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A Model for Discharge Planning in Nursing

Education
Amy P. Slevin
Published online: 07 Jun 2010.

To cite this article: Amy P. Slevin (1986) A Model for Discharge Planning in Nursing Education, Journal of
Community Health Nursing, 3:1, 35-42, DOI: 10.1207/s15327655jchn0301_5

To link to this article: http://dx.doi.org/10.1207/s15327655jchn0301_5

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 JOURNAL OF COMMUNITY HEALTH NURSING, 1986,3(1), 35-42
Copyright Q 1986, Lawrence Erlbaum Associates, Inc.

A Model for Discharge Planning in Nursing

Education

Amy P. Slevin, RN, MA

Bradley University
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The benefits of discharge planning have been well-documented. However, there is little
description of how nurse educators prepare students for this role.
This article describes a model for providing a discharge planning clinical experience to
nursing students at the same time as their acute care experience. The benefits, problems,
and solutions of the experience are discussed.

As cost containment becomes a priority, there is a need to provide careful planning

for the client who will spend less time in the acute care facility and more time
convalescing at home. Much has been written about the preparation of staff nurses
for the role of discharge planning but little has been published about the educational
process of preparing nursing students for this role. Nursing educators need to prepare
their students by emphasizing the process and practice of discharge planning in their
curricula.
Two recent studies reinforce the need for the practice of discharge planning in
schools of nursing. In one study the majority of staff nurses surveyed in five acute
care hospitals perceived that 81% to 100% of all hospitalized clients required dis-
charge teaching but that a very minimal amount of time was set aside by nursing staff
for carrying out this requirement (Caldera et al., 1980). In a survey regarding quality
assurance, nursing administrators recommended to faculty surveyors that students
learn to formally structure their client teaching and that they receive more experience
in discharge planning (Dexter & Laidig, 1980).
The need for students to have clinical practice in discharge planning has also been
observed in one baccalaureate nursing program discussed in this article. Students
were presented with lecture material on the basics of discharge planning, which in-
cluded material discussing which particular client problems constitute priorities for

Requests for reprints should be sent to Amy P. Slevin, RN, MA, Assistant Professor, Division of
Nursing. Bradley University, Peoria, IL 61625.
 36 Slevin

discharge planning, assessment tools for discharge planning, implementation of cli-

ent and family conferences, client teaching, team collaboration, and the initiation of
appropriate referrals. The information presented was retained adequately by most
students so that they were able to respond appropriately to case presentation testing
techniques. For example, when given a clinical simulation, most students were able to
identify what they would teach and demonstrate, what home areas they would assess,
how they would confer with family, physicians, physical therapists, dieticians, and
whom they would contact regarding needed follow-up for the client at home.
In the clinical setting, however, the faculty observed that students were not using
this knowledge. Students were neither using assessment guidelines to identify whether
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the client was a priority for discharge planning, nor were they including the discharge
planning interventions of educating, collaborating, and referring in their written
preparation for the clinical experience, or initiating these discharge planning nursing X.

interventions on the clinical units.

CLINICAL MODEL IN DISCHARGE PLANNING

--.
As a result of the identified need to assist students in applying their knowledge of dis-
charge planning, a five-stageclinical model using the nursing process was established
for a clinical nursing student experience in discharge planning. The lecture content de-
w

scribed above was presented to first semester senior students. Case simulation format
was used on the written testing of this material. However, grading for this unit was ex-
panded to include not only the results of the written exam but also a paper in which -
students were required to describe their involvement in discharge planning on one of
the acute care units to which they were assigned. The model shown in Fig. 1 was uti-
lized to enable students to obtain a clinical experience in discharge planning at the --
same time as their acute care experience.

