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Published on April 27, 2014

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COMMUNICATION ESSENTIALS: Interdisciplinary Discharge Planning

NURSING CORE COMPETENCIES: FOR INTERDISCIPLINARY DISCHARGE PLANNING Communication  “The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making to enhance patient satisfaction and health outcomes” (Masters, 2014, p.78). Teamwork  “The Nurse of the Future will function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development” (Masters, 2014, p.78)

WHAT IS COMMUNICATION?  A process that includes 5 factors:  SENDER – encodes a message to be transmitted;  MESSAGE – the ideas, symbols, signals being transmitted;  CHANNEL/MEDIUM – the means by which a message travels;  RECEIVER – receives and decodes the message; and  FEEDBACK – Receiver provides feedback to Sender to signal effective reception of intended message (Oxford University Press, 2014; Communication Models and Theories, n.d.).

COMMUNICATION: PROCESS CYCLE Sender Message Chanel/MediumReceiver Feedback (Oxford University Press,2014).

NURSE-PATIENT COMMUNICATION: SUCCESSFUL INTERACTION  Scenario: During Admission Intake, Nurse Hope Soeiltry would like to obtain a medication list from Patient Will U. Listinclose for a safe medication reconciliation.  Sender (Nurse: Hope) – encodes her message with words by asking a question  Message (The Question) – what medications do you take at home? Can you tell me and write them down on this paper to include the name, dose, and time you take them?  Channel/Medium (Verbal/Written) – both verbal and written responses  Receiver (Patient Will) – decodes the message; begins to tell Nurse Hope his medications from home while writing them down  Feedback (Patient: Will) - asks if he should write down his over-the-counter medications while showing Nurse Hope his medication list in progress. Nurse Hope nods in agreement while saying, “absolutely correct!”.  Outcome of Communication: SUCCESS!

EFFECTIVE COMMUNICATION: BARRIERS TO SUCCESS  Noise or Interference – ambient noise, alarms, bells, televisions, radios;  Medium chosen poorly – incompatible language, incompatible medium i.e. hearing impaired (chose verbal transmission), visually impaired or illiterate (chose written transmission);  Message – unclear, inappropriate, incongruent, lacks context;  Receiver – emotionally/psychologically compromised (angry, anxious, sad, fearful, uncooperative/unreceptive); physically compromised (pain, fatigue, altered mental status);  Feedback – Receiver did not provide feedback to ensure successful communication occurred; Sender did not request for feedback (Communication Models and Theories, n.d.).

STRATEGIES TO OVERCOME BARRIERS: EFFECTIVE COMMUNICATION  Sender – is clear, concise, and congruent during message transmission process;  Reduce or Eliminate – sources of interference with a calm, quiet, and timely delivery environment for the communication to take place;  Select Appropriate Medium – relative to the age, ethnic/cultural, and language determined to be compatible with the receiver;  Assess the Receiver – for readiness i.e. Alert, oriented, well rested, with a reasonable mood disposition; and  Request Feedback – ask the receiver is they understood the message delivered; exercise a repeat-back and verify process to ensure successful delivery.

DISCHARGE PLANNING AND EFFECTIVE COMMUNICATION: WHAT & WHEN Definition:  “Preparation for moving a patient from one level of care to another within or outside the current health care agency” (Bulechek, Butcher, Dochterman, & Wagner, 2013, p.150). When:  “Planning for discharge begins during the initial contact with the client by establishing the expected outcomes and anticipating follow-up care that may be needed” (Harkreader, 2007, p.206).

DISCHARGE PLANNING AND EFFECTIVE COMMUNICATION: RATIONALES Poor Planning and Discharge Communication is Costly:  “Poor communication can endanger patients’ lives and waste fiscal and human resources” (Lattimer, 2011).  “Delays, omissions, and inaccuracy of discharge information are common at hospital discharge and put patients at risk for adverse outcomes” (Harlan, 2010).  “It’s often poor communication, coupled with an expectation that patients or caregivers will remember and relate critical information, which can lead to dangerous, even life-threatening, situations” (Lattimer, 2011).

RN DISCHARGE ACTIVITIES: OVERVIEW NURSING INTERVENTIONS CLASSIFICATION (NIC) SUMMARY  Assist patient/family/significant others to prepare for discharge;  Collaborate with interdisciplinary team/patient/family/significant others;  Coordinate with other providers for a timely discharge;  Identify patient / caregiver knowledge or skills required for discharge;  Identify patient teaching required for post-discharge care;  Communicate patient discharge plans as appropriate;  Monitor readiness for discharge;  Formulate discharge maintenance plan;  Arrange post-discharge evaluation; and  Discharge to next level of care (Bulechek et al., 2013 p.150).

