Intensive and Critical Care Nursing (2005) 21, 302—313

ORIGINAL ARTICLE

Factors that enhance or impede critical carenurses’ discharge planning practices

Rosemary Wattsa,∗, Heather Gardnerb, Jane Piersonb

a Centre for Clinical Nursing Research, Epworth Hospital, Deakin University, Epworth Foundation,89 Bridge Road, Richmond, Vic. 3121, Australiab School of Public Health, Faculty of Health Sciences, La Trobe University,Bundoora, Vic. 3083, Australia

Accepted 26 January 2005

KEYWORDSDischarge planning;Critical care;Discharge planningpractices;Critical care nurses

SummaryIntroduction: Any illness that is serious enough to require admission to the criticalcare unit will intensify the physical and psychological effects that the patient andtheir significant others experience. Hence, the discharge needs of patients admittedto critical care are unquestionably complex, diverse and dynamic.Methods: Utilising an exploratory descriptive approach 502 critical care nurses,identified from the Australian College of Critical Care Nursing (ACCCN) (Victoria)database were invited to participate in this study. A 31-item questionnaire was de-veloped and distributed. A total of 218 eligible participants completed the survey.One-to-one semi-structured interviews with 13 Victorian critical care nurses werealso conducted.Results: Participants reported that a lack of time was a barrier to discharge planning.Communication however, could enhance or impede the discharge planning processin critical care. Participants considered that the critical pathway, used in the careof cardiothoracic patients, did assist with communication of discharge planning pro-cesses, hence enhancing the process.Conclusions: While these findings provide some understanding of the factors thatenhanced or impeded critical care nurses’ discharge planning practices further re-search is indicated. The findings reported here may, however, provide a startingpoint for improving the discharge planning process in critical care.© 2005 Elsevier Ltd. All rights reserved.

∗ Corresponding author. Tel.: +61 3 9244 6123;fax: +61 3 9244 6159.

E-mail address: rjwatts@deakin.edu.au (R. Watts).

1. Introduction

There is no question that discharge planning hasemerged world-wide as a complex area of prac-tice in the health care system, and is, perhaps,most complex in the critical care environment. The

0964-3397/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2005.01.005

Critical care nurses’ discharge planning practices 303

potential variables that exist within the criticalcare environment, such as the severity of the pa-tient’s condition, invasive monitoring, fear, drugtherapy and impaired cognition all affect patients’functional and decisional ability and hence reducetheir capacity to participate in discharge planning.The critical care unit is a particularly difficult en-vironment in which to assess the patient’s ability,and the family’s ability, to take part in the dischargeplanning process. This widens the gap between theideals of discharge planning and reality.

As the length of hospital stays are reduced,discharge planning must move into the criticalcare area. Carr (1988) argues that, by virtue oftheir knowledge and skills, critical care nursesare ideally suited to begin the discharge plan-ning process. She believes that all that is neededfor the critical care nurse to initiate the pro-cess is recognition of the importance of dischargeplanning.

There is no argument that the discharge needsof patients who have spent time in critical care arecomplex and inter-related (Alspach, 1985; Pray andHoff, 1992; Schlemmer, 1989). These needs includea range of physical, psychosocial, and economicfe

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peatedly cited is that critical care nurses usuallydelay discharge planning until the patient’s careneeds have progressed beyond the acute stage, andtheir condition has stabilised (Alspach, 1985; Carr,1988).

Schlemmer (1989) suggests that discharge plan-ning in the critical care environment is not con-sciously overlooked by critical care nurses but isnot initiated or completed due to time constraintsand high workloads. Critical care nurses actually at-tended to discharge planning after the health careneeds of the critically ill patients had progressedbeyond the acute state (Alspach, 1985). Carr (1988)agrees that, for the patient hospitalised in the crit-ical care unit, discharge planning is usually delayeduntil the patient has stabilised and been transferredto a less acute care area. Life support and minute-by-minute clinical changes in the patient’s condi-tion can make discharge planning a low priority andmake discharge seem far away.

Schlemmer’s (1989) exploratory study aimed toidentify current discharge planning processes thatexist in critical care units in the state of Wash-ington in the USA and to identify the role of thecritical care nurse in the discharge planning pro-cqridScoicummbctidcccctu

