Nurses Role in Discharge Planning

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Nurses role in patients discharge planning atthe AGA KHAN University hospital, Pakistan

ARTICLE in JOURNAL FOR NURSES IN STAFF DEVELOPMENT - JNSD NOVEMBER 2001

DOI: 10.1097/00124645-200111000-00009 Source: PubMed

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Nasreen Lalani

University of Alberta

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314 http://www.nursingcenter.com November/December 2001

their families following discharge.However, various studies haveshown that nurses are often more

involved in routine activities suchas physical care and tend to ignoretheir essential roles as dischargeplanners (Alderman, 1994; Vol-land, 1989; Waters, 1987). There-fore, there is a need to strengthenthis role of nursing and to identifythe factors leading to lack of dis-charge planning.

The study was carried out at theAga Khan University Hospital, aprivate tertiary teaching hospitalin Karachi, Pakistan. Observationsby the researchers during the clin-

Background

Discharge planning as a part ofcontinuity of care is a key conceptin the delivery of healthcare. Dis-

charge planning is an interdiscipli-nary hospital-wide process thatshould be available to patients andtheir families in developing a fea-sible posthospital plan of care(Volland, 1989). Given todays ris-ing healthcare costs, dischargeplanning is becoming increasinglyimportant with patients demand-ing cost-effective, high-qualitycare. Nurses play a vital role in thedischarge planning process be-

cause they are involved in directpatient care activities. It is the re-sponsibility of the nurses to assesspatients thoroughly, evaluate theirneed for assistance, and give ade-quate information to patients and

J O U R N A L F O R N U R S E S I N S TA F F D E V E L O P M E N T Volume 17, Number 6, 314319 2001 Lippincott Williams & Wilkins, Inc.

This descriptive cross-sectionalstudy was designed to assessnurses knowledge, perceptions,

and actual practice with relation topatient discharge. Two separatesemistructured questionnaires wereused. A convenience sample of 15nurses and 15 patients was takenfrom four medical-surgical units.Fifteen patients records were alsostudied. Analysis of the findingsrevealed that nurses lackedknowledge regarding dischargeplanning which also had an

impact on their current dischargeplanning practices. Recommenda-tions are provided to improve thisknowledge deficit.

K E Y W O R D S

DISCHARGE PLANNING

NURSES KNOWLEDGE

ASSESSMENT

Nasreen Sulaiman Lalani, BScN, RN, andAshraf Zulfiqar Gulzar, BScN, RN

NURSES ROLE IN PATIENTS

DISCHARGE PLANNING AT THE

AGA KHAN UNIVERSITY

HOSPITAL, PAKISTAN

Nasreen Sulaiman Lalani, BScN, RN, is Acting Head Nurse, Aga Khan University Hospital,Karachi, Pakistan.

Ashraf Zulfiqar Gulzar, BScN, RN, is an Instructor, The Aga Khan University, School of Nursing,Karachi, Pakistan.


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JOURNAL FOR NURSES IN STAFF DEVELOPMENT http://www.nursingcenter.com 315

ical experience revealed thatnurses on medical-surgical units

were not carrying out effectivedischarge planning activities.Moreover, other than an adminis-trative policy, there was no docu-

mented clinical policy or proce-dure for discharge planning. Thisresulted in increased length ofstay, recurrent readmission, in-creased healthcare costs, and dis-satisfaction to the patients. The di-rector and managers of nursingservices also expressed majorconcerns about the role of nursesin discharge planning. Therefore,the nurses role in discharge plan-ning needed to be assessed and a

successful plan developed andimplemented in the future.Purposes of the study were to

identify nurses knowledge, per-ceptions, and practices of dis-charge planning;

identify the factors that inhibitnurses role in discharge plan-ning; and

identify solutions to strengthennurses role in discharge planning.

Brooten, Brown, and Munro (citedin Lowenstein & Hoff, 1994) statedthat in order to control increasinghealthcare costs, the patient mustreceive the best possible care in theshortest period. Therefore, cost-ef-fective, coordinated, high-qualitydischarge planning is necessary.Reiley and colleagues (1996) sug-gested that as acute hospital lengthsof stay decrease, and care shifts in-creasingly to communities andhomes, hospital personnel must be-come more adept at preparing pa-tients for discharge. Victor, Young,Hudson, and Wallace (1991) statedthat nurses should take the formalresponsibility for organizing thedischarge of patients.

