Hospital discharge planning: a qualitative study of new graduate physiotherapists’ experiences

Romany Martin ¹, Andrew Phan ², Shaun Tan ², Allison Mandrusiak ², Roma Forbes ²

Abstract

Purpose: Discharge planning constitutes a large part of a physiotherapist’s role when working in hospital settings. The challenges of decision-making related to discharge planning have been identified by experienced physiotherapists. Despite known challenges associated with the transition from student to clinician, the experiences of new graduates undertaking discharge planning are largely unknown. Therefore, this study aimed to explore:

1. new graduate physiotherapists’ experiences of discharge planning in hospital settings, and
2. the influence of pre-professional training on their perceived preparedness for discharge planning.

Design: A qualitative general inductive approach using semi-structured interviews. New graduate physiotherapists (n = 14) working in hospital settings were recruited.

Finding: Four themes were generated: 1) responding to the pressures associated with discharging patients, 2) complex decision-making, 3) the role of the interprofessional team and 4) desiring additional context and complexity from pre-professional training.

Practice Implications: The study has identified that new graduates underestimate the extent to which discharge planning features in their roles within hospital settings and are unaware of the interprofessional practice required. While they felt that their pre-professional training provided the technical skills required for their roles, they felt they were not prepared for their role within the broader healthcare system or the complexity of clinical practice. This study encourages education providers to emphasise the role of physiotherapists within the broader healthcare system by highlighting contexts where physiotherapy knowledge can be applied (i.e., discharge planning) and understanding the physiotherapist’s role within the interprofessional team.

Limitations: Important perspectives of mentors and other members of the interprofessional team involved in discharge planning have not been included in this study, which may have impacted the interpretation of the results.

Keywords: physiotherapy, discharge planning, hospital, qualitative, new graduate

INTRODUCTION

Discharge planning constitutes a significant role of physiotherapists working in hospital settings (Atwal, McIntyre & Wiggett 2012). Patient discharge can be summarised by three pathways: discharge to the patient’s home, ongoing rehabilitation or residential care placement (Pitas 2017). In addition to determining the timing of discharge, physiotherapists significantly influence the discharge destination decisions made by patients, their families and interprofessional teams (Potthoff, Kane & Franco 1997).

Perception of risks associated with discharge is known to impact discharge decision-making and discharge destination (Atwal, McIntyre & Wiggett 2012). These risks include adverse events occurring after discharge, such as failed discharge (Mathew et al. 2015), falls at home (Worley, Barras & Grimmer-Somers 2010) and, in extreme cases, death (Yu et al. 2011). Clinicians perceive additional risks associated with discharge planning, with these risks being linked closely to accountability and blame in the event of negative outcomes (Bowling & Ebrahim 2001). The implications of decision-making in this context can also be compounded by pressure on clinicians to prioritise discharge and improve patient flow through the hospital system (Goldman et al. 2016).

Experienced physiotherapists have identified the complexity of decision-making related to discharge planning. They report that they tend to place more emphasis on the unique needs and goals of the patient rather than on specific objective measures (Taylor et al. 2010). This was reinforced by Jette, Grover and Keck (2003), who reported that when formulating discharge decisions, physiotherapists and occupational therapists consider the patient’s preferences and needs, ability to participate in care, level of functioning and life context (Jette, Grover & Keck 2003). To assist physiotherapists with decision-making regarding discharge, there are multiple discharge tools available for different patient presentations (Lati et al. 2014); however, it is acknowledged that each unique patient presentation must inform decision-making (Taylor et al. 2010). Therefore, the complexity of decision-making relating to discharge planning (Frost 2001; Jette, Grover & Keck 2003; Taylor et al. 2010) is considered an important area for pre-professional training and ongoing professional development (Frost 2001).

New graduates transitioning from student to clinician face unique challenges as they commence professional practice and workplace support during this time (Forbes et al. 2021). Stoikov et al. (2020) identified that new graduates in hospital settings are particularly challenged by the increased caseload volume and complexity of their roles compared to the protected workloads they experienced as students (Stoikov et al. 2020). New graduates working in hospitals have also reported difficulty coping with increased independence and managing expectations of themselves (Stoikov et al. 2020). This echoes research identifying that new graduates may not have the clinical experience to rely on when applying clinical reasoning in new settings (Martin et al. 2021). There are recommendations that training students to formulate and practice discharge decision-making should prioritise the patient as an individual and consider the complex environments in which they live (Jette, Grover & Keck 2003). This recommendation for strengthening new graduate physiotherapists’ skills and readiness for discharge planning is further emphasised by potential interprofessional tensions caused by conflicting discharge priorities (Mizuma et al. 2020) and interpersonal tensions due to organisational expectations concerning patient safety and patient flow (Goldman et al. 2016).

