Kyle Thompson – 05970640
Management of discharge Management skills in adult nursing UZTR6D4-40-2

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The NMC Code (2008) charges nurses to protect confidential information, and to only use it for the purposes given – for their treatment. Therefore all patients and events mentioned in this essay are inspired by real patients and events, but names, locations, dates and other details have been altered or obscured to make identification impossible. Following the introduction of the knowledge and skills framework (DH 2004a) and emphasis on quality of health care and patient centred, interprofessional, health and social care (DH 2000; Leathard 2003; Thompson et al. 2002) health care professionals and students will need to be able to demonstrate the quality of our care and team working abilities. There is a connection between practice and thinking about practice – action and reflection are interdependent; they need one another. Reflection may be triggered by an awareness of a gap between theory and practice, a difference between what ‘should be’ and ‘what is’ (Sullivan & Decker 2005). Our actions and the quality of our care are improved by reflection-on-action, by making sense of what we have experienced, and thinking about how we might act differently in the future (Lillyman & Ghaye 2000). Reflection has a rôle in maintaining one's personal portfolio and maintaining competency and continuing professional development. Support and supervision from managers, who already have a responsibility for assessing competence and continuing professional development of staff can help make this process much easier (Jasper 2001). Reflection is a very personal matter, through our reflections we learn not only about our own feelings and knowledge of the situation reflected upon, but also something about our own personality (Rolfe & Gardner 2006). Unlike most academic work a reflection is presented in the first person – this is an account of how I personally feel, and whilst others may feel the same way a reflection is not a generalisable source of knowledge that will apply to a large number of health care professionals. Lillyman & Ghaye (2000) showed that reflection can show us how to influence practice and colleagues – in health and social care collaboration is required, no one profession alone can meet all of a patients needs (Irvine et al. 2002). Lillyman & Ghaye (2000) too show the importance of reflection in improving our practice in the clinical domain – the importance of the action in providing care for our patients. Our course is a combination of theory and practical learning. It is through combining this learning and by reflecting on my experiences throughout the course, that what I have learnt becomes concrete in my mind allowing me to create a set of personal experiences and a knowledge base that I can use to deal with new situations. By testing my developed ideas I can identify areas that require further research and can relate theory to practice, using a combination of learning styles using experience, experiment, reflection and conceptualisation (Rolfe & Gardner 2006). Discharge management is an interactive process that should begin at the time of a patient's admission to hospital (Corman 2005) where patients' needs are identified and a plan is made to meet those needs and make a smooth transition from one environment to another. It is a complex area requiring active communication between the patient and their family and the interprofessional health and social care 2

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team involved in their care (Corman 2005; Macleod 2006). Discharge management is interprofessional in nature, but the nurse has a key rôle in initiating discharge planning as they have daily contact with the hospitalised patient (Watts et al. 2007) which allows us to get to know the patient through our assessments and reassessments. This aids us in decision making with appropriate referrals and delegation and helps meet the goal of individualised care by reinforcing the concept of the patient as an individual (Radwin 1996; Walker et al. 2007). From a personal point of view my interest in discharge planning was aroused in my first year by a patient who was regularly readmitted to our ward, Evelyn Short. At the time I felt that she was being sent home without appropriate support, but as a first year student nurse I did not confident enough to make my opinions heard. During her last admission Evelyn was made homeless but noöne on the ward seemed concerned by this, so I contacted Evelyn's social worker myself, being aware that whilst fundamentally important to Evelyn's well being arranging accommodation was beyond the scope of my practice and so required the involvement of other health and social care professionals. If Evelyn's social worker had not been able to arrange new housing for her I often wonder what might have happened, my colleagues seemed quite content to concentrate on their own speciality, and neglect the other health and social care needs of our patients (Glasby 2003). From this experience I feel I gained some confidence to stand up for my patients, and I gained knowledge of the rôle other health and social care professionals play in the care of our patients. Assessment of needs at admission and discharge is often subjective and dependent on the nurse assessing (Lees & Emmerson 2006). Our assessment can have long term consequences for our patients' future (in)dependence (Anon 2005) – providing 'too much' care can lead to increased dependence, lack of confidence to cope alone and can lead to premature admission to care homes (Anon 2005; Macleod 2006). From personal experience I know I have anticipated needs that have not manifested, and indeed have discovered needs arising that were not evident upon my initial assessment. The skill of assessing needs is not necessarily one that is taught during pre-registration education (Macleod 2006), but is one that comes with on-the-job learning and experience (Benner 1984). Throughout my experience during the past three years in health care I have learnt of various community services and agencies one can refer to, an important component of the nurse's knowledge base when it comes to discharge management (Kennedy 2003; Watts et al. 2007). The majority of patients in acute hospital beds are older patients – 65 years and older – (ONS 2002), these patients often have greatest need at discharge (Walker et al. 2007). The older person is at increased risk of complications caused by treatment, such as drug interactions, falls and poor health outcomes following discharge from hospital leading to an increased risk of readmission (Hickman et al. 2007). Discharge management is an aspect of health and social care that is regulated by local and government policies (DH 2000; DH 2001). The nurse's rôle in discharge planning links to many important themes within nursing and management such as clinical governance, accountability and overall management of our care delivery, include good interprofessional communication skills, and delegation. In The NHS Plan the 3

