Discharge preparation: Do healthcare professionals differ in their opinions?

Ideological dilemmas of healthcare professionals who do not speak up at interprofessional team meetings

In healthcare settings, speaking up is considered essential for patient safety. Indeed, voice opportunities are widely available mandatory mechanisms for speaking up at the routine interprofessional team meetings of our study site. Yet, healthcare professionals in team meetings often do not go beyond straightforward reporting of test results and biomedical-functional parameters, suggesting that members with psycho-social information related to the patient are not participating fully in team meetings. Post-meeting interviews with some of the team members revealed the moments of silence and the ideological contradictions underlying team discussions. We explored silences and contradictions as argumentative meanings inherent in naturally occurring speech. The identification of opposing meanings tells of ideological dilemmas that may explain why healthcare practitioners do not speak up vigorously. We identified three such dilemmas: the ideology of working in teams versus the ideology of working solo; the ideology of autonomy versus the ideology of paternalism; and the ideology of collectivism versus the ideology of individuality. The dilemmas made visible the dimensions of silence as well as silencing as an imposition of silence from above. We suggest focussing on mapping disciplinary and interpretive differences and their effects amongst team members may motivate voice. Further studies should explore the affective dimensions of silence in interprofessional team meetings.

Factors Related to Family Caregivers’ Readiness for the Hospital Discharge of Advanced Cancer Patients

Background: Many family caregivers of advanced cancer patients worry about being unable to provide in-home care and delay the discharge. Little is known about the influencing factors of discharge readiness. Methods: This study aimed to investigate the influencing factors of family caregivers’ readiness, used a cross-sectional survey, and enrolled 123 sets of advanced cancer patients and family caregivers using convenience sampling from four oncology wards in a medical centre in northern Taiwan. A self-developed five-point Likert questionnaire, the “Discharge Care Assessment Scale”, surveyed the family caregivers’ difficulties with providing in-home care. Results: The study showed that the discharge readiness of family caregivers affects whether patients can be discharged home. Moreover, the influencing factors of family caregivers’ discharge readiness were the patient’s physical activity performance status and expressed discharge willingness; the presence of someone to assist family caregivers with in-home care; and the difficulties of in-home care. The best prediction model accuracy was78.0%, and the Nagelkerke R² was 0.52. Conclusion: Discharge planning should start at the point of admission data collection, with the influencing factors of family caregivers’ discharge readiness. It is essential to help patients increase the likelihood of being discharged home.

Beliefs about medication after hospital discharge in geriatric patients with polypharmacy

OBJECTIVES

To describe beliefs about medication in geriatric patients with polypharmacy post-discharge and to evaluate the impact of discharge management on patients' medication beliefs.

METHODS

A cross-sectional study was conducted between November 2019 and March 2020 in twelve general hospitals in Belgium. Four hundred geriatric patients with polypharmacy were surveyed at hospital discharge and two to five days post-discharge using the Beliefs about Medicines Questionnaire and self-developed questionnaires.

RESULTS

According to participants, the benefits of medication outweighed the disadvantages as the mean necessity score (19.4/25) outweighed the mean concern score (11.9/25). Patients receiving help with medication management post-discharge had stronger necessity-, concern- and overuse-related beliefs. No patient- or discharge management-related factors were significant predictors of medication beliefs.

CONCLUSIONS

Assessing patients' medication beliefs and identifying and addressing patients' concerns, can be an opportunity to improve medication use, to prevent non-adherence and to enhance safe medication practices at home.

Methods and Effectiveness of Communication Between Hospital Allied Health and Primary Care Practitioners: A Systematic Narrative Review

Background

There is a compelling rationale that effective communication between hospital allied health and primary care practitioners may improve the quality and continuity of patient care. It is not known which methods of communication to use, nor how effectively they facilitate the transition of care when a patient is discharged home from hospital. Our systematic review aims to investigate the methods and effectiveness of communication between hospital allied health and primary care practitioners.

Methods

Systematic review of quantitative and qualitative studies with narrative synthesis. Medline, CINAHL, EMBASE, PsycInfo and Proquest Nursing and Allied Health Sources were searched from January 2003 until January 2020 for studies that examined hospital-based allied health professionals communicating with community-based primary care practitioners. Risk of bias in the different study designs was appraised using recognized tools and a content analysis conducted of the methodologies used.

