Front-line decision-making: a thematic analysis of interviews with hospital staff on referrals, admissions, and care for people with multiple long-term conditions

BACKGROUND: Multiple long-term conditions (MLTC) are increasingly common and present challenges for hospital healthcare professionals (HCPs) making decisions about admissions, referrals, and care management in the context of a single-organ oriented health system. This qualitative study examined how HCPs in emergency and acute hospital settings make such decisions for people living with MLTC, exploring factors that influence clinical judgement and how HCPs respond to these challenges. METHODS: HCPs involved in making decisions about care for people living with MLTC presenting to hospital were recruited via National Health Service (NHS) research delivery networks and professional contacts, using purposive and snowball sampling. Semi-structured individual interviews were conducted, focusing on how HCPs make decisions regarding the care of people living with MLTC and factors influencing such decisions. Reflexive thematic analysis was undertaken. Themes relating to influences on decision-making were organised using the Social Ecological Model (SEM). RESULTS: We interviewed 40 HCPs working in NHS emergency departments and acute assessment units across multiple regions, specialties and roles. Seven themes were constructed and organised into two overarching categories. The first category 'Factors Influencing Decision-Making' included the themes the complex patient, professional expertise and identity, system pressures and inflexible structures. These themes were mapped to the SEM, demonstrating influences across individual and environmental levels. The second category 'Adaptive Decision-Making Strategies' included the themes Mitigating risk and Relying on heuristics capturing how HCPs navigate the uncertainty created by these influences. The theme, Relational care, operated between categories, illustrating how relationships both shape what decisions are possible (interpersonal level of SEM) and provide a means of navigating uncertainty. CONCLUSIONS: Clinical decision-making for people living with MLTC in emergency and acute settings is shaped by uncertainty arising from the interaction of factors operating across individual, interpersonal and environmental levels. To manage this uncertainty, staff employ a range of adaptive strategies. However, participants described this level of compensatory work as challenging and potentially insufficient on its own. Supporting decision-making and reducing reliance on adaptive responses may benefit from system‑level change, including improved community care, enhanced generalist expertise, opportunities for relational decision-making, better continuity and shared ownership of care, and flexible care pathways.