1. Background
Implementation of discharge planning is one of the significant issues in the health care system (1). Patients' discharge time is a vulnerable time, and approximately 19 - 21% of patients manifest a complication after discharge, among which the drug side effects are most common (2). A discharge planning is successful when patients are prepared before the discharge process, the needs of the discharge time and after discharge are assessed, and patients are prepared to take self-care. Patients should be followed up after discharge and referred to the hospital if necessary. In a comprehensive discharge program, patients' families are also considered (3). Studies show that with effective discharge planning, in addition to making behavioral changes in the patient, it is possible to save costs and reduce the heavy economic burden of society (4).
Today, due to structural changes in families, an aging population, and an increase in chronic diseases, the need for chronic care is felt more than ever. In this regard, most institutions in different countries suffer from many problems with the discharge program. On the other hand, the lack of approved standards for measuring the discharge program reduces the effective discharge process of patients, and there are apparent differences in treatment outcomes (5). Research shows that nurses' roles are often not clearly stated in the discharge program. Nurses state that decisions about patients' discharge are made by physicians during the visit and that there is not enough time for effective patient discharge planning. Also, nurses perform the discharge program only in the last minutes, are not aware of the importance and value of the discharge program, and focus only on the urgent needs of patients and ignore the discharge process (6). Numerous factors, such as nurses' business and lack of time, have been implicated in the non-implementation of discharge program (7). Also, the behavior of organizations, organizational structural changes, and payment systems should be considered by managers and nurses (8).
The purpose of qualitative research is to create a deep understanding of the social world of the participants by gaining their views, experiences, ideas, history, and feelings. Using the experiences of nurses involved in discharge can help better evaluate the discharge planning. Unfortunately, in Iran, qualitative studies have not been conducted to examine the experiences of nurses regarding the discharge program, and the research conducted is mainly quantitative or on other topics. With these studies, the concepts of qualitative study cannot be understood. It seems that nurses' experiences in a qualitative study can reveal the different dimensions of feelings, experiences, ideas, and views of nurses involved in the discharge program (9). Accordingly, the present qualitative research aimed to examine the challenges and implementation strategies of discharge planning based on the nurses' experiences.
2. Objectives
The present study aimed to survey the nurses' experiences about challenges and implementation strategies of discharge planning.
3. Methods
3.1. Design
In this study, we used content analysis to study nurses' experiences regarding discharge planning.
3.2. Participants
In this study, purposeful sampling was performed among volunteer nurses from November 2016 to April 2018 in Birjand, Iran. The participants were selected with maximum diversity in terms of age, gender, and work experience. Inclusion criteria included at least ten years of work experience (to achieve the maximum and best results) and agreement to participate in the study. Therefore, among the nurses of two educational hospitals with different working conditions and experiences, those who had the most experience and information about the discharge planning were selected by purposive sampling. The interview was conducted in a quiet and private environment where the participants were comfortable.
3.3. Data Collection
The data collection process was performed by the corresponding author through semi-structured interviews. Interviews with nurses were conducted after working hours and for approximately 30 - 60 minutes (at least 40 minutes). Participants were interviewed in a quiet and private environment. First, demographic information, including age, sex, job title, and work experience was collected. The interview began with the main question, "Please tell us about your experience with the patient discharge process in your ward?". When participants moved away from the focus of the discussion, we confronted him/her with exploring questions such as "Can you explain more about this?" and "What do you mean?". Data collection stopped when all categories were saturated and no new data sets were generated. In total, 15 interviews were conducted.
3.4. Data Analysis
Data analysis began immediately after the first interview and continued at the same time as the data collection process. The Lincoln and Guba approach was used for qualitative content analysis (10). Two researchers listened to the interviews several times and made a written reproduction of them. Afterward, interview transcripts were studied repeatedly to acquire a general and correct understanding of the data. Then, the sentences containing essential points about the outcomes of hospital accreditation were identified as the units of analysis and discovered the meaning unit. In the next step, the meaning units were abstracted and labeled as a code. Then, the codes were compared, and related content was arranged into categories (10).