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actors that require holistic management (Daffurnt al., 1994).Rorden and Taff’s (1990) definition of discharge

lanning is utilised for the purposes of this paper.hey define discharge planning as ‘‘. . . a processade up of several steps or phases whose imme-iate goal is to anticipate changes in patient careeeds and whose long term goal is to insure continu-ty of health care’’ (p.22). This multi-faceted def-nition describes discharge planning as a dynamicrocess that involves a variety of specific skills andequires all members of the health care team toork together in a coordinated manner to achieveutually agreed goals and, ultimately, continuity ofare (Watts, 2004). Interestingly, Watts et al. (2005)eported that Victorian critical care nurses were un-ertain of the endpoint of the discharge planningrocess and argue that clarification is needed as tohether the discharge planning process in the criti-al care environment is conceptualised as preparinghe patient for the next phase of care within thateriod of hospitalisation, or as anticipating, plan-ing and/or preparing health care service provisioneyond hospitalisation.While the ideal is for the discharge planning

rocess to commence on, or prior to, the pa-ient’s admission to hospital (Clare and Hofmeyer,998; Huerta-Torres, 1998; Pray and Hoff, 1992;illiams, 1991) the literature suggests that therere a variety of reasons why this does not occurn the critical care environment. One reason re-

esses in these units. One hundred and twenty-fiveuestionnaires were distributed, with a responseate of 55%. The structure of discharge planningn the units in which the participants worked wasescribed as unstructured by 67% of participants.ixty-nine percent of participants stated that theirritical care units did not have written standardsutlining criteria for discharge planning in the crit-cal care setting. Staff responsibility for the dis-harge planning process varied among critical carenits, with a designated discharge planner beingost frequently responsible, followed by the nurseanager. The bedside nurse had the most responsi-ility for initiating post-hospital care referrals. In-reased nursing workload was perceived as havinghe greatest impact in delaying discharge planningn critical care units. The majority of participantsid not perceive discharge planning as a priority forritical care nurses and thought it was not practi-al to implement discharge planning in the criti-al care unit. In general, it was perceived that dis-harge planning was a process that should begin af-er the patient is transferred from the critical carenit.Thompson (1985) examined discharge planning in

he critical care environment inWest Virginia (USA).uestionnaires were sent to 100 randomly-selectedritical care nurses to evaluate their understandingf discharge planning and how it was accomplished.hompson found that 70% of participants thoughthat discharge planning was not applicable to their

304 R. Watts et al.

units. It should be noted that although 100 ques-tionnaires were distributed the actual response ratewas not stated.

In a study conducted in Sydney, Australia,Daffurn et al. (1994) studied 54 patients, with alength of stay in critical care of more than 48 h, todetermine functional outcome and quality of life inthe weeks after discharge. The patients were in-terviewed 3 months after leaving critical care. Themajor finding from this study indicated that manyof the patients were suffering mild to moderate se-quelae. The authors suggested that a more com-prehensive discharge process was required. Leith(1998) argues that discharge planning should notbe limited to transfer from the hospital but shouldinclude planning for a patient’s transfer from thecritical care unit to another unit within that hospi-tal. She believes that the barriers to providing dis-charge planning to patients in anticipation of trans-fer from the critical care unit must be overcome.Critical care nurses have a responsibility to provideappropriate continuity of care in order to reducetransfer anxiety in critical care patients and familymembers.

There is a paucity of recent literature specific

2. Method

2.1. Design

Utilising an exploratory descriptive approach, thisstudy was conducted using a questionnaire com-pleted by 218 participants and also involved in-depth interviews with 13 critical care nurses. Thestudy was approved by the LaTrobe University Fac-ulty of Health Sciences Human Ethics committee(FHEC). Approval was also sought from and grantedby the Confederation of the Australian Critical CareNurses (CACCN) Victorian Branch (now known asthe Australian College of Critical Care Nursing (AC-CCN) Victorian Branch) research subcommittee toaccess their membership database in order to re-cruit participants. At the time of CACCN (Victo-rian Branch) initial membership application and an-nual membership renewal, members are asked toconsent to participating in research deemed suit-able by the CACCN (Victorian Branch) researchsubcommittee.

2.2. Sample

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to the discharge planning process in critical care.While it is recognised that the above literatureis somewhat dated, the majority of recent litera-ture in the area, has focused on patients’ experi-ences of being a patient in critical care and theexperiences of transfer from the critical care envi-ronment to the general ward (Coyle, 2001; Green,1996; McKinney and Melby, 2002; Odell, 2000; Stein-Parbury and McKinley, 2000) and the multifunctionrole of the critical care liaison nurse (Barbetti andChoates, 2003; Chaboyer et al., 2004; Green andEdmonds, 2004). Little recent attention has beenpaid to nurses’ understandings and beliefs of thedischarge planning process in the critical care en-vironment.

The findings reported here are part of a largerstudy that aimed to explore critical care nurses’perceptions and understanding of the dischargeplanning process in the health care system in thestate of Victoria, Australia, and hence gain an in-sight into how the discharge planning process fitsinto the critical care environment from a nursingperspective. A key finding from this study was thatcritical care nurses were uncertain of the endpointof the process however there was a general empha-sis on the general movement of the patient fromthe critical care environment (Watts et al., 2005).In this article, we report on the key factors par-ticipants identified as enhancing or impeding theirdischarge planning practices in the critical care en-vironment.

he members of CACCN (Victorian Branch) providedhe cohort for this study. The CACCN database al-owed identification of those members who wereorking in critical care areas as opposed to mem-ers, for example, who held specialist critical careualifications but had academic appointments andere not working in the critical care environment.n the basis of the primary area of work namedy members of the CACCN renewal form (1998) 502ritical care nurses were identified as working inritical care units and were approached to partici-ate in the study. Participants could work full-timer part-time and have varying professional back-rounds.