Given the significance of decision-making for discharge planning (Frost 2001) and the need to consider factors beyond specific objective criteria (Taylor et al. 2010), the experience and readiness of new graduate physiotherapists undertaking discharge planning are of interest. Despite research investigating new graduate readiness for managing different conditions (Forbes & Ingram 2019), workplace contexts (Martin et al. 2020; Stoikov et al. 2020) and interprofessional practice (Jones, Ingram & Forbes 2020), no investigation to date has explored the perceptions of new graduate physiotherapists regarding discharge planning in hospital settings. This is significant given the identified challenges of new graduate physiotherapy practice within hospital settings (Stoikov et al. 2020) and the established complexities of discharge planning (Jette, Grover & Keck 2003). A better understanding of new graduate experiences and readiness for this challenging area of hospital practice will provide employers and training providers insight into how to prepare and support new graduates undertaking patient-centred discharge planning when entering hospital settings (Durocher et al. 2015). Therefore, this study aims to explore:

1. new graduate physiotherapists’ experiences of discharge planning in hospital settings, and
2. the influence of pre-professional training on their perceived preparedness for discharge planning in hospital settings.

MATERIALS AND METHODS

This study applied a general inductive approach to explore the experiences of new graduate physiotherapists undertaking discharge planning in hospital settings. An interview guide was created, informed by a review of the literature regarding discharge planning and the research team’s expertise. The research team included physiotherapy students, clinicians and academics with experience working in hospital settings, preparing physiotherapy students for hospital practice and researching new graduate readiness and experiences in the professional setting. The interview guide (Figure 1) was intentionally designed to uncover the meaning of participants’ initial responses and to convey the participants’ experiences in their own words (Patton 2002). The interview was piloted by a team member (RM) who works as a physiotherapist in a hospital setting. This resulted in minor changes to the interview guide to refine the included questions and introduce broader prompts for meaning and details.

Figure 1: Interview guide

PARTICIPANTS

New graduate physiotherapists working in hospital settings were recruited for the study. Inclusion criteria stipulated that participants must have been employed for a minimum of eight weeks in a hospital to ensure adequate exposure to the setting and that they had been working for two years or less since graduation (Chipchase, Williams & Robertson 2008). A snowballing sample of participants was established via professional contacts from the research team(Palinkas et al. 2015). Professional contacts were asked to approach new graduates in their workplaces regarding consent to be contacted by the researchers. New graduates who consented were then emailed with additional information regarding the study and to arrange a mutually convenient time to be interviewed.

DATA COLLECTION

All interviews were conducted via telephone by one of two research team members (AP, ST) in April 2021. Interviews were audio-recorded on a second device, with reference to the interview guide (Figure 1) (Patton 2002). Before each interview, participants were provided with a working definition of discharge planning; that being:

• Discharge planning includes making decisions about discharging a patient from the inpatient setting to either their previous residence or a residence that supports their current level of function and working with others to make these decisions.

The interviews ranged from 28 to 42 minutes. Data collection was ceased when no new ideas or perspectives were obtained from three consecutive interviews, signifying that data saturation had been reached (Varpio et al. 2017).

DATA ANALYSIS

Verbatim transcription and analysis were undertaken concurrently to inform data saturation. Analysis was undertaken independently by two members of the research team (RM, RF). These researchers immersed themselves in the data by reading through the transcripts multiple times and listening to the audio for contextual meaning from the participants. The researchers then annotated the transcript to identify statements of significance, recurring ideas and concepts. These annotations and their corresponding text were then compiled in a table and organised into groups and initial themes. The research team frequently met to discuss discrepancies in interpretation and refined the themes until a consensus was reached. Illustrative quotes were assigned to each code and theme to ensure data validity and reliability.

