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  • 1. ISSU ES I N CLINICA L NUR SIN G General surgical patients’ perspectives of the adequacy and appropriateness of discharge planning to facilitate health decision-making at home Anne McMurray PhD, RN, FRCNA Peel Health Campus Chair in Nursing, Murdoch University, Mandurah, WA, Australia Patricia Johnson PhD, RN Senior Lecturer, Griffith University, Research Centre for Clinical Practice Innovation, Qld, Australia Marianne Wallis PhD, RN, FRCNA Gold Coast Hospital Chair in Clinical Nursing, Research Centre for Clinical Practice Innovation, Qld, Australia Elizabeth Patterson PhD, RN, FRCNA Dean, Faculty of Nursing & Midwifery, Research Centre for Clinical Practice Innovation, Griffith University, Qld, Australia Susan Griffiths BA Research Assistant, Research Centre for Clinical Practice Innovation, Griffith University, Qld, Australia Submitted for publication: 13 January 2006 Accepted for publication: 30 April 2006 Correspondence: McMURRAY A, JOHNSON P, WALLIS M, PATTERSON E & GRIFFITHS S Anne McMurray ( 2 0 0 7 ) Journal of Clinical Nursing 16, 1602–1609 Peel Health Campus Chair in Nursing General surgical patients’ perspectives of the adequacy and appropriateness of Murdoch University discharge planning to facilitate health decision-making at home 15–17 Carleton Place Aim. To investigate general surgical patients’ perspectives of the adequacy and Mandurah WA 6210 appropriateness of their discharge planning. Australia Objectives. To identify any aspects of discharge planning that could be strengthened to Telephone: þ61 0895825503 assist people in managing their posthospital care and maintaining continuity of care. E-mail: a.mcmurray@murdoch.edu.au Background. Appropriate discharge planning is a priority in today’s healthcare environment in which patients are discharged ‘quicker and sicker’, sometimes without home support. Adequate and appropriate discharge planning helps promote health literacy, which has benefits for both patients and their caregivers in helping them manage postsurgical recovery at home. Design. A qualitative, interpretive study was designed in which patients were interviewed at least one week after they returned home from hospital. Methods. Purposeful sampling was used to interview 13 general surgical patients from one of three hospitals (two public and one private) in New South Wales and Queensland, Australia. Data were collected in unstructured interviews and analysed using thematic analysis. Reflective analysis by individual research team members generated preliminary themes, which were then analysed 1602 Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2702.2006.01725.x
  • 2. Issues in clinical nursing Discharge planning following surgery collectively by all members of the research team to achieve consensus on patients’ perspectives. Results. Themes included a ‘one-size-fits-all’ approach to providing discharge information; inconsistent or variable advice from different health professionals; a lack of predischarge assessment of their home and/or work conditions and the need for follow-up assessment of patient and carer needs. Conclusions. The findings of this study illuminate the need for a more individualized approach to discharge planning, taking into account the patient’s age, gender, surgical procedure and family and community support for immediate and longer-term nursing follow-up. Relevance to clinical practice. Patients would be more adequately prepared for their recovery period at home, by encouraging client-centred, interdisciplinary communi- cation between health practitioners; adopting a flexible, approach to discharge planning which is tailored to individual needs of postsurgical patients, particularly in relation to advice and information related to recovery; and encouraging and supporting adequate health literacy for self-management. Key words: community health care, continuity of care, health literacy, nursing, patient discharge, patient education Introduction Literature on discharge planning This study is based on the need to understand better the The literature suggests that DP is a critical component of both processes and clinical outcomes of discharge planning (DP) to hospital and community care. Discharge planning that ensure continuity of care across the hospital, home and includes appropriate and useful information for patients and community. Discharge planning consists of individualized their family caregivers is attributed with such beneficial effects plans, developed in hospital with the aim of containing costs as reduced length of hospital stay (LOS), improved quality of and improving outcomes once the patient is at home (Parkes inpatient and home care, increased patient satisfaction and & Shepperd 2001). One of the most important outcomes of reduction in the number of unplanned hospital readmissions DP is the client’s access to adequate and appropriate infor- (Hohenleitner & Minniti 1998, Laing & Behrend 1998, mation as a resource for making health-related decisions Russell 1999, 2000, Bixby et al. 2000, Driscoll 2000, Naylor (Fitzgerald et al. 2003). The need for information differs 2000, 2002, Payne et al. 2002, Holland et al. 2003). However, between clients, given the variability in people’s level of health three separate systematic reviews indicate that DP studies