Mary K. Anthony, PhD,RN1,2

Kathleen Vidal, MSN,RN2 Pimpanitta Jittapiriom, PhD (candidate)1

Carolyn Kleman, MSN, RN1

Amany Farag, PhD,RN3

Supported by Kent State University University Hospitals Case Medical Center

1Kent State University,2University Hospitals

Case Medical Center,3University of Iowa

RELATIONAL NURSING CARE: A Strategic Model Of Care To

Improve Discharge Readiness and Safe Transitions

BACKGROUND

• Discharge represents a time that bridges the transition from hospital to home.

• Profile − Nearly 40 million discharges per year

− Approximately 20% are readmitted within 30 days

− Up to one third of these readmissions are preventable

− 19% have an adverse event post discharge

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BACKGROUND

• Many interdisciplinary and interdisciplinary models have been designed and implemented to address the challenges of discharge.

• Models address structure of discharge, processes of discharge and standardization of both structure and processes.

• Failure of existing systems.

Models of care built around relational capital may offer promise as a strategic driver in accomplishing safe discharge.

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BACKGROUND

• Is discharge the most important conversation in a hospitalization?

• Characteristics of Discharge Communication

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PURPOSE

To assess the extent that core processes in a model of nursing care delivery explain nurse and patient perception of discharge readiness.

The underpinnings of the model: To build relationships

and promote information

sharing.

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METHOD

Design: Cross-sectional correlational

Sample: Convenience

Setting:

Hospital: One Healthcare System

Medical Surgical Units Practicing Relationship Based Care

Academic Medical Center (1) 13

Community (2) 4

Rural (1) 3

Critical Access (2) 3

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METHODInclusion Criteria

RN Sample • Worked as bedside nurse in one of 6 hospitals within the healthcare system

• Worked on a medical –surgical unit where relationship based care had been practiced for at least one year

• Full or part time (least one day a week); • PRN (if assigned to an eligible unit • Permanent member of the staff

Patient Sample

• 21 years of age• Cognitively Intact• Speak and Understand English• Discharged home

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RN DATA COLLECTION

• Hospital Liaison for each hospital • Unit meeting to explain the study• Survey placed in unit mailboxes• Reminder Flyers posted on units at specified

intervals:− The same day of survey distribution− One week after survey distribution− Two weeks after survey distribution− Three weeks after survey distribution

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PATIENT DATA COLLECTION

• Data collected from patients during the same time month of RN data collection.

• Recruited patients who met following criteria: − Discharge within 4-6 hours− Discharged home − Consent obtained

• Survey was given to patient along with a envelope to place questionnaire and return to drop box on unit.

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METHOD

Response Rate

RN A total of 554 surveys were distributed; 222 were returned and usable for a 40% response rate

Patient Patients recruited per unit 5-28

Number of patients who signed a consent

444

Number of patients who returned a survey

376 (86% return rate)

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RN DEMOGRAPHICS

Unit Individual

Mean yrs (SD) Mean yrs (SD)

Age 37.05 (4.73) 36.20 (11.03)

Unit Experience 4.31 (2.09) 7.99 ( 9.48)

Experience with manager

2.20 (1.35) 2.52 ( 2.73)

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PATIENT DEMOGRAPHICS

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Patient Sample Gender

Male (n = 166) 44.4%

Female (n= 208) 55.6%

Previous Hospitalization (n = 340)

90.4%

How long have you been in the hospital?

4.8 days (4.28)Range 1-36 days

How many times have you been hospitalized?

74 % reported being hospitalized 1-5 times

INSTRUMENTS: Relationship Based Care

(Anthony et al., 2009)

1. “Think back over the last week (7 days).

