a priori issues.39,40 Framework analysis is an extension of thematic analysis but unlike thematic analysis, it aims to go beyond purely description, to explore abstract concepts and interpret the data.40,41 Transcripts were read and reread by researcher SE and highlighter pens and post it notes used to aid the analysis. Ongoing data analysis was discussed regularly by both authors and a consensus reached. Microsoft Excel was used as described by Swallow et al42 to aid the data management process.

The stages ranged from data management to abstraction and interpretation. These included familiarisation, constructing an initial thematic framework, indexing and sorting, data summary and display, constructing categories,

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identifying linkage with the BCW and accounting for patterns. Transcripts were read during familiarisation to identify key themes. These were grouped into a thematic framework (one framework for barriers and one for facilitators) for coding the data. As interviews were read and reread the framework was updated and refined. An analytical log was maintained and notes and memos written. Lines of data were coded using the framework and lines of data were indexed, sorted and displayed in summary tables using Microsoft Excel. Post it notes were used and coded data was refined into coherent groups to identify detected elements which contributed to key dimensions and then finally linked key dimensions formed categories. This terminology has been previously defined38. The barriers encompassed in each category were then mapped to the six elements of the COM-B model in the BCW to determine which elements of behaviour needed to be targeted with which intervention functions to change behaviour.

ResultsThe interviews provided ‘thick’ descriptive data and saturation was achieved.43 Nine main categories were identified that encompassed the barriers and facilitators identified in this study, Table 1. The identified barriers and facilitators were then mapped with the main components of the COM-B model to identify which components of behaviour each aspect impacted upon, Table 1. The identified barriers often mapped to several components of the COM-B model. For example, barriers within the leadership category impacted on physical and social opportunity but also on reflective and automatic motivation. The results section is therefore laid out so that categories or individual barriers that have a major contributing influence to an element of the COM-B model are discussed under that section. For example the leadership category is discussed under physical and social opportunity. However, the leadership category also encompasses the barrier “medico legal justifications” which is discussed under automatic and reflective motivation. It is recognised that most categories overlap with several elements of the COM-B model and are not necessarily mutually exclusive. Quotes are used to illustrate key findings. Where text has been removed from quotes to aid clarity this is indicated by an ellipsis (…).

Physical and Psychological capability

Skill developmentDoctors described being unsure as to what information was expected in each section of an electronic discharge summary, despite a template being in use. This appeared to be due to a lack of explicit training on the process.

“Well none of us are trained to write discharge summaries, it’s just one of those things you sort of pick up along the way” FY1, Interview 8

Doctors described going through their own learning process to perfect their skills in writing discharge summaries. They described initially ‘cutting and pasting data’ from EPR and writing ‘small novels’, recording ‘everything they could

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possibly think of’ in their discharge summaries. However, with time, doctors described getting better at ‘filtering out’ relevant information and learning to write more concise discharge summaries. The doctors learnt this ‘skill’ by a combination of experience as a GP, reading their own and others discharge summaries and responding to feedback. Improving clinical competence also helped develop their discharge summary writing skills. Some doctors described a realisation that they had been writing their discharge summaries for other FY doctors rather than for GPs. They then described putting themselves ‘in the shoes of the GP’ to help determine what information was important in the discharge summary. Some of their time invested in developing their discharge summary writing skills focused on learning about the process of using the EPR system efficiently to subsequently reduce the time spent on writing discharge summaries. They described the EPR system as having ‘infinite possibilities’ and stated it takes time to ‘know the tricks of EPR’.

When FY doctors commenced work they learnt about the medicines reconciliation document (completed by the ward pharmacist) at various stages in their training. At first they were not aware of its existance and described having to ‘cobble along’ (i.e. quickly and carelessly) themselves to try and work out medication changes. The document was viewed as very much one that was ‘owned’ by the pharmacy team and it took time for the FY doctors to become aware of its usefulness. Once they were, they viewed it as a reliable document and saw how it could benefit them when they were compiling discharge summaries and including information on medication changes.

Impact of documentationThe doctor’s capability to record information on medication changes on discharge summaries was dependent on whether information was documented in the medical records in the first place. This did not always occur. Identified barriers included medications not being prescribed at admission, unreliable documentation as to why medicines had been suspended or no reasons documented as to ‘why’ medications had been stopped.

“…the hardest thing is just medications that have never been prescribed since the patient’s been here. And no one has seemingly stopped it. No one’s, you know, made any decision about it, it’s just not been known or realised and they've not been on it or just, yeah things out of the blue have been stopped and you cannot find any clinical reason for it.” FY2, Interview 7

It was suggested that the reasons for medication changes not being documented included doctors ‘being in a rush’ or the information being entered into the notes by a ‘third person’ and not by the decision maker. Another reason included the information being considered ‘clinically obvious’ to another clinician. Doctors suggested it was more ‘time consuming’, and ‘more diligence’ was required, to identify medication changes, compared to finding out about newly prescribed medications. Several doctors suggested medications that had been commenced due to an ‘acute event’, such as antibiotics and steroids, were more likely to be documented than were medication changes.