knowledge and previous experience in dealing with healthcare have been plagued by methodologically inconsistent research issues. These are encompassed in the conceptual notion of approaches and a lack of generalizability from studies health literacy, the ability to find, assess and understand comparing disparate patient groups (Naylor 2002, Payne health information and health services (Nutbeam 2000, et al. 2002, Richards & Coast 2003). To date, few studies Hixon 2004, Rootman & Ronson 2005). Health literate have developed valid approaches that would capture the people are better able to communicate their needs and patient, rather than health provider perspective and that preferences and to make decisions that will help them stay include patients’ particular needs, circumstances and prefer- healthy and recover from an illness episode, including surgery ences for care coordination throughout the recovery period. (Ratzan 2001, Rootman & Ronson 2005). Health literacy is Richards and Coast’s (2003) review into postdischarge care essential for surgical patients in today’s healthcare climate of revealed that a combination of needs assessment, coordinated rapid transition through the healthcare system. Because they DP and a method for facilitating implementation of these are discharged ‘quicker and sicker’ it is important to investi- plans was more effective in maintaining continuity of gate the adequacy and appropriateness of DP in preparing care than services that do not include posthospital follow-up. them for both acute and longer-term periods of recovery, An American research team developed and validated an particularly in relation to differences in gender, age, type of instrument to measure the quality of care transitions from surgery or other influences that may affect their ability to self- the patient’s perspective as a basis for quality improvement manage and knowledge of when and how to seek assistance. in posthospital care (Coleman et al. 2005). Their Care Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd 1603
  • 3. A McMurray et al. Transitions Measure was found to discriminate among differ- inform the adequacy and appropriateness of postsurgical ent health-care institutions and remains to be tested as a useful follow-up care, especially if it reveals identification of unmet benchmarking instrument in planning for continuity of care. needs for information or other factors influencing recovery. That study and Payne et al.’s (2002) systematic review on communication of information after discharge identified the Methods need for a ‘key worker’, such as a transition nurse, to ensure successful coordination of postdischarge services, especially The aim of the study was to elicit perceptions from surgical the transfer of information between hospital and community. patients of the adequacy and appropriateness of their Some studies on DP have focused on perceptions of care preparation for discharge home from one of three hospitals, and symptom management, typically measuring satisfaction, including one public hospital in New South Wales (NSW), ratings of health, or symptoms such as pain or wound healing one in Queensland and a private Queensland hospital. Ethical (Grimmer & Moss 2001, Henderson & Zernike 2001, approval was received from each of the hospitals and the McMurray et al. 2002, 2005). Talaminni et al. (2004) University to meet the Australian National Health and developed the Surgical Recovery Index (SRI) to measure time Medical Research Council (NHMRC) ethical guidelines. to recovery for pain and activity resumption, which have The study was advertized in all general surgical wards of been identified as the two main concerns of people following the three hospitals. Inclusion criteria consisted of having surgery (Krupat et al. 2000, Henderson & Zernike 2001). general surgery involving hospitalization of at least two Another approach has been to investigate life satisfaction and overnight stays. Non-English speaking patients and those active coping style as predictors of surgical recovery (Kopp living at too far a distance from the research setting were et al. 2003). These findings, which concur with those of other excluded. An Information Sheet for the Staff and Participant researchers focusing on psychological factors in recovery, Information Sheet and Consent Form, described the purpose indicate that pain management is the central need and it and aim of the study and contact details of the researchers. should be addressed in surgery-specific protocols (Cox & The Registered Nurses (RN) involved in DP, in consultation O’Connell 2003, Shaw et al. 2003, Pavlin et al. 2004). Other with the Charge Nurse (CN) from each unit, were asked to researchers agree, reporting that patients who receive condi- identify patients who met the study criteria. Patients identi- tion-specific information feel more satisfied and better fied as eligible were then contacted by telephone by a member informed about their condition (Helms & Anderson 1998, of the research team to gain verbal agreement to participate Bradshaw et al. 1999, McNamee & Wallis 1999, Henderson in the study; none declined. A Participant Information Sheet & Zernike 2001, Theobald & McMurray 2004). and Consent Form, contact details form and a reply paid Nursing specific measures reveal mixed views on where envelope were sent