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Department of Health (2000) initiated intermediate care within the community to not only facilitate early discharge but to prevent initial hospital admission. Promotion of integration of health and social care (DH 2000), and reducing the number of delays (DH 2003) continue to be prominent themes is discharge management but can sometimes seem to take precedence over goals of patient centred care (Hickman et al. 2007; Jumaa & Crossan 2007). Within the NHS knowledge and skills framework (DH 2004a), domains HWB2 (assessment and care planning to meet health and wellbeing needs), HWB4 (enablement to address health and wellbeing needs) and HWB6 (assessment and treatment planning) have considerable relevance to discharge management, along with core skills of communication and maintaining health, security and safety. These knowledge and skills domains equip nurses to assess and reassess patients' health, psychological and social needs (Kennedy 2003) and plan care to help meet those needs, help them to maintain or regain independence and educate patients about their health and services available to them. Reflection is a very personal matter, working within one's own knowledge and experience is a central component of any reflective work: we do not all view the world in the same way, so each experience is open to many different interpretations from the participating health care professionals (Lillyman & Ghaye 2000). Sharing of oneself and one's ideas promotes collaboration and develops reciprocal dialogue and new knowledge (Ipperciel 2003). By using reflection as a means to access personal practice knowledge, with respect to Kolb's learning cycle – namely that one learns by doing and realising what came of those actions – we can uncover our unspoken, implicit knowledge. Compare this to Johns' theories of reflection as a way of life – rather than reflecting on past actions and knowledge of practice the health care professional reflects upon themselves as practitioners and their ability to use the knowledge they have (Rolfe & Gardner 2006). With this in mind I have chosen to use Gibbs' reflective cycle (1988) to give structure to my reflection on my experience of discharge management and my learning. I have chosen Gibbs as I feel it allows for more freedom in reflection and it is the best fit with my way of working. Government guidelines (DH 2001) and professional codes of conduct (NMC 2008; GMC 2006) demand that health care professionals work together as a team and communicate effectively, emphasising the need to overcome professional boundaries and placing the patient at the centre of care (Waters 1998). This communication may take the form of written medical, nursing or interprofessional notes, or discussion (Hardy et al. 2000). Throughout my education I have experienced many different types of communication and interprofessional working styles from highly cohesive teams to groups of health care professionals who just happen to work together. The best teams were non-hierarchical where everyone's input was valued whilst the worst teams did not seem to communicate across or even within professions. Ensuring support for colleagues and effective teamwork is an important aspect of a management rôle (Paliadelis et al. 2007; Whyte 2007). Discharge planning is interprofessional in nature, but the nurse has a rôle is management of discharge 4