Other conscious measures were undertaken to ensure the trustworthiness, credibility and transparency of the data collection and analysis (Patton 2002). Initially, the authors undertaking the qualitative analysis (RM, RF) undertook the process of epoche to document their relevant opinions and beliefs about discharge planning (Englander 2016). The lead researcher (RM) is a physiotherapist with experience working across multiple hospital settings. The author undertaking the secondary independent analysis (RF) is a titled musculoskeletal physiotherapist and senior lecturer with significant experience in new graduate research. This ensured that their pre-existing views did not influence their analysis and that the study results were only informed by the data collected rather than the researchers’ own bias (Varpio et al. 2017). Other measures included compliance with the interview guide to ensure consistency, a secondary review of all audio recordings post-transcription, two experienced independent reviewers completing the coding process and reflexivity among the research team to aid methodological rigour.

RESULTS

From the snowballing recruitment, a total of 15 participants consented to be interviewed. One participant did not meet the inclusion criteria for the length of time they had worked in the hospital setting and was subsequently removed from the study. A total of 14 participants were interviewed. All participants consented to involvement before the interview and were informed that they were able to withdraw consent up to the point of publication. Among the participants, there was a mean age of 23.5 years (range 22–29 years). Most participants were female (n=11, 79%), which reflects the trends of the larger physiotherapy workforce (Health Workforce Australia 2014). Further demographic data is outlined in Table 1.

Table 1: De-identified participant interview details*

Participant Number	Gender	Age	Participant Number	Employment Status	Time Employed (months)
1	Female	22	Female	Full time	4
2	Female	23	Female	Full time	4
3	Male	22	Male	Part-time	4
4	Female	22	Female	Full time	2.5
5	Female	22	Female	Full time	3.5
6	Female	25	Female	Full time	16
7	Female	25	Female	Full time	3
8	Female	23	Female	Part-time	18
9	Male	22	Male	Full time	16
10	Female	23	Female	Full time	16
11	Male	25	Male	Full time	3
12	Female	23	Female	Full time	6
13	Female	23	Female	Full time	19
14	Female	29	Female	Full time	16

^* At the time of the interview.

Four key themes were generated following data analysis: 1) responding to the pressures associated with discharging patients, 2) complex decision-making, 3) the role of the interprofessional team and 4) desiring additional context and complexity from pre-professional training.

These themes and associated codes are summarised in Figure 2.

Figure 2: Summarised results

Theme 1	Responding to the pressures associated with discharging patients
Codes	Working in a fast-paced setting			Perceived pressures from other staff to make discharge decisions
Theme 2	Complex decision-making
Codes	Surprise at the complexity of discharge planning	Challenged to make decisions with significant consequences		Relying on senior staff when faced with complexity		Overcoming complex barriers to discharge
Theme 3	The role of the interprofessional team
Codes	Interprofessional practice is crucial for effective discharge planning		Communication within the interprofessional team		Advocating within the interprofessional team as the physiotherapist Full time
Theme 4	Desiring additional context and complexity from pre-professional training
Codes	Lacking context about their roles within the hospital setting		Wanting additional preparation for interprofessional practice		Wanting additional preparation for the complexity of discharge planning

THEME: RESPONDING TO THE PRESSURES ASSOCIATED WITH DISCHARGE

Participants reflected on the fast-paced nature of working in a hospital setting and voiced that the rapid pace required was one of the main challenges of discharge planning. The majority of participants reflected on the fast-paced nature positively and felt that their roles were ‘rewarding’ (P11):

‘I enjoy the fast pace and seeing a big number of patients in a day. And I enjoy the discharge planning and trying to make sure that people expect to get home as soon as possible.’ (P11)

‘It is a very fast-paced environment … it can be really, really exciting, a lot of really interesting cases, lots of really interesting people.’ (P6)

Participants had a perception that there was ‘pressure’ (P10, P14) to discharge patients as fast as possible to relieve the pressures of ‘bed capacity’ (P13) and to enhance patient outcomes:

‘Often people are in and out quite quickly and being in a public hospital, there’s quite a lot of pressure to sort of discharge people as quickly as possible.’ (P8)

‘There’s big push to discharge people as soon as possible and reduce length of stay … high pressure and fast environment, but that’s what I love about it.’ (P5)

Given the importance of achieving timely discharge, participants began planning for discharge from their first contact with the patient and made an effort to ‘consider discharge planning from day one’ (P6). This created structured goal-setting for participants, as they prioritised discharge and goals specific to achieving discharge, such as progressing mobility aids or a stairs assessment:

‘In terms of discharge planning, once I have an idea of what someone’s follow-up might be, just starting the referral that day, rather than leaving things to the end of the week to sort of alleviate any pressure that can come closer to discharge.’ (P10)

