Nurses´ Conceptions of Elderly´S Participation in Coordinated Discharge Planning from Hospital Wards

Research Article

Ann Nurs Res Pract. 2019; 4(1): 1035.

# Nurses’ Conceptions of Elderly´S Participation in Coordinated Discharge Planning from Hospital Wards

Sällström CRN1 and Johansson IRNT2*

¹Faculty of Health, Science and Technology, Department of Health Science, Karlstad University, Sweden

²Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Gjövik, Norway, Sweden

*Corresponding author: Johansson IRNT, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Gjövik, Norway, Sweden

Received: November 05, 2019; Accepted: December 05, 2019; Published: December 12, 2019

## Abstract

The discharge care planning (DP) is a complex assignment and challenging. Research shows that aspects of patient participation in DP are often ignored or neglected and assessments are rarely coordinated by nurses. The aim of the study was to explore nurses’ conceptions of elderly’s participation in the DP. Fifteen registered nurses were interviewed. A phenomenographic analysis by Åkerlind was used. Categories of description showed that the elderly’s participation is prerequisite and it requires grounding. Themes of awareness highlighted the nurses´ insight to undertake the role of advocacy and to take on ethical responsibilities. Complex ethical issues arise in DP and the difference between what is beneficial for the elderly and the elderly’s autonomy is a key issue and should be constantly discussed.

Keywords: Discharge Planning; Participation; Nurses ‘Conceptions; Phenomenography

## Introduction

In the health care system worldwide of today there have been changes in elderly care, which have led to a reduced number of available beds in health services [1,2]. These studies also showed that older patients discharged from hospitals were in a worse condition and more dependent than before. Further, the elderly’s role has changed from passive recipient of care to more active and informed co-producer of health [3]. Discharge planning (DP) from hospital to home care is a complex commitment and a challenge with different organizational contributors [2]. Problems are shown in the literature e.g; inadequate assessment, failure in communication and information transfer between hospital and community care [2,4]. This can lead to unnecessary readmissions which can be life threatening for the patients [5]. According to [6] DP facilitated with a structured, systematic and coordinated procedures ensures a smooth patient transition from hospital to the community and improved patient health outcomes. DP is a process for identifying and organizing the services and prevents problems after discharge that a person with diseases and other vulnerabilities will need after hospital discharge [7,8]. However, DP does not always satisfy patients and relatives’ rights to express their personal wishes in a dignified manner, which may result in their needs not becoming evident [9].

The goal of DP is to reduce the length of stay in the hospital and unplanned readmission to the hospital, and improve the coordination of services following discharge from the hospital [10]. A meta-synthesis by Waibel, Henao, Aller, Vargas and Vázquez [11] focused on patients’ experiences of continuity of care showed that communication and information transfer across care settings and holistic information about the patient promoted continuity of care.

In the rhetoric in European countries about patients’ possibilities to take an active part in their own health care, a prominent argument has been that social protection and social inclusion is crucial for reducing inequalities in health. Patient participation is fundamental for implementing nursing interventions in all types of nursing care [12,13] and to avoid readmissions, increase satisfaction, reduce anxiety, complications and mortality [14]. However, health care professionals do not always focus on elderly’s participation in planning for discharge [15-17]. The following factors have been described as important; information for elderly patients such as; time for discharge, use of medication, factors related to the community service, degree of information, and finally, how their practical problems could be solved [18]. Larsson, Sahlsten, Segesten and Plos [19] found that patients participating in DP experienced barriers in participation their experiences were facing own inability, meeting lack of empathy, meeting a paternalistic attitude and sensing structural barriers. On the other hand factors that contributed to the elderly´s participation in the DP were related to their; knowledge about their changed life situation, how to regain health` and positive interaction with the staff [20].

The concept participation has been studied in different contexts within nursing science since 1980 [21]. In this study, we used the definition “patient participation is an established relationship between nurse and patient, a surrendering of some power or control by the nurse, shared information and knowledge, and active engagement together in intellectual and/or physical activities” [21]. Findings in studies by [22,23] suggested that clarifying the roles of the professionals together with cooperation between the caregivers can contribute effectively to the DP process. To promote and stimulate patients’ active participation in the DP process Nilsson, From and Lindwall [24] indicated that nurses should see the patient as an equal partner and balance obstacles for patient’s participation. Further, studies show that nurses’ conceptions of the patient’s participation in DP are characterized by a good relationship between the patient and nurses, satisfactory information and that the patient’s resources are being used [13,20,25]. Communication problems could be a major factor that hindered an effective DP [26]. Interviews with nurses [25] showed that aspects of patient participation in DP were often ignored or neglected and assessments were rarely coordinated. Lack of time was reported to be the greatest barrier that affected the coordination of assessment. According to Norheim and Gutormensen Visnes [27] nurses’ express difficulties in meeting all obligations to enable the patient’s participation due to cutbacks in finances and staff.