3.5. Trustworthiness
Lincoln and Guba's approach, including credibility, dependability, confirmability, and transferability was used to validate the data (11). For verifying credibility, the researchers ensured that the participants were carefully identified and represented accurately. Data collection lasted for about eight months. Dependability means the stability of data over time and under various conditions. The research team assured dependability by peer checking and external expert checking to audit the interview process, coding, and analysis. Conformability was related to objectivity; we guaranteed conformability by member checking, confirmation of the codes by participants, and reading the interviews several times. We confirmed transferability by member checking and sampling with the greatest diversity. The study context was described in detail to enable readers to decide about using the results in another setting (11, 12). Finally, the categories extracted from the study were given to two external nurses. They confirmed that our findings were close to their experiences.
4. Results
This content analysis was conducted with the participation of 15 nurses with at least ten years of experience. Two participants are now in managerial positions. The average work experience of the participants was 15.6 ± 5.13 years, and nine (60%) participants were male. The mean age of participants was 44 years. All participants were familiar with the discharge process. A total of 15 interviews were conducted. A total of 286 codes were divided into five main categories and 14 subcategories (Table 1). The main categories included inadequate attention to the discharge process, lack of standard and approved discharge planning, defects in organizational sub-structure, social barriers, and perceived defects of the current discharge situation. The subcategories of each category are presented in Table 1.
Table 1.Categories and Subcategories of Study
| Categories | Subcategories |
|---|---|
| 1. Inadequate attention to the discharge process | 1.1. Lack of motivation to perform discharge process |
| 1.2. Not following the discharge planning program | |
| 1.3. Lack of information about the discharge planning | |
| 2. Lack of standard and approved discharge planning | 2.1. Uncertainty of instructions and policies |
| 2.2. Lack of written and standard discharge planning | |
| 3. Defects in organizational sub-structure | 3.1. Lack of discharge nurse (lack of personnel) |
| 3.2. Crowded wards and busy nurses | |
| 3.3. Incomplete treatment team and lack of proper communication between them | |
| 3.4. Not specifying the specific place of discharge and budget discussion | |
| 4. Social barriers | 4.1. Access to services |
| 4.2. Some cultural differences | |
| 5. Perceived defects of the current discharge situation | 5.1. Not follow.up of patients after discharge |
| 5.2. Unawareness of the patient and his/her family of the right to the discharge program | |
| 5.3. Dispersion of discharge time |
4.1. Inadequate Attention to the Discharge Process
The participants' experiences showed that the medical system did not pay enough attention to the patient's discharge planning. This category included three subcategories.
4.1.1. Lack of Motivation to Perform the Discharge Planning
Motivation is an important element of health care because it affects the performance and quality of patient care. Therefore, nursing managers must have the ability to motivate their nursing staff (13).
"Most nurses are unaware of the importance of educating the patient and the consequences if the patient is abandoned. We have low motivation to do the discharge process". (P2)
"The nurse is not interested in taking the time to discharge. There has not been enough education in this section. It is better to take discharge education more seriously. The nurse should be told of the consequences of not being educated to the patient". (P11).
4.1.2. Not Following the Discharge Planning Program
Participants believed that medical staff, including doctors and nurses, were unaware of the discharge planning program and its importance.
"I feel that our medical staff is not very serious about the discharge program and is not aware of the importance of this process. Many readmissions are due to neglecting this issue." (P5)
Another participant stated, "I recommend that, in addition to nurses, physicians be aware of the importance of the discharge program, participate in the discharge process, and educate their patients about post-discharge risks. It requires teamwork." (P6).
4.1.3. Lack of Information About the Discharge Planning
The issue of education in the discharge program is very important, and all participants unanimously believed that the issue of education in the discharge program is not serious because the medical staff has not received sufficient education on this topic.
"We do not receive discharge education. If our medical staff does not receive enough education, the consequences will be felt by the patient. Many nurses still do not know that the nurse must meet the patient at home after discharge." (P12)
"Nurses' information about the discharge process is not enough. The need for education is felt. It is better to have workshops constantly." (P1)
"It has been proven to us that nurses are good educators if they are instructed." (P15)
4.2. Lack of Standard and Approved Discharge Planning
A standard discharge planning is required for hospitals. The nurses believed that they did not have an approved and standard program. This category included two subcategories.