‘I think in the hospital settings it’s [discharge planning] one of the biggest parts of the job, you sort of have to be thinking about it all the time and considering it before for all the patients from as soon as they get in there.’ (P12)

Participants were often overwhelmed by the tasks and decision-making required for discharge planning. They knew the consequences of not completing discharge planning efficiently and effectively. These perceived consequences included prolonged hospital admissions for patients, in addition to negative repercussions for the participants such as frustration from the interprofessional team:

‘Making sure that you’re starting early because if you haven’t sort of organised things, prior to when the discharge is coming around, then it can increase their length of stay and you can frustrate other members of the team with that.’ (P8)

In addition to their prioritisation of discharge planning, participants felt pressure from other staff and the hospital system itself to discharge patients. This was often in the scenario where the patient may have been medically stable but was not considered ready for discharge from the physiotherapy perspective. The participants were concerned that other staff viewed them as unreasonably withholding discharge, or that they were burdening the team by not discharging the patient. This pressure for decision-making was a significant source of stress and ‘conflict’ (P11) for the participants and had a negative impact on the participants’ self-efficacy:

‘You either knew that the patient was safe, or you knew the patient wasn’t safe mobilising at home … you then need to communicate that to the doctors if they are really pushing the patient and explaining why they can’t get discharged.’ (P11)

‘The times where I found it difficult is when doctors have wanted to push them out of hospital a lot quicker so then there have been those bed pressures or they’ve been medically stable, but they need ongoing physio or OT!’ (P6)

‘The pressure from like consultants to discharge a patient, even though they’re definitely not ready from a liability perspective, which can be a little bit tricky.’ (P14)

THEME: COMPLEX DECISION-MAKING REQUIRED

Participants were surprised by the number of factors that complicated discharge, including shifting baselines, social situations, financial complications, difficult home environments or homelessness and requirements for ongoing medical care. Participants felt these comorbidities were what made discharge planning ‘quite complex and difficult’ (P1):

‘The more challenging people are where they’ve got communication barriers, difficult discharge plans, or no discharge plan, where their mobility has deteriorated quite a lot, but they’ve got to get home or achieve a pretty high level of mobility.’ (P9)

‘Mainly complex medical patients, lots of them have complex social histories … the discharge planning, which is often hard with those.’ (P13)

Clinical reasoning as a new graduate was complicated by limited exposure to similar cases. With limited understanding of the clinical procedure, participants struggled to problem-solve every individual patient case promptly:

‘People don’t get back to their baseline and, and you have to think of alternate options …I think that’s what I found the most difficult because it’s not really as easy to practice, it’s a bit more different case-by-case.’ (P1)

‘On placement, you would go and talk to your clinical educator and sort of run your ideas past them. Whereas when you start, you kind of let loose to reason it with yourself, and no one’s there checking anything.’ (P5)

Participants felt significant ownership of their clinical decisions and felt that the consequences of making decisions that had negative outcomes were ‘100% on you’ (P7). They reflected on the shift of patient ownership during their transition from student to clinician and found their new responsibility daunting:

‘My experience has been daunting. It’s something I haven’t enjoyed because I don’t have experience in it and at times I’ve proven that I haven’t been perfect and patients have come back in because we haven’t made the right call.’ (P7)

Participants relied heavily on more experienced colleagues for input when they are unsure about their decision-making. Participants valued their seniors’ input and viewed them as a wealth of knowledge and a ‘broader toolkit’ (P4) for ways in which patients can present as well as treatment plans:

‘Either they’ve got some sort of variable or condition that I don’t know a great deal about … or if they’ve got quite a complex presentation in terms of discharge planning … those two key things that flag the patient’s being more complex, and that makes me think, okay, maybe I need someone with a bit more experience.’ (P4)

‘Just talking through those cases with the senior to see how it can, how things can be changed … having just different opinions on treatment plans and discharge plans.’ (P1)

THEME: THE ROLE OF THE INTERPROFESSIONAL TEAM

Participants strongly acknowledged that interprofessional practice plays a significant role in discharge planning and found the interprofessional practice to be a productive and positive part of their workdays:

‘We work quite closely with the treating teams, as in the doctors, and also with the nursing staff, there’s a lot of coordination with nursing staff and with the other multidisciplinary team … there’s a lot of, a lot of collaboration, you’re rarely kind of, you’re rarely planning and treating by yourself.’ (P1)