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planning as we are in a unique position of working with patients on a daily basis (Watts et al. 2007). There is a tendency to reduce patients to a sum of their health needs, bypassing their psychological and social needs (Hardy et al. 2000), such as my example of Evelyn Short in my first year – concentrating on the concept of 'medically fit' bypassing all other needs. Health and social care professionals working collaboratively, away from this 'medical model' of care, involving patients and family is needed to best meet patient's health and social care needs (Salladay 2006). During my current placement in an acute medical ward two discharges have stuck in my mind as notable – Marita Ulvskog's discharge one for its ease whilst Peter Oakley's was distinct for some problems experienced Marita Ulvskog is a lady in her 90s who came into our ward with acute exacerbation of existing heart failure. Before admission Marita already had home care and meal services and used a 'dossette box' to aid concordance with medication. Marita was discharged home following surgery for a pacemaker, with a modified 'dossette box' and a re-started package of home care. From a follow-up appointment I have learnt that she is continuing to live independently at home with her home care and family support. Using Gibbs' (1988) reflective cycle to explore this event my involvement with Marita was one of supporting her to remain as independent as possible to prepare to return home and carry on as she was before her admission. Through working with her during various shifts I felt that I got to know her (Radwin 1996) and was in a position to assess what her needs on discharge might be. Arranging for Marita's home care to be restarted was a simple matter of a phone call to social services to find out a start date. Assessment and discharge planning is dependent on the individual making the decision, their knowledge, experience and personal values (Sandland 2002; Young & Cooke 2002), and is often a combination of experiential intuitive decision making and rational analytical decision making methods (Harbison 2001). Thompson (1999) suggested this 'common ground' using a combination of two theories of decision making as a basis for nursing decisions exist on a 'cognitive continuum' between intuitive and analytical decision making. Documentation of Marita's abilities during her hospital stay and the extent of help she required enabled us to ensure that she was sent home with an appropriate level of care. Having assessed Marita's needs we were able to delegate care to support staff (NMC 2007a), which enabled us to plan for discharge. Whilst Marita's nursing needs were very simply met, her being such an independent lady, my rôle in supporting her care and discharge was one of assessment and promoting independence. It is important to gain the coöperation of our patients (Jumaa & Crossan 2007) – personally I always tell my patients I am 'working with them', rather than 'looking after them', in doing so I feel I am collaborating with my patients in their care and offering patient empowerment offering health promotion and education, rather than a pedagogical model of care simply instructing patients (Smith & Liles 2007). Whilst allowing for maximum patient autonomy as a registered nurse I will be accountable for the care I give or omit, balancing autonomy and beneficence – when does granting a patient's autonomy meet non-maleficence 5