4.2.1. Uncertainty of Instructions and Policies
One of the nurses stated, "General policies of the discharge planning should be described and emphasized to the hospitals; and they should be careful about its implementation." (P11)
"Even if we want to execute, shouldn't we have a clear and unified instruction? How long should the patient be followed up? Should we call the patient? Are these mentioned in the instructions? Do we have any instructions at all? We have not seen them yet." (P14)
4.2.2. Lack of a Written and Standard Discharge Planning
"We do not have a written program to tell us whether to provide this education or not. The patient discharge planning, similar to the patient admission planning, must be clear and organized, and we must start the education for patient discharge as soon as the patient is admitted." (P8)
"In recent years, such educational programs have improved, but they are still far from the standard of discharge program. We receive discharge education in the hospital that should be considered seriously, but the discharge planning has not been implemented yet, and the discharge planning, which is not just education; the patient should be followed-up later." (P13)
4.3. Defects in Organizational Sub-structure
The issue of defects in organizational sub-structure is very important. The implementation of a program is primarily due to having its sub-structure. This category included four subcategories.
4.3.1. Lack of Discharge Nurse (Lack of Personnel)
"It is not clear who is responsible for the patient's discharge. It is better to have a specific person for patient discharge. If we want this program to be implemented properly, we must provide this possibility, or everyone is responsible for their patient discharge." (P5)
"In many cases, the patient goes home without any education because we may not have time to educate the patient due to lack of manpower." (P9)
4.3.2. Crowded Wards and Busy Nurses
"Wards are crowded, admissions and discharges are very high, the nurse does not have time at all. When I have a more important task, I sacrifice discharge for other tasks." (P6)
"Every day, more workload is added, and the nurses are busy. We are going from the practice to the paperwork. Every day a new task is added to the nurses, and we have to do it with the same amount of personnel. Well, it is natural to fall behind in some things." (P7)
4.3.3. Incomplete Treatment Team and Lack of Proper Communication Between Treatment Team
"In my opinion, our medical team is not perfect. For proper implementation of a discharge program, we must have a proper and complete team. We do not have any coordination and teamwork." (P7)
"A good communication should be established between the members of the treatment team, including the doctor, nurses, and all system parts. When this communication is done correctly, we will have a complete treatment team, and the patient will be understood by the system and potential problems will be prevented." (P8)
4.3.4. Not Specifying the Specific Place of Discharge and Budget Discussion
Participants agreed that a suitable place for discharge should be considered.
"Sometimes we educate the patients in the corridors or the room with other patients." (P12)
"It is better to educate patients with the same diagnoses in a suitable place for patient discharge. We do not have a discharge room, and this may be due to a budget problem." (P3)
4.4. Social Barriers
This category included two subcategories.
4.4.1. Access to Services
"The issue of providing services to patients living in the city and patients who are several kilometers away from the city is different. They do not have access to important services." (P6)
"It takes a long time for a patient to go to the hospital from the village, or when discharged, he has to go a long way, which will sometimes cause problems." (P14)
"Performing a follow-up for a patient that is several kilometers away from you is not so easy." (P2)
4.4.2. Some Cultural Differences
"There are patients who even have difficulty communicating, do not know how to communicate, or are ashamed to speak. The way of dealing with each patient is different." (P4)
"For the nurse to be able to communicate properly, s/he must know the patient and his/her culture; and this requires high knowledge of the patient and regular education and proper communication with the patient." (P10)
4.5. Perceived Defects of the Current Discharge Situation
This category included three subcategories.
4.5.1. Not Follow-up of Patients After Discharge
Patients should be followed up after discharge and referred to the hospital if necessary (3). But participants believed that:
"The patient is left alone after discharge, and we have no plan to follow-up with the patient. We do not know about the patient at all, and our next visit may be due to infection or any other problem." (P7)
"If patients are followed up after discharge, they will not have all these problems. Many readmissions after discharge are due to ignoring these issues." (P8)
"We have never had a follow-up program after discharge; but we should have it. Its instructions should be prepared and communicated." (P12)
"It is essential to follow-up all patients in any way, such as the presence of a nurse in the patient’s home, sending text messages, making telephone calls, or other cases such as patient visits by a health practitioner in the villages." (P13)
4.5.2. Unawareness of the Patient and His/Her Family of the Right to the Discharge Program
"The patient and his/her family must be educated about the discharge by the doctor and the nurse.
