User Story: Informal learning – handover of patient care [Health Care context]

In what situation? Learning trigger?

Brian is a GP on a home visit to a 62 year old patient with diabetes who was discharged from hospital the previous day with an infected foot. The patient is on antibiotics but both the patient and Brian are unsure for how long the patient should be on antibiotics since there is only sufficient medication for the next 48 hours and the discharge letter contains no information about the length of the course. [Note: Brian had checked SystmOne before leaving for the home visit to see if the practice had received the discharge letter for this patient but it had not yet arrived. However, the patient was given their copy of the discharge letter when they left the hospital, and this is what he shows to Brian.]

What happens? (Sequence of the main actions performed), With which tools and physical objects?, Which actors are involved?

  1. Brian uses his smartphone (iphone) to contact the ward by making a phone call. The junior doctor who signed the discharge letter is off duty but the ward sister says that she will get junior doctor to ring the GP later that morning.
  2. Brian uses his iphone to access Google using “clindamycin diabetes foot infection” and there are several websites that quickly appear. The advice is vague and suggest that the optimum time varies from 6 weeks to 3 months.
  3. Brian returns to surgery but by the end of the day he still has had no phone call from the hospital. He logs into SystmOne to see if the discharge summary has now arrived and to doublecheck the wording of the discharge letter (he had been unable to access SystmOne whilst he was on the home visit). The letter has now arrived at the practice and the receptionist has scanned it into SystmOne but it is no different from the copy held by the patient and there is no mention of the length of the course of antibiotics. Brian decides to wait until the following day before making another phone call using the practice telephone.
  4. The junior hospital doctor returns the call later in the morning, directly to Brian’s iphone. The junior hospital doctor is not sure but he will be speaking to his consultant later in the day when the consultant has a ward round.
  5. The district nurse contacts Brian by the practice telephone at the end of evening surgery requesting a continuation of the antibiotics for the patient since they will run out at the end of the next day.
  6. Brian writes out a prescription for four days of the antibiotics and this is sent to the pharmacist next door to the practice.
  7. Brian still has had no reply from the hospital and the following morning he re-contacts the junior hospital doctor using the practice phone. The doctor apologies and states that the GP should follow the “standard protocol” that is on the hospital website.
  8. Brian searches the hospital website using the practice computer and quickly finds the protocol that states the usual treatment is 6 weeks “unless advised by a consultant”.
  9. Brian is still unsure if he should continue the antibiotics for 6 weeks or continue for longer. He decides to send an email using the NHS net email system (see footnote to story 1 for differences between the two NHS email systems) and the practice computer to the consultant.
  10. Brian receives a reply using theon his NHS net email account from the consultant on the following day. The consultant recommends continuing the antibiotics until the patient is seen by the consultant at the outpatient review clinic in 4 weeks, when the consultant will make a further recommendation.

The final result

  1. Brian has used a smartphone and a computer to search a range of different information resources and used synthesis and appraisal of the web sites to learn by actively creating “useful” personal knowledge that can inform his future practice. However in this case none of the websites gave him the definitive answers (or a process for reaching a decision himself) that he required.
  2. Brian reached his decision finally by using the email opinion of the local consultant who he regards as an external reliable source of knowledge.
  3. However, Brian himself is still unsure about the reasons behind the clinical decision and is not sure that he would consider himself to have learned anything from this experience.
  4. Brian was frustrated by the “pass the parcel” approach to learning and opinion seeking.
  5. In future Brian is likely to still follow the process of accessing a recommended website first but as the information on these sites is generic they often don’t directly answer his learning needs or they require time to analyse and explore. So to help him treat the patient appropriately and quickly he would much prefer the option of obtaining an opinion quickly from a trusted expert such as the consultant.
  6. Most of the other actors in this learning episode (patient, junior doctor, district nurse or ward sister, receptionist) would not really consider themselves to have been involved in learning. They have each played a small part in the process but only Brian has really had the overview of the whole situation that gives him some opportunity for reflection and learning.
  7. The consultant may be involved in learning if he reflects on either the information they included in the discharge letter and consider whether he could have improved on this and/or if at his 4 week review clinic with the patient he reflects on whether the antibiotic regime for this patient should have been different after all. However, in the high pressure of the working day it is possible that the consultant will not have time to properly reflect on either of these and potentially no improvements to either the communication or prescribing process will be made the next time a similar situation occurs.


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