Literature Review

fective participation in dischargeplanning, there is a need to assesstheir knowledge, perception, andattitude in the discharge process ofpatients.

This descriptive, cross-sectionalstudy was conducted in three 60-bed medical-surgical units of the

Aga Khan University Hospital. A tri-angulation approach of data collec-tion was used. A convenience sam-ple of 15 registered nurses, 15patients, and 15 record files was

taken. Separate interviews wereconducted with nurses and patientsfrom all three medical-surgical units.The patients were randomly se-lected from a group of current pa-tients who had an admission anddischarge within the past 3 months.The records of 15 patientsinclud-ing nursing assessment forms,nurses notes, and nursing careplanswere randomly selected.Files were reviewed to assess the

frequency of documentation of dis-charge planning by nurses.

Two separate semistructured inter-view tools made by the investiga-tors were used for both nurse andpatient subjects. Content validity ofthe questionnaires was determinedby a senior research faculty. Thequestionnaires were pilot tested onthree staff nurses and three patients

who did not participate in the actualstudy. Modifications were madebased on the content review andpilot study.

The questionnaire for nursesconsisted of 22 items and con-tained three sections. Section A ofthe questionnaire assessed demo-graphic variables (see Table 1).Section B was comprised of 12

Questionnaire

Methodology

Despite the importance of thenurses role in discharge planning,previous studies indicate thatnurses often do not effectively par-ticipate in the process. Waters(1987) supported that nurses and

physicians do not see dischargeplanning as a priority. Cohen(1995) stated that although nursesare at the center of discharge plan-ning, often physicians are seen asmore actively involved in it. Astudy conducted by Lowensteinand Hoff (1994) regarding nurses

The nurses role in discharge

planning needed to be

assessed and a successful

plan developed and

implemented in the future.

involvement in discharge planningrevealed that although nurses ac-knowledged the importance of thenursing leadership role in the dis-charge planning process, the ma-jority of nurses were confusedabout how discharge planning wasaccomplished in their hospitals.

Hinchliff (cited in Smith, 1996)stated that the nurses use ofknowledge and its application di-rectly influence their approach tonursing. Therefore, inadequateknowledge of discharge proce-dures is a major factor that reducesthe quality of discharge care givenby nurses to patients. Moreover, hestated that nursing staff often donot know the policies and proce-dures regarding discharge plan-ning in the hospital. Other factorsimpeding this role include lack oforganizational support and com-munity resources. Therefore, ifnurses are to be prepared for ef-


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statements using a 5-point Likert-type scale, ranging from stronglyagree (4), agree (3), disagree (2),strongly disagree (1), and dontknow (0). Section C was com-prised of 10 descriptive questions.Sections B and C mainly assessed

the nurses knowledge, percep-tions, and actual discharge plan-ning practices.

The questionnaire for patientsubjects was divided into two sec-tions. Section A consisted of de-mographic variables (see Table 3).Section B consisted of 11 descrip-

tive questions, which assessed thepatients perceptions regarding thedischarge process.

The nurses and the patients gaveverbal consent prior to the inter-views. Subjects were told the pur-poses of the study. Anonymity wasassured. Each interview required ap-proximately 30 min. Interviews weredone in the local language: Urdu.

Procedure

Pairs of interviewers collected thedata. One investigator interviewedand the other transcribed the infor-mation provided by the subject.

