Nurse and Patient Perceptions of Discharge Readiness in Relation to Postdischarge Utilization

Background: Prevention of hospital readmission and emergency department (ED) utilization will be a crucial strategy in reducing health care costs. There has been limited research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes. Objectives: To investigate the association of nurse and patient assessments of discharge readiness with postdischarge readmissions and ED visits. Research Design: Hierarchical regression analysis of readmission or ED utilization using independent nurse and patient assessments of discharge readiness and patient characteristics as explanatory variables, with hospital and unit fixed effects. Subjects: A total of 162 adult medical-surgical patients and their discharging nurses from 13 medical-surgical units of 4 Midwestern hospitals. Measures: Readiness for Hospital Discharge Scale completed independently by patients and their discharging nurses within 4 hours before hospital discharge; Postdischarge utilization (unplanned readmission or ED visit within 30 days postdischarge). Results: Correlations between nurse assessment and patient perceptions of discharge readiness were low (r = 0.15- 0.32). Nurses rated patient readiness higher than patients themselves. Controlling for patient characteristics, nurse readiness for hospital discharge scale score (odds ratio = 0.57, P = 0.05) but not patient readiness for hospital discharge scale score was associated with postdischarge utilization. Conclusions: Nurse assessment was more strongly associated with postdischarge utilization than patient self-assessment. Formalizing nurse assessment of discharge readiness could facilitate identification of patients at risk for readmission or ED utilization before discharge when anticipatory interventions could prevent avoidable postdischarge utilization

Validation of the Registered Nurse Assessment of Readiness for Hospital Discharge Scale

Background Statistical models for predicting readmissions have been published for high-risk patient populations but typically focus on patient characteristics; nurse judgment is rarely considered in a formalized way to supplement prediction models. Objectives The purpose of this study was to determine psychometric properties of long and short forms of the Registered Nurse Readiness for Hospital Discharge Scale (RN-RHDS), including reliability, factor structure, and predictive validity. Methods Data were aggregated from two studies conducted at four hospitals in the Midwestern United States. The RN-RHDS was completed within 4 hours before hospital discharge by the discharging nurse. Data on readmissions and emergency department visits within 30 days were extracted from electronic medical records. Results The RN-RHDS, both long and short forms, demonstrate acceptable reliability (Cronbach’s alphas of .90 and .73, respectively). Confirmatory factor analysis demonstrated less than adequate fit with the same four-factor structure observed in the patient version. Exploratory factor analysis identified three factors, explaining 60.2% of the variance. When nurses rate patients as less ready to go home (\u3c7 out of 10), patients are 6.4–9.3 times more likely to return to the hospital within 30 days, in adjusted models. Discussion The RN-RHDS, long and short forms, can be used to identify medical-surgical patients at risk for potential unplanned return to hospital within 30 days, allowing nurses to use their clinical judgment to implement interventions prior to discharge. Use of the RN-RHDS could enhance current readmission risk prediction models

Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital

Objective: To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits. Data Sources/Study Setting: A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. Study Design Prospective longitudinal design, multinomial logistic regression analysis. Data Collection/Extraction Methods: Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. Principal Findings: Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits. Conclusions: Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk

Aligning Evidence-Based Practice With Translational Research: Opportunities for Clinical Practice Research

Magnet(R) and other organizations investing resources in evidence-based practice (EBP) are ideal laboratories for translational nursing research. Translational research, the study of implementation of evidence into practice, provides a unique opportunity to leverage local EBP work for maximum impact. Aligning EBP projects with rigorous translational research can efficiently meet both EBP and research requirements for Magnet designation or redesignation, inform clinical practice, and place organizations at the leading edge of practice-based knowledge development for the nursing discipline

Teaching students to teach patients: A theory-guided approach

Nurses in every setting provide patient teaching on a routine basis, often several times a day. Patient teaching skills are essential competencies to be developed during pre-licensure nursing education. While students learn what to teach for specific conditions, they often lack competence in how to teach in ways that individualize and optimize patient learning. The ultimate goal of patient teaching is to arm patients with the knowledge and skills, and the desire and confidence in their ability to reach their targeted health outcomes. We describe the creation of a theoretical framework to guide development of patient teaching skills. The framework, rooted in the contemporary health care values of patient-centered care, is a synthesis of four evidence-based approaches to patient teaching: patient engagement, motivational interviewing, adult learning theory, and teach-back method. Specific patient teaching skills, derived from each of the approaches, are applied within the context of discharge teaching, an important nursing practice linked to patient outcomes. This exemplar emphasizes the use of critical teaching process skills and targeted informational content. An online student learning module based on the theoretical framework and combined with simulation experiences provides the nurse educator with one strategy for use with nursing students. The theoretical framework has applicability for skill development during pre-licensure education and skill refinement for nurses in clinical practice