Client Selection --

Students were instructed to select a client from their acute care clinical who fit the pri-
ority guidelines for discharge planning. These guidelines included: certain diagnoses, -
social, economic, and environmental situations or factors that affect successful
follow-through of medical and nursing management.
The priority diagnoses or conditions that alert the student to the need for discharge -
planning include those conditions that usually indicate a need for in-depth health
teaching and/or long-term therapy and follow-up such as diabetes, hypertension, car-
diac disease, chronic obstructive lung disease, cerebral vascular accidents, orthopedic
surgeries, and terminal illness. The priority social, economic, and environmental situ-
ations that alert the student to the need for discharge planning include situations that
-
 Discharge Planning 37

THEORY PRESENTATION PRACTICE EXPECTATION

GUIDELINES FOR CLIENTS USE PRIORITY GUIDELINES

WITH PRIORITY NEEDS FOR CUENT SELECTION TO SELECT CLIENT FROM
DISCHARGE PLANNING ACLTE CARE PRACTICUM
I I
4
USE GUIDELINES
ASSESSMENT GUIDELINES

I
t

-
COME CRITERIA
0i;T DEVELOP OUTCOME CRmRlA
ADVOCACY PLAN DISCUSS WITH FAMILY
COLLABORATE WITH PROFESSIONALS
ADVOCATE FOR CUEFTTS
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IDENTIFY AGENCIES FOR:

COMMUNITY RESOURCE GUIDES
COMMUNTTY NUTRITION
CLIENT Br REFERRAL SERVICES
PROFESSIONAL COLLABORATION
- RESOURCES

1
FINANCES
PERSONAL CARE
PROFESSIONAL CARE SERVICE
I
IMPLEMENT

- -
&
REFERRAL PROCESS EVALUATE HEALTH EWCATION
INITIATE REFERRAL PROCESS
DOCUMENT
EVALUATE OUTCOME CRmERlA

FIG. 1 Clinical model in discharge planning, by Amy P. Slevin.

would make it difficult for the client to continue to follow the health providers' plan
of care after his or her discharge from the acute care setting. These conditions include:
persons living alone and elderly couples (either of whom may be homebound), envi-
ronmental conditions (e.g., the number of steps, the bathrooom facilities, the availa-
bility of transportation), and the health and capabilities of other family members and
the clients' ability to read and write. The factors that affect successful follow through
include: the client's attitude, the client's present and future clinical course, the com-
plexity of medications and/or treatments, and the need for special equipment or con-
tinued services in the home.

Client Assessment

Students were then asked to perform a comprehensive assessment, utilizing the above
criteria, and any of the assessment guidelines available in the literature, or those de-
veloped in the units to which the client was assigned.
The literature contained several guides to which students were directed to assist
them in their assessments (Stone, 1979). The Discharge Planning Assessment Guide
(Connolly, 1981) and Who's Eligible for Home Health Service? (Harvey, 1981) were
 38 Slevin

checklist-type assessment guides that students found helpful in performing the dis- --
charge planning assessments. The most frequently utilized guide was the METHOD
method of discharge planning (Cucuzzo, 1976) adapted and described by Huey et al.
(1981). Students found this guide easy to remember and less cumbersome than some --
of the longer lists. Students on many occasions found excellent discharge planning
guides on the specialty units to which they were assigned. Staff on these units had de-
veloped guides geared to the problems commonly found in clients with the specific di-
agnostic conditions of their units.

Discharge Plan
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The students were then to establish a complete discharge plan including measurable
client outcome criteria. This was to include professional collaboration, health educa-
tion, client advocacy, and the use of the referral process to outside agencies or to the
discharge planner whenever appropriate. Students were encouraged to collaborate
with the appropriate other disciplines including physicians, therapists, nursing staff,
as well as hospital discharge planners. They were instructed to implement the plan as
far as was appropriate for the client on the day they were on the unit. The implementa-
tion was then to be appropriately documented and discussed with the nurse coor-
dinator so that the rest of the plan could be implemented by the staff on the unit.