Nurses Questionnaire

Descriptive statistics (e.g., percent-ages, frequencies, and variance)

were used to analyze sections Aand B of the nurses questionnaire.For reporting purposes, the cate-

Data Analysis

T A B L E 1

Demographic Variables of Nurses [Section A]

(n) % Range (in years) M (in years) SD

Registered Nurse (RN) (9) 60 Age 2249 29.5 8.48RNs, Registered Midwives (RM) (6) 40 Years of Experience 110 4 2.85

Female Nurses (13) 87 Year of Graduation 124 8.33 6.88From Nursing Diploma

Male Nurses (2) 13

T A B L E 2

Nurses Knowledge and Perceptions Regarding Discharge Planning from

the Likert-Type Scale [Section B]Statements Agree % Disagree % Dont know %

1. Discharge planning is an important role of nurses. 100 0 02. In your unit, staff nurses effectively participate

in discharge planning. 40 60 03. Nurses in your unit regularly carry out the needs

assessment for discharge planning. 33.7 66.7 04. In your unit, most physicians are actively involved in

discharge planning. 73.3 26.7 05. In your unit, families are involved in their relatives

discharge planning. 46.7 53.33 06. Discharge planning begins early in the hospital

stay of most patients. 33.4 66.7 07. As a nurse, I dont have enough time to plan dischargefor my patients. 60 40 0

8. Overall discharge planning in this hospital is carried outappropriately to meet patient needs. 33.3 66.7 0

9. Documentation of all discharge activities must be doneon a regular basis. 80 20 0

10. Discharge planning is an essential part of the patients NCP. 46.6 53.4 011. Discharge planning is a part of the nursing process. 93.3 0 6.7 12. An appropriate orientation to discharge planning is

provided for new staff members. 53.33 40 6.7

Note: Findings from the Likert-type scale, strongly agree, and agree were merged to a single unit agree. Similarly,strongly disagree and disagree were merged to disagree.


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gories in the Likert-type scale (sec-tion B) were collapsed to oneagree and one disagree unit.Dont know was kept as a sepa-rate category. Section C, the de-scriptive part, was categorizedunder separate themes.

Patients Questionnaire

Descriptive statistics (e.g., percent-ages, frequencies, and variance)

were used to analyze section A ofthe patients questionnaire. SectionB, the descriptive part, was cate-gorized under separate themes.

Nurses Knowledge andPerceptions RegardingDischarge Planning From theLikert-Type Scale [Section A]

All of the nurses agreed that dis-

charge planning is an important roleof nursing. However, only 40%agreed that they effectively partici-pate in discharge planning. Most(73.33%) agreed that physicians

were actively involved in dischargeplanning. Nearly one-half (46.7%)of the nurses agreed that families

were involved in discharge plan-ning. One third (33.4%) reportedthat discharge planning begins earlyin their units (see Table 2).

Reasons for Inability to PerformDischarge Planning

In this item, multiple responseswere accepted. Most (93%) of thenurses said they were unable to

perform discharge planning wellbecause of increased workload.Other reasons given were lack oftime (60%), lack of interest andmotivation (27%), and lack ofawareness and late information re-ceived from the physicians aboutthe patients discharge (20%).

Patients Perceptions RegardingTheir Involvement in Discharge

Planning: [Section B]A majority of patients (73%) saidthat they had not been involved intheir discharge planning, whereas27% said that they were involved.Furthermore, when those 27% ofthe patients were asked who dis-cussed the plan with them, re-sponses were the physicians (73%),no one (13%), and both nurses andphysicians (7%). Moreover, whenasked whether the discharge in-

structions helped at home, 53% re-sponded yes whereas 47% saidno. Approximately one-half (53%)said that because of the lack of in-formation given about their post-care, they incurred expenses ontheir postcare aside from hospitalcharges. They required frequentfollow-up visits. No significant dif-ferences were found between theinformation given by male and fe-male participants.

Documentation

The majority of the nurses (93%)reported documenting all of thedischarge planning activities in thenurses notes, 13% in the nursingcare plan, and 7% in the nursingassessment form. (Note: Multipleresponses were allowed.)

However, when the 15 separatefiles were reviewed, 60% of the files

Descriptive Questions [Section C]The descriptive section focusedmainly on asking the nurses aboutdischarge planning: the teachingsthey gave and the factors that in-hibited discharge planning. Only20% of the nurses were able togive the appropriate definition fordischarge planning; 33% saidthat they did not know the defini-tion of discharge planning. The re-maining 46.66% were found to be

unclear. In addition, nurses wereasked when they should start theprocess of discharge planning. Inresponse, 67% of the nurses saidthat discharge planning starts afterthe physician writes the dischargeorders, whereas 33% reported itshould begin at the time of admis-sion. The average time nursesspend on discharge planning was10.42 min.

