Transcript Patient

RELATIONAL NURSING CARE:
A Strategic Model Of Care To
Improve Discharge Readiness and
Safe Transitions
M a r y K . A n t h o n y, P h D , R N 1 , 2
Kathleen Vidal, MSN,RN2
Pimpanitta Jittapiriom, PhD (candidate)1
Carolyn Kleman, MSN, RN1
Amany Farag, PhD,RN 3
Supported by Kent State University
University Hospitals Case Medical Center
1K
e n t S t a t e U n i v e r s i t y , 2U n i v e r s i t y H o s p i t a l s
C a s e M e d i c a l C e n t e r , 3U n i v e r s i t y o f I o w a
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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University Hospitals Case Medical Center
BACKGROUND
• Is discharge the most important conversation
in a hospitalization?
• Characteristics of Discharge Communication
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University Hospitals Case Medical Center
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.
Kent State University
University Hospitals Case Medical Center
METHOD
Design:
Sample:
Setting:
Cross-sectional correlational
Convenience
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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University Hospitals Case Medical Center
METHOD
Inclusion 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
Kent State University
University Hospitals Case Medical Center
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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University Hospitals Case Medical Center
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.
Kent State University
University Hospitals Case Medical Center
METHOD
Response Rate
A total of 554 surveys were
distributed; 222 were returned and
usable for a 40% response rate
RN
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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University Hospitals Case Medical Center
RN DEMOGRAPHICS
Age
Unit
Individual
Mean yrs (SD)
Mean yrs (SD)
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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University Hospitals Case Medical Center
PATIENT DEMOGRAPHICS
Patient Sample
Gender
Male (n = 166)
44.4%
Female (n= 208)
55.6%
Previous Hospitalization
90.4%
(n = 340)
How long have you been in the 4.8 days (4.28)
hospital?
Range 1-36 days
How many times have you
been hospitalized?
74 % reported being
hospitalized 1-5 times
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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.
Kent State University
University Hospitals Case Medical Center
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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University Hospitals Case Medical Center
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
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)
(1 is most important)
Kent State University
University Hospitals Case Medical Center
READINESS FOR DISCHARGE
Unit
Perception of Readiness for
Discharge
Patient
Individual
M (SD)
M (SD)
8.11 (.53)
8.13 (1.43)
2.73 (.26)
2.70 ( .61)
(0-10)
RN
(1-4)
Kent State University
University Hospitals Case Medical Center
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
RN Perception of
Patient Readiness
Patient Perception of
Readiness
.20
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Hospitals Case Medical Center
p
.35
CORRELATION
RN Perception of
Readiness for
Discharge
Conducting Admission
Interview
p
- .20
.35
Conduct Daily Sit Down Rounds
.50
.01
Conduct Discharge Interview
.30
.15
- .32
.14
.10
.64
- .15
.47
.06
.79
Importance of:
Discharge Planning
Patient Education
Sit Down with Patient
Conversation with patient
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Hospitals Case Medical Center
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
Discharge Planning
- .32
.13
Patient Education
- .03
.90
Sit Down with Patient
- .09
.66
.10
.63
Importance of:
Conversation with patient
Kent State University-University
Hospitals Case Medical Center
RN PERCEPTION OF PATIENT
READINESS FOR DISCHARGE
(N = 23)
Admission Interview
Sit down rounds
Discharge Interview
Importance of
Discharge Planning
Beta
- .10
.55
- .07
t
- .55
2.30
- .31
p
.58
.03
.76
- .28
-1.46
.16
Model R2=.38, F 4, 18= 2.80 p = .057
*p<
.05,* * p < .01 ***p < .001
Kent State University
University Hospitals Case Medical Center
PATIENT PERCEPTION OF PATIENT
READINESS FOR DISCHARGE
(N = 23)
Admission Interview
Sit down rounds
Discharge Interview
Importance of
Discharge Planning
Beta
.29
.12
.15
t
1.38
0.46
0.55
p
.18
.65
.58
-.34
- 1.56
.13
Model R2=.23, F 4, 18= 1.36 p = .28
*p<
.05,* * p < .01 ***p < .001
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University Hospitals Case Medical Center
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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University Hospitals Case Medical Center
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?
Kent State University
University Hospitals Case Medical Center