Table 2 Themes and illustrative quotes from participants improvement

1. Identification of discharge planning needs

First, we need to determine whether patients are able to perform our nursing techniques on their own after discharge. Second, if patients have problems after getting discharged because the doctor’s orders were not followed or the issue was not solved, they can ask for help. (PGY20)

2. Self-identification

I think discharge planning is a good idea because patients really need this service. It involves many tasks. Following up with patients after discharge is good for the patients, but it is also an opportunity for me to learn and grow. (PGY27)

Helping doctors depends, in part, on the situation. I am a relatively inexperienced physician, and it enhances our learning to understand a patient's discharge process, that is, the difficulties encountered during discharge and resources available. With the help of the discharge planning team, I learn more details. (PGY25)

3. Improving division of labor and the relationship between team members

The division of labor across different roles is quite helpful to our medical care team, and their advice tends to be more comprehensive. (PGY18)

4. Improving the physician–patient relationship (discharge follow-up)

We need to understand the changes in the patient’s condition and listen to what is bothering them. If we spend more time communicating with them, patient satisfaction and comfort will improve. The more the patients know, the safer they will feel. (PGY18)