CASE MANAGEMENT: OVERVIEW DISCHARGE ACTIVITIES  Screening and Intake – identify discharge disposition / placement and destination;  Assess needs – financial resources, treatment plans coordinated with physician, patient and family for smooth discharge transitions;  Service planning – initiate plan of care, identify barriers to outcomes achievement, post-discharge service need identification, setting mutual goals with family/patient;  Link patient to what they need – resource utilization, appropriate length of stay planning, evaluation of expected outcomes progress;  Implement Interdisciplinary Treatment Plan – monitor expected outcomes, begin arranging post-discharge arrangements, re-evaluate discharge destination if needed; and  Evaluate Patient Care Outcomes – based on plan of care progress towards achieving outcomes; round with the attending physician to obtain progress feedback (Cesta, 2013).

DISCHARGE COMMUNICATION: INTERDISCIPLINARY STRATEGIES  Team Approach:  Discharge Planning Teams (Rose & Haugen, 2010).  Standardizing Communication:  “S-B-A-R” (Bengasco et al., 2013).  Evidence-Based Discharge Education:  “Teach-Back” (Kornburger et al., 2013).

DISCHARGE PLANNING TEAMS: MULTIDISCIPLINARY INTERVENTION STUDY  Based on a study conducted in a Progressive Care Unit (PCU) in a Midwestern Hospital (Rose & Haugen, 2010):  Problem – Current Discharge Process Concerns  Incomplete / Inaccurate Discharge Summaries  Incomplete Prescriptions  Inconsistent Discharge Education  Communication Gaps regarding: Discharge dates, time, and disposition  Intervention – Formation of Discharge Planning Teams  Possible Outcomes – Effective Discharge Planning  Decreases Re-admissions  Promotes Cost-effective Use of Inpatient Beds  Increased Patient / Staff Satisfaction

DISCHARGE PLANNING TEAMS: IDENTIFYING KEY MEMBERS  Physician,  Physician Assistant (P.A.),  Nurse Manager,  Registered Nurse,  Pharmacist,  Social Worker,  Discharge Planner,  Secretary, and  Continuous Improvement Specialist (Rose & Haugen, 2010).

DISCHARGE PLANNING TEAMS: ACTIVITIES PER DISCIPLINE  Physician & P.A.:  Education on pathology and surgical reports,  Writes discharge prescriptions the night before discharge, and  Completion of discharge summaries;  Registered Nurse:  Education on post-discharge care requirements night before discharge and on the day, and  Coordinate follow up for outstanding discharge items to be completed;  Pharmacist:  Fills prescriptions at Hospital Outpatient Pharmacy; and  Verifies insurance information as soon as possible to fill script promptly (Rose & Haugen, 2010).

DISCHARGE PLANNING TEAMS: JOINT ACTIVITIES –SURVEY, AUDIT & RESULTS  Pre-implementation of Discharge Planning Teams:  Discharge Summaries – 60% completion rate,  Prescriptions Written – 45% completed night before discharge,  Nursing Staff Satisfaction – 37% contentment with discharge process, and  Patient Satisfaction – 93% perceived a smooth process;  Post-implementation of Discharge Planning Teams:  Discharge Summaries – 91% completion rate by 2007,  Prescriptions Written – 88% completed night before discharge by 2007,  Nursing Staff Satisfaction – 91% contentment with discharge process by 2007, and  Patient Satisfaction – 100% perceived a smooth process by 2007 (Rose & Haugen, 2010).

DISCHARGE PLANNING TEAMS: KEYS TO SUCCESSFUL IMPLEMENTATION  Communication Remains Open – Across all disciplines must be open to facilitate acceptance of changes in processes;  Multidisciplinary Involvement – input from various disciplines facilitated the efficiency of workflow by identifying barriers related to other departments/services; and  Continuous Improvement Process – teams must be cognizant of the changes in health care environment: Payer systems, regulatory agencies, and processes, ready to adapt to changing conditions (Rose & Haugen, 2010).

STANDARDIZING COMMUNICATION: RATIONALES FOR IMPLEMENTATION  Good Communication is characterized by:  Timeliness,  Standardization of Content, and  Well coordinated between disciplines (Reilly, Marcotte, Berns, & Shea, 2013).  Errors in Communication results in:  Adverse Events with Negative Patient Outcomes,  Negative Emotional Impacts for Patients & Caregivers,  Increased associated Costs,  Increased Length of Hospital Stay,  Loss of Patient Trust, and  Increased Risk for Litigation (Bagnasco et al., 2013; Reilly et al., 2013).

STANDARDIZED COMMUNICATION: PROPOSED METHODS  S.B.A.R – Situation, Background, Assessment, & Recommendations:  Recommended as a Standardized Communication Tool, and  Has Written and Verbal components for Communication at Patient Hand-off and Transfer (Bagnasco et at., 2013).  Proposed Benefits – S.B.A.R Implementation:  Mitigation of Risk associated with poor Communication during Patient Hand-off and Transfer i.e. Memory Failures,  Standardizes Communication Styles of various healthcare workers to create uniformity, and  Optimizes communication timing via Standardized reporting procedure (Bagnasco et al., 2013).