to patients with a request that they and when DP should take place and discrepancies between contact one of the researchers by telephone or by mail. Once nurses’ and patients’ understandings of the appropriate a mutually agreeable time was established, members of the content (Grimmer & Moss 2001, Chaboyer et al. 2002). research team conducted the interviews in pairs, in the One group devised a study to investigate common informa- patients’ homes over a three-month period in 2005. The tion needs for patients having six different types of general following questions were developed through a round of surgery in the UK (Bradshaw et al. 1999). Using Delphi consensus conferences with team members and used as a techniques they identified key areas where day surgery guide to the interviews: patients had been provided with inadequate or confusing 1 What information were you given about your posthospital information, including postoperative pain, wound problems, recovery? bathing, stretching and heavy exercise, return to work, 2 Who provided this information? driving and sex. Studies specific to information needs, 3 What skills were you taught to manage your recovery? including Cochrane Reviews conducted by Mistaen and Poot 4 What things helped you to understand and apply this (2003) and Parkes and Shepperd (2001) argue that meeting information? information needs has the strongest link with successful 5 What things hindered your understanding/ability to man- recovery at home, particularly concerning medications (Dris- age your recovery? coll 2000, Cleary et al. 2003, Johnson et al. 2003). Carers 6 What could the hospital staff have performed better to also underline the need for medication advice, as well as improve your confidence in managing your posthospital specific information on physical activity levels and/or limita- recovery? tions, wound care and possible complications (Driscoll All interviews were audiotaped and transcribed for analy- 2000). Clearly, there remains a need to provide evidence to sis. All members of the team conducted individual analyses of 1604 Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd
  • 4. Issues in clinical nursing Discharge planning following surgery interview transcripts using thematic analysis techniques they had difficulties judging how much activity was allowed; (DeSantis & Ugarriza 2000). Each transcript was analysed would it be helpful to go for walks, or should they confine by three researchers, each of whom generated preliminary activity to merely walking around the house? This type of themes arising from the data. All members then participated confusion seemed to be more evident in patients experiencing in joint analysis of the combined data to identify unique and their first hospitalization. Those with prior experience, common meanings, linked to verbatim comments from recounted fewer issues, perhaps as an indication of feeling participants. confident in their own knowledge. Several patients felt they had received excellent advice from other health professionals, for example, physiotherapists, Results dietitians and occupational therapists and others. One patient The sample included 13 people who were interviewed in their expressed high regard for the dietitian who undertook a home, most occurring at around three weeks following comprehensive assessment of her needs, then went away to discharge from hospital. Of the six males and seven females; develop a written set of instructions tailored to her specific four had surgery in the private hospital, four in the queries. She also provided contact details for follow-up Queensland public hospital and five in the NSW public advice, which others found missing in their DP. Most had hospital. The type of surgery included two who had spinal high praise for hospital staff, especially the nurses. They surgery, one neurosurgery, one cholecystectomy, four having explained their helpfulness in terms of information on some form of bowel surgery, two hernia repairs, one partial dressings, activities and bowel management: ‘nursing staff mastectomy and two having surgery on their prostate. were absolutely terrific…up walking, shower, quick to Analysis revealed four major themes: a ‘one-size-fits-all’ respond to my needs, meds for pain…whatever was happen- approach to the provision of information, confusion created ing they fixed it up’. Similar comments were made on the by inconsistent or variable advice from different health quality of the hospital care provided, such as ‘I can’t speak professionals, a lack of assessment of home and/or work more highly of them…helps you recuperate doesn’t it’? conditions and the need for follow-up. Patients differed in the type, source and timing of infor- mation they sought. One mentioned that he would have liked someone to ask how he wished to receive information One-size-fits all information provision relevant to his condition and where it could be accessed. Most patients reported that they had been given information Several would have preferred written information as a source on what to expect in their surgery, but they felt that pre- of follow-up care, yet others did not. One patient commented operative information focused on the surgery, not the that he had rather have someone sit down and explain to him management of their postoperative or postdischarge care. what