.3. Procedure

he findings reported in this paper are part of aarger study examining the discharge planning prac-ices and beliefs of critical care nurses in the Victo-ian health care system. Study 1 involved a surveyf 218 Victorian critical care nurses’ discharge plan-ing beliefs and practices. As no reliable and validool could be found for this purpose, a new tool waseveloped.The questionnaire was specifically developed

nd used to collect data from critical care nursesorking in the critical care environment. The devel-pment of the instrument occurred in stages. Ini-ially, literature searches were undertaken to de-

Critical care nurses’ discharge planning practices 305

termine current national and international viewsof the beliefs and attitudes of nurses to dischargeplanning. Themes in the literature were identified.The findings from previous research undertaken bythe researcher (Watts and Gardner, in press) ex-ploring acute care nurses’ perceptions of the dis-charge planning process were also drawn upon,as was discussion with colleagues who had exper-tise in the area of discharge planning and crit-ical care nursing. Information was collated fromall of these sources and used to formulate a draftquestionnaire for use in the pilot study. Ques-tionnaires were distributed, as part of a pilotstudy, to eight practicing critical care nurses, con-sidered to be expert critical care nurses work-ing in the Victorian health care system. The re-searcher knew these participants, but they didnot participate in the study reported in this pa-per. In accordance with the feedback from theparticipants about the wording and ordering ofthe questions and the adequacy of the alterna-tives, minor changes were made to the wordingof some questions. The category ‘Pre-admissionclinic’ was added as a response alternative forthe two questions about the timing of dischargepanaatq

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perience and are identified as Participants A—G.The researcher believed that this group of par-ticipants did not represent a substantial sub-group of critical care nurses and an additionalgroup of participants was therefore recruited forinterview.

As reported in the CACCN (Victorian Branch)1998—1999 Annual Report, CACCN (VictorianBranch) had a total membership of 682 nurses.Forty-nine percent of CACCN (Victorian Branch)members had 6—10 years experience in criticalcare. It was therefore considered necessary torecruit and interview additional participants,these participants being critical care nurses withless than 6 years experience in the critical careenvironment. In order to recruit this cohort ofparticipants, professional associates of the re-searcher, who had contacts working in criticalcare, were asked to help recruit participantsby word of mouth. It was decided to use thismethod of recruitment as the original request toparticipate in the study via the flyer sent with thequestionnaire had failed to attract interest fromCACCN critical care nurses with less than 6 yearsexperience in critical care. The university FHECwtohaiictpwwa

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lanning in critical care. An open-ended questionsking participants to define the discharge plan-ing process as it relates to critical care wasdded to the questionnaire. Space was made avail-ble for optional comments at three points inhe second (perceptions/experience) section of theuestionnaire.In order to assess face validity, experts were

sked whether the scope of the items on the ques-ionnaire covered the area of discharge planning inritical care or whether items need to be added.nformal comparison of responses to similar issuessked in related questions showed a high degreef correlation suggesting internal reliability of thetudy instrument. While this study was conductedn a heterogeneous group, critical care nurses witharying years of experience in critical care, the reli-bility of the instrument was not assessed with sta-istical procedures. Therefore, it is recommendedhat the tool should only be used in future researchfter further evaluation.In-depth one-to-one interviews of a total of 13

ritical care nurses allowed clarification and ex-loration of findings from the questionnaire re-ponses. Participants who received the surveyere also invited to a one-to-one interview thatasted approximately 30—40min. Twelve criticalare nurses who had participated in the survey vol-nteered to be interviewed, of which seven ac-ually participated in an interview. These nursesll had greater than 6 years of critical care ex-

as notified of and approved this amendment inhe project protocol, with regard to recruitmentf further participants. The recruited participantsad no professional association with the researchernd were not coerced in any way to participaten the study. Once possible participants expressednterest in taking part in the study, names and aontact number were given by the associate tohe researcher, who then contacted the potentialarticipants, explained the study and asked if theyould participate. A further six critical care nursesere recruited. These participants are identifieds Participants H—M.All potential participants, who expressed inter-

st in being interviewed, were invited to an in-erview that lasted approximately 30—40min, atpre-arranged time convenient to both the re-

earcher and the participant. An interview scheduleas utilised, consisting mainly of open-ended ques-ions. Using the process of funnelling (Minichiellot al., 1991) general broad questions were askedt the beginning of the interview, then the par-icipants were asked specific questions relatingo their own discharge planning beliefs and prac-ices. The interviews were openly tape recordednd then transcribed. Using the transcripts, cat-gorisation and ordering of the information wasonducted to allow the researcher to make sensef the data. A coding system was developedo organise the data and allow identification ofhemes.

306 R. Watts et al.

Table 1 Demographic characteristics of the sample(survey participants).