Variability in Catheter-Associated Asymptomatic Bacteriuria Rates Among Individual Nurses in Intensive Care Units: An Observational Cross-Sectional Study

Catheter-associated asymptomatic bacteriuria (CAABU) is frequent in intensive care units (ICUs) and contributes to the routine use of antibiotics and to antibiotic-resistant infections. While nurses are responsible for the implementation of CAABU-prevention guidelines, variability in how individual nurses contribute to CAABU-free rates in ICUs has not been previously explored. This study’s objective was to examine the variability in CAABU-free outcomes of individual ICU nurses. This observational cross-sectional study used shift-level nurse-patient data from the electronic health records from two ICUs in a tertiary medical center in the US between July 2015 and June 2016. We included all adult (18+) catheterized patients with no prior CAABU during the hospital encounter and nurses who provided their care. The CAABU-free outcome was defined as a 0/1 indicator identifying shifts where a previously CAABU-free patient remained CAABU-free (absence of a confirmed urine sample) 24–48 hours following end of shift. The analytical approach used Value-Added Modeling and a split-sample design to estimate and validate nurse-level CAABU-free rates while adjusting for patient characteristics, shift, and ICU type. The sample included 94 nurses, 2,150 patients with 256 confirmed CAABU cases, and 21,729 patient shifts. Patients were 55% male, average age was 60 years. CAABU-free rates of individual nurses varied between 94 and 100 per 100 shifts (Wald test: 227.88, P\u3c0.001) and were robust in cross-validation analyses (correlation coefficient: 0.66, P\u3c0.001). Learning and disseminating effective CAABU-avoidance strategies from top-performers throughout the nursing teams could improve quality of care in ICUs

A Model for Hospital Discharge Preparation: From Case Management to Care Transition

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge

Individual Nurse Productivity in Preparing Patients for Discharge Is Associated with Patient Likelihood of 30-Day Return to Hospital

Objective: Applied to value-based health care, the economic term “individual productivity” refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient’s likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. Subjects: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. Measures: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. Results: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (−0.48 absolute percentage points, P\u3c0.001) and an ED visit (−0.29 absolute percentage points, P=0.042). Conclusions: Variability in individual clinician productivity can have implications for acute care quality patient outcomes

Using the Consolidated Framework for Implementation Research to Evaluate Clinical Trials: An Example from Multisite Nursing Research

Background The Consolidated Framework for Implementation Research (CFIR) is a comprehensive guide for determining the factors that affect successful implementation of complex interventions embedded in real-time clinical practice. Purpose The study aim was to understand implementation constructs in a multi-site translational research study on readiness for hospital discharge that distinguished study sites with low versus high implementation fidelity. Methods In this descriptive study, site Principal Investigator interviews (from 8 highest and 8 lowest fidelity sites) were framed with questions from 20 relevant CFIR constructs. Analysis used CFIR rules and rating scale (+2 to −2 per site) and memos created in NVivo 11. Findings From a bimodal distribution of differences (1.5 and 5), 7 constructs distinguished high and low fidelity sites with ≥5-point difference. Discussion CFIR provided a determinant framework for identifying elements of a study site\u27s context that impact implementation fidelity and clinical research outcomes

Clinical Nurses\u27 Perspectives on Discharge Practice Changes from Participating in a Translational Research Study

Aim To describe clinical nurses\u27 experiences with practice change associated with participation in a multi‐site nursing translational research study implementing new protocols for hospital discharge readiness assessment. Background Nurses\u27 participation in translational research studies provides an opportunity to evaluate how implementation of new nursing interventions affects care processes within a local context. These insights can provide information that leads to successful adoption and sustainability of the intervention. Methods Semi‐structured focus groups from 30 of 33 participating study hospitals lead by team nurse researchers. Results Nurses reported improved and earlier awareness of patients\u27 discharge needs, changes in discharge practices, greater patient/family involvement in discharge, synergy and enhanced discharge processes, and implementation challenges. Participating nurses related the benefits of participation in nursing research. Conclusion Participation in a unit‐level translational research project was a successful strategy for engaging nurses in practice change to improve hospital discharge. Implications for Nursing Management Leading unit‐based implementation of a structured discharge readiness assessment including nurse assessment and patient self‐assessment encourages earlier awareness of patients\u27 discharge needs, improved patient assessment and greater patient/family involvement in discharge preparation. Integrating discharge readiness assessments into existing discharge care promotes communication between health team members that facilitates a timely, coordinated discharge