Discharge Teaching

Almost 60% of the nurses said thatthey give discharge teaching re-garding diet and medications

whereas 40% said that it includesinformation regarding the follow-up visits. Only 27% reported that itincludes information about diet,medication, activity, exercise, andfollow-up visits.

T A B L E 3

Demographic Variables of Patients [Section A]

n (%)

Male 7 (47)Female 8 (53)

Married 13 (87)Single 2 (13)

M SD

Age (ranged from 3660 yrs) 47.8 (in yrs) 10.72 (in yrs)Previous admission (ranged 2.66 (in months) 0.89 (in months)

from 14 months)Length of stay of previous 12.66 (in days) 14.36 (in days)

admission (ranged from415 days)


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did not show any nurses notesabout discharge planning. In 40%of the files, there were incompletenurses notes present, which weremostly written at the time when thepatient was being prepared for dis-

charge and at the time of actuallygoing home. No information re-garding patients care plans wasdocumented. Ninety percent of theassessment forms showed no docu-mentation about discharge plans.No nursing care plan containeddocumentation regarding patientsdischarge planning.

The findings generated from thisstudy revealed that there were rela-tionships between the nursesknowledge, their perception, andtheir actual practice of dischargeplanning. It was found that nurseshad a limited understanding regard-ing the concept of discharge plan-ning. It was obvious from the find-ings that although 100% of the

nurses believed discharge planningto be an essential part of nursingcare, only 20% were able to clearlydefine what discharge planning in-

volved. Nearly 67% of the nursesbelieved that it should be started onthe day of discharge, and, therefore,they were preparing patients fordischarge on their discharge day.

Almost 75% of the nurses were con-fused between the terms dischargeteaching and discharge planning.Similarly, Lowenstein and Hoff(1994) found that nurses were oftenconfused about discharge planningand how it could be accomplished.Nonetheless, nurses believed thatdischarge planning is a part of thenursing process, but were unable torecognize it as a part of nursing careplans, which showed that the re-lated concepts were unclear andfragmented. This was also a majorfactor in nurses inability to carryout discharge planning activities.

Discussion

According to Roberts (1975),discharge planning includes theassessment of continuing health-care needs required by the pa-tients. It also includes working

with families to develop a realistic

plan that could assist them in thepatients postcare. However, in thisstudy only 34% of the nurses re-ported that they regularly carriedout a needs assessment of patients.In addition, only 47% said that

charge either when patients wereordered for discharge or after theyhad left the hospital. This findingrevealed a possible lack of com-munication between the nursesand the physicians.

In addition, the nurses werespending only 2% of their totaltime from the 8-hr shift with pa-tients to prepare them for dis-charge. According to Reiley et al.(1996), time spent preparing a pa-tient for discharge may affect a pa-tients understanding of the treat-ment plan. At the time ofdischarge, patients are anxious;therefore, the information givenmight not have any effect on their

posthospital needs and care.Therefore, this area also needs tobe examined in more detail.

The nursing records also sug-gested that assessing and planningfor discharge were not considereda priority by the nurses on thesefour units. Nurses notes containedlittle information about patientteaching that was provided by thenurses. No details such as diet ormedication information were pre-

sent. Nursing assessment formswere incomplete. There was noevidence of formal review or eval-uation of the nursing care plans.

Johnson (cited in Naylor, 1990)also supported that because dis-charge planning was not consid-ered a priority by most health pro-fessionals, it often suffered fromdelayed and inadequate assess-ment, poor documentation, andfragmented implementation.

Based on the results, certain rec-ommendations were made to en-hance nurses role in dischargeplanning.

A separate discharge planningteam could be formalized,

which would involve nurses,

Recommendations

Nurses notes contained little

information about patient

teaching that was providedby the nurses. No details such

as diet or medication

information were present.

they involve families in thisprocess.