Results

From the located 12,281 papers (duplicates removed), 24 studies met the inclusion criteria with hospital allied health communicating in some form with primary care practitioners. While none of the included studies specifically investigated the methods or effectiveness of communication between hospital allied health and primary care practitioners, 12 of the 24 studies described processes that addressed components of their discharge communication. Four enablers to effective communication between hospital allied health and primary care practitioners were identified: multidisciplinary care plans, patient and caregiver involvement, health information technology and a designated person for follow up/care management.

Conclusion

There is currently no “gold standard” method or measure of communication between hospital allied health and primary care practitioners. There is an urgent need to develop and evaluate multidisciplinary communication with enhanced information technologies to improve collaboration across care settings and facilitate the continuity of integrated people-centered care.

Clarifying differences in viewpoints between multiple healthcare professionals during discharge planning assessments when discharging patients from a long-term care hospital to home

Comprehensive discharge planning provided by interprofessional collaboration is critical for discharging patients from hospitals to home. For effective interprofessional discharge planning, the evaluation that clarifies the differences in assessment viewpoints between various healthcare professionals is needed. This study aimed to clarify the assessment viewpoints of multiple healthcare professional groups when discharging patients from a long-term care hospital (LTCH) to home. We reviewed 102 medical records from an LTCH in Japan, extracted descriptions of discharge planning assessments written by 3 doctors, 13 nurses, 3 physical therapists, 13 care workers, and 2 social workers, linked these to the International Classification of Functioning, Disability and Health, and conducted the statistical analysis. Doctors and nurses significantly focused on "Body Functions". Physical therapists and care workers significantly focused on "Activities and Participation". Social workers significantly focused on "Environmental Factors". We also identified the factors less or missing from assessments in the clinical field of the LTCH. Our findings could be contributed as a base of knowledge to foster a better understanding of different healthcare professionals' assessment viewpoints. The further development of comprehensive discharge planning assessment tools, service programs, and research on discharge planning methods that could contribute to effective interprofessional discharge planning is needed.

Nurses' experiences and perspectives on collaborative discharge planning when patients receiving palliative care for cancer are discharged home from hospitals

AIMS AND OBJECTIVES

To explore nurses' experiences and perspectives on discharge collaboration when patients receiving palliative care for cancer are discharged home from hospitals.

BACKGROUND

Patients receiving palliative care for cancer experience multiple transitions between the hospital and their home. Poor discharge collaboration is a major cause of preventable hospital readmissions. Collaborative discharge planning could improve the care for these patients outside the hospital setting. Previous research has mostly been conducted in noncancer populations. Further research regarding both home care nurses' and hospital nurses' perspectives on care transitions is required.

DESIGN

A qualitative study with descriptive and explorative design.

METHODS

Data were collected through 10 individual, semi-structured interviews of nurses working at two oncology wards at a university hospital and home care services in four municipalities within the hospital's catchment area. Data were analysed using systematic text condensation. COREQ guidelines were adhered to in the reporting of this study.

RESULTS

Three categories emerged from the data analysis: lack of familiarity and different perceptions lead to distrust; inefficient communication creates a need for informal collaboration; and delayed discharge planning challenges collaboration.

CONCLUSIONS

The nurses lacked an understanding of each other's work situation, which created distrust, misunderstandings and misconceptions regarding each other's abilities to care for the patient. This led to inefficient communication, relying on individual knowledge, informal communication and personal networking. Delays in the discharge planning resulted in poorly prepared discharges often lacking necessary equipment and documentation.

RELEVANCE TO CLINICAL PRACTICE

To improve the care of patients receiving palliative care for cancer outside the hospital setting, better communication is a key factor to promote confidence and understanding between nurses working in different settings of health care.