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“It’s much easier to write what’s new than actually what’s changed, I would say. I don’t know why but it is. It’s easier to pick up, you know, I guess if they’ve come in with a problem, they have been diagnosed, you know immediately from training the kinda meds they’re probably going to be on, whereas if things have been tinkered with or doses have been changed that’s much harder to pick up on.” FY2, Interview 6

Even when reasons were not always documented, the EPR system appeared to facilitate the process whereby doctors could identify the date a medication had been stopped, by whom and when. Although this was a time consuming process, from this they could cross reference to the corresponding dated medical notes within the EPR and ‘work out’ or infer ‘the more logical assumption’ as to why medication may have been changed.

“…there are times where it just makes a lot of sense and it is hard to imagine any other possible reason [why a medication was stopped]… and again the anti-hypertensives is a good example because there might be some comment about AKI [acute kidney injury] and then some very vaguely worded comment from someone like, eerm, AKI measures or something that isn’t really clear but because you can see the time and the time that was written was say e.g. 2.53 on the date, whatever date and then at 2.57 on the same date these medicines were stopped and you can see the bloods came back – it all fits together.” FY2, Interview 1

Physical and Social Opportunity

Patient factors Knowledge of the patient emerged as a major influence when writing discharge summaries. Doctors felt that, if they knew the patient, then they would know the reasons behind decisions. They were thus more likely to be able to write discharge summaries from memory and it was felt that items were less likely to be missed out. Not knowing the patient meant it took longer to write a good quality discharge summary. The doctors described being reliant on the information recorded in the medical notes, in order to ‘get to know the patients’ and to establish what had happened, so that information could be conveyed to the GP. Having no knowledge of the patient meant that completing the discharge summary was viewed as a mechanistic task and was ‘….just a bit of paperwork’. In contrast, if doctors knew the patients then they had more connection with them and were more motivated to want to provide detailed information in a discharge summary.

“…If it’s a patient you’ve seen their whole way through hospital then you feel connected to that discharge summary and you feel this is my description of the patient’s, you know, journey through their hospital that, you know, I want to make sure that the next person who reads this understands what happened to them because, you were there too, you want them to know why you did what you did.” FY1, Interview 2

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Patients who had had a longer admission tended to have more documented notes and it was harder for doctors to establish what the medication changes had been. This was exacerbated further if the doctors did not know the patients. In contrast, shorter admissions made it easier to write electronic discharge summaries even if the doctors did not know the patients, as there was less information to ‘trawl through’. Typically, short admissions occurred on the medical admissions unit or for elective surgical patients.

“The summaries are typically easier [on call on the medical admissions unit] because they’re much shorter admissions” FY1, Interview 12

“For short admissions there’s often a clear reason behind stopping a medication. Often when you’re doing the discharge summary you’ll be looking through the admission and the post take documents to see why they’ve stopped them. You don’t have to trawl through a huge quantity of notes again to find out exactly why.” FY1, Interview 12

Impact of being on call When doctors were on call, various factors impacted on their physical opportunity to complete electronic discharge summaries. Having less staff on duty meant there were fewer people staff to ask about medication changes, particularly important if they did not know the patient. It also meant there were more jobs to juggle and the discharge summaries were considered a low priority compared to other tasks. When they were on call, doctors could not anticipate their workload and therefore could not forward plan and set aside time for discharge summaries to be completed.

Doctors felt comfortable justifying the lower priority status discharge summaries took on call due to the higher priority clinical tasks that took precedence. However, they described feeling pressurised by other staff to get the discharge summary done even when they were not on call. This was driven by the need to discharge patients in a timely manner, to free up beds and to assist in meeting the national target of a maximum four hour waiting time in the emergency department. Both ‘limited time on call’ and the effect of pressure from staff had similar outcomes and resulted in doctors approaching the completion of a discharge summary in a different way than at other times. Doctors described completing the summaries quickly by ‘skimming through’ EPR notes and aiming to locate the main changes that may have been documented. They suggested that they did not necessarily aim to spend a certain amount of time on a discharge summary but rather that they aimed to achieve a minimum ‘safe’ standard. There appeared to be a recognition and acceptance that the quality of the discharge summaries would be reduced, as they did not have time to check thoroughly for reasons why medications may have stopped.

“…often when you’re on call on the weekend and you’re on the wards or something and someone is being discharged on the wards and you’re really under loads of time pressure and you‘ve got this discharge summary to do as well…it feels like a complete pain at the time…that’s probably when you’re really rushed and you don’t have time to be going back through the notes to try and find out why the statin was

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stopped, you know…those discharged on the weekends and out of hours is probably when they’re done worst.” FY2, Interview 7

Leadership Interpersonal influences from the senior doctors within specialist teams had a hugely positive influence on motivating the doctors to complete information on medication changes on discharge summaries. Certain specialist teams were seen as champions, promoting this work and actively engaging in it. They allowed the time on ward rounds to review medicines, thus providing the physical opportunity for reflective motivation and social opportunity, so that junior doctors could complete discharge summaries with information on medication changes. Influences in other specialist areas varied and did not have such a positive effect. Within surgery, it was felt there was no emphasis on reviewing medication changes because of lack of time on ward rounds, fewer medication changes occurring and cultural attitudes relating to who should make changes to prescribed medication.