Various factors that discouragethe nurses participation in dis-

charge planning include the con-cerns about the time required, fail-ure to recognize the dischargeplanning needs of all patients, in-terdisciplinary struggles, or roleconfusion (Rorden & Taft, 1990).The results of this study showedsimilar findings. The majority ofnurses reported increased work-load and lack of time as the majorreasons for not planning patientsdischarge. According to Rordenand Taft (1990), discharge plan-ning is not something that is sepa-rate from what nurses really do,rather it is an expression of nurses

view to include longer term goals(p. 32). Thus, role confusion couldbe a major reason impeding thenurses role in discharge planning.It was reported by the majority ofpatients that mostly the physicians

were actively involved in the dis-charge planning process. Nursesusually learned about patients dis-


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physicians, and the nursing ad-ministrators. This will facilitatecollaboration and allow moretime and resources to plan pa-tient discharge activities.

Assessment forms should be re-

viewed and modified. A com-prehensive assessment formthat provides detailed informa-tion about the patients in rela-tion to discharge is needed.

Inservice programs must enhancethe nurses knowledge about dis-charge planning concepts.

Proper orientation regarding thedischarge planning activitiesmust be given to all staff nursesat the time of hire.

A liaison could be made withdifferent community centers indifferent parts of the city to en-sure the continuity of care.

A clinical-based discharge pol-icy should be formulated.

Further studies could be donewith a larger random sample,using alternative study designsto explore the phenomenon indepth.

The study strongly suggests thatnurses role and their knowledgeregarding discharge planning needto be strengthened and reinforced.Nurses must realize the impor-

Conclusion

Naylor, S. (1990). Complicated dis-charge planning for hospital elderly: Apilot study. Nursing Research, 39(3),156161.

Reiley, P., Lezzoni, L. I., Phillips, R.,Davis, R. B., Tuchin, L. I., & Calkin, D.

(1996). Discharge planning: Compari-son of patients and nurses percep-tions of patients following hospital dis-charge. Image: Journal of NursingScholarship, 28(2), 143147.

Roberts, I. (1975). Discharge from hos-pital. London: Royal.

Rorden, J., & Taft, E. (1990). Dischargeplanning guide for nurses. Toronto:Saunders.

Smith, S. (1996). Discharge planning:The need for effective communication.

Nursing Standard, 10(38), 3941.Victor, C. R., Young, E., Hudson, M., &Wallace, P. (1993). Whose responsibil-ity is it any way? Hospital admissionand discharge of older people in aninner London District Health Authority.Journal of Advanced Nursing, 18,

12971304.

Volland, P. J. (1989). Discharge plan-ning: An interdisciplinary approach to

continuity of care. Baltimore, Mary-land: National Health Publishing.

Waters, K. R. (1987). Discharge plan-ning: An exploratory study of theprocess of discharge planning on geri-atric wards. Journal of Nursing Ad-ministration, 12, 7183.

Address for reprints: Ashraf ZulfiqarGulzar, BScN, RN, Instructor, Aga KhanUniversity School of Nursing, Stadium Road,P.O. Box 3500, Karachi 74800, Pakistan; e-mail for coauthor: [email protected]

tance of discharge planning inorder to provide cost-effective,high-quality nursing care. More-over, it is the responsibility ofnursing managers and nursing in-structors to emphasize this impor-

tant role among nurses.On the basis of the study out-

comes, the following implementa-tion occurred. Some of thesechanges are still in progress:

1.A clinical discharge policy wasformulated in coordination withthe policy and procedure commit-tee after the approval of nursingmanagement.

2. A task force was formed to

search for community resourcesfor proper referral and follow-upof patients after discharge. More-over, the group is in the process offormulating a community resourcedirectory for the hospital.

3. Nursing assessment forms werereviewed in which comprehensivepatients data regarding dischargeplanning were added. Inservicesessions were given to staff nursesfor adequate documentation.

R E F E R E N C E S

Alderman, C. (1994). No time to care.Nursing Standard, 8(47), 1620.

Lowenstein, J. A., & Hoff, P. S. (1994).Discharge planning: A study of nursingstaff involvement. Journal of NursingAdministration, 24(4), 4550.

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Nurses Role in Discharge Planning