In your day to day interactions, on days you worked, how often did you conduct the following activities with your assigned patients”

− Admission Interview− Sit down Daily Rounds− Discharge Interview− Follow-up phone call

Not at all (1) to All the time (4)

2. Nurses were asked to rank order a series of activities related to providing care.

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INSTRUMENTS Perception Of Readiness For Discharge

Nurse Perception of Readiness

Nurse Perception of Quality Care (Aiken, 2002)•Nurses rated confidence in patients ability to manage care at time of discharge

Confident (1) to Not Confident at All (4) (reverse scored)

Patient Perception of Readiness Patient Readiness for Discharge (Weiss, 2006)

•7-item instrument•Responses on the RHDS are on an 11-point summated numeric rating scale

Not at All (0) to Totally (10)

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RELATIONSHIP BASED CARE

Relationship Based Care

Unit Individual

M (SD) M (SD)

Admission Interview 4.39 (.58) 4.39 (1.63)

Daily Sit down Round 3.93 (.98) 3.81 (1.69)

Discharge Interview 3.68 (.84) 3.55 (1.85)

Importance of Discharge (mean Rank)

5.19 (.95) 7.42 (1.80)

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RANK ORDER OF NURSING CARE ACTIVITIES

Nursing Activity Rank Order

(1 is most important)

Unit Level

M (SD)

Individual Level

M (SD)

Discharge Planning 7.27 ( .75) 7.42 (1.8)

IV Care 3.66 ( .71) 3.79 (1.7)

Complete update interview profile 7.41 ( .66) 7.48 (1.8)

Sit down with patient 5.84 ( .95) 5.81 (2.2)

Patient Education 5.19 ( .80) 5.11 (1.7)

Treatments 3.91 ( .78) 3.78 (1.7)

Charting 5.64 ( .96) 5.63 (2.2)

Conversation with patient 3.61 (1.00) 3.61 (2.3)

Passing Medications 2.17 ( .73) 2.15 (1.6)

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READINESS FOR DISCHARGE

Unit Individual

Perception of Readiness for Discharge

M (SD) M (SD)

Patient(0-10)

8.11 (.53) 8.13 (1.43)

RN(1-4)

2.73 (.26) 2.70 ( .61)

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RESEARCH QUESTIONS

1. What are the relationships among:

a. RN perception of readiness and patient perception of readiness for discharge?

b. Readiness for discharge (patient and nurse) with core processes of relationship based care and their relative importance?

2. Based on univariate analysis, what is the explanatory power of a relationship based model of care on nurse and patient readiness for discharge?

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RELATIONSHIP OF DISCHARGE READINESS

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RN Perception of Patient Readiness p

Patient Perception of Readiness

.20 .35

CORRELATION

RN Perception of Readiness for Discharge p

Conducting Admission Interview

- .20 .35

Conduct Daily Sit Down Rounds .50 .01

Conduct Discharge Interview .30 .15

Importance of:

Discharge Planning - .32 .14

Patient Education .10 .64

Sit Down with Patient - .15 .47

Conversation with patient .06 .79

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CORRELATION

Patient Perception of Readiness for Discharge

p

Conducting Admission Interview .20 .36

Conduct Daily Sit Down Rounds .20 .36

Conduct Discharge Interview .27 .20

Importance of:

Discharge Planning - .32 .13

Patient Education - .03 .90

Sit Down with Patient - .09 .66

Conversation with patient .10 .63

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RN PERCEPTION OF PATIENT READINESS FOR DISCHARGE

(N = 23)

Beta t p

Admission Interview - .10 - .55 .58Sit down rounds .55 2.30 .03Discharge Interview - .07 - .31 .76 Importance of Discharge Planning - .28 -1.46 .16

Model R2=.38, F 4, 18= 2.80 p = .057 *p< .05,* * p < .01 ***p < .001

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PATIENT PERCEPTION OF PATIENT READINESS FOR DISCHARGE

(N = 23)

Beta t p

Admission Interview .29 1.38 .18Sit down rounds .12 0.46 .65Discharge Interview .15 0.55 .58 Importance of Discharge Planning -.34 - 1.56 .13

Model R2=.23, F 4, 18= 1.36 p = .28 *p< .05,* * p < .01 ***p < .001

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CONCLUSIONS

• RN sample, the sit down rounds and relative ranking of discharge planning were important to their perception that patients were ready for discharge.

• Patient sample, the admission interview and relative ranking of discharge planning were to their perception of being ready for discharge.

• What is in common is that both the admission interview and sit down rounds involve focused conversations.

• The small sample likely accounted for moderate effects to be nonsignificant.

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IMPLICATIONS

• Discharge Information− What helps patients manage this complex information?− What helps patients make sense of complex information?− What helps them differentiate information?

What is the discussion around structured conversation with relational conversation in managing discharge?

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