NURSING CORE COMPETENCIES:
FOR INTERDISCIPLINARY DISCHARGE PLANNING
“The Nurse of the Future will interact effectively with patients,
families, and colleagues, fostering mutual respect and shared
decision making to enhance patient satisfaction and health
outcomes” (Masters, 2014, p.78).
“The Nurse of the Future will function effectively within nursing
and interdisciplinary teams, fostering open communication,
mutual respect, shared decision making, team learning, and
development” (Masters, 2014, p.78)
WHAT IS COMMUNICATION?
A process that includes 5 factors:
SENDER – encodes a message to be transmitted;
MESSAGE – the ideas, symbols, signals being transmitted;
CHANNEL/MEDIUM – the means by which a message travels;
RECEIVER – receives and decodes the message; and
FEEDBACK – Receiver provides feedback to Sender to signal
effective reception of intended message (Oxford University
Press, 2014; Communication Models and Theories, n.d.).
Scenario: During Admission Intake, Nurse Hope Soeiltry would like to
obtain a medication list from Patient Will U. Listinclose for a safe medication
Sender (Nurse: Hope) – encodes her message with words by asking a question
Message (The Question) – what medications do you take at home? Can you tell
me and write them down on this paper to include the name, dose, and time you
Channel/Medium (Verbal/Written) – both verbal and written responses
Receiver (Patient Will) – decodes the message; begins to tell Nurse Hope his
medications from home while writing them down
Feedback (Patient: Will) - asks if he should write down his over-the-counter
medications while showing Nurse Hope his medication list in progress. Nurse
Hope nods in agreement while saying, “absolutely correct!”.
Outcome of Communication: SUCCESS!
BARRIERS TO SUCCESS
Noise or Interference – ambient noise, alarms, bells, televisions,
Medium chosen poorly – incompatible language, incompatible
medium i.e. hearing impaired (chose verbal transmission), visually
impaired or illiterate (chose written transmission);
Message – unclear, inappropriate, incongruent, lacks context;
Receiver – emotionally/psychologically compromised (angry,
anxious, sad, fearful, uncooperative/unreceptive); physically
compromised (pain, fatigue, altered mental status);
Feedback – Receiver did not provide feedback to ensure
successful communication occurred; Sender did not request for
feedback (Communication Models and Theories, n.d.).
STRATEGIES TO OVERCOME
Sender – is clear, concise, and congruent during message
Reduce or Eliminate – sources of interference with a calm, quiet,
and timely delivery environment for the communication to take
Select Appropriate Medium – relative to the age, ethnic/cultural,
and language determined to be compatible with the receiver;
Assess the Receiver – for readiness i.e. Alert, oriented, well
rested, with a reasonable mood disposition; and
Request Feedback – ask the receiver is they understood the
message delivered; exercise a repeat-back and verify process to
ensure successful delivery.
DISCHARGE PLANNING AND
EFFECTIVE COMMUNICATION: WHAT &
“Preparation for moving a patient from one level of care to
another within or outside the current health care agency”
(Bulechek, Butcher, Dochterman, & Wagner, 2013, p.150).
“Planning for discharge begins during the initial contact with
the client by establishing the expected outcomes and
anticipating follow-up care that may be needed”
(Harkreader, 2007, p.206).
DISCHARGE PLANNING AND
Poor Planning and Discharge Communication is Costly:
“Poor communication can endanger patients’ lives and waste
fiscal and human resources” (Lattimer, 2011).
“Delays, omissions, and inaccuracy of discharge information are
common at hospital discharge and put patients at risk for adverse
outcomes” (Harlan, 2010).
“It’s often poor communication, coupled with an expectation that
patients or caregivers will remember and relate critical
information, which can lead to dangerous, even life-threatening,
situations” (Lattimer, 2011).
RN DISCHARGE ACTIVITIES:
NURSING INTERVENTIONS CLASSIFICATION (NIC) SUMMARY
Assist patient/family/significant others to prepare for discharge;
Collaborate with interdisciplinary team/patient/family/significant
Coordinate with other providers for a timely discharge;
Identify patient / caregiver knowledge or skills required for
Identify patient teaching required for post-discharge care;
Communicate patient discharge plans as appropriate;
Monitor readiness for discharge;
Formulate discharge maintenance plan;
Arrange post-discharge evaluation; and
Discharge to next level of care (Bulechek et al., 2013 p.150).
CASE MANAGEMENT: OVERVIEW
Screening and Intake – identify discharge disposition / placement and
Assess needs – financial resources, treatment plans coordinated with
physician, patient and family for smooth discharge transitions;
Service planning – initiate plan of care, identify barriers to outcomes
achievement, post-discharge service need identification, setting mutual goals
Link patient to what they need – resource utilization, appropriate length of
stay planning, evaluation of expected outcomes progress;
Implement Interdisciplinary Treatment Plan – monitor expected outcomes,
begin arranging post-discharge arrangements, re-evaluate discharge
destination if needed; and
Evaluate Patient Care Outcomes – based on plan of care progress towards
achieving outcomes; round with the attending physician to obtain progress
feedback (Cesta, 2013).
Discharge Planning Teams (Rose & Haugen, 2010).
“S-B-A-R” (Bengasco et al., 2013).
Evidence-Based Discharge Education:
“Teach-Back” (Kornburger et al., 2013).