Communication among the interprofessional team was recognised by participants to be one of the most important factors for effective discharge planning:

‘I think the probably the most important thing is communication and early communication … I’d sort of talk to the allied health team members and go and chat to the doctors about it. So, making sure they knew where we’re up to, what needed to be done for discharge.’ (P8)

‘I think the doctors on the team are very appreciative of that because it gives them the heads up and it gives us something to work towards. So, I think that constant communication is really helpful.’ (P6)

This positive influence of effective communication on discharge planning is also felt to be true in reverse, with reflected poor communication resulting in poor discharge planning:

‘There was a patient who was a paraplegic from a previous spinal injury and he had come in for a washout of the wound and so he didn’t really need physio input because his transfers were at his baseline. He’d been there for probably about a week or so before I got a referral to see him because he was reporting low back pain and they were saying that the only barrier to discharge was physio, but they’d only referred me after he’d been there for a week.’ (P8)

Participants felt that a large part of their role within the hospital settings was advocating as the physiotherapist within the interprofessional team. They viewed their involvement in interprofessional practice positively and found it to be rewarding:

‘As a physio, it’s exciting that you get to advocate for your patients, and the doctors often make them better but we give them greater quality of life, which I find is really, yeah, really great.’ (P6)

‘I find working in an acute setting really rewarding … I enjoy the discharge planning and trying to make sure that people expect to get home as soon as possible.’ (P11)

This role was still viewed positively, even when the participants were advocating against the advice of medical staff or the wishes of patients discharging to unsafe environments.

‘Patients, for instance, have been stubborn and declined any equipment, despite it being free for 28 days. But in hindsight, I guess we learn to be a little bit bossier and advocate for our patients to take equipment where need be and stand up for our patients, and advocate for their inpatient stay to be extended despite medical clearance. Even when the doctors are keen to discharge.’ (P7)

THEME: DESIRING ADDITIONAL CONTEXT AND COMPLEXITY FROM PRE-PROFESSIONAL TRAINING

Participants felt that while their pre-professional training prepared them well, they did not realise ‘how important it was [discharge planning] and how much of a role we played’ (P1). Participants voiced that they would have liked additional preparation for discharge planning during their university training, with desired content revolving around learning more about the context of their roles and their contributions to the team:

‘Maybe emphasise discharge planning a little bit more because it wasn’t until I got to placement, and then started working, that I realised that it’s … one of the most important parts of our job.’ (P9)

‘I found mostly I became aware of essentially what discharge planning was when I was on placement and a lot of the uni lectures are very much like this is the management of a patient, but that’s it. Yeah, it’s just something that wasn’t really ever explicitly mentioned.’ (P10)

Participants also strongly voiced that they desired additional preparation for interprofessional practice at a university level. Given the importance of interprofessional practice for discharge planning, participants felt that this was a priority:

‘I feel like we didn’t do a whole lot of it [interprofessional practice] in subjects. There was more when we got to placement where I really developed those skills.’ (P5)

‘I think the hands-on stuff and the clinical skills and practical field I think I felt really prepared for and that was quite an easy well, not easy transition, but a smooth transition … I wasn’t as aware of like discharge planning and teamwork and all that kind of stuff.’ (P1)

The preparation that they discussed included learning about interprofessional team roles to assist with discharge planning processes, with one participant explaining that they wanted ‘more of an understanding of their roles in the broader team’ (P6):

‘I think asking other physios for help, my confidence was fine. Asking other members of the multidisciplinary team was probably something that I’ve grown in confidence with, as I’ve sort of been out of uni because you learn sort of what disciplines do and who you need to talk to about certain issues that arise.’ (P8)

Further, participants felt underprepared for the complexities of discharge planning resulting from comorbidities and pressures within the hospital. They felt that more complex cases and realistic comorbidities would have better prepared them for practice where ‘it was not clear what we were supposed to do’ (P5). However, they also recognise that it is not feasible to only feature complex cases, given that they are learning the base skills during their pre-professional training:

‘I think the transition could have been assisted with at university looking at more complex cases. I know this is virtually impossible, because if we didn’t do the easy cases, shall we say, we’d not be able to have the skills to deal with the complex cases.’ (P7)

Recognising the inability of the curriculum to fully address the context and complexity of discharge planning, participants identified clinical placements as the most intrinsic way to facilitate the growth from student to clinician for discharge planning:

‘Placement was really the place where we got exposed to complex cases and that’s, I guess, for me … that’s what helped me be prepared for my hospital role now.’ (P7)

DISCUSSION

This study has explored new graduate physiotherapists’ experiences of discharge planning in hospital settings and the perceived influence of their pre-professional training on their preparedness for discharge planning. New graduates were unaware of the extent to which discharge planning would feature in their roles in the hospital setting and the interprofessional practice required. Some new graduates experienced discharge planning as a source of anxiety, given the high levels of perceived risks to both patients and themselves. New graduates felt they had not developed the clinical reasoning skills required for complex discharge planning and instead relied heavily on mentorship and guidance from more experienced colleagues and the wider interprofessional team. While they felt that their pre-professional training provided strong foundational skills, new graduates voiced that more training in interprofessional practice, additional clinical reasoning for complex cases and more context for their roles within the hospital setting would be of value to aid readiness.

New graduate physiotherapists identified that discharge planning was an important aspect of their role. They felt that they understood both their contribution to achieving discharge and the implications of making appropriate discharge decisions, including falls and re-admission to hospital. Similar acknowledgements have been made by new graduate physiotherapists in other studies who recognise their role in hospitals as restoration or improvement and prevention (Barradell, Peseta & Barrie 2018). Barradell, Peseta and Barrie (2018, p. 398) quoted a new graduate physiotherapist as saying, ‘it’s not just about treating what you can see so they can go home but also preventing things in the future’. The acknowledgement of discharge planning requires consideration for both the present and future, reflecting the complexity that is involved (Taylor et al. 2010).

New graduates were significantly challenged with the clinical reasoning required for complex discharge planning, which often involved biopsychosocial considerations for the patient and the context of the discharge destination. Experienced physiotherapists similarly recognise the complexity of discharge planning and are known to place more emphasis on the specific needs and goals of the patient rather than meeting objective hospital-based criteria (Taylor et al. 2010). When making decisions around discharge planning, experienced physiotherapists are known to critique protocols and generic rules of practice and ‘interpret the boundaries of practice according to the circumstance’ (Smith, Joy & Ellis 2010, p. 95). Conversely, the discharge planning of novice physiotherapists is known to have a more external focus, taking into consideration published contraindications and precautions, advice from other colleagues and workplace policy (Smith, Joy & Ellis 2010). These findings are consistent with the results of the current study, where new graduates felt strongly influenced by others in the discharge planning, reasoning and decision-making.

There is additional risk perceived by clinicians undertaking discharge planning, with negative outcomes closely associated with feelings of accountability and blame (Bowling & Ebrahim 2001). This risk was a point of frustration and anxiety for new graduates, with one participant going as far as voicing a sense of responsibility for a failed discharge. Discharge planning has historically been driven by ‘protecting’ the patient’s physical safety, often at the expense of their self-declared interests and values (Durocher, Gibson & Rappolt 2017). Contemporary literature has called on clinicians to break down the barriers to discharge home, including fear of risk to the patient (Durocher, Gibson & Rappolt 2017; Durocher et al. 2015; Frost 2001). New graduates in this study experienced anxiety around discharge decisions and personally attributed negative patient outcomes to their inexperience, rather than to the inherent risk present. Smith et al. (2018) reported similar experiences among novice physiotherapists who felt uncertain about the adequacy of their knowledge related to discharge planning. Despite identifying that they had less knowledge, they could not distinguish between their knowledge and what could be known, leading to an increased sense of anxiety, similar to the participants in the current study (Smith, Joy & Ellis 2010). Further investigation is warranted into how fear and feelings of inadequacy affect discharge planning decisions and the implications for physiotherapists, patients and the wider health setting.