Occupational therapy for adults with brain tumors in the acute care setting

The number of adults diagnosed with brain tumors is increasing, as are the survival rates. Neurological impairments from brain tumors can impact activity and participation. Adults with brain tumors benefit from post-acute rehabilitation. However, there is limited evidence from the acute care setting. The purpose of this study was to examine how acute care occupational therapy services were utilized and whether patients made functional gains after receiving occupational therapy services. A retrospective chart review of 153 electronic medical records was completed for patients who received occupational therapy services at a large teaching hospital. Data collected included number of occupational therapy visits, the types of interventions, and patient performance using the Boston University Activity Measure for Post-Acute Care "6 Clicks for Daily Activity" short form (AM-PAC). More than half the patients received one occupational therapy visit (54.2%) with a median length of stay of three days. Most interventions focused on activities of daily living (ADLs). Of those patients who received more than one visit, 67% showed improvements in their AM-PAC scores. Occupational therapy practitioners provided interventions that addressed ADLs, and patients demonstrated gains in functional performance. These findings suggest that patients benefit from occupational therapy services provided in the acute care setting.

Exercise and Dementia in Nursing Homes: Views of Staff and Family Carers

This paper reports the qualitative component of a randomized controlled trial which evaluated the impact and feasibility of a physical exercise intervention on individuals living with dementia in nursing homes. Interviews were conducted with 10 staff and nine family carers about their views and opinions of physical exercise (n = 19). Thematic content analysis revealed both benefits and barriers to physical exercise for individuals living with dementia in nursing homes. Another theme was the influences of knowledge and understanding on individuals' views of physical exercise. The involvement of staff and family carers in research encourage their involvement in the implementation of research into clinical practice. This can help to improve provisions of meaningful and beneficial activities for individuals living with dementia in nursing homes. The views and opinions of individuals living with dementia in nursing homes were not considered, though it would be beneficial to include them in future research.

Exploring challenges in the patient's discharge process from the internal medicine service: A qualitative study of patients' and providers' perceptions

In hospital-based medicine units, patients have a wide range of complex medical conditions, requiring timely and accurate communication between multiple interprofessional providers at the time of discharge. Limited work has investigated the challenges in interprofessional collaboration and communication during the patient discharge process. In this study, authors qualitatively assessed the experiences of internal medicine providers and patients about roles, challenges, and potential solutions in the discharge process, with a phenomenological focus on the process of collaboration. Authors conducted interviews with 87 providers and patients-41 providers in eight focus-groups, 39 providers in individual interviews, and seven individual patient interviews. Provider roles included physicians, nurses, therapists, pharmacists, care coordinators, and social workers. Interviews were audio-recorded and transcribed verbatim, followed by iterative review of transcripts using qualitative coding and content analysis. Participants identified several barriers related to interprofessional collaboration during the discharge process, including systems insufficiencies (e.g., medication reconciliation process, staffing challenges); lack of understanding others' roles (e.g., unclear which provider should be completing the discharge summary); information-communication breakdowns (e.g., inaccurate information communicated to the primary medical team); patient issues (e.g., patient preferences misaligned with recommendations); and poor collaboration processes (e.g., lack of structured interprofessional rounds). These results provide context for targeting improvement in interprofessional collaboration in medicine units during patient discharges. Implementing changes in care delivery processes may increase potential for accurate and timely coordination, thereby improving the quality of care transitions.

Forecasting Daily Patient Outflow From a Ward Having No Real-Time Clinical Data

Background: Modeling patient flow is crucial in understanding resource demand and prioritization. We study patient outflow from an open ward in an Australian hospital, where currently bed allocation is carried out by a manager relying on past experiences and looking at demand. Automatic methods that provide a reasonable estimate of total next-day discharges can aid in efficient bed management. The challenges in building such methods lie in dealing with large amounts of discharge noise introduced by the nonlinear nature of hospital procedures, and the nonavailability of real-time clinical information in wards.

Delays in Discharge in Neuro-Oncology: Using a Lean Six Sigma-Inspired Approach to Identify Internal Causes

Discharge planning processes have implications for patients and families, healthcare providers, and organizations at large. As such, delays in discharge may result in suboptimal patient outcomes, increased resource utilization, and overall disruptions to patient flow. A quality improvement project was conducted using a Lean Six Sigma approach to identify internal causes of delays in discharge in newly diagnosed patients with a high grade glioma on a neurosurgical unit. Internal causes of delays in discharge were related to communication. The main subthemes were multidisciplinary rounds, incongruent messages being delivered to patients and families, and discrepancies between team members resulting in unclear plans. Findings from this project may be used to promote more effective communication that will facilitate safe and timely discharge for neuro-oncology patients.