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(Manos & Braun 2006)? Accountability is defined by the NMC as a responsibility to others who rely on the registered nurse. Nurses are accountable to the NMC, their employers through contract terms and are also accountable to the law for action and inactions, and have a duty of care to provide a reasonable standard of care, which can be tested in law by the Bolam Test, a test of the level of skill that can be expected of the average skilled nurse (Dimond 1995; NMC 2008; 2006a, b). Accountability is independent of any advice or instructions given by any other health care professional – it is up to the nurse to determine if any activity is in the best interests of each individual patient using their professional knowledge, judgement and skills in making our decisions (NMC 2008; 2006a). In delegating tasks to support staff, accountability lies with the health care professional delegating, for which they should ensure that the delegate is competent to undertake those tasks (NMC 2008; 2007a). Concluding Marita Ulvskog's discharge our interprofessional plan centred around assessment of her needs and abilities in conjunction with her changing well being and medical needs. Marita's personal abilities to cope with her activities of daily living (Anon 2002) did not change during her admission and she was able to return home with her minimal assistance to wash and dress and meal service. Her new pacemaker, along with her age and history of cardiac problems meant we booked her a six week follow-up appointment, with further follow-ups at the discretion of the reviewing consultant. From her first follow-up I learnt that Marita has had no further cardiac problems and is continuing to live with supported independence in her own home. Through thorough assessment we were able to formulate a plan for discharge in liaison with the medical team, Marita and her family. In making decisions about Marita's care we used intuitive knowledge from experience in combination with theoretical, evidence-based knowledge (Goodman 2006; Thompson et al. 2002) as well as knowledge gained from colleagues in our interprofessional team (Kennedy 2003). An essential feature of all decisions relating to patients is their involvement in the decision making process (Thompson et al. 2002), and fitting our care around them (Carr 2004). Making decisions making is a key skill of the nurse, and is an important part of preregistration education (Harbison 1991), a skill that combines all the science, ethics, art of nursing, and personal values – in conjunction, not any one feature alone (Kennedy 2003). My personal involvement with Marita reinforced the importance of patient centred care and thorough assessment. Peter Oakley was a man in his 80s who came into our ward with acute oedema and reduced mobility complicated by multiple organ failure and shortness of breath. Peter also had an history of pancreatic cancer. Before admission Peter had been living independently in a warden controlled flat. Peter's oedema and breathing difficulties were resolved and he returned to independence but within the space of a couple of days complications from his cancer caused a decline in his abilities and it was evident that he only had a few days left. Peter expressed a wish to return home to die. Palliative care and a local hospice had been involved with Peter for some time, so we planned an urgent discharge home to allow for Peter's wishes. Unfortunately for Peter there was not the structural capacity to care for him at home for nearly a week, so we continued to care for him in our ward. Eventually Peter managed to return home, but was only there for an hour before he passed away. Using Gibbs' 6

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(1988) reflective cycle to explore this event I can see that our nursing assessment was at the core of our plans for Peter. Whilst independence was regained for a few days, it soon became clear that his final decline would indeed be his final decline. At this point the nurse's rôle changes slightly – rather than bringing the means to cure and comfort, we disregard the cure and concentrate on the comfort, ensuring privacy and dignity, supporting both the patient and their family (Woogara 2004; WHO 2007). Effective communication between providers – primary and secondary care and the voluntary sector – are fundamental to ensure appropriate, timely care is available for patients throughout their cancer treatment (Farquhar et al. 2005). Peter was involved with a local hospice and had a key contact there, and indeed had been there many times for periods of respite. During his admission the hospice had been kept informed and his key nurse had visited him too. Even though we had resolved his cardiac problems his decline meant that he was not going to be able to return home without care, as he had been independent before his admission. To organise a package of care involves communication, coördination and coöperation between various health and social care professionals (Farquhar et al. 2005). Despite the involvement of the palliative care team and a local hospice, the fact that Peter was only in his own home for an hour before he died meant that I felt we had failed him. Blaming one another is a human condition, perhaps to overcome feelings of inadequacy when we let people down – when we fail to provide the care we feel our patients need. Conversely when we can discharge a patient from hospital to their own home with an appropriate care package not only does the patient get the care they need but all health and social care professionals involved can feel happy with a positive outcome (Glasby 2003). However despite feeling we let Peter down, I know that our assessment and referrals to other services were well planned and implemented and it was only the structural capacity of the hospice that meant Peter could not return home as soon as he wished. Looking into the reasons for delayed discharges we see that the process brings to the fore many of the problems between health and social care. Problems lie with poor coördination, lack of clear rôle responsibilities, lack of communication, inadequate assessment and planning for discharge, poor communication with patients, carers and family regarding needs on discharge (Henwood 2006). Leppa & Terry (2004) suggest that in the UK nurses coöperate in discharging patients before they are ready in order to assist with meeting targets and easing problems related to bed shortages. It is essential to have knowledge of how the social and political system of the organisation affects care delivery – we can only question practice with a sound knowledge of health and social care system limitations and options available (Leppa & Terry 2004). Peter's case reinforced the importance of assessment in any plan for discharge, but this can sometimes be complicated by a lack of time to get to know our patients (Radwin 1996). During a hospital admission patients will work with many different health care professionals, and may move various times within any ward and between wards – from discussions with patients I have learnt that during an average stay patients may be admitted to four or five different wards and sometimes can be 7