Characteristic Valuea

Age (years)25—35 5335—44 40>44 7

Number of years qualified as acritical care nurse (years)7 or less 468—14 4015 or more 14

Position titleRegistered nurse 35Clinical nurse specialist 25Associate charge nurse 22Nurse manager 7Clinical educator 7

Area of specializationGeneral ICU 31Coronary care 7Cardiothoracic 9Trauma ICU 3Combined ICU 41

Model of allocationPrimary nursing 19Patient allocation by shift 65Other 16a Where percentages do not equal 100 there is missing

data.

3. Findings

3.1. Questionnaire

Demographic characteristics of survey participantsare presented in Table 1.

3.1.1. Key factors in the discharge planningprocess in critical careTable 2 profiles responses to the question ‘What fac-tor/s do you believe enhance the discharge plan-ning process in your unit?’ Participants were asked

to rank the alternatives in order from the mostimportant (1) to the least important (5). The ta-ble shows, for each alternative, the percentageof participants who ranked it as (1)—–most impor-tant, and, for each alternative, the percentage whoranked it as (5)—–least important. Missing refers tothose cases where participants either did not an-swer the question at all, or just indicated one al-ternative as the most important but did not rankthe other alternatives.

Just under one-half (43%) of the participantsidentified effective communication as the most im-portant factor in enhancing the discharge planningprocess in their unit, one-fifth (20%) of participantsrated continuity of staff as the most important fac-tor, followed by planned discharges (18%). A fewparticipants (8%) identified knowledge as the mostimportant factor and available time was rated themost important factor by 6% of participants.

More than one-third (38%) of participants rankedplanned discharges as the least important factor inenhancing the discharge planning process in theirunit. Continuity of staff was identified as the leastimportant factor by approximately one-fifth (22%)of the participants, 21% identified available timeaio

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Table 2 Factors that enhance the discharge planning proc

Most important factor in enhancing thedischarge planning process in critical careEffective communication (%) 43Continuity of staff (%) 20Planned discharges (%) 19Knowledge (%) 8Available time (%) 6

Missing (%) 4

nd 14% knowledge. Effective communication wasdentified as the least important factor by only 1%f participants.Table 3 profiles the responses for the question

What factor/s do you believe impede the dischargelanning process in your unit?’ Participants weresked to rank the alternatives in order from theost important (1) to the least important (5). Theable shows, for each alternative, the percentagef participants who ranked it as (1)—–most impor-ant, and, for each alternative, the percentage whoanked it as (5)—–least important. Missing refers tohose cases where participants either did not an-wer the question at all, or just indicated one al-ernative as the most important but did not rankhe other alternatives.Inadequate communication was identified as

he most important factor in impeding the dis-harge planning process in the critical care en-

ess in the critical care unit.

Least important factor in enhancing thedischarge planning process in critical carePlanned discharge (%) 38Continuity of staff (%) 22Available time (%) 21Knowledge (%) 14Effective communication (%) 1

Missing (%) 4

Critical care nurses’ discharge planning practices 307

Table 3 Factors that impede the discharge planning process in the critical care unit.

Most important factor in impeding thedischarge planning process in critical care

Least important factor in impeding thedischarge planning process in critical care

Inadequate communication (%) 33 Continuity of staff (%) 38Unplanned discharges (%) 30 Lack of knowledge (%) 21Lack of time (%) 17 Unplanned discharges (%) 20Lack of knowledge (%) 9 Lack of time (%) 10Continuity of staff (%) 7 Inadequate communication (%) 7

Missing (%) 4 Missing (%) 4

vironment by one-third (33%) of the participants.Unplanned discharges were identified by (approx-imately) another one-third (30%) of the partici-pants as the most important factor, followed bylack of time (17%). The remaining participantsrated lack of knowledge (9%) and continuity ofstaff (7%) as the most important factor in impedingthe discharge planning process in the critical careenvironment.

Continuity of staff was identified by over one-third (38%) of participants as the least importantfactor in impeding the discharge planning processin critical care. Lack of knowledge was rated asthe least important factor in impeding the dis-charge planning process by approximately one-fifth (21%) of the participants and unplanned dis-

charges by 20%. The remaining participants iden-tified lack of time (10%) and inadequate commu-nication (7%) as the least important factor in im-peding the discharge planning process in criticalcare.

3.2. Interviews

Demographic characteristics of the interview par-ticipants are presented in Table 4.

3.2.1. Communication of the discharge planThe interview participants indicated that the dis-charge planning process was communicated in twomain ways between critical care nurses, between

Table 4 Demographics: interview participants.