Interprofessional collaboration and integration as experienced by social workers in health care

Interprofessional collaboration in health care is gaining popularity. This secondary analysis focuses on social workers' experiences on interprofessional teams. The data revealed that social workers perceived overall collaboration as positive. However, concerns were made apparent regarding not having the opportunity to work to full scope and a lack of understanding of social work ideology from other professionals. Both factors seem to impede integration of and collaboration with social workers on health care teams. This study confirms the need to encourage and support health care providers to more fully understand the foundation, role, and efficacy of social work on interprofessional teams.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Patients' goals, resources, and barriers to future change: A qualitative study of patient reflections at hospital discharge after myocardial infarction

BACKGROUND

Myocardial infarction (MI) patients may find it challenging to adhere to lifestyle advice and medications. Understanding motivational factors and barriers to change is crucial. However, empirical evidence on patients' ability to effect lifestyle changes at the time of discharge is limited.

AIM

The aim of this study was to identify at the time of hospital discharge the goals, resources, and barriers to future change in MI patients.

METHODS

We conducted a qualitative interview study with a purposive sample of 20 MI patients (eight women) in a cardiac department at a university hospital in Norway. All interviews were conducted before hospital discharge, transcribed verbatim, and analysed using qualitative content analysis.

FINDINGS

Three themes suggested that, at the time of discharge, patients' views of their MI were complex and diverse. Patients were motivated to change their lifestyle and contemplated taking their life in new directions, adopting a change of life perspective. Frequently, patients struggled to understand the context of living with an MI, manage symptoms, and understand the precipitating causes of MI. There were also patients who wanted to maintain their present lifestyle and live as normal as possible. They just wanted to keep going.

CONCLUSIONS AND IMPLICATIONS

There is a need for a different approach to communicating with MI patients at the time of discharge. Person-centred care that allows personal narratives to emerge may enable health-care professionals to offer more individualised guidance to MI patients that will help them cope with the everyday challenges they experience after discharge.

Interprofessional Communication Patterns During Patient Discharges: A Social Network Analysis

BACKGROUND

Optimal care delivery requires timely, efficient, and accurate communication among numerous providers and their patients, especially during hospital discharge. Little is known about communication patterns during this process.

OBJECTIVE

Our aim was to assess the frequency and patterns of communication between patients and providers during patient discharges from a hospital-based medicine unit.

DESIGN AND APPROACH

On the day of the patient's discharge, the patient and all healthcare providers involved in the discharge were interviewed using structured questions related to information exchange during the discharge process. Each interview identified the frequency and method of communication between participants, including synchronous (e.g., face-to-face) and asynchronous (e.g., through electronic medical record) routes. Communication patterns were visually diagramed using social network analysis.

PARTICIPANTS

Forty-six patients were screened for inclusion in the network analysis. Of those, seven patients who were fully oriented and able to complete an interview and all providers who participated in their care during the discharge were selected for inclusion in the analysis. In all, 72 healthcare professionals contributing to the discharge process were interviewed, including physicians, nurses, therapists, pharmacists, care coordinators, social workers, and nutritionists.

KEY RESULTS

Patients' mean age was 63, length-of-stay was 7.8 days, and most (86 %) were discharged to home. On average, 11 roles were involved with each discharge. The majority of communication was synchronous (562 events vs. 469 asynchronous events, p = 0.004). Most communication events occurred between the primary nurse and patient and the care coordinator and primary nurse (mean 3.9 and 2.3 events/discharge, respectively). Participants identified intern physicians as most important in the discharge process, followed by primary nurses and care coordinators.

CONCLUSIONS

In patients being discharged from the medicine service, communication was more frequently synchronous, and occurred between intern physicians, primary nurses, and patients. Potential improvements in coordinating patients' discharges are possible by reorganizing systems to optimize efficient communication.

