Introduction
The American Nurses Association (ANA) defined discharge planning as, "part of the continuity of care process which is designed to prepare the patient for the next phase of care and to assist in making any necessary arrangements for that phase of care" (Rose, 2010, P. 47). Discharge planning is a continued and ongoing process that allows the health care team to bring the patient to an appropriate level of care. Significant amounts of research supports that preparing the family for discharge has become more complex over the last several years. According to researcher Cheryl Kornburger (2013) “The current emphasis on shorter hospital stays results in patients and their caregivers being discharged from the hospital with much more complex and complicated home care instructions” (Kornburger, 2013 p 282). To tackle this problem the importance of “Teach Back” or return demonstration in discharge instruction was highlighted. This method helps the nursing staff to validate the understanding of information presented to the patient prior to being discharged.
Review of the Research Literature
One of the most important elements in discharge teaching is the concept of health literacy. This can be defined as: “…the ability of the patient to understand and obtain basic health information services,” (Kornburger, 2013 p. 288). This information is to help patient better understand about their illness and treatment. Another research done by Weiss (2007) states that, “The relationship between limited health literacy
and poorer health occurs in all socioeconomic groups and in many disease states”. This researcher also adds that 89 to 90 million adults in the United States have limited health literacy. Given this data, it is possible ...
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... Nurses, 19(1), 47.
Suzanne Bench, MSc, PGDipHE, BSc (Hons), RGN Tina Day, PhD, MSc, BSc (Hons), RN, Cert Ed RNT, Peter Griffiths, PhD and BA (Hons), RN (2013). Effectiveness of critical care Discharge Information in Supporting Early Recovery From Critical Illness. Critical Care Nurses, 33(3), 41-51. Retrieved on February 10,2014, from
Weiss, B. D. (2007). Health literacy and patient safety: Help patients understand
Retrieved on March 20, 2014, from
Zeng-Treitler, Q. Kim, H. & Hunter, M. (2008). Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. In AMIA Annual Symposium Proceedings (Vol. 2008, p. 849). American Medical Informatics Association
...s, K.D., London, F. (2005). Patient education in health and illness (5th ed.). New York: Lippincott.
State and federal regulations, national accreditation standards, and clinical practice standards are created, and updated regularly. In addition, to these regulations, OIG publishes a compliance work plan annually that focuses on protecting the integrity of the program, and prevention of fraud and abuse. The Office of the Inspector General examines quality‐of‐care issues in nursing facilities, organizations, community‐based settings and occurrences in which the programs may have been billed for medically unnecessary services. The Office of the Inspector General’s work plan for the fiscal year 2011 highlights five areas of investigation for acute care hospitals. Reliability of hospital-reported quality measure data, hospital readmissions, hospital admissions with conditions
Discharge planning and education has been one of the most important component of patients education provided y nurses and other health care providers. According to Bastable (2008) patient education is the process of assisting people to learn health related behavior that can be incorporated into everyday life with the goal of optimal health and independent in health care. She also mentioned that key to learning and changing is the individual cognition, perception, thoughts, memory, and ways of processing and structuring information. The purpose of this discussion is to provide a home discharge planning for Tina Jones on wound care, diabetes and asthma management (Bastable, Susan Bacorn, 2008).
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
setting and as the patient returns to their home and community. The goal by all involved is to move the patient towards
nurses who frequently enhance the communication problems in discharge planning, and who strive to improve the working relationship, collaboration and who use the teamwork approach to patient and family centered discharge planning will greatly reduce patient readmission (Lo, Stuenkel, and Rodriguez, 2009, p. 160). Lo, Stuenkel and Rodriguez (2009) emphasize that an organized and well prepared discharge planning, education of patients with multi-lingual services and use of different methods of teaching greatly improves the patients’ outcome (p.157). These include an experienced and well-taught phone call follow-up sessions after discharge along with ensuring the extension of adequate postoperative care. Another way nurses can deliver a planned discharged teaching is by providing direct checklist for patient and family to follow. One must understand that these approaches will enforce the staff nurses and other health care providers to develop the safe patient transition to home.