Participantidentification

Job title Number of yearsexperience incritical care

Qualification(s)

A CNSa 6 Graduate Certificate in Critical CareB Nurse educator 6 Graduate Diploma in Critical CareC ACNb 10 Critical Care (hospital certificate);

Graduate Diploma in Education

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D RNc 20E Nurse managerd 15

F CNS 11H Agency nursee 10

I CNS 3(3/4)J RN 2(3/4)K CNS 4(1/2)L RN 2(3/4)M CNS 5N RN 1

a CNS (clinical nurse) is a RN who functions as an interdepchange agent for the purpose of improving nursing practice.

b ACN (associate charge nurse) usually responsible for coordinatic RN (registered nurse) is a first level nurse who is licensed to prd NM (nurse manager) is predominately responsible for the unit ae Agency nurse, is a registered nurse who is employed through an

Critical Care (hospital certificate)Coronary Care (hospitalcertificate); Graduate Diploma inCritical CareCritical Care (hospital certificate)Coronary Care Certificate (hospitalcertificate); Bachelor of Education.Graduate Diploma in Critical CareGraduate Diploma in Advanced Nursing (Critical Care)Graduate Diploma in Advanced Nursing (Critical Care)Graduate Certificate in Critical CareGraduate Diploma in Advanced Nursing (Critical Care)Graduate Diploma in CommunityHealth; Graduate Certificate inCritical Care

t member of the health team with responsibility to act as a

ng patient care during a shift.actice nursing.dministration.organisation external to the hospital, known as an agency.

308 R. Watts et al.

critical care nurses and medical staff, and betweencritical care nurses and ward staff. These communi-cations were in the form of verbal instructions, andwritten documentation. The degree of written doc-umentation of the patient’s discharge plan variedgreatly, with each participant reporting a differentsystem in the workplace. However, in general, theinterview participants focused little on the writtencommunication of the discharge plan rather, theyraised many issues in relation to verbal communi-cation of the discharge plan.

3.2.1.1. Verbal communication between criticalcare nurses. The majority of participants thoughtthat the discharge plan was communicated verballybetween critical care nurses and that there was lit-tle formal written communication. Verbal commu-nication regarding the discharge plan occurred prin-cipally between senior members of staff especiallyat ‘hand-over’ time, and the bedside nurse was notnecessarily involved.

Participant B explained that discharge planningis communicated in two ways in her work place:verbally and by documentation. However, as dis-cussed below, for cardiothoracic patients, there isa tendency for nurses to utilise the care path that

charge planning process. As to who determineswhen the patient is going to be discharged, theparticipants reported that this was a physician’sdecision:

I’d have to say mostly the doctors. It’s probably amedical decision (Participant J).

It was reported that in the workplace this oc-curred due to dominance of the doctors and theassociated issue of power and control, and/or theurgent need to admit another patient. Participantsconsistently indicated that physicians play a ma-jor role in decisions to admit or transfer patients incritical care units and this occurred in both the pub-lic and private health care sectors. Frustration withthe whole process was displayed, and the need tomake the process a more collaborative effort wasrecognised:

. . . usually what happens is that they do their round,they say okay ‘‘you’re ready to go to the ward andwe’ve got someone, somewhere, who had just hadan arrest, who can we get out of here’’? And that’susually your discharge plan, who can we get out ofhere and how quickly can we get them out (Partic-ipant G).

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has a space clearly devoted to discharge planning,with team leaders playing a principal role in com-municating the discharge plan. It was reported thatthe team leaders have a series of handover cards,which are used as the basis for subsequent ver-bal communication of the discharge plan ‘‘I thinkthere is a heading ‘discharge’ but it is more to dowith the date and time . . .’’ (Participant B). In com-parison, discharge planning for the general ICU pa-tient is once again communicated through the teamleader’s notes and the nursing care plan, however,there is no heading on the care plan assigned todischarge planning. This suggests that senior mem-bers of staff, rather than the bedside nurses, arethe key stakeholders in the discharge planning pro-cess. Participant F explained that a similar meansof communication occurred in her unit:

It’s both, the critical pathway, that’s what I’m try-ing to think of, the first page of that actually hasa lot of information about the patient, their fam-ily and the physiotherapist . . . The other part ofthe process is that the team leaders, the personin charge of each shift, actually also hands over alot of information and that’s kept on a card system(Participant F).

3.2.1.2. Verbal communication between criticalcare nurses and medical staff. There was a per-ception by some participants that, in reality, crit-ical care nurses have little control over the dis-

.2.1.3. Verbal communication between criticalare nurses and ward staff. In this study, thereas no consistency in responses with regard to com-unication between critical care nurses and wardursing staff. Whether ward staff met the patientrior to discharge from critical care and admissiono the ward appeared to depend on the individualard policy and in some cases on the individual pa-ient.Participants reported that ward staff were more

ikely to be involved at an earlier stage if theatient was classified as ‘long-term’, and this in-reased the likelihood of involvement of ward staffrior to the discharge of the patient from criticalare. However, only a few participants indicatedhat this in fact was routine:

es, we would routinely do that for all the long termpatients], so the people who have been in for aboutwo weeks or more, we involve the ward staff (Par-icipant C).

n my experience, the patient going out to the wards the first time the ward sees them . . . if the wardtaff have met the patient in the first instance [aard patient who has been admitted to ICU] theyill generally, I find, follow them through. If theyaven’t, they don’t come in to see what we’veot because they are too busy dealing with whathey’ve got (Participant D).