There is a growing body of research on the DP process related to elderly´s participation, which is often found to be complicated and problematic. The importance of mutual communication and cooperation between caregivers and elderly´s participation has been highlighted as a key to effective DP. However, there is a lack of studies showing Registered Nurses (RN) in hospitals own experiences of their roles and responsibilities for patient involvement in decision making during DP.

This study aimed to explore registered nurses’ conceptions of elderly’s participation in the discharge planning process and to identify the structure of awareness underlying the nurses’ varying experiences of participation.

## Methods

This study is a part of the research project “Elderly and Discharge Planning (DP)”, which aims to describe different perspectives related to discharge planning for elderly persons from hospital to home or residential care facilities. The present study focuses on nurses’ conceptions of the elderly’s participation in DP.

## Design

The present study has a phenomenographic approach with semistructured interviews to describe the qualitatively different ways in which individuals experience, conceptualize, perceive and understand different aspects of the world [28,29]. The aim of phenomenography is to detect and describe different ways of conceptualize phenomena in the surrounding world, and there are only a limited number of qualitatively different ways a phenomenon can be experienced [29]. The term Conception is defined as different ways in which people discern and experience various phenomena in the world around us. Phenomenographic analysis seeks to explore the Conceptions, which are implicit in the descriptions of a particular phenomenon [30].

According to Åkerlind (2008, 2012) the different conceptions are seen as structurally related in a hierarchy of inclusiveness. Different ways of experiencing a phenomenon i.e. Conceptions are compared regarding similarities and summarized into different Categories of Description. These Categories of Description are logically inclusive structures representing different ways of experiencing. These ways of experiencing can be ordered in terms of inclusivity of awareness, where more inclusive ways also represent more multifaceted descriptions, indicated by an increasing breadth of awareness of different aspects of the phenomenon being investigated. The more complex views includes awareness of the dimensions of growth and development in the process to articulate the conceptions of the phenomenon under investigation. The expansion of individuals’ awareness includes discernment of additional aspects of the phenomenon, presented as Themes of Expanded Awareness [31,32].

The logical structuring of the relationships between Categories of Description and Themes of Expanded Awareness composes the structure of the Outcome Space in a holistic way [33]. The Outcome Space represent the full range of possible ways of experiencing the phenomenon in question. Categories of Description intertwined with Themes of expanding awareness, in this particular point of time, for the population represented by the group collectively outline the Outcome Space [34].

## Informants

Fifteen Registered Nurses (RN) working in four of seven medical wards and three of five surgical wards in one hospital in Sweden were included in the study. Inclusion criteria were; informants that mastered Swedish language and had at least one year’s experience working as a nurse and experience of discharge planning. Information about the research project was given to the medical director of the medical and surgical wards by the authors and informed consent was obtained. The head nurse at each ward was asked to forward an information sheet about the study by e-mail to RNs who met the inclusion criteria. The master students involved in the project visited the wards weekly to receive information about RNs who had participated in any DP. These nurses were then contacted and asked for consent to participate in the study. Agreement of place and time for an interview was obtained within seven days after the DP. Of the fifteen informants, one was a man. The length of their professional career varied between 1.5 to 38 years (median 5 years).

## Study context

Different laws regulate community care, The Swedish Social Service Act [35] and The Health Care Act [36], The National Board of Health and Welfare is the regulating authority for the care of elderly people in Sweden. The county council in each region is responsible for health and medical care in primary and hospital care and the municipalities are responsible for long-term elder care, such as homebased care and nursing homes. The county council and municipalities are responsible for drawing up the procedures in cooperation for the discharge planning [37]. DP conferences should be organized as a cross-professional meeting that includes the patient and/or next of kin [37].