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transferred between hospital sites. Working with individual patients for short periods of time reduces our ability to get to know the patient as an individual (Radwin 1996). The patient stress related with moving is becoming an increasing problem and can lead to insecurity, anxiety, lack of trust and feelings of rejection (Beard 2005). Indeed the hospitals at which I have worked tend have an admissions and assessment unit, which leads to patients being admitted to a specialist ward as appropriate, possibly followed by a period of rehab in another ward. Even if patients are discharged directly home from the specialist ward once medically fit for discharge they may be 'outlied' to another ward to free beds. Whilst we could conclude that Peter's discharge was not satisfactory in outcome for himself we could conversely conclude that the discharge plan was successful – we assessed, planned and implemented (Moore 1996) an appropriate discharge plan with the interprofessional health and social care team, it is only in evaluation of our plan that the limitations of the service providers caused delay (Leppa & Terry 2004). For my future practice I feel that, as with Marita, assessment has been reinforced in importance, along with interprofessional communication amongst the health and social care team in order to fully meet my patients needs. Discharge management is a process that should begin at the time of a patient's admission to hospital (Corman 2005), assessing needs and other services involved so we can keep the whole health and social care team informed of our patients' progress. Reflecting upon the discharge process in general terms using Gibbs' (1988) reflective cycle I have already stressed the importance of assessment and interprofessional team working as the basis of discharge plans in my experience, and with my first example of Evelyn Short with her continual readmissions followed failed discharges we can seen the effects inappropriate discharges can have on our patients and the health and social care system. Management skills taught in preregistration education can help prepare us for our rôle as a qualified nurse but we also need to learn from one another in practice in order to fully appreciate how teams can work together (Scholes & Vaughan 2002). Planning for discharge requires us to work in collaboration with the interprofessional health and social care team and the patient and any carers, formal or informal (Farquhar et al. 2005). In my practice I endeavour to put the patient's preferences at the centre of their care where practicable (Allmark 2005) and take their opinion into account when making decisions about their care. Having an ethical approach to health and social care is an important feature of nursing for me. Overcoming tradition and ritual (Walsh & Ford 1989) involves reflection on what is the ethical or 'right thing to do'? Reflecting on 'usual practice' (ritual) without a base knowledge of how things should or could be done differently perpetuates ritualistic behaviour (Leppa & Terry 2004; Sullivan & Decker 2005). Ethics are tricky as they are a very personal in nature; it is possible to ethically argue for opposing decisions with an equal value of 'correctness' depending on one's own morals (Husted & Husted 2001). There are many ethical theories (Leppa & Terry 2004; Tschudin 1994) but since it is such a personal area who is to say which more correct? Two long-established theories are the Socratic method, considering 8

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alternatives and their outcomes in order to make a choice, and the Aristotelian 'argument' method, which involves finding a common starting point and working out a decision through discussion (Tschudin 1994). In any case, discussion, especially involving the patient is an important ethical principal in care planning (Ipperciel 2003). Ethics encompass a number of principle and rights: a right for autonomy, the right to live one's life as one wishes it (Carr 2004); the principles of beneficence and nonmaleficence along with equality and justice (Manos & Braun 2006), although in the personal nature of ethics it is possible to approach these values from opposing view points, such as utilitarian “greater good” vs. deontological “duty to others”. In any decision making scenario, patient choice, however non-rational, should be central to any decision (Allmark 2005). Taking responsibility for our own continuing professional development and ensuring we practice in a safe and accountable manner is dependent on our ability to reflect upon our own practice and that of others. Whilst comments from colleagues are useful, ultimately it is my own self evaluation that is important in reflecting on my experiences. Reflections are often private and not intended to be shared with others, whilst others can help oneself and others to develop (Lillyman & Ghaye 2000). As adult learners working in a profession that values and requires continuing professional development we have autonomy in our own learning; diminished boundaries between student and teacher, reflection upon our learning, and our own view of nursing and participation in practice leading to awareness of our own personal and professional development (Bankert & Kozel 2005). Effective evidence based care is a duty of the registered nurse: The NMC Code (2008) tells us we must 'deliver care based on the best available evidence or best practice' (NMC 2008. p7). Overcoming the barriers, actual or perceived, is important in providing the highest quality care. In order to properly implement evidence based practice we need to take into account the triad of a sound evidence base, patient preference where practicable and the experience and expertise of the health care professional (Hek & Moule 2006). Discharge planning is seen as an uninteresting aspect of the nurse's rôle (Lees & Emmerson 2006), a fact that has be corroborated with discussion amongst my peers. However the nurse is in a unique position to best inform and manage discharge of any specific patient through the process of knowing the patient throughout their admission. Knowing the patient is important concept in decision making and allows us to plan for truly individualised care (Radwin 1996). Thirty years ago patients often did not know exactly what their plan of care involved and were very much nonparticipant with their own care (Roberts 1975; Gay & Pitkeathley 1979). Today a more educated public has lost its intrinsic deference towards health care professionals and is less tolerant of being expected to be a passive participant in health care (Leathard 2003). Discharge management, except for the very simplest of discharges when the patient goes home fully independent without needing any health and social care services (DH 2004b), requires implicit interprofessional working to achieve a good, timely discharge (Hickman et al. 2007). The 2001 census showed that for the first time there 9