Critical care nurses’ discharge planning practices 309

Sometimes (Participant B)Participants reported that although a discharge

report was forwarded to the wards the specific nurs-ing information conveyed varied, as did thememberof the nursing staff who was responsible for supply-ing the information.

3.2.2. Written documentationThe additional written documentation perceived tobe associated with discharge planning was clearlyconsidered the major barrier to the process in thecritical care environment. Participants thought thatthere was already considerable documentation toattend to when caring for a critically ill patient, forexample, the constant documentation of observa-tions, fluid status, and drug administration. Docu-mentation associated with discharge planning wasperceived to be an added burden, especially in lightof its perceived limited value, especially when thepatient is acutely ill:

You know we have a lot of documentation to do, wehave the routine data collection and then you haveto write what you normally do, so it is asking a lotfor people to add another document . . . especiallyi

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3.2.3. Tools availableClinical pathways have been implemented in someof the critical care settings in which the partici-pants worked, to assist with the management ofcardiothoracic and coronary care patients, and, ac-cording to the participants’ responses, the imple-mentation had been successful. The discharge planis built into the clinical pathway document, hencethis had enhanced discharge planning in this co-hort of patients admitted to critical care. In con-trast, there are few clinical pathways availablefor the general intensive care patient, as it isperceived to be too difficult to predict the carethey will require due to the critical nature andrelated unpredictability of their illness. The sec-ond group of interview participants (with less than6 years experience in the critical care environ-ment) reported that clinical pathways had onlyjust been introduced into the ward where the ma-jority of the participants worked, consequentlyonly the first group of interview participants’ com-ments were considered with regard to availabletools.

These participants reported utilising clinicalpathways when caring for cardiothoracic patients,bwpbtttor

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f they don’t value it (Participant C).

However, on further investigation there was per-eived to be a lack of specific documentation re-ated to the discharge planning process as illus-rated in the following response:

here’s very little documentation . . . our writtenommunication is quite poor. But organisationally its quite good; the unit managers meet each morningnd discuss things like potential discharge from ICUo the wards so there is forward planning in thatay . . . the communication is not fantastic, . . . weave no written plan for discharge (Participant C).

Participant K reported that the discharge planas actually documented on the day of dischargend up until this time significant events were doc-mented, however, the effectiveness of the dis-harge plan depended very much on the premise‘If you have time, please fill it out, especially ifou know the patient’’. This response summarisedey elements of all responses in that the tim-ng of the formulation of the discharge plan wasd hoc and there was an emphasis on significantvents:

hen it’s really busy and you’re just happy to do allhe care, sometimes the paperwork is the last thinghat gets done, gets forgotten, maybe not picked upy someone else (Participant K).

ut none of them reported using clinical path-ays when caring for the general intensive careatient. The clinical pathway was considered toe a vehicle that improved discharge planning forhe cardiothoracic patients because of the very na-ure of having the necessary steps documented andhe requirement of ticking and signing the stepn its completion, as illustrated by the followingesponses:

think our cardiac patients are well catered for,nd in having the critical pathway it is all there younow, you can’t ignore it, it has to be ticked andigned . . . but in our general patients you know . . .

t is a variable kind of thing . . . so you can’t putolicies in place (Participant B).

ardiac is easy, the intensive care patients are dif-cult and, as I said there are, there’s few care mapset aside for the intensive care patient, that’s muchore ad hoc on a needs day-to-day basis . . . (Par-icipant E).

Participant C expressed her concern regardinghe reliance nurses have on clinical pathways andhe danger that nurses would blindly follow theathway without considering the individual naturef the patient in regard to their discharge planningequirements, ‘‘. . . there is no conscious planningoing on because the document is there and peopleon’t have to think about it’’.

310 R. Watts et al.

3.2.4. Time availableA reason why the discharge planning process wasnot considered a priority in the initial phase of thepatient’s admission to critical care was a perceivedlack of time to engage in discharge planning. Par-ticipants reported lack of time on two levels—–timedemands due to the patient’s critical physical con-dition and time demands due to overall high work-loads. First, participants consistently reported thatit was not possible to engage in the discharge plan-ning process because they were caught up withthe acute aspects of the patient’s condition andhence they did not have time to undertake dis-charge planning. The discharge planning process re-ceived some consideration when the patient’s con-dition was considered not life threatening, as illus-trated by the following quote:

. . .you’re busy, you know, with the physical prob-lems . . . that are life threatening issues, and I sup-pose when you reach the discharge planning stage,um, it’s not so acute . . . (Participant A).

Second, inadequate time was also perceived tobe a factor in limiting discharge planning when itwas considered that the unit as a whole was busy:

while the interviews generated considerable discus-sion in the topic area. However, both the survey andinterview participants consistently reported thatcommunication is an important factor in either en-hancing or impeding the discharge planning processin critical care.

