A discharge planning questionnaire for clinical practice

Clinical A Discharge Planning Questionnaire for Clinical Practice

Margaret J. Bull

E

ACH YEAR more than one third of persons age 65 or over are hospitalized (National Center for Health Statistics, 1991). With lengthsof hospital stays averaging 6.3 days, health care professionalshave lesstime in which to identify older persons’needsfor follow-up care and lesstime in which to arrange for care (National Center for Health Statistics, 1991). In fact, practitioners report that discharge planning rarely occurs smoothly; often assessments are incomplete, and the information needed for successful discharge planning is not recorded (Proctor & MorrowHowell, 1990; Waters, 1980). Determining patients’ and family members’ perspectives of their situation and their needs is an important component of a comprehensivenursing assessment-one that is vital for effective dischargeplanning. Existing discharge screensfocus on information such as patient’s age, diagnosis, and living arrangementswith little or no attention to patient or family expectations (Berkman & Abrams, 1986; Wallace & Steinhauer, 1988). The CAAST (continence, age, ambulation, social background, and thought [processes]) is one of the few objective clinical measuresdeveloped to assesspatient’s posthospital needs. The CAAST scaleis basedon the patient’s statusof continence, age, ambulation, social background, and thought processes.Scores for each category range from 0, indicating no problem in an area, to 2, reflecting persistentproblems. Composite scoresrange from 0 to 10, with higher scores implying more complex needsafter hospitalization (Glass & Weiner, 1976). However, Inui and colleagues (1981) reported that the CAAST identified only 63% of patients who require special arrangementsfor discharge placement. Although broad diagnostic and demographic screeningcriteApplied

Nursing

Research,

Vol.

7, No. 4 (November),

1994:

193-207

Methods

ria are widely used in practice situations, investigators indicate that these criteria have not been effective in identifying personswho need followup care (Berkman & Abrams, 1986). Previous screensfor discharge planning were developed for useexclusively by professionalsand tended to communicatefactual information suchas age, diagnosis, living arrangements,and previous hospitalizations (Matz & Berke, 1986). More recent screensemphasizepatient functioning, availability of support, and someaspectsof their physical environment (Berkman & Abrams, 1986; Wallace & Steinhauer, 1988). Less attention has beengiven to systematicways of eliciting patients’ and family members’ perspectives and expectations about posthospital care and identifying discrepancies between facts, beliefs, and expectations. Becausea measurefor patient’s expectations and perspectives on their needs for posthospital care could not be found, the Discharge Planning Questionnaire (DPQ) was developed to aid clinicians in identifying patients’ and family members’ perspectiveson their needsfor follow-up care. VALIDITY

Content Validity Qualitative data were collected in semistructured interviews with a purposive sample of 38 health care professionals (19 nurses, 11 physicians, and 8 social workers) and 25 eldersto identify content important to include in a discharge planning screen for elders. Elders ranged in age from 68 to 90 years with an average age of 78 years. All had been hospitalized for an acute episodeof a chronic illness such as congestive heart failure, chronic obstructive pulmonary disease (COPD), or diabetes mellitus and had recent experience with planning to leave the hospital. Elders’ educationranged from lessthan eighth grade to a graduate degreewith a median of high school graduate. All elderswere able to speakand understand English and had been discharged from an acute care hospital within the past 2 weeks. The health care professionalsselectedhad been in practice for an averageof 11 years (range 1 to 29 years) 193

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and were involved in planning for elderly patients’ hospital discharge. Interview data were coded for categories that were important to consider in planning for discharge, and desired postdischarge outcomes. Intercoder reliability was established by having the investigator and two research assistants code the same interviews for 20% of the sample. Patients and professionals identified a total of 52 items important to consider in planning for discharge. These items were classified into five categories: activities of daily living (ADLs), instrumental activities of daily living (IADLs), availability of and access to social support, characteristics of the patient’s environment before admission, and patient/ family preferences. Verbatims from the data were used in developing the items for each of the four categories in order to enhance face and content validity. The items were reviewed by two panels of experts. The professional panel was comprised of eight health care professionals involved in discharge planning for older adults (physicians, nurses, and social workers). The consumer panel was comprised of eight elders who had recently experienced a hospitalization for an acute episode of congestive heart failure, diabetes mellitus, or chronic obstructive pulmonary disease. Health professionalswere askedto indicate the items that they believed were important to include, whether any areasthey consideredimportant were missing, and whether items belonged in the categories in which they had been placed. An Index of Content Validity (CVI) was calculated by dividing the total number of important items by the total number of items (Lynn, 1986). The overall CVI for the health professionalpanel was 0.92. A CVI of at least .80 is recommended for new instruments (Davies, 1992). Elders were asked to circle words or items that were unclear, to indicate the items that they believed were important to include, and to indicate whether any important areashad been missed.The overall CVI was 0.77 for the panel of elders. Examination of items within categoriesindicated that eldersand professionalsdiffered on the importance assignedto patient and family preferencesas well as assistanceavailable from family. Elders rated all three preference items very important, whereas professionalsrated only one item important. ProfessionaIsrated all social support items as very important, whereaselders did not consistently rate