The National Council of State Boards in Nursing defines delegation as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (National Council of State Boards of Nursing, Resources section, 4). When delegating, the registered nurse (RN) assigns nursing tasks to unlicensed assistive personnel (UAP) while still remaining accountable for the patient and the task that was assigned. Delegating is a management strategy that is used to provide more efficient care to patients. Authorizing other individuals to take on nursing responsibilities allows the nurse to complete other tasks that need tended to. However, delegation is done at the nurses’ discretion and is a personal choice. Nurses must make careful decisions regarding delegation, taking into account the skill and training of the UAP, the difficulty and risk of the task, and the patient’s condition. The expected outcomes, a time frame for completion, and any limitations should be explained to the UAP at the time that the task was delegated.
Conaty-Buck, S. (2009). Unblocking barriers: Clearing the channel to improve communication between practitioners and patients with low health literacy. (Order No. 3364864, University of Virginia). ProQuest Dissertations and Theses, , 121. Retrieved from http://search.proquest.com.uproxy.library.dc-uoit.ca/docview/305011452?accountid=14694. (305011452).
However, health literacy is more than just read and write; it is the ability to understand and able to use health information to make choices about their health (Benyon, 2014). Low health literacy can have detrimental effect on the health of the client because it may cause misunderstand of the medical label or health information. According to McMurray & Clendon (2015), health literacy divided into three different levels which are functional, interactive/communicative and critical health literacy. As for functional levels, it is the most general and fundamental level for the general public because individuals need to receive and understand the information of health such as risk of health decision, consent forms, health instruction or medicine labels. (McMurray & Clendo , 2015) Turning to the next level, interactive/communicative health literacy, mainly involved personal skills to spread health knowledge to the community, and also , people are able to influence social norm and help others individuals to develop their personal health capacity. Because of this, understanding of how organization work and resounding communication skill which can help to support others and knowing how to get different health services other individuals need (McMurray & Clendo , 2015). The third level is critical health literacy, mainly divided to
Also, includes examples of nursing hands off that will be implemented, such as including the patient at the bedside. Having small trainings to provide information that will be needed to implement this, being sure all the important parts are cover, such as vitals, assessment, labs, and medication. Using online aids to help assist, providing additional information to those who need it.
A transitional care nurse or nurse navigator could be utilized to assure a smooth transition from the hospital into the community. The nurse navigator bridges the gap between the hospital care and post-acute care, while working closely with hospital staff, primary care doctors, specialists and community resources (Lamb, 2014, p. 191). Following the client’s discharge, a home health nurse would assume care and begin coordinating services. This nurse would be responsible to assure that all the care services are in place and there is a smooth
...be provided practical discharge instruction and information about pain management, wound care, returning to daily activities and following up with their primary-care physician.
Health literacy is a term not widely understood by the general population. It is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness,” (About health literacy, 2014). A person’s level of health literacy is based on their age, education level, socioeconomic standing, and cultural background. Patients with low health literacy have a more difficult time navigating the health care system. According to the U.S. Department of Health and Human Services, this group of patients may find it harder to find medical services and health care providers, fill out health forms, provide their complete medical history with their providers, seek preventative care, understand the health risks associated with some behaviors, taking care of chronic health conditions, and understanding how to take prescribed medications (About health literacy, 2014). It is to a certain extent the patient’s responsibility to increase their own health literacy knowledge. But to what extent can they learn on their own? Those working in the health field have been trained to navigate the health system and understand the medical terms. They have the knowledge and capability to pass on that understanding to their patients. Health care professionals have a shared responsibility to help improve patients’ health literacy.
OUTCOME/GOAL STATEMENT: Short Term: Pt will verbalize feelings of concern regarding at home maintenance of self with SO prior to discharge. Long Term: (after discharge) Pt will work with home health care giver to relief frustration and avoid further depression.
Instead of having a transition coach an advanced practice registered nurse (APRN) works to come up with the best pre-discharge patient assessment depending on the patient and their needs. The APRN gives multiple phone calls and home visits after discharge to the patient to make sure the patients do not have any questions and directions given are followed to reduce hospital readmission. They even go with the patient on their first visit to the PCP to make sure all information needed is given to the PCP to ensure better recovery (Nelson & Pulley,