The interview participants considered the writ-ten documentation associated with the dischargeplanning process an additional burden. The writtennursing care plan has long been considered the toolto communicate patient care needs with regards toplanning and implementing the required care andsubsequently promoting continuity of care. How-ever, in reality, there are problems associated withthe use of care plans. For example, many nursesshow poor compliance with their use, often docu-mentation is incomplete and there are perceivedinefficiencies in the use of nurses’ time (Twardonand Gartner, 1993). These are all factors identifiedby the study participants. Critical pathways werereported as a tool that enhanced communicationof the discharge plan specifically for the cardiotho-racic patient.

Participants reported verbal communication re-garding the discharge planning process in criticalcbnmitslctbanctamctctreinsnup

c

. . . if the unit was working at greater than 70 per-cent capacity, discharge planning became such alow priority that eventually it just faded and disap-peared again (Participant G).

While lack of timewas recognised by participantsas a key factor contributing to inconsistencies inhow well patients are prepared for discharge fromthe critical care environment, only one participantoffered a possible strategy to improve this situa-tion. This participant suggested that bedside nursesneeded to be given time to reflect on their patients’needs. Thus, it was perceived that the nurse re-quired time, away from the bedside, to consider thepatient’s discharge needs without having to dealwith all other bedside issues:

. . .I think it’s probably a time and experience thing.That people have things to deal with at the bedsideand don’t often get to step away from the bedside(Participant H).

4. Discussion

In this paper, reporting of findings of the question-naire survey and interview data may appear unbal-anced, with the second given a higher profile inspite of a small sample size. This is attributed tospecific questions being asked in the questionnaire

are as taking place primarily between senior mem-ers of staff, often to the exclusion of the bedsideurse. Just how effective verbal or written com-unication of the discharge plan is between nurs-

ng staff at the bedside appears to relate directly tohe commitment of the individual nurse. It was alsouggested, by some participants, that there was aack of interest among bedside nurses in communi-ating the discharge plan. These findings highlighthe need for an improved communication processetween critical care nursing staff, and as such,starting point may be to improve critical careurses’ knowledge of the discharge planning pro-ess and the importance of communicating the plano other members of the health care team. Rordennd Taff (1990) suggest that well-constructed docu-entation, which clearly outlines the patient’s dis-harge plan, is essential in order to prevent poten-ial problems, such as inadequate verbal communi-ation among critical care nurses. This finding andhat from the survey, of continuity of staff beinganked as the second most important factor thatnhances the discharge planning process, may bendicative of the shortage of critical care trainedurses in Victoria (de Sales and Ogle, 1999). Thishortage has been paralleled by a decline in theumber of permanent staff working in critical carenits in Victoria, and an increase in the number ofart-time and agency staff.The major theme that arose from discussion of

ommunication of the discharge plan between crit-

Critical care nurses’ discharge planning practices 311

ical care nurses and medical staff was that the par-ticipants felt that, in reality, they had little con-trol of the discharge planning process. While it wasreported that it was a medical decision to deter-mine when a patient was to be discharged, partic-ipants were clearly frustrated with the perceivedlack of collaboration between medical and nursingstaff underpinning the discharge planning processin critical care. While Oddi and Huerta (1990) be-lieve that it is the physician who must have the finalsay in deciding which patient requires admission ortransfer from the critical care unit, Clausen (1984)argues that a discharge planning model that contin-ually seeks physicians’ orders and permission canlimit nurses’ initiatives. Such a model may in factencourage nurses to blame doctors for the nurses’poor planning and allow nurses to shirk their re-sponsibility in discharge planning. Dawson (1993)believes that if nurses are removed from the de-cision making process, resentment will occur.

The participants reported communication be-tween critical care staff and ward staff as variable.There was no consistent policy of involvement ofward staff, prior to the discharge of the critical carepatient to the general ward, within organisations orbwvwatstip

dtionwatfi(ibttcoeptu

If we return to Rorden and Taff’s (1990) defini-tion of discharge planning it is difficult to know howmembers of the health care team can work togetherin a coordinatedmanner to achievemutually agreedupon goals and, ultimately, continuity of care if in-adequate communication is perceived to be a ma-jor factor that both enhances and impedes the dis-charge planning process in critical care. Becausedischarge planning contributes to the provisionof continuity of care for patients (Alspach, 1985;Hartigan and Brown, 1985; Zarle, 1989) the findingsreported here from the survey and interviews sug-gest that continuity of care for patients admittedto the critical care environment warrants furtherresearch.