Community Resources and the Referral Process

Students were asked to identify all community resources that might be beneficial to
the selected client during any stage of his or her illness. This included resources related
to the client's need for assistance in nutrition, personal care, finances, and profes-
sional care. Following resource identification, students were required to identify
w

those resources that were appropriate for the client at his or her present status. This
aspect of the assignment was included so that students could learn how to utilize the
community resource guides, client and referral services, and other professionals in -
identifying community services. The learning emphasis was placed on how to find out
about available resources rather than learning about the services of a few specific
agencies. Students were required to identify whether or not a referral was necessary --
for their client. If the client required a referral, the student was to describe how the re-
ferral process would be implemented.
-
Implementation and Evaluation of Discharge Planning

Students were asked to describe the nursing interventions utilized in relation to dis-
charge planning and to evaluate them in terms of the measurable outcome criteria
identified in their plan.
 Discharge Planning 39

APPLICATION OF THE MODEL

The following is an example of how students have used the model.

Client Selection

Sixty-six-year-old Mary Smith is recovering from a total hip replacement on the or-
thopedic unit of the local hospital. Her incision is healing well. She is currently
transferring with assistance and is exercising in preparation for ambulation with a
walker. At home, she will be expected to keep her hip in abduction and to avoid ex-
treme hip flexion. Ms. Smith will go home on prophylactic antibiotics and anti-
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coagulation medication. Ms. Smith lives alone in a two-story private home in a resi-
dential area.

Client Assessment

Ms. Smith's diagnosis of having had orthopedic surgery meets the criteria for dis-
charge planning. She lives alone in a two-story house. Her environmental status re-
garding the number of stairs and the availability of bathroom facilities on the lower
level will need to be assessed. The availability of transportation from family, friends,
or community agencies requires assessment. Ms. Smith's need for special equipment
in the home as well as for continued therapy will need to be checked with her physician
and her physical therapist. Ms. Smith's medications, the need for laboratory tests,
and the need for health teaching may indicate further follow-up in the home. Ms.
Smith's need for supportive services will also require assessment.

Plan and Community Resources

Utilizing the METHOD method (Huey et al., 1981), the following outcome criteria
are planned for Ms. Smith:

Medications
Ms. Smith will verbalize the purpose of her antibiotic and anticoagulant medica-
tion. She will verbalize the times she is to take her medication and what she will re-
port to her physician.
Environmental
Ms. Smith will remain on the lower level of her two-story home. She will use a
raised toilet seat that will be arranged for by the discharge planner.
Treatment
Ms. Smith will demonstrate how to care for her incision. She will verbalize what
signs and symptoms she will report to her physician. Ms. Smith's neighbor will
 40 Slevin

demonstrate how to apply the antiembolic stockings. Ms. Smith will demonstrate
use of a pillow between her knees for supine or side lying positions.
Outpatient Referral
Ms. Smith will receive services from a home health agency for I to 2 weeks. The
nurse will review her medication compliance, assess her for signs and symptoms of
infection and bleeding, draw weekly protimes, observe her incision, review her ex-
ercises, and report her progress to the physician. The home health agency physical
therapist will assist Ms. Smith in continuing the exercise and ambulation program
in the home. A physician's appointment will be made. Ms. Smith's neighbor will
provide transportation.
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Diet
Ms. Smith will receive Meals on Wheels for 2 weeks. Her neighbor will assist her
with shopping and food preparation after the second week.

Implementation and Evaluation

---
The health teaching regarding medications and incision care was implemented by the
student. Ms. Smith was able to verbalize the purpose and times of the medication. The
staff nurse will reinforce this teaching. The environment was discussed with Ms. .--
Smith. She does have a small bedroom with bathroom facilities on the lower level of
her home. She plans to use this bedroom when she returns home. Ms. Smith will re-
quest some assistance from her neighbor for shopping and transportation. The neigh- ---
bor will be visiting daily and will assist her in applying her antiembolic stockings. Ms.
Smith was willing to receive the home health services as well as the Meals on Wheels
program. Ms. Smith was informed about a community transportation agency if her *-

neighbor was unable to assist her. The staff nurse will contact the physician and the
discharge planner regarding the referrals.

