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,
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
discharge planning to facilitate health decision-making at home
15–17 Carleton Place
Aim. To investigate general surgical patients’ perspectives of the adequacy and
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: firstname.lastname@example.org 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
Issues in clinical nursing Discharge planning following surgery
collectively by all members of the research team to achieve consensus on patients’
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
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
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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
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
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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,
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
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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
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
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
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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-
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
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A McMurray et al.
patients (Grimmer & Moss 2001), both nurses and patients
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
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
informational needs is the GP and towards that end, we
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