“In the medication changes section there’s very few things that the surgeons think are important…The attitude towards the whole thing is it’s a tedious task and no one ever reads it anyway, but, and they sort of instil that on us … as surgical juniors, which they may or may not be right.” FY1, Interview 8

Doctors felt they should be the ones to complete the medication section on the discharge summaries but felt reassured that the pharmacist was checking their work and played a role in detecting changes relating to medications. Some doctors suggested they relied on the pharmacists to confirm that the quality of their discharge summaries was acceptable, if they had completed them in a rush. However, several doctors suggested the input from pharmacists was variable and their involvement in checking medication changes on discharge summaries was not always consistent,

“Sometimes they do [query the section on the discharge summary on medication changes]. They’ll [the pharmacists] sometimes call up…It’s done by the good pharmacists. But not all the pharmacists do that. But most, like the majority, I would say, do it, the majority.” FY1, Interview 5

Infrastructure and EPR factorsA lack of computers on surgical wards and the lack of a conducive environment to write a discharge summary also influenced physical and social opportunity. Technological issues also impacted on the physical opportunity. For example, the inability to compare the medicines reconciliation document with the medicines the patient was prescribed at discharge, side-by-side on the same screen, made the process of writing a discharge summary cumbersome and long winded.

Reflective and automatic motivation

Impact of Doctors perceptions

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Doctors perceived the process of completing a discharge summary as an administrative task, which was both menial and tedious. However, it was also accepted as an important task and one that junior doctors were expected to do. Some doctors described making an effort to find out and document reasons for medication changes, perhaps on ward rounds, in case they had eventually to write the patient’s discharge summary. However, the cultural view that completing a discharge summary is a task for junior doctors appeared to have led to senior staff disengaging with the task.

“….they are not a particularly skilful task, they are always handed to the lowest or probably most junior member of the team so it’s almost like a rite of passage that everyone has to get through, so I don’t think anyone speaks particularly positively of them.” FY2, Interview 6

Patient safety Doctors expressed an understanding of why it was important to complete information on medication changes and referred to patient safety issues. They were motivated to complete the section on medication changes due to personal and professional reasons. Motivating factors included mirroring the behaviour of their consultants if they aspired to work in their field and the inherent desire to ‘do a good job’. Doctors frequently described trying to prevent the GP having to ‘decode’ what had happened to the patient. These ‘reflections’ on what the GP required appeared to motivate the doctors to complete the medication changes section.

The type of medication involved also influenced doctors’ actions when completing a discharge summary. They appeared to make a ‘risk assessment’ based on the medication involved. If a ‘high risk’ medication was mentioned in the EPR, this prompted doctors to consider, for example, whether it needed reinstating if it had been suspended, or whether the GP needed to be asked to review it. It also influenced the time spent on investigating the reasons for changes. In contrast, medicines considered low risk were more likely to be missed off discharge summaries and there was less likely to be information documented within the EPR regarding their change.

“So it's sort of the effect it’s gonna have on them. If you reinstate all their anti-hypertensives at once they may have a fall due to postural hypotension. I suppose things like Laxido [macrogol based laxative], people don't care that much - doctors will be careful of things like beta blockers but Laxido....everyone's on it. You're probably not going to spend five minutes delving into the history.” FY2, Interview 3

The threat of medico legal consequences led doctors to justify why they could not complete the discharge summary in full even if they aimed to ‘do a good job’.

“I would just usually write at the top of my discharge, this is written, in retrospect from the notes, please note that I have not actually reviewed this patient. Just I think cause there’s that level of medico-legally protecting yourself really… cause if it did come back and it was incorrect you can say well, I was asked to write it, I did

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it from the best of my ability from the available notes but I wasn’t involved in the management here.” FY2, Interview 11

Some doctors would document what they could, whilst for others, the medico-legal implications meant they might leave some elements of the discharge summary blank if they were unsure. Some doctors did not believe there would be consequences if they did not complete the section on medication changes. Others felt there could be consequences depending on how serious an incident could be. This mixed view suggested the possibility of sanctions was not the only driving force in motivating them to complete the information on medication changes.

Many viewed the point of discharge as being a transfer of responsibility back to the GP. This was coupled with the view that any medication issues that cropped up after discharge were likely to be resolved by the GP without the hospital staff, necessarily, being made aware of any issues. It appeared that this perception that the GP should take on all responsibility for the patient, after their discharge, also applied to medications. Some junior doctors tried to find out the reasons for medication changes. However, when they could not, they felt justified in transferring the issue to the GP who would ‘take over’ the responsibility for the patient. The referral of the problem to the GP was viewed as a ‘safety net’. However, some did not see this as an appropriate solution, whilst others felt it was not ideal but there was no realistic option.