It is the patient's right to receive complete discharge education, and the nurse must inform the patient about the charter of rights." (P15)
"Patients and their family are sometimes discharged without education due to lack of awareness of the importance of the discharge program, and then seek solutions, and may take actions unintentionally and cause more problems for them." (P3)
4.5.3. Dispersion of Discharge Time
"It has sometimes been observed that the patient is discharged in the evening or night shift. This scattering of discharge at different times reduces the education." (P14)
"In my opinion, it is better to perform discharge in the morning shift after the visit and education of the physician. Patients may be left in other shifts without the least education. This shortcoming is because the patient is discharged in the evening or night shift and is not visited by a doctor or a nurse." (P12)
5. Discussion
According to our results, the implementation of the discharge planning was not performed seriously. Also, there was the lack of a standard and approved discharge planning, as well as deficiencies in organizational sub-structure.
In connection with the category "Lack of standard and approved discharge planning", Wong demonstrated that there was a lack of a standard discharge program and the lack of communication and coordination between health care providers and patients (14), which is in line with our study. In our study, the most emphasized issue was the lack of a standard program with specific instructions and policies. Also, the lack of communication between the treatment team at different levels was mentioned. In this regard, the participants suggested the need for effective implementation of the discharge plan and the clarity of the role of health personnel, coordination and cooperation, and effective communication between different caring departments, health care providers, and patients as practical keys in the discharge plan.
Regarding the category "Defects in organizational sub-structure", Gholizadeh conducted a qualitative study and divided the results into four items: organizational behaviors, structural changes, payment system, system rules, and regulations; these topics were identified as necessary for managers and nurses (8), which is consistent with our study. The rules and regulations of systems are another significant issue. In this regard, it was suggested that the possible system-related problems, including financial problems and equipment should be removed, and laws and regulations should be approved and applied in an integrated practice. In discussing the behavior of service providers, the need for teamwork and appropriate systemic communication has been emphasized.
Okoniewska also pointed to the crucial factors of communication, unclear roles, and lack of resources, and suggested improving communication, organizational structure, and the performance of medical teams and leaders (15). As in our study, the poor performance of the treatment team in the discharge process, lack of proper communication, lack of discharge nurses, and lack of clarity of roles were stated. Lack of resources has always been a regular part of the proper implementation of discharge planning.
Hesselink et al. reported that several factors could affect the discharge process, the most important of which is the lack of adequate education and counseling for the discharged patients due to insufficient time for nurses and lack of a clear and ordered counseling program, insufficient preparation of patients for discharge and post-discharge care, disproportionate education of patients' needs, organizational barriers including resources, disseminated discharge on holidays and without orders (16), which was similar to the points already mentioned in the "Perceived defects of the current discharge situation" and "Inadequate attention to the discharge process" categories in the present study. In our study, the lack of education and information about the discharge planning was emphasized. Dispersion of discharge time, unspecified discharge planning, poor communication, and unscheduled discharge were also mentioned in both studies.
Ghafari highlighted that the nurses' high working load, inconvenient situation of their work, and the lack of familiarity of nurses, patients, and their families with discharge planning are related to a lack of sufficient information, in-service education, and the structural issue; this is also in line with our results.
Social barriers and perceived defects of the current discharge situation were among the unique categories of our study that were not found in other studies.
As mentioned, the first discussion is related to the approval of precise discharge planning, the development of instructions, and the united strategy and its communication. Other important issues mentioned in previous studies include communication reform, budget reform, education of nurses and other medical staff, and identifying the needs of patients before discharge.
5.1. Limitations
The main limitations of this present study include the lack of access to some nurses and the reluctance of some nurses to participate.
5.2. Conclusions
According to the results, a practical step can be taken to better implement the discharge planning through approving a written discharge planning, educating the staff and patients, paying attention to patient follow-up after discharge, improving the sub-structure, and considering the patient needs. Following that, the complications after discharge will be reduced, and the discharge process will be done slowly and without complications.