METHODS

assistancefrom family members not living with them as important. Becausethis may reflect different values on the part of professionals and elders, the decision was madeto leave all the preference and social support items in the questionnaire. One item in the environment category, which askedabout the type of community in which the elder lived (e.g., urban, rural, suburban), was dropped becauseit was not considered important by the majority of professionalsor elders (CVI for the item was 0.33). Based on the panels’ comments, the responses defining the scale steps were shortened, and changeswere made in phrasing to improve item clarity. The following questionswere addedbased on suggestionsfrom the panel: Do you think you will be able to get out of your tub/shower at home? How many stepsdo you have to enter your house/ apartment? Next, the revised questionnaire was reviewed for item clarity by the researcherand three project consultantswho have expertise in geriatrics. The DPQ was reviewed by four community residing elders who also completed the questionnaire and indicated that it required approximately 1.5to 20 minutes to answer all of the questions. The final questionnaire consisted of 51 items. Subjects are asked to respond to questions about ADLs and IADLs on a scale from 0, indicating complete independence,to 4, reflecting complete dependence. For example, the scores on ADLs might range from 0 to 28. Overall, higher scores indicate more dependence.For questionsrelated to social support and environment, respondentscircle either yes, no, or uncertain. A decimal figure (1.1) was used to signify uncertainty in scoring responses.If items within a category were summed, an uncertain responsefor several items would result in a higher decimal in the score thereby alerting health care professionalsthat an elder may require closer monitoring in planning for discharge needs.Sample items appear in Figure 1. Concurrent Validity Concurrent validity is determined by correlating the test scoresof a group of subjectsto a criterion measure that is administered concurrently or within a short spanof time (McLaughlin & Marascuilo, 1990). The Performance ADL scale developed by Kane, Riegler, Bell, Potter, and Koshland (1983) was selectedas a criterion measurebecause

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METHODS

DIrections and SamDIe Items for the Discharae Plannine Ouestionnaire Your responses to the following questions may help you, andthe health care professionals caring for you, to identify your needs for care following hospitalization.

Please circle the response for each

item that best describes your situation as you see it today.

ACTIVITIES OF DAILY LIVING ThCjilStSt?tafpt?StiOlKUkMUZtpUlUCflbkWdOtoday.

Are you able to get on and off the toilet? 0

Yes, without help

1

Yes, but need to rest first

1.1 Not sure, or uncertain 2

Yes, but need to use a device (e.g. grab bars or elevated seat)

3

Yes, with help from another person

4

No, need to use bedpan

Are you able to walk on a flat surface without losing your balance or feeling like you might fall? (for example, can you walk from your bed to the bathroom)? 0

Yes, easily without help

I

Yes, but need to rest in between

I. I Not sure 2

Yes, but it’s difficult, need to use a device

3

Yes, but it’s very difficult, need help from another person

4

No, someone has to do this for me

Figure

1.

Directions

and sample

items

for discharge

observation of ADLs; and other investigators reported that older adults who believe that their autonomy is threatened may overrate their ability to perform ADLs (Kane et al., 1983). A nurse who was a member of the research team, interviewed patients within 24 hours of their completing the DPQ using the Performance ADL Scale (Kane et al., 1983). The scalewasdeveloped to assessincremental changesin older adult’s functional status over time. The scale combinesdirect observation and self-reported information on abilit uses direct

planning

questionnaire

(continued

on next

page).

ities to perform basic daily activities such as bathing, toileting, dressing, feeding, and moving in bed. Participants are asked to perform tasks such as putting on a shirt and taking medications. The coefficient of reliability for the observed itemswas reported as .93 (Kane et al., 1983) indicating acceptable reliability. The DPQ was piloted with 42 elders who were hospitalized for an acute episodeof a chronic condition. The average age of subjects was 73 years with a range of 65 to 87 years. The majority were

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INSTRUMENTAL

ACTIVITIES

OF DAILY

METHODS

LIVING

~joltowingqustionrarrLwivrtyou~tobc~r0&nhnvoulumthe;hosoita. 1. Will you be able to go grocery shopping and run errands 0

Yes, easily without help

1

Yes, but need to rest in between

1.1 Not sure

2

Yes, but can only manage short trips and small purchases

3

Yes, but it’s very diffkult,

4

No, someone has to do this for me

need someone to accompany me

Will you be able to plan and prepare your meals? 0

Yes, without help

I

Yes. but need to rest in between

I. I Not sure, or uncertain

2

Yes, if it is only a simple meal such as making a sandwich

3

Yes, if it is heating a frozen dinner

4

No, someone has to do this for me

ENVIRONMENT

Thequestions in this sectionpertain to the settingin n&h you liwd just prior to thisadmissionto the hospital. Pleasecirclethe response that bestdescribes your sitution. Do you have steps to climb to enter your house or apartment?

2

Yes

1. I

Don’t know

I

No

If Yes, how many? __ Do you have a safety bar/grab bar in your tub or shower? 1

Yes

1.1 Don’t know

2

No Figure

1

(continued).

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METHODS

SOCIAL

SUPPORT

17rc quarlons circle

in this

tk

reqonse

seaion that

best

relate

to people

&xribes

your

n&o

might

be andable

w assist

you

@er

you

Lzave

the hospital.

shution.

IS the person with whom you live someone you could count on for assistance with the following? Provide companionship

1.

Yes

2.

No

1.1.

Uncertain

Listen to your concerns

1.

Yes

2.

No

1.1

Uncertain

Run errands

1.

Yes

2.

No

1.1.

Uncertain

Do laundry

1.

Yes

2.

No

1.1.