“If it’s not a patient you know and you're unsure whether to restart or start [something] I would just say to the GP to review it. It's such a scapegoat answer, it probably goes on every single discharge summary, especially the ones on EAU [Emergency Admission Unit] because once they no longer need hospital then you do expect the GP to just follow up everything else…. Including watching their blood pressure and checking their bloods… I'm very aware that it probably doesn't always happen, but I don’t know that there’s much else you can do.” FY1, Interview 2

A potential demotivating factor was that some doctors were unsure what happened with the discharge summary once it was completed. This ranged from being unsure when the document went off to the GP, to whether the GP would be informed if they made changes to the discharge summary. The need for doctors to have ownership over the content of discharge summaries also had an influence on their willingness to prepare them in advance of the patient going home. Some doctors were reluctant to rely on someone else’s work, so looked through the clinical notes and made their own checks of any discharge summaries that may have been written in advance by a colleague. Other doctors believed some colleagues perceived a discharge summary as a ‘tick box’ exercise. This demotivated them to complete discharge summaries in advance, because they were concerned about patient safety if an incomplete discharge summary was printed off and given to a patient.

Development of Interventions

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The results of this study identified barriers across nine categories which impacted on all three components of behaviour - capability, opportunity and motivation.  The identified categories and barriers as described in Table 1 were then used to help design interventions. These are presented in Table 2 and discussed in detail below. Interventions were designed so that they would target the specific barrier and change the element of behavior it impacted on as described in Table 1.

DiscussionThe aim of this study was achieved by using the BCW to help design tailored interventions to target these components of behaviour, influence change and improve the transfer of information on medication changes, Table 2. Other studies have similarly recommended a range of interventions to help improve the transition of care at discharge.39–44  Many of these studies related to the medicines reconciliation process.  Nonetheless, there are parallels between the recommended interventions in the published studies and those recommended in this study.  This suggests the processes of completing discharge summaries and medicines reconciliation have similarities.   Our results suggest that all intervention functions in the BCW potentially need to be addressed. Environmental restructuring, which may require financial resources to facilitate behaviour change, is briefly mentioned but not discussed here in detail. Such restructuring includes having ‘quiet zones’ available and having enough computers to write discharge summaries.  Instead, the discussion focuses on less costly interventions aimed at the people writing the discharge summary i.e. the junior doctors.

Interventions to provide environmental restructuring, restrictions and modelling to target capability.

Increasing access to computers and having quiet zones available where the environment is conducive to writing discharge summaries might target the capability of junior doctors to include information on medication changes in discharge summaries. Doctors also need to be provided with knowledge and understanding on what national standards exist around writing discharge summaries. Examples of what constitute a good quality discharge summary are required. There should also be a facility that staff can only print off the discharge summary once its been signed off as complete by the prescriber.

As others identified, behavioural factors, such as doctors entering data into medical records, remain important to the successful transfer of information on electronic discharge summaries.2,44,45 Failure to document the reasons why medication had been suspended (put on hold) acted as a barrier, as previously identified.46 Several doctors felt this occurred due to the limited choice of options available on the EPR system. This forced doctors to use ‘workarounds’ to trick the system and document something, even though it was not always accurate. The use of ‘workarounds’ to trick a system so that it keeps on functioning without interfering with the acute, practical situation at hand was previously identified and described by Berg.47 The addition of more specific

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options to the EPR system might help limit the use of ‘workarounds’. Restricting the options available may be helpful but they need to be complete and specific else the use of ‘workarounds’ will continue. An alternative is to remove the options but restrict staff so that they are forced to type a ‘free text’ reason. This is counter intuitive to the idea that restraining the use of ‘free text’ options may help clinicians complete standardised medical records.48 As Berg48 suggests, more research is required to determine if this ‘ideal type image’ of using standardised terminology, for example in EPR systems, needs modifying.

Ashcroft and colleagues2 identified ‘failure to prescribe pre-admission medication’ as the most common error in their study on prescribing errors. They suggested that the implementation of medicines reconciliation could improve this situation and improve medication safety at transitions between healthcare settings.2 This study, however, revealed that, in spite of a medicines reconciliation document being completed at admission, failure to prescribe admission medication was still an issue. The medicines reconciliation process consists of the ‘3Cs’ - Collecting, Checking and Communicating.49 This study suggested that only the collecting stage is occurring and that ‘checking’ and ‘communicating’ stages are not routinely being achieved. Consequently, this is impacting on junior doctors ability to complete information on medication changes at discharge. This needs to be addressed by educating doctors to include information on medication changes in medical notes. There needs to be developments within EPR functionality to encourage and help doctors document medication changes. However, the results also suggested a need for staff to be able to compare medications listed in the medication reconciliation document with those the patient is on at discharge. This facility should be built into electronic prescribing systems.