The results of this study suggest that new graduate physiotherapists often perceive pressure from medical staff to discharge patients when it is not indicated from a physiotherapy perspective. This was attributed to reducing ‘bed block’ within the hospital, reducing nursing staff workload and ‘cherry-picking’ anecdotally ‘difficult’ patients to discharge based on staff preferences. Goldman et al. (2016) also reported on the tensions present among healthcare providers undertaking discharge planning and attributed them to differences in professional responsibilities (Goldman et al. 2016). While this has merit, there must also be an acknowledgement of the learning that occurs during the transition from student to clinician, and that for new graduates, the greatest acquisition of clinical competencies occurs from three to six months of practice (Cheng et al. 2014). Considering this, the new graduates in this study are inferred to be learning the nuances of appropriate hospital discharge, and that some of the perceived pressure from medical staff for discharge may have been clinically warranted. However, the new graduates also perceived reduced pressure from clinicians who approached discharge planning with clear communication regarding their clinical reasoning. In other settings, transparent communication practices have been established to lessen tensions and improve efficacy within the interprofessional team (Goldman et al. 2016). Multiple authors have concluded similar inferences about interprofessional practice for discharge planning; for example, that discharge planning relies on complying with multiple viewpoints based on a mutual understanding (Mizuma et al. 2020), and that poor communication between the interprofessional team is the main contributor to poor discharge (Lobchuk et al. 2021). Effective communication and collaboration among the interprofessional team lessens perceived pressures associated with discharge planning (Smith, Joy & Ellis 2010), and is vital for the sustainability and efficacy of the model.

While new graduates found interprofessional practice rewarding, they felt underprepared for their roles within the interprofessional team and believed strongly that additional pre-professional preparation would have been beneficial. Successful preparation of new graduates for interprofessional discharge planning features strongly in the literature (Robertson et al. 2021; Smith et al. 2018). Evaluation of an interprofessional simulation for discharge planning has been shown to significantly enhance physiotherapy students’ perceptions of their roles and their understanding of their interprofessional team members’ roles (Kraft et al. 2013). During the COVID-19 lockdowns, educators created synchronous virtual interprofessional simulations focused on discharge planning for nursing and medical students, highlighting another example of effective pedagogy for these skills (Robertson et al. 2021). Critically, Stokes et al. (2020) found that occupational therapy and physiotherapy students who undertook interprofessional collaboration significantly improved their discharge decisions when evaluated against expert opinions. This acknowledgement of interprofessional practice both facilitating discharge planning and improving the clinical reasoning of novice practitioners around discharge planning highlights the significance of pre-professional training for interprofessional practice (Stokes et al. 2020).

IMPLICATIONS

This study adds to the body of work concerning new graduate physiotherapists’ experiences in hospital settings, with implications for both higher education providers and new graduate employers. This study encourages education providers to emphasise the role of physiotherapists within the broader healthcare system by highlighting contexts where physiotherapy knowledge can be applied (i.e., discharge planning) and understanding the physiotherapist’s role within the interprofessional team. While this study solely investigated discharge planning, broader implications may be drawn around the need to better prepare future physiotherapists for interprofessional practice. Additionally, this study advocates for employers of new graduate physiotherapists to ensure appropriate support is provided to graduates during the transition from student to clinician. This support from senior clinicians is actively sought by new graduates and is supported by previous research into new graduate mentorship (Forbes et al. 2021). Further research into the preparation for and support of new graduate physiotherapists in the hospital setting is warranted, given the multi-faceted roles of physiotherapists in this context.

LIMITATIONS

Firstly, participant self-selection presents as a limitation of the research, which may result in the exclusion of experiences or participants. Mainly, participants with negative experiences of transitioning from student to clinician in the hospital setting may not be reflected by this sample. Additionally, most participants involved in the study were recruited from one state in Australia, which may limit the generalisability of the results on both the national and international scales. This was compounded by the sampling method of snowballing recruitment, as new graduates not associated with the authors were unable to be considered for the study, which may have impacted the findings of the research. Further, the important perspectives of mentors and other members of the interprofessional team involved in discharge planning have not been included in this study, potentially impacting the interpretation of the results. Finally, while this study is a useful foundation for research regarding discharge planning, further research featuring different sampling methods, increased geographic diversity and increased diversity of practice setting is warranted.

CONCLUSION

This study has explored new graduate physiotherapists’ experiences of discharge planning in hospital settings and the perception of their pre-professional training on their preparedness for discharge planning. The results indicate that new graduates underestimate the extent to which discharge planning would feature in their roles in the hospital setting and may underestimate the interprofessional practice required. While they felt that their pre-professional training provided strong foundational skills, new graduates voiced that more training in interprofessional practice, additional clinical reasoning for complex cases and more context for their roles within the hospital would be of benefit. Further research is required into how best to prepare new graduate physiotherapists for their roles in hospital settings.

Acknowledgements

The authors wish to thank the physiotherapists who participated in this project.

Conflict of Interest

The authors declare no conflict of interest.

Funding

There are no sources of funding to declare.

Ethical Statement

Ethical clearance was gained for this study from the University of Queensland - Human Research Ethics, approval number 2020002698.

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