had been performed. Others hesitated in asking for Explanations given by the specialists were often quite anything that was not provided. One woman, for example, detailed, but with few exceptions, information was not experienced postoperative pain, but because no one asked tailored to individual needs. These patients described it as a whether she wanted medication for her pain, she assumed it ‘one-size-fits-all’ approach, where information was too gen- was better to put up with it. Her view was, ‘I thought that if eral to be meaningful. They would have liked someone to ask they didn’t offer it I didn’t need it’. Some used the Internet to how they wished to receive information relevant to their validate what they had been told about their medical condition and where it could be accessed. Several patients condition prior to surgery or after learning the outcome of had bowel surgery, one of whom was given a detailed surgery. Another chose not to know ‘I don’t want to become explanation on managing her diverticulitis, which she found an expert…I just want to leave the experts to do their job’. ‘curious’, given that she had been managing it for many years This woman was totally confident in her surgeon and wanted and she believed her surgery would be curative. The same to leave all the information up to her, with full trust in her woman was given a lengthy advice about managing any decisions. Another man was informed after surgery that his postoperative diarrhoea, but had no idea of how she should tumour was ‘bigger than expected’. He was left to wonder manage constipation if it occurred at home. Another reflected about the surgeon’s prior expectations and sought details of on the pre-admission information being less than helpful, his surgery only after returning home. Yet his greatest source given that after surgery, his condition had changed remark- of confusion was the information he received when the ably. Several patients reported that the information provided surgeon told him that they’d ‘found cancer in two out of five was too vague to be meaningful; for example: ‘take it easy’ nodes’. He thought ‘oh two out of five doesn’t sound bad, at was an often-repeated phrase. Once patients returned home least it beats the hell out of three out of five’. Then the doctor Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd 1605
  • 5. A McMurray et al. explained, ‘It doesn’t matter if you’ve got four out of six or five to six weeks; by another that he could go back to exercise six out of six’, which further confused him. In his words, ‘As in two to three weeks. Evidently, they had not communicated we walked out of there I thought, Oh hell, what was that all with one another. In another case the patient was instructed about?…we were thinking…you just go down and get the pre-operatively by his doctor that they may find a malignant treatment and everything is alright and now he [has] tumour once he was in surgery. Because no one mentioned explained that that is not so’. the outcome during his hospital stay, he assumed the surgeon Others also found the reactions of their doctor confusing. had found nothing to worry about. Not having been visited The oldest participant, an 87-year-old woman, commented by the surgeon while in hospital, he prepared for discharge that, after her surgery, the doctor repeated three times ‘you’re and was given two appointment cards by the nurse as he left lucky to be alive’. She explained this as ‘I think they’re being the hospital, one of which was to see an oncologist. He was a bit dramatic. I was perfectly healthy’. Another patient disappointed at having to learn of the seriousness of his decided to hold her doctor accountable for advice, perhaps condition in this way. because of her assertiveness. She wanted information from the surgeon so made a list prior to her follow-up visit and Lack of assessment of home and/or work conditions decided to say ‘I’m not moving from this chair until you tell me because I need to know…I think you need to know what’s One unexpected finding was that many patients were happened to your body!’ discharged home by simply being told to go home, with no one accompanying them out of the building or making sure their departure needs were met. They were also discharged to Inconsistent or variable advice from different health their home circumstances with no assessment of what professionals awaited them. One was sent home to a very dependent Many comments regarding health professionals’ communi- father for whom she was the primary carer. She felt fortunate cation with one another revolved around the accessibility of in being able to organize family home help for the first week information. Different comments were made by patients after discharge, but at no time did any health professional discharged from the private rather than public hospitals, in assess her learning needs, give her advice on resources, or ask that the private patients had been seen by only one doctor, about her home situation. In another case, a patient was told who seemed to be the only source of information. They found to lift no more than 5 kg, but the advice was not followed by few opportunities to gain information in the limited number any probing questions on how that would affect him in his of medical visits, when these occurred and felt there were no daily