DISCHARGE EDUCATION: EVIDENCE-BASED STRATEGIES  “Teach-Back” Process – “a comprehensive, interdisciplinary, evidence- based strategy which can empower nursing staff to verify understanding, correct inaccurate information, and reinforce medication teaching and new home care skills with patients and families” (Kornburger et al., 2013).  Proposed Benefits – “Teach-Back”: Implementation  Provides opportunity to Verify Understanding, Correct Inaccurate Information, and Reinforce Medication Education and Home Care Skills;  Valuable, Easily Implemented and Understood, and Cost-effective Education Strategy;  Engages Patients and Families in learning activities;  Patient and Family-centered Education Strategy (Kornburger et al., 2013).

DISCHARGE EDUCATION: TEACH-BACK PROCESS  “Teach-Back” Goal – Effective Family / Patient Self-Management:  Step 1: Teach a New Concept or Skill,  Step 2: Clarify or Correct Misunderstandings,  Step 3: Acknowledge any Questions Patient/Family may Have, and  Step 4: Continue the Process until Concept or Skill is Understood (Kornburger et al., 2013).  Nurse Competencies – Understand Health Literacy Principles:  Encourage Patient/Family Questions,  Use Plain Language,  Limit Teaching to 3-5 Concepts, and  Document “Teach-Back” education in the approved form (Kornburger et al., 2013).

SUMMARY & CONCLUSION  Communication Highlights:  Is a vital function to ensure Patient Safety;  Failures occur mostly during points of Transfer of Care;  Failures carry a significant potential for Adverse Patient Events;  Standardized Communication methods optimize outcomes;  Discharge Planning Highlights:  Requires an Integrated, Multidisciplinary & Team Approach;  Begins at Admission, is ongoing, and is constantly re-evaluative in nature;  Is Patient and Family-centered; anticipating needs constantly;  Requires effective communication between patients, family, and Healthcare Team; and  Requires pre-emptive, evidence-based discharge Education from entire team (Bagnasco et al., 2013; Kornburger et al., 2013; Reilly et al., 2013; Rose & Haugen, 2010).

REFERENCES Bagnasco, A., Tubino, B., Piccotti, E., Rosa, F., Aleo, G., Di Pietro, P., & Sasso, L. (2013). Identifying and correcting communication failures among health professionals working in the Emergency Department. International Emergency Nursing, 21(3), 168- 172. doi:10.1016/ j.ienj.2012.07.005 Bulechek, G., Butcher, H., Dochterman, J., & Wagner, C. (2013). Nursing Interventions Classification (NIC). (6th ed.). St. Louis, MO: Mosby Elsevier. Cesta, T. (2013). Back to Basics: A Day in the Life of a Hospital Case Manager - Part 1. Hospital Case Management, 21(8), 107-110. Communication Models and Theories. (n.d.). retrieved from http:// Harkreader, H. (2007). Fundamentals of Nursing: Caring and Clinical Judgment. (3rd ed.). St. Louis, MO: W.B. Saunders Company Elsevier. Harlan, G. A., Nkoy, F. L., Srivastava, R., Lattin, G., Wolfe, D., Mundorff, M. B., & ... Maloney, C. G. (2010). Improving Transitions of Care at Hospital Discharge- Implications for Pediatric Hospitalists and Primary Care Providers. Journal For Healthcare Quality: Promoting Excellence In Healthcare, 32(5), 51-60. doi:10.1111/j.1945-1474.2010.00105.x

REFERENCES Kornburger, C., Gibson, C., Sadowski, S., Maletta, K., & Klingbeil, C. (2013). Using “Teach-Back” to Promote a Safe Transition From Hospital to Home: An Evidence-Based Approach to Improving the Discharge Process. Journal Of Pediatric Nursing, 28(3), 282-291. doi:10.1016/j.pedn.2012.10.007 Lattimer, C. (2011). When It Comes to Transitions in Patient Care, Effective Communication Can Make All the Difference. Generations, 35(1), 69-72. Masters, K. (2014). Role Development in Professional Nursing Practice. (3rd ed.). New York: Jones & Bartlett. Oxford University Press. (2014). Shannon and Weaver’s model. Retrieved from 36 Reilly, J. B., Marcotte, L. M., Berns, J. S., & Shea, J. A. (2013). Handoff Communication Between Hospital and Outpatient Dialysis Units at Patient Discharge: A Qualitative Study. Joint Commission Journal On Quality & Patient Safety, 39(2), 70-76. Rose, K., & Haugen, M. (2010). Discharge planning: your last chance to make a good impression. MEDSURG Nursing, 19(1), 47.

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