Negotiating discharge decisions: a case study tracing interprofessional communication over time

Interprofessional communication is central to discharge decision-making. In rehabilitation, discharge decisions require patient, family, and clinician input at different time periods, yet little is known about how these decisions are negotiated over time. In this longitudinal case study we examined discharge decision-making within a rehabilitation team using Cultural Historical Activity Theory and the concept of "knotworking" as sensitizing lenses. Four interprofessional meetings were observed over consecutive weeks, and five stimulated recall interviews were conducted. Discussions relating to seven patient discharge cases were analyzed using constant comparative methods. Discharge decisions were negotiated through trajectories of interconnected communication during patients' admissions. These trajectories involved multiple "knots" through which information and perspectives were assembled, relayed, and reassembled over time. Interprofessional meetings, specific clinician roles, and written communication supported continuity, whereas competing perspectives generated additional communicative work and disrupted information flow, which could delay decisions. Patient and family perspectives were commonly represented through clinicians' accounts rather than communicated directly within interprofessional decision-making interactions. Distributed communication enabled flexibility and ongoing negotiation of discharge plans, but also created vulnerabilities when information was delayed, missing, or misinterpreted. Findings highlight opportunities to strengthen patient involvement in discharge decision-making and to better prepare clinicians for the distributed nature of interprofessional communication.