activities, particularly in his work situation. He related other sources of advice when issues arose. The following case what he had wanted to ask but did not because of a lack of illustrates: opportunity: I was sort of trying to speak to the Dr. all the time…I didn’t get a lot How long before I am able to sit for any length of time? What of information…I thought, you’d think he could just pop around for restrictions will I have on bending? I was told when leaving the just 5 minutes and just tell me what he had done instead of hearing it hospital not to bend excessively or lift anything above five kilos. second hand and not knowing exactly what had happened…the local Please explain why this limitation and what damage do I need to doctors came around every morning and just sort of checked on prevent? When the foot plaster is taken off, do you recommend water you…but I kept trying to see my doctor for five minutes to just find aerobics for example, deep water running and swimming? What out what had happened, you know.’ Two weeks after discharge she should I expect long term for work restrictions? Can I do yoga? saw the surgeon who showed her the X Ray and explained how much Another patient was discharged home on chemotherapy with of her bowel they had removed. ‘I just wanted to know exactly what no way of getting out to shop for food that might help happened…what he found and everything else, you know. Just from overcome her nausea. This caused her to stop eating during the guy who did it. the course of chemotherapy treatments. This lack of assess- Public hospital patients felt they had a range of health-care ment seemed more important for those whose surgery was professionals from whom to seek information and advice. unexpected; for example, the result of an accidental injury. They also commented on opportunities to at least ask One patient in this situation left hospital in a quandary about questions during daily medical rounds; however, this was why his work-related injury had occurred. He speculated that balanced by the fact that multiple sources of advice also to prevent it happening again, he might want to avoid certain brought opportunities for confusing or conflicting informa- activities during those times when he got ‘all sweaty’. No one tion. One patient was told by one doctor to not exercise for seemed to have assessed him for whether or not he was 1606 Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd
  • 6. Issues in clinical nursing Discharge planning following surgery suffering from hypoglycaemic attacks or some other precipi- his or her home circumstances and needs. This is particularly tating factor, even when he mentioned that it had occurred important where there are family caregivers taking over the previously. Instead, his advice was targeted at his current ongoing care at home, or no family or social support, or injuries. In his case, preparation for discharge was performed where the patient has had little or no previous experience through a ‘tick box’ approach, which failed to consider the with hospitals. Another problem with systematic ‘tick and potential for accidents. Like several others, he felt this was a flick’ assessments lies in the assumption that postdischarge perfunctory exercise and not designed to gain a complete problems and issues can be categorized according to popu- picture of their needs. lation norms, diagnostic groups or other demographic features. However, the threat of a postdischarge problem arising for the majority of surgical patients is no guarantee The need for follow-up that it will be either problematic or readily solved for others, All patients reported that they would have liked someone to as norms and aggregated benchmarks show little of the telephone them after they returned home, especially in the intensity of symptoms or the way they are experienced by immediate period. Most mentioned this in conjunction with individual patients. Evidence-based practice and the need to the timing of their advice in hospital. They felt they would benchmark quality indicators have helped systematize health- have appropriate questions to ask after a day or so at home. care processes, but this may have occurred at the expense of This was one area where public patients mentioned they had the ‘outliers’ who may be experiencing significant problems. better follow-up aftercare than private patients. Several had One of the most important findings from Payne et al.’s previously been hospitalized and had been telephoned by (2002) systematic review of patients’ information needs was someone from the hospital. One patient wanted access to that practitioners have little understanding and, in some follow-up care because he felt ‘drugged…a bit scattered’ cases, respect, for each other’s role and this mitigates against while he was in the hospital and was preoccupied the entire information transfer across professional and organizational time, with how he would manage to pay his bill, given that he service boundaries. The reviewers’ analysis identified the was uninsured. In his view, information in hospital would priorities of hospital workers as shorter stays, pressure of have confused him: ‘I needed time to think, to reassess’. work, bed availability and reducing readmissions, whereas Another said ‘I wasn’t coping with chemo so I took myself off the concern