Of the 502 critical care nurses invited to partic-ipate in the interviews, 12 volunteered initially toparticipate (seven of whom were subsequently in-terviewed). One can only speculate about why sucha small number of critical care nurses offered toparticipate. Possible reasons might include a reluc-tance to spend time outside work hours involvedwith research, or perhaps the critical care nursesdid not want to be interviewed one-to-one. Otherreasons might be that the topic area was not ofinnn

ppailifkamdtpcr

5

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etween organisations. It appeared that whetherard staff visited a patient in the critical care en-ironment, prior to transfer to the general ward,as dependent on the individual ward nurse. It waslso more common for ward staff to visit the pa-ient in critical care prior to transfer if the wardtaff knew the patient, or in other words a rela-ionship already existed. This perhaps then discrim-nated against patients and their families where norior relationship had been established.While the survey participants ranked unplanned

ischarges as the second major factor that impedeshe discharge planning process in critical care, thenterview participants consistently reported a lackf time as a barrier to engaging in discharge plan-ing in the critical care environment. A lack of timeas largely attributed to dealing with the manycute aspects of the patient’s condition and, atimes, a busy environment compounded this. Thisnding is consistent with the finding in Schlemmer’s1989) study that discharge planning is often notnitiated or completed by the critical care nurseecause of time constraints. Interestingly, 17% ofhe interview participants reported lack of time ashe most important factor that impedes the dis-harge planning process in critical care. The findingf unplanned discharges against the finding of inad-quate time may be attributed to the type of unitarticipants worked in and the predictability of pa-ient transfer, for example, a general intensive carenit or a cardiothoracic unit.

nterest, was considered to be of a low priority tourses working in the clinical area, or the topic wasot perceived to be of relevance to critical careurses.All of the initial seven participants, who partici-

ated in the in-depth interviews, had extensive ex-erience with critical care patients and consider-ble knowledge of discharge planning in the crit-cal care environment. They were able to articu-ate their experience from their perspective dur-ng the in-depth semi-structured interviews, thusulfilling Streiner and Norman (1995) criteria ofey informants. However, while key informants areble to provide particularly useful information, aajor limitation is that their perspective may beistorted or biased (Patton, 1990). In this study,he additional perspectives provided by the sixarticipants with less than 6 years experience inritical care, reduced the potential distortion ofesults.

. Limitations

ecause this study is an exploratory descriptivetudy, future research is needed to investigate theractice of discharge planning in critical care. It iscknowledged that a descriptive study cannot an-wer the question of cause and effect. It is alsocknowledged that, as a whole, the nurses who

312 R. Watts et al.

participated may not be entirely representative ofcritical care nurses practising in Victoria. There-fore, the results might have been more general-isable if critical care nurses who are not mem-bers of CACCN (Victorian Branch) had also beensurveyed.

6. Conclusion

Participants’ years of critical care experience didnot appear to have significance in regard to the find-ings of this study. Two key factors that enhancedor impeded the discharge planning process in thecritical care environment were communication andtime available. While survey participants identifiedcommunication as both the most important fac-tor enhancing and impeding the discharge planningprocess, the principal modes of communication ofthe discharge planning process discussed by inter-view participants were verbal and written docu-mentation. Verbal communication was consideredon three levels, communication between criticalcare nurses, between critical care nurses and medi-cal staff, and between critical care nurses and ward

Carr P. Discharge planning: a critical care responsibility. Crit CareNurse 1988;8(5):78—81.

Chaboyer W, Foster M, Foster M, Kendall E. The Intensive CareUnit liaison nurse: towards a clear role description. IntensiveCrit Care Nurs 2004;20:77—86.

Clare J, Hofmeyer A. Discharge planning and continuity ofcare for aged people: Indicators of satisfaction and im-plications for practice. Aust J Adv Nurs 1998;16(1):7—13.

Clausen C. Staff RN: a discharge planner for every patient. NursManage 1984;15(11):58—61.

Coyle MA. Transfer anxiety: preparing to leave intensive care.Intensive Crit Care Nurs 2001;17:138—43.

Daffurn K, Bishop GF, Hillman KM, Bauman A. Problems follow-ing discharge after intensive care. Intensive Crit Care Nurs1994;10:244—51.

Dawson JA. Admission, discharge, and triage in critical care. CritCare Clin 1993;9(3):555—73.

de Sales T, Ogle KR. A qualitative study of Victorian criti-cal care nurse labour force. Aust Crit Care 1999;12(1):6—10.

Green A. An exploratory study of patients’ memory recall oftheir stay in an adult intensive therapy unit. Intensive CritCare Nurs 1996;12:131—7.

Green A, Edmonds L. Bridging the gap between the intensive careunit and general wards - the ICU Liaison Nurse. Intensive CritCare Nurs 2004;20:133—43.

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nurses. Communication at all three levels was foundto be problematic and in need of review at wardlevel.

These findings provide some understanding ofthe two key factors that impact on critical carenurses’ ability to engage in the discharge plan-ning process in the critical care environment. How-ever, it is perhaps more important to recognise thatthese factors are relatively unchanged from thosereported in the 1980’s (Alspach, 1985; Carr, 1988;Schlemmer, 1989). Further research is therefore in-dicated to examine these factors in more depth.These findings may, however, form part of the basisfor improving the discharge planning process in thecurrent critical care environment.

Acknowledgement

This study was supported by the Dean’s Ph.D. Schol-arship, Faculty of Health Sciences, La Trobe Univer-sity.

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