DISCHARGE PLANNING TEAMS:
Based on a study conducted in a Progressive Care Unit (PCU) in a
Midwestern Hospital (Rose & Haugen, 2010):
Problem – Current Discharge Process Concerns
Incomplete / Inaccurate Discharge Summaries
Inconsistent Discharge Education
Communication Gaps regarding: Discharge dates, time, and disposition
Intervention – Formation of Discharge Planning Teams
Possible Outcomes – Effective Discharge Planning
Promotes Cost-effective Use of Inpatient Beds
Increased Patient / Staff Satisfaction
DISCHARGE PLANNING TEAMS:
ACTIVITIES PER DISCIPLINE
Physician & P.A.:
Education on pathology and surgical reports,
Writes discharge prescriptions the night before discharge, and
Completion of discharge summaries;
Education on post-discharge care requirements night before
discharge and on the day, and
Coordinate follow up for outstanding discharge items to be
Fills prescriptions at Hospital Outpatient Pharmacy; and
Verifies insurance information as soon as possible to fill script
promptly (Rose & Haugen, 2010).
DISCHARGE PLANNING TEAMS:
JOINT ACTIVITIES –SURVEY, AUDIT &
Pre-implementation of Discharge Planning Teams:
Discharge Summaries – 60% completion rate,
Prescriptions Written – 45% completed night before discharge,
Nursing Staff Satisfaction – 37% contentment with discharge process, and
Patient Satisfaction – 93% perceived a smooth process;
Post-implementation of Discharge Planning Teams:
Discharge Summaries – 91% completion rate by 2007,
Prescriptions Written – 88% completed night before discharge by 2007,
Nursing Staff Satisfaction – 91% contentment with discharge process by
Patient Satisfaction – 100% perceived a smooth process by 2007 (Rose &
DISCHARGE PLANNING TEAMS:
KEYS TO SUCCESSFUL
Communication Remains Open – Across all disciplines
must be open to facilitate acceptance of changes in processes;
Multidisciplinary Involvement – input from various
disciplines facilitated the efficiency of workflow by identifying
barriers related to other departments/services; and
Continuous Improvement Process – teams must be
cognizant of the changes in health care environment: Payer
systems, regulatory agencies, and processes, ready to adapt to
changing conditions (Rose & Haugen, 2010).
RATIONALES FOR IMPLEMENTATION
Good Communication is characterized by:
Standardization of Content, and
Well coordinated between disciplines (Reilly, Marcotte, Berns, & Shea,
Errors in Communication results in:
Adverse Events with Negative Patient Outcomes,
Negative Emotional Impacts for Patients & Caregivers,
Increased associated Costs,
Increased Length of Hospital Stay,
Loss of Patient Trust, and
Increased Risk for Litigation (Bagnasco et al., 2013; Reilly et al., 2013).
S.B.A.R – Situation, Background, Assessment, &
Recommended as a Standardized Communication Tool, and
Has Written and Verbal components for Communication at Patient
Hand-off and Transfer (Bagnasco et at., 2013).
Proposed Benefits – S.B.A.R Implementation:
Mitigation of Risk associated with poor Communication during Patient
Hand-off and Transfer i.e. Memory Failures,
Standardizes Communication Styles of various healthcare workers to
create uniformity, and
Optimizes communication timing via Standardized reporting
procedure (Bagnasco et al., 2013).
“Teach-Back” Process – “a comprehensive, interdisciplinary, evidence-
based strategy which can empower nursing staff to verify understanding,
correct inaccurate information, and reinforce medication teaching and
new home care skills with patients and families” (Kornburger et al., 2013).
Proposed Benefits – “Teach-Back”: Implementation
Provides opportunity to Verify Understanding, Correct Inaccurate Information,
and Reinforce Medication Education and Home Care Skills;
Valuable, Easily Implemented and Understood, and Cost-effective Education
Engages Patients and Families in learning activities;
Patient and Family-centered Education Strategy (Kornburger et al., 2013).
“Teach-Back” Goal – Effective Family / Patient Self-Management:
Step 1: Teach a New Concept or Skill,
Step 2: Clarify or Correct Misunderstandings,
Step 3: Acknowledge any Questions Patient/Family may Have, and
Step 4: Continue the Process until Concept or Skill is Understood (Kornburger
et al., 2013).
Nurse Competencies – Understand Health Literacy Principles:
Encourage Patient/Family Questions,
Use Plain Language,
Limit Teaching to 3-5 Concepts, and
Document “Teach-Back” education in the approved form (Kornburger et al.,
SUMMARY & CONCLUSION
Is a vital function to ensure Patient Safety;
Failures occur mostly during points of Transfer of Care;
Failures carry a significant potential for Adverse Patient Events;
Standardized Communication methods optimize outcomes;
Discharge Planning Highlights:
Requires an Integrated, Multidisciplinary & Team Approach;
Begins at Admission, is ongoing, and is constantly re-evaluative in nature;
Is Patient and Family-centered; anticipating needs constantly;
Requires effective communication between patients, family, and Healthcare
Requires pre-emptive, evidence-based discharge Education from entire team
(Bagnasco et al., 2013; Kornburger et al., 2013; Reilly et al., 2013; Rose &
Bagnasco, A., Tubino, B., Piccotti, E., Rosa, F., Aleo, G., Di Pietro, P., & Sasso, L. (2013).
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