The concept “clinically ready for discharge” is applied when the investigations of the patient’s disease and medical status are finished – when further medical treatment is no longer needed [36]. The regulation stipulates a policy to promote and support the elderly’s continued needs of care. When patients are clinically ready for discharge, the municipalities have five business days to plan for elderly homecare or other care facilities [38]. Otherwise, the municipalities must pay a fee to the county council from the sixth day [38]. As stated in the regulation, the health care providers are required to collaborate during the DP process and information about the patient can be obtained before the DP meeting. However, the organizations sometimes use different administrative systems for patient documentation, leading to missing or discrepancy in information [39]. This was the current circumstances in time of the present study. In 2117 the National Board of Health and Welfare has changed the regulation

## Data collection

Fifteen semi-structured individual interviews were conducted with RNs, who were asked to describe their experiences and thoughts about DP that they have been involved in with focus on elderly patient’s participation. Before the interview, the nurses’ were asked to think about an average elderly person, 80 years old or elder, and was to be transformed to their home or municipal health care services. During the interviews, the nurses were also asked to elaborate on their answers, such as: “How do you mean?” or “Can you describe more?” The interviews were digitally recorded and lasted between 20- 45 minutes. The interviews were performed by two master students and were preceded by three test interviews. These test interviews were transcribed and discussed in the research group, the interview guide was reformulated and reorganized and the two master students were given feedback on their performance in order to learn interview technique.

## Data analysis

A phenomenographic analysis described by Åkerlind was used. The analysis was carried out by the two authors. In the data analysis, Åkerlind argues that the different ways of experiencing are not constituted independently, but in relation to each other, ordered in terms of inclusivity of awareness. This analysis model is based on the arguments of Marton and Booth, who claim that the experience of any phenomenon may be seen as involving both a ‘what’ and a ‘how’ aspect. The interview was transcribed verbatim by the interviewers and analyzed by the authors. The following three steps were used in the analysis process [32,33].

The first step was to read each transcript three times, and during the third reading, notes were made about what emerged in the context of the other transcripts. Key questions and themes that emerged were summarized in relation to the uttered conceptions of the phenomenon. The second step involved grouping similar transcriptions together after repeatedly rereading the transcripts and notes. The third step involved rearranging the groups of data after further reading, searching for similarities in the overall meanings within the emerging categories and differences between the categories, so called “categories of description” [33]. Next step in the analysis was to search for Themes of awareness running through the set of categories of description, every theme linked to a set of different dimensions of variation. The themes of awareness may then be hierarchically ordered on the basis of increasing breadth of awareness, as a more complex way of understanding. The categories of description constituted by the researchers to represent different ways of experiencing elderly’s participation, and the themes of expanding awareness are thus seen as representing a structured set. The logical and hierarchical structuring of the relationships between the categories of description and the themes of expanding awareness constitute the final outcome space [32,33].

Åkerlind emphasizes the importance of those categories being allowed to emerge from the data and not being decided in advance. To strengthen the trustworthiness, the authors worked together in a critical dialogue through all steps. Preliminary categories were discussed and re-analyzed until consensus was reached. The final outcome unavoidably reflects both the data and the researchers’ judgments’ in interpreting the data.

## Ethical consideration

The Regional Committee for Medical Research Ethics in Uppsala, Sweden, approved the study (registration number 2012/028). The study was carried out in accordance with the Ethical guidelines for nursing in the Nordic countries [40]. The RNs who participated in the study were given oral and written information and informed consent was obtained in writing. The informants were also informed of the voluntary nature of the study and that they could withdraw at any time without negative consequences. The digitally recorded interviews and transcriptions were kept separate and stored in such a manner that only authors and students had access to them.

## Results

The result contains three sections; Categories of Descriptions, Themes of Expanding Awareness and the Outcome Space. The first section show nurses qualitatively different ways of conceiving the phenomenon of elderly’s participation in care planning. The Categories of Description that emerged were: Elderly being present and taking part - a prerequisite, The requirement of preparing and orienting the elderly to reality, Occasional inability to actively participate, Disparities in whether family members act supportive or discouraging, Imbalance of power in facilitating active participation. Each Category of Description is described in more detail below with a description of key aspects of the categories and with quotations and written in italics. Quotes are used to exemplify the variation within the categories, not to validate the analysis that is not possible because one quote could not represent the category of description, which reflects the total group (Table 1).

Citation: Sällström CRN and Johansson IRNT. Nurses´ Conceptions of Elderly´S Participation in Coordinated Discharge Planning from Hospital Wards. Ann Nurs Res Pract. 2019; 4(1): 1035.