BENEFITS OF THIS ASSIGNMENT

The focus provided by this assignment enabled students to develop skill in planning
-
and implementing discharge planning for a specific client. It gave them experience in
finding out about community resources as well as initiating collaborative efforts on
behalf of their clients. The goal of increased experience in discharge planning was at-
-
tained without the need for additional faculty or for a significant increase in the time
expenditure of the present faculty. -

PROBLEMS AND SOLUTIONS

-
Students had difficulty in selecting a client from their acute care assignments because
they considered discharge planning to be limited to those clients requiring the injtia-
-
 Discharge Planning 41

tion of a referral. Most of the students were in the same clinical area for only 1 day a
week. It was difficult for them to find a client in their acute care clinical assignment
who was appropriate for a community agency referral at the time in the client's hospi-
tal stay when they were assigned. Students had to be reassured that they were not re-
quired to initiate a referral, even though they were required to identify community re-
sources that might be of benefit to the client. The health teaching aspects of discharge
planning were re-emphasized in the selection of the client for this assignment. The stu-
dents were advised to state why a referral was not necessary and to emphasize the
teaching, collaborative and/or advocacy aspects of the discharge planning. Another
strategy that assisted students in identifying clients for discharge planning was a col-
laborative effort between the faculty and the discharge planning unit of the hospital.
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Several post clinical conferences were held during the acute care clinicals with the
focus on discharge planning. The conferences included the total student clinical
group, the acute care faculty, the discharge planning faculty (community health), and
the hospital discharge planner. Each student presented some identifying data on the
clients they had cared for that day. They then presented their assessment of the dis-
charge planning needs of each client. Their assessment was then expanded to include
information from other students, the discharge planner, and the faculty. The stu-
dents' assessment was then reinforced, corrected, or expanded and the entire clinical
group gained the knowledge of discharge planning and community resources from
each presentation. The presence of the hospital discharge planner gave the students an
idea of the importance that the hospital placed on the concept of discharge planning.
Although the conferences were time consuming for the discharge planner, she also
shared in the benefits of the conferences since she obtained an excellent source of cli-
ent assessment and information on those clients requiring follow-up from her
department.

CONCLUSIONS

The benefits of discharge planning have been well-documented in the literature.

However, there is little description of how nursing educators prepare students for as-
suming the responsibility of assessing and intervening in the discharge planning role.
The above model was a successful attempt to provide students with an experience in
dishcarge planning with little requirements for additional faculty time.

REFERENCES

Caldera, K., Colangelo, R., DiBlasi, M., Garman, D., Kowalczyk, S., Mason, S., Murphy, M., Olson,
A., Orr, C., & Quellettc, F. (1980). Exploration of the effect of educationallevel on the nurse's attitude
toward discharge planning. Journal of Nursing Education. 19(8), 24-32.
 Connolly, M. L. (1981). Organize your workday for more effective discharge planning. Nursing, 11(7),
44-47.
Cucuzzo, R. (1976). Discharge planning. Supervisor Nurse, 7, 43-45.
Dexter, P. A., & Laidig, J. (1980). Breaking the educational/service barrier. Nursing Outlook, 28,
179-182.
Harvey, B. L. (1981). Your patient's discharge plan-Does it include home care referral? Nursing, 11(7),
48-5 1.
Huey, R., Kiernan, L., Loomis, J., Madonna, M., Owen, D., Quaife, M., & Rosson, T. (1981).
Discharge planning: Good planning means fewer hospitalizations for the chronically ill. Nursing,
11(5), 70-75.
Stone, M. (1979). Discharge planning guide. American Journal of Nursing, 79, 1446-1447.
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