Interventions to provide education to target capability and opportunity

The staff in this study already appeared to possess automatic motivation which would suggest there needs to be a greater focus on education to target capability over training which the BCW indicates will target motivation. Doctors require knowledge on how to construct a discharge summary and also knowledge of what information should be included. The use of structured, electronic, templates has been demonstrated to save time when writing discharge summaries.50 However, the use of electronic systems means a wealth of information is available to doctors when they come to write electronic discharge summaries. This study identified how doctors ‘learn’ to write succinct discharge summaries efficiently. They made a transition from ‘cutting and pasting’ everything to conceptualising the information provided and providing a handover document that focused on future plans and follow up directions for the GP. This is congruent with Berg and Goorman51 who suggested that ‘to conceptualise the broad range of medical data on a patient as bits and pieces of an emerging story is much more apt than to consider them as a ‘heap of facts’.

The findings in this study suggest that doctors are conscious about the way in which they transfer information to the GP. They were motivated by the need to

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provide medication information in a way that meant the GP did not need to ‘decode’ everything. The results of this study suggest the junior doctors identified, themselves, the need to move from, as Tully and colleagues described, ‘providing data and information to providing knowledge’ (the latter defined as contexualised information that allows the user to understand useful actions).52 However, the results suggest that doctors may not necessarily have the knowledge or skills to achieve this. In addition, it takes time for the doctors to learn skills to use EPR to be able to assemble and interpret the data. Similarly, Tully and colleagues 52 reported that junior doctors could not always analyse and prioritise the data and information they had available.

Doctors in this study suggested medication changes might not be recorded in medical notes because doctors felt the information was obvious. This was also identified previously.46,53 However, this assumes all junior doctors have established the same tacit knowledge and are able to ‘work out’ the reasons why medication changes are made. Although, the results suggests the EPR system can help doctors ‘work out’ reasons it may not always be helpful until they have developed their clinical knowledge and established their tacit knowledge. Without this tacit knowledge doctors are unable to reverse engineer outcomes documented in the medical notes.

Education sessions on writing discharge summaries should be taught early in the foundation year, or at undergraduate level. Education sessions should focus on both the content required in discharge summaries and the process of constructing them using EPR systems. GPs should also be involved to highlight what they require in discharge summaries. This may save the junior doctors’ time, leaving them more time to invest in finding out why medication changes have occurred. This would provide doctors with the psychological capability to write electronic discharge summaries. This may limit the temptation to copy and paste everything on the assumption the GP will have all the information they need and be able to pick out the relevant facts.52 Various studies have reported improvements to the quality of discharge summaries after educational interventions. However, all used different techniques and have measured different outcomes so it is unclear which approach is most effective.54–58

Interventions to provide persuasion and incentivisation to target opportunity

This study identified that junior doctors viewed the task of completing a discharge summary as a menial one. This has parallels with other studies that described medicines reconciliation in the same way.26 In spite of this, doctors included in this study had clear views on the role of the discharge summary and did not lack automatic motivation. It appeared, despite the lack of sanctions, that doctors were driven by their professionalism and concern for patient safety to try and complete the section on medication changes. Similarly, Boncella et al59 identified professionalism and the amount of time staff are willing to invest determined what data were entered onto electronic health records. Therefore, intervention functions such as financial incentives may be less effective. This is

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because it would fail to influence either professional or patient safety drivers for junior doctors motivation. Indeed, Bischoff et al identified that systems changes more than financial incentive accounted for behaviour change in their study.60 ‘Champions’ will however, target professional motivations of junior doctors. The benefits of senior staff acting as ‘champions’ to encourage the completion of medication changes on discharge summaries was evident in this study and has been previously identified.46 However, ‘champions’ were not present in all clinical areas and it appears engrained cultures, in some clinical areas, acted as a barrier to the inclusion of medication changes on electronic discharge summaries. The presence of ‘champions’ in all clinical areas may help promote discussion of medication changes on ward rounds and promote a sense of team work. It may also help tackle the culture that it is only the junior doctors who can complete patient’s discharge summaries or information on medication changes. Through persuasion, this may help promote the inclusion of information on medication changes in the medical notes, by all staff, as routine practice. This will make it easier for junior staff to include medication changes on their discharge summaries.

Previous studies have similarly identified that when on call, discharge summaries are considered a high priority by bed managers and nursing staff but are pushed to the bottom of a doctors priority list.46 This resulted in less time being spent on discharge summaries.23,25,26,28,46 Grimes46, similarly identified that pressure from staff had the potential to affect the quality of discharge summaries when the focus was on achieving targets for discharge times. In the UK, the Francis report reminds us that any targets put in place should not be to the detriment of quality of patient care.61 Multidisciplinary team meetings , which include discharge planning staff, may persuade staff of the importance of allowing time for doctors to complete discharge summaries to ensure quality information is transferred. Inclusion of information on the possible consequences when quality information is not transferred could help persuade staff and contribute to behaviour change.