of community health professionals is continuity it…I was sort of left a bit floundering’. of care, planning for services, equipment and support. This distinction is important in light of our findings that people felt a sense of disconnection between hospital and commu- Discussion nity. Collaboration between the two types of services is The original impetus for this study was an evaluation important in light of the few opportunities people have to conducted in one of the hospitals indicating that the level seek information, especially during the immediate recovery of patient satisfaction with DP had declined from the period when they may not be able to comprehend the advice previous year. We were interested in knowing whether this given. A further issue in relation to accessibility of informa- was peculiar to the organization, or a sign that today’s short- tion is that the questions they need answered cannot always stay patients may be under-prepared for discharge home. This be directed at the appropriate practitioner, especially in the seems to be the case. Patients had received written pamphlets private system, where they rely on only one medical practi- with instructions specific to their surgery at hospital dis- tioner for advice, instead of having access to an entire team as charge, as well as written instructions from their medical occurs in the public system. Improving structures and specialists at their last visit before surgery. Although all three processes with the potential to break down the barriers and hospitals use clinical protocols and/or pathways to ensure facilitate collaboration would be a major step in redressing comprehensive and consistent DP, those providing verbal the communication difficulties experienced by postsurgical instructions may have relied too heavily on assumptions that patients. Most of our participants described good informa- patients were adequately prepared for discharge. This runs tion as that given in response to direct questions, at the right the risk of being less attentive to assessing patients’ needs and time, tailored to personal needs and with follow-up contact ensuring adequacy of personalized communication, which details. was also a finding of McCabe’s (2004) study of nurse–patient In previous research, we have suggested the need for communication. Appropriate communication would see the telephone follow-up (McNamee & Wallis 1999, Theobald & health professional conducting discharge assessments con- McMurray 2004, McMurray et al. 2005) and, despite some centrate on client identified health needs, contextualized to difficulties reported in telephone follow-up of surgical Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd 1607
  • 7. A McMurray et al. patients (Grimmer & Moss 2001), both nurses and patients Acknowledgements concur that it is an important element in home care (MacLachlan 2004). Telephone follow-up can be used to The authors are indebted to the Research Centre for Clinical verify whether providing information is actually improving Practice Innovation, Griffith University for the research grant health literacy and it can provide an opportunity for to support the study. evaluating the retention and usefulness of postdischarge advice. Australia is about to introduce a national telephone Contributions information service for patients and it would be feasible to incorporate postdischarge follow-up as part of this service. Study design: AM, PJ, MW, EP, SG; data collection and An optimal use of such a service would see all surgical analysis: AM, PJ, MW, EP, SG and manuscript preparation: patients have access to help lines, such as those currently AM, PJ, MW, EP, SG. implemented in coronary care, perhaps because of the high profile of cardiac surgery. Another avenue for meeting References informational needs is the GP and towards that end, we should rely on the growing trend towards employing practice Bixby M, Konick B, McMahon J & McKenna C (2000) Applying the nurses as strategic resources to maintain continuity of transitional care model to elderly patients with heart failure. communication between acute care settings and GP practice Journal of Cardiovascular Nursing 14, 53–63. Bradshaw C, Pritchett C, Bryce C, Coleman S & Nattrass H (1999) (Patterson et al. 1999a,b). Technological solutions to deliv- Information needs of general day surgery patients. Ambulatory ering health information are another option, but while they Surgery 7, 39–44. may expedite information transfer, they do not necessarily Chaboyer W, Foster M, Kendall E & James H (2002) ICU nurses’ offer opportunities for developing health literacy. perceptions of discharge planning: a preliminary study. Intensive Although the study is limited to a small convenience and Critical Care Nursing 18, 90–95. Cleary M, Horsfall J & Hunt G (2003) Consumer feedback on sample at each hospital there are some common issues that nursing care and discharge planning. Journal of Advanced Nursing may apply to postsurgical patients in preparation for 42, 269–277. discharge. The challenging issues for the future will involve Coleman E, Mahoney E & Parry C (2005) Assessing the quality of ways of enhancing health literacy for patients and the preparation for posthospital care from the patient’s perspective: the community at large. 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