The making of local hospital discharge arrangements: specifying the role of professional groups

BACKGROUND

Timely discharge is a key component of contemporary hospital governance and raises questions about how to move to more explicit discharge arrangements. Although associated organisational changes closely intersect with professional interests, there are relatively few studies in the literature on hospital discharge that explicitly examine the role of professional groups. Recent contributions to the literature on organisational studies of the professions help to specify how professional groups in hospitals contribute to the introduction and routinisation of discharge arrangements. This study builds on a view of organisational and professional projects as closely intertwined, where professionals take up organising roles and where organisations shape professionalism.

METHODS

The analysis is based on a case study of the introduction and routinisation of explicit discharge arrangements for patients with prostate cancer in two hospitals in Denmark. This represents a typical case that involves changes in professional practice without being first and foremost a professional project. The multiple case design also makes the findings more robust. The analysis draws from 12 focus groups with doctors, nurses and secretaries conducted at two different stages in the process of the making of the local discharge arrangements.

RESULTS

From the analysis, two distinct local models of discharge arrangements that connect more or less directly to existing professional practice emerge: an 'add-on' model, which relies on extra resources, special activities and enforced change; and an 'embedded model', which builds on existing ways of working, current resources, and perspectives of professional groups. The two models reveal differences in the roles of professional groups in terms of their stakes and involvement in the process of organisational change: whereas in the 'add on' model the professional groups remain at a distance, in the 'embedded model' they are closely engaged.

CONCLUSIONS

In terms of understanding the making of hospital discharge arrangements, the study contributes two sets of insights into the specific roles of professional groups. First, professional interests are an important driver for health professionals to engage in adapting discharge arrangements; and second, professional practice offers a powerful lever for turning new discharge arrangements into organisational routines.

Insights into hospitalisation of advanced cancer patients: a study of medical records

The aim of this study was to explore reasons for the hospitalisation and place of death outcomes of terminal cancer patients. The methodology involved a qualitative content analysis of medical records pertaining to the last 3 months of life of 39 patients with one of four malignancies: prostate, breast, lung, or haematological. The results presentation is organised around three themes: decision hierarchy in health care, meanings of 'home', and late recognition of dying. Based on the detailed findings, this paper suggests that important insights into the broader goals of advanced cancer patients are offered by allied health staff, and that more effective use of the multidisciplinary team may support endeavours to achieve more home deaths for cancer patients who want this outcome. The analysis also provides new insights into the meaning of 'home' in interactions between advanced cancer patients and health professionals. The wish for 'home' appears bound up with other patient goals and the implications of this are discussed.

Mental health care professionals' experiences with the discharge planning process and transitioning patients attending outpatient clinics into community care

BACKGROUND

Health care reform promotes delivery of mental health care in the community. Outpatient mental healthcare professionals (HCPs) are pressured to discharge patients. This study's purpose: to understand the experience and perceptions of mental HCPs with discharge planning and transitioning patients into community care.

METHODS

Twelve HCPs participated in semi-structured qualitative interviews.

FINDINGS

Three main categories: engaging in the discharge planning process, making the transition smooth, and guiding values emerged. A conceptual framework was created to explain the phenomenon.

CONCLUSION

HCPs valued strengthening partnerships and building relationships to ensure smooth transition. Sufficient resources and trust imperative for safe patient discharge.

Determinants of Health in Discharge Planning for Seniors: Asking the Right Questions

Les praticiens sont encouragés à envisager un changement de perspective philosophie sur la façon dont les équipes interdisciplinaires interrogent les personnes âgées et leurs soignants au cours du processus de la sortie de l’hôpital. Les équipes engagées dans le planification des congés de l’hôpital peuvent commencer systematiquement à poser des questions qui vont au-delà du mise au point médical traditionnel sur les prescriptions, la réhabilitation et les soins, s’ils sont engagés dans un cadre de la décharge englobant attention aux déterminants sociaux de la santé. Une telle approche pourrait révéler les points forts et aussi pourrait exposer les inégalités sanitaires et sociales que les aînés doivent confronter en arrivant chez eux. Cette information peut ouvrir une porte d’entrée reliant les personnes âgées aux ressources sociales et économiques qui les soutiennes afin qu’elles puissent rester en bonne santé et productives.