Interventions to provide enablement, training and coercion to target motivation

Berg and Goorman62 suggested that all medical information is written within a specific context and so removing the facts from that context make the information into purely a ‘commodity’. When writing a discharge summary, the doctors have to both disentangle the information in order to provide key salient points to the GP and reproduce the context, so that details of reasons ‘why’ decisions were made can be shared.62 As with the process of disentanglement, reproducing the context also takes time and effort. As the results of this study demonstrate, this effort can only be achieved by sitting down and reading the notes. This is likely to lead to duplication of effort and wasted time. On call, time is a scarce resource and it seems counterproductive to have to reproduce effort and work to write a discharge summary at that stage. In addition, if the doctors do not know the patient they can only reproduce the context if all information is recorded or if there is someone they can seek advice from. The results suggested there are invariably gaps in the available information as to why medications

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were changed. This means the discharge summary remains a document containing ‘chunks of information’, as one junior doctor described it and they are unable to produce a coherent story. This explains the importance ‘knowledge of the patient’ has when writing an electronic discharge summary. This is particularly relevant when doctor’s are providing on call services or when writing discharges on emergency/medical admission units. The culture of delegating the writing of discharge summaries to junior doctors on call, who do not know the patient, is likely to be lead to poorer quality information transfer, as highlighted previously.46 The results suggest doctors who know the patient, rather, could write discharge summaries quickly and from memory. In addition, the quality of the discharge summary will be enhanced because doctors are more likely to know the context and therefore the reasons ‘why’ medication changes were made. Doctors who have more connection with the patient are also more likely to be motivated to take ownership of the discharge summary and want to transfer information to the GP.

In this study, doctors relied on pharmacists as a ‘safety net’ to check their work, particularly, when completing electronic discharge summaries under pressure. However, the results suggested the involvement of the pharmacists in reviewing electronic discharge summaries was variable. Although guidance and studies have advised medicines reconciliation should be done at discharge, some hospitals still focus on this task at admission only.10,46 Studies, have also suggested, that if the medicines reconciliation at discharge is a multi-disciplinary process26 then this may encourage staff not to view discharge as an end to their obligation to patients and promote safe and efficient transition of care.63,64 It has been suggested that pharmacists and doctors should partner up during the discharge process to ensure complete information is provided.46,63 A multi-disciplinary approach may be successful. If the aim is to ensure ‘completeness’ of information on medication changes when providing information on discharge summaries then there is a strong argument for a formalised multi-disciplinary approach to completing them. As Grimes46 identified this plays to the strengths and motivations of each professional group. A systematic review by Chhabra et al65 suggests involvement by pharmacists in the medicines reconciliation process at discharge could reduce medication errors and improve the quality of prescribing. A multi-disciplinary approach would allow doctors to maintain ownership of the their discharge summaries and focus on safety considerations and the acute medicines. Whilst this may not necessarily achieve a complete discharge summary the pharmacist can focus on providing a complete discharge summary and take a more holistic approach to include medicines viewed as ‘lower risk’. Indeed, successful multi-disciplinary approaches have been reported.66–68 However, if this intervention is introduced there needs to be clear role definition.27,29,46

In this study, many doctors did not know what happened with the information on a discharge summary after it was completed. This may have had an additional impact on the their reflective motivation. This may result in demotivation if they believe their effort put into establishing information on medication changes may be a fruitless task. This is supported by Berg and Goorman’s62 view that problems can arise if doctors feel they are asked to disentangle data for which

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they themselves may not use again for the patient. Despite this, many of the doctors in this study discussed trying to provide information. However, this is only possible if there is available information documented in the medical notes. There was evidence in this study that some doctors documented information in medical notes, on the basis that they may use that information later on, if they themselves had to write the patient’s discharge summary. So ‘action now for benefits later’, seems to be a motivational factor for junior doctors documenting information. Despite this, doctors still reported that the information recorded in the EPR, during the patient’s admission was unreliable or lacking. This is similar to previous findings29,46 and makes it difficult for junior doctors to write discharge summaries and transfer knowledge.52 In this study some doctors reported boxes were left blank on the discharge summaries. Doctors, therefore need educating on what happens to the information on medication changes once patients are discharged. However, feedback and training is also recommended to ensure motivation is maintained and skills develop. There is evidence that this leads to continuous quality improvement of discharge summaries51,69 and professional practice.70 Training sessions can ensure staff maintain and develop skills in using EPR and know how to write discharge summaries efficiently. Further, it may also help reinforce education provided on why the content on medication changes is important on discharge summaries and what happens with the information provided.26–28,71 However, it is unclear the best way of providing feedback and which staff are best placed to do this.70

Study strengths and limitationsThe use of semi-structured interviews and the reflexive decision not to reveal the profession of the researcher helped the participants be open and honest in their discussions. The use of framework analysis ensured the results were grounded in the data, adding to their confirmability.72 The results have similarities with the findings of previous studies and this adds strength to the evidence base for the recommended interventions and credibility to the results. However, as the study only included six interviews with each grade then saturation may not have been met for each grade of doctor.