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are more people over 60 than there are children, and with expectations only for an increasing older population (ONS 2005) and technological advances in health care enable people to survive acute illness and accidents can lead to more complicated discharge needs (Watts et al. 2007).

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Sandland D. (2002) The characteristics of decision making in health care (p79-99) in Young A. P. & Cooke M. (eds) Managing and Implementing Decisions in Health Care London: Baillière Tindall Scholes J. & Vaughan B. (2002) Cross-boundary working: implications for the multiprofessional team Journal of Clinical Nursing 11 p399-408 Smith J. & Liles C. (2007) Information needs before hospital discharge of myocardial infarction patients: a comparative, descriptive study Journal of Clinical Nursing 16 p662– 671 Stapleton P., Henderson A., Creedy D. K., Cooke M., Patterson E., Alexander H., Haywood A. & Dalton M. (2007) Boosting morale and improving performance in the nursing setting Journal of Nursing Management 15 p811-816 Sullivan E. & Decker P. (2005) Effective Leadership and Management in Nursing, 6TH Edition Prentice Hall, New Jersey Thompson C. (1999) A conceptual treadmill: the need for 'middle ground' in clinical decision making theory in nursing Journal of Advanced Nursing 30(5) p1222-1229 Thompson C., McCaughan D., Cullum N., Sheldon T., Thompson D. & Mulhall A. (2002) Nurses’ Use Of Research Information In Clinical Decision Making: A Descriptive and Analytical Study York: University of York Tschudin V. (1994) Nursing ethics IV: theories and principles Nursing Standard 9(2) p51-55 Walker C., Hogstel M. O. & Curry L. C. (2007) Hospital Discharge of Older Adults – How nurses can ease the transition American Journal of Nursing 107(6) p60-70 Walsh M. & Ford P. (1989) Nursing Rituals: Research and Rational Actions Oxford: Butterworth-Heinemann Waters A. (1998) Breaking down boundaries Nursing Standard 12(22) p14 Watts R., Pierson J. & Gardner H. (2007) Co-ordination of the discharge planning process in critical care Journal of Clinical Nursing 16 p194-202 Whyte L. (2007) The team wheel Nursing Management 13(9) p22-24 Woogara J. (2004) Patients' Rights to Privacy and Dignity in the NHS Nursing Standard 19(18) 33-37 World Health Organization (2007) Palliative Care Geneva: WHO Young A. P. (2002) The political context of decision making (p3-21) in Young A. P. & Cooke M. (eds) Managing and Implementing Decisions in Health Care London: Baillière Tindall Young A. P. & Cooke M. (2002) Managing and Implementing Decisions in Health Care London: Baillière Tindall

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Word Count
Word count (not including front page, contents or reference list) 4228

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