Discharge planning is an important care process, but deficits in planning are common. The aim of this study was to explore district nurses’ (DNs) and home care organizers’ (HCOs) experiences and views of the workflow during the discharge planning process (DPP). Demands, workload, time, collaboration, and engagement, together with knowledge and professional confidence, are factors that influence workflow and outcome of the DPP for DNs and HCOs. Strengths and obstacles at the organization, group, and individual levels affect the workflow during the discharge planning. Knowledge of these strengths and obstacles should help care providers in their practice as well as help management and politicians become more aware of prerequisites needed to achieve a safe and efficient workflow for securing the patient’s discharge.
KripalaniSLeFevreFPhillipsCOWilliamsMVBasaviahPBakerDW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
2.
CwinnMAForsterAJCwinnAAHebertGCalderLStiellIG. EM Advances: prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM. 2009;11(5):462-471.
3.
PhillipsCOWrightSMKernDESingaRMShepperdSRubinHR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure. JAMA. 2004;291(11):1358-1367.
4.
LinPWangCChenCLiaoLKaoSWuH. To evaluate the effectiveness of a discharge-planning programme for hip fracture patients. J Clin Nurs. 2009;18(11):1632-1639.
5.
PreenDBBaileyBESWrightA. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Int J Qual Health Care. 2005;17(1):43-51.
GrayCHoggRKennedyC. Professional boundary work in the face of change to generalist working in community nursing in Scotland. J Adv Nurs. 2011;67(8):1695-1704.
8.
LehouxP. Patients’ perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies. BMC Health Serv Res. 2004;4(1):28.
9.
OrrevallYTishelmanCHerringtonMKPermertJ. The path from oral nutrition to home parenteral nutrition: a qualitative interview study of the experiences of advanced cancer patients and their families. Clin Nutr. 2004;23(6):1280-1287.
10.
AdlerALipkinCCooperLAgolinoMJonesV. Effect of social work intervention on hospital discharge transition planning in a special needs population. Manag Care. 2009;18(11):50-53.
11.
BlumenfeldSRosenbergG. Towards a network of social health services. Soc Work Health Care. 1988;13(4):31-48.
12.
HollimanDCDziegielewskSFDattaP. Discharge planning and social work practice. Soc Work Health Care. 2001;32(3):1-19.
13.
Department of Health. Discharge From Hospital: Pathway, Process and Practice. London, England:Health and Social Care Joint Unit and Change Agents Team; 2003.
14.
Department of Human Services. Effective Discharge Strategy Background Paper: A Framework for Effective Discharge. Melbourne, Australia: Victorian Government Health Information; 1998.
15.
Department of Health. The Performance, Acute Programs and Rural Health Branch, Victorian Public Hospital Specialist Clinics: Discharge Guidelines. Melbourne, Australia: State Government Victoria; 2010.
16.
Department of Health and Children. The National Health Strategy, Quality and Fairness. Dublin, Ireland: Department of Health and Children; 2001.
17.
The Health Boards Executive. Admission and discharge guidelines. Tullamore, Ireland: Department of Health and Children; 2003. http://lenus.ie/hse/handle/10147/43554. Accessed January 21, 2015.
18.
KatikireddiSVCloudGC. Planning a patient’s discharge from hospital. BMJ. 2008;337:a2694.
Ministry of Health and Social Affairs, the Swedish Government. SFS 1990:1404 Lag om kommunernas betalningsansvar för viss hälso- och sjukvård [Law for the communities’ payment liability for certain healthcare]. Stockholm: Ministry of Health and Social Affairs, the Swedish Government; 1990. (In Swedish)
ShepperdSMcClaranJPhillipsCO. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2010;CD000313.
23.
EfraimssonESandmanPRasmussenBH. “They were talking about me”—elderly women’s experiences of taking part in a discharge planning conference. Scand J Caring Sci. 2006;20(1):68-78.
24.
HofflanderMNilssonLEriksénSBorgC. Discharge planning: narrated by nursing staff in primary healthcare and their concerns about using video conferencing in the planning session—an interview study. J Nurs Educ Pract. 2013;3(1):88.
25.
KergoatMLatourJJulienI. A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model. BMC Geriatr. 2010;10(1):69.
26.
HesselinkGSchoonhovenLPlasMWollersheimHVernooij-DassenM. Quality and safety of hospital discharge: a study on experiences and perceptions of patients, relatives and care providers. Int J Qual Health Care. 2013;25(1):66-74.
27.
AlmborgAUlanderKThulinABergS. Patients’ perceptions of their participation in discharge planning after acute stroke. J Clin Nurs. 2009;18(2):199-209.
28.
AtwalA. Nurses’ perceptions of discharge planning in acute health care: a case study in one British teaching hospital. J Adv Nurs. 2002;39(5):450-458.
29.
NosbuschJMWeissMEBobayKL. An integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning. J Clin Nurs. 2011;20(5-6):754-774.
30.
FrydenbergKBrekkeM. Poor communication on patients’ medication across health care levels leads to potentially harmful medication errors. Scand J Prim Health Care. 2012;30(4):234-240.
31.
HellesøR., Information handling in the nursing discharge note. J Clin Nurs. 2006;15(1):11-21.
32.
PolitDFBeckCT. Nursing research: generating and assessing evidence for nursing practice. 8th ed.Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.
33.
SandelowskiM. Reembodying qualitative inquiry. Qual Health Res. 2002;12(1):104-115.
KvaleS. Den kvalitativa forskningsintervjun. Lund, Sweden: Studentlitteratur; 2009.
36.
National Borad of Health and Welfare. SOSFS 2005:27 Socialstyrelsens föreskrifter om samverkan vid in- och utskrivning av patienter i sluten vård [Instructions for collaboration at admission and discharge of patients in hospitals]. Stockholm: National Board of Health and Welfare; 2005. (In Swedish)
37.
NordmarkSSöderbergSSkärL. Information exchange between registered nurses and district nurses during the discharge planning process: cross-sectional analysis of survey data. Inform Health and Soc Care. 2014;1-22. doi:10.3109/17538157.2013.872110.
38.
GraneheimUHLundmanB. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-112.
39.
JenningsBM. Work stress and burnout among nurses: role of the work environment and working conditions. In: HughesRG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:137-158, chap 26.
40.
PoghosyanLClarkeSPFinlaysonMAikenLH. Nurse burnout and quality of care: cross-national investigation in six countries. Res Nurs Health. 2010;33(4):288-298.
41.
VaheyDCAikenLHSloaneDMClarkeSPVargasD. Nurse burnout and patient satisfaction. Med Care. 2004;42(2):57-66.
42.
OlsenRMHellzénOSkotnesLHEnmarkerI. Content of nursing discharge notes: associations with patient and transfer characteristics. Open J Nurs. 2012;2:277-287.
43.
MesteigMHelbostadJSletvoldORosstadTSaltvedtI. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Serv Res. 2010;10(1):1.
44.
AmmenwerthEMansmannUIllerCEichstaedterR. Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study. J Am Med Inform Assoc. 2003;10(1):69-84.
45.
BaskaranVDavisKBaliRKNaguibRNGWickramasingheN. Managing information and knowledge within maternity services: privacy and consent issues. Inform Health Soc Care. 2013;38(3):196-210.
46.
OlsenRHellzénOEnmarkerI. Nurses’ information exchange during older patient transfer: prevalence and associations with patient and transfer characteristics. Int J Integr Care. 2013;13(1). URN:NBN:NL:UI:10-1-114282.
47.
GrönroosEPeräläM-L. Home care personnel’s perspectives on successful discharge of elderly clients from hospital to home setting. Scand J Caring Sci. 2005;19(3):288-295.
48.
SpearsJFitzsimonsCDoranRSaundersJFariaLEatonK. The role of discharge co-ordinator in oncology. Cancer Nurs Pract. 2014;13(3):21-26.
49.
OlsenRMØstnorBHEnmarkerIHellzénO. Barriers to information exchange during older patients’ transfer: nurses’ experiences. J Clin Nurs. 2013;22(19):2964-2973.