It is recognised the recommended interventions were based around the views of doctors who were one and two years post graduation from medical school. The views of other staff within the medical hierarchy, and the views of other members of the multidisciplinary team, were not captured. Future studies could explore their views to facilitate refinement of the suggested interventions.

This study was conducted at one institution where EPR and the use of electronic discharge summaries was embedded within the hospital. However, the results have similarities to those found in studies that involved paper discharge summaries, suggesting the results are transferable to other institutions.10,23,46 The sample employed in this study, however, cannot be said to be representative of all populations of staff who write discharge summaries.

It is possible this study attracted the participation of those doctors who already had an interest in improving the standard of electronic discharge summaries.

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This may have meant the views of those who do not routinely complete details of medication changes on electronic discharge summaries were not captured. However, the participants talked freely about behaviours in peers that they did not always agree with, suggesting they were able to provide a balanced account. The similarity of the results with existing studies involving both discharge summaries and medicines reconciliation suggests this may not have biased the results.

ConclusionsIn this study, using the BCW as a theoretical lens enabled interventions to be identified that targeted specific components of behaviour that were highlighted as requiring changing. Such tailoring is important for trust managers and policy makers as it strengthens the evidenced base for interventions in an NHS where resources are scarce. Those developing interventions need to be cognisant of all the interventions. It is the combined affect of all these interventions that is likely to help improve the completion of medication changes on electronic discharge summaries.

The results demonstrated similarities with findings from studies that had explored the medicines reconciliation process. Future research should consider the most effective way to provide education and feedback on completing electronic discharge summaries. The impact that EPR systems have on what clinicians choose to document also warrants further investigation. Research studies could also investigate how the use of structured ward round documents which encourage medication review, can be embedded into clinical work where culturally there is a view that there is no time to complete such documents.

AcknowledgementsThanks go to [xxxx Removed to blind manuscript xxxx] for their assistance in this research. Thanks, also, to all the willing volunteer junior doctors who took part in this research.

Conflict of Interest/Funding: The researcher was awarded an HEE/NIHR studentship to complete this piece of research as part of a Masters in Clinical Research.

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Table 1 Identified barriers and facilitators to the transfer of information on medication changes on electronic discharge summariesCategory Barrier Facilitator Component of COM-B

model which barrier/facilitator impacts on

Skill development

Writing the discharge summary for a junior doctor and not a GPTime spent learning all the techniques of using EPR & workarounds

Learning to write a succinct discharge summary for the GPDeveloping confidence in discharge summary writing skills as clinical skills developLearning an effective process for establishing medication changes

Physical capabilityPsychological capabilityPhysical opportunity

Impact of documentation

Unreliable records relating to suspended medicinesLack of documentation:- relating to thought processes and reasons for

medication changesbecause the reason for the changes is considered obvious

Accurate & clear documentation Psychological capabilityPhysical opportunityPhysical capability

Patient factors No knowledge of the patientLong patient admissionComplex patientsImpact of surgical speciality

Knowledge of the patientShort patient admissionElective surgical patients

Social opportunityPsychological capabilityAutomatic motivation

Impact of on call

Lack of staff to discuss queries withJuggling competing tasks & time pressuresIncreased workloadLow priority task for doctors but high priority for other staff

None identified Physical opportunityPsychological capability

Leadership Failure to complete of all stages of the medicines Champions to promote Automatic motivation

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reconciliation process e.g. not prescribing at admissionPoor communication across the teamCultural views within surgical specialityShifting professional responsibility to GPMedico-legal justifications prevent writing a discharge summary in advance.Limited transfer of information when all details unknown

discussion/review of medication changesTaking on ownership to improve qualityTeam work & supporting colleaguesRole of the pharmacistEnsuring the most appropriate person completes the discharge summaryPlanning aheadMedico-legal justifications to promote ownership of content of discharge summary.

Reflective motivationPsychological capabilityPhysical capabilityPhysical opportunitySocial opportunity

Infrastructure issues

Lack of formalised trainingNo knowledge of recommended standards/guidelines for completing a discharge summaryLack of sanctions/consequencesPressure from staff to get discharge summary completedLack of conducive environment to complete discharge summaryLack of computers on the surgical ward

Staff trainingUse of a discharge summary template

Physical capabilityPsychological capability Physical opportunitySocial opportunityReflective motivationAutomatic Motivation

EPR factor Difficulties spotting information on medication changesDifficulties in viewing all medicines that had been prescribed in pastLack of ability to compare medicines reconciliation document with current electronic discharge summary and easily identify changes

EPR enables access to a wealth of informationEPR aids process of ‘working out’ what has changed and helps incur logical assumptions.

Physical opportunityPhysical capability

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Impact of doctor's perceptions

View that completing a discharge summary is a menial/administrative taskView that completing discharge summaries is a task for the junior doctorsNot knowing what is expected in the boxes of an electronic discharge summary documentFocussing on the patients presenting complaintDoctors unaware what happens to discharge summary once it is saved

View that discharge summary is just part of the jobSense of professionalismPersonal MotivationsPutting oneself in the shoes of the GPPreventing GPs having to decode everything

Psychological capabilityPhysical capabilityPhysical opportunitySocial opportunityReflective motivationAutomatic motivation

Patient Safety Ensuring the discharge summary is safe, rather than complete.Inclusion of low risk medication

Inclusion of high risk medication Reflective motivationAutomatic Motivation

Footnote: GP – General Practitioner, community based doctor in United Kingdom, EPR – Electronic Patient Record

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Table 2 – Suggested Interventions

Element of behaviour intervention targets

Suggested Intervention Function served by intervention21

Physical & Psychological Capability

Educate on what expected to be included in electronic discharge summaries and how to provide this using electronic systems. Include why it is important to routinely record information on medication changes in medical notes.

Educate on what is considered a good quality discharge summary/minimum standard. Provide information relating to national standards on what constitutes a good quality discharge summary. Involve general practitioners in delivering this education.

Education

ModellingEducation

Develop EPR technology to allow easier comparison of medication at admission with discharge medication and identify changes to medication.

Environmental restructuringEnablement

Develop EPR capability so doctors are ‘forced’ to record reasons for medication changes or why medications are suspended

RestrictionEnablement

Develop EPR capability so staff cannot print off discharge summaries before fully completed and signed off as complete by a prescriber. RestrictionIncrease access to computers on wards.Have available ‘quiet zones’ conducive to writing electronic discharge summaries Environmental

restructuring

Social & Physical Opportunity

Multidisciplinary meeting to include discharge planning staff to promote understanding of role of electronic discharge summaries and appreciation of time needed to complete job well.

EducationPersuasion

Promote a change in culture so completion of discharge summaries is not viewed as solely the job of junior doctors.

Persuasion

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Encourage ‘champions’ from several professional groups to promote completion of medication changes within EPR (e.g. during communication on ward rounds) and on discharge summaries. Champions should encourage staff to aspire to complete this as a routine task and lead by example.

IncentivisationPersuasion

Reflective & Automatic Motivation

Ensure only doctors who have knowledge of the patient complete the electronic discharge summary

EnablementIncentivisationPersuasion

Provide sessions on skills of using EPR at start of foundation year to impart skills on how to write an electronic discharge summary efficiently

Training

Promote completion of medicines reconciliation at discharge. This should be a multidisciplinary team effort with clear role allocation and understanding of patient consequences when this task is not completed.

EnablementTrainingCoercion

Promote understanding amongst junior doctors of how the information in electronic discharge summaries is used by general practitioners and disadvantages if information is not provided.

EducationCoercion

Use formalised feedback methods from general to help improve quality of electronic discharge summaries and maintain motivation.

Training

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Appendix 1

Semi Structured Interview Topic GuideIntroductions Details when qualified as a doctor. Area currently working in, grade.

Who usually prepares patient discharge summaries on the ward you work on?

Opening question Tell me about your VIEWS ON THE ROLE of the discharge summary

o Prompt –explore views on the role of the section on medicines/medicine changes

Talk me through HOW you PREPARE a discharge summary – with a focus on the medicines section.

Talk me through YOUR EXPERIENCES of preparing discharge summaries.

If not mentioned explore:o What INFORMATION do you include on the discharge summary?o What makes completion physically HARD/EASY? Whyo What do YOU NEED to be in place to complete the discharge

summary? – are these available?o Are you CONFIDENT in carrying out the task? Whyo Anything MISSING? Knowledge? Knowledge of electronic systems?

What are your VIEWS on training on completing discharge summaries?Prompt – do they receive any? Is it perceived as needed?o What is their awareness of local trust/national guidance on

completing discharge summaries – what is best practice?

Now I’d like to focus on the section of the discharge summary on MEDICATION CHANGES

What are your THOUGHTS on COMPLETING the section on MEDICATION CHANGES on a discharge summary?

Promptso What support is in place to help you complete the section on

medicines?o Are there any facilitators to completing the medicines section – what

are these?o Are there any barriers to you completing the medicines section – why

are these barriers? Do you try and overcome these? Why ? How?o What are you VIEWS on the PROCESS of completing the section on

medication changes? Is there a NEED to complete it? If not completed – what are perceived

sanctions/consequences of non-completion?

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Why is it important /not important to complete the section on medicines?

If barriers overcome – How? Why? What influences decision? What drives tenacity (if present) to complete this section even when difficult?

What makes them want to complete this section or not complete it?

Are there other priorities? What? Why? Is completion of information on medicines a routine task? Is it

habit – why? how did completing become habit? What would you say are your peers/senior colleagues (e.g. registrars,

consultants) views on discharge summaries (focus on medicines section)

o Prompts - Are they considered high priority, what about the section on medication changes?

Do they perceive there to be ANY DIFFERENCES when completing information of medication changes on discharges in surgery compared with medicine or for different specialities? Or at weekends?

o Prompt - Explore - What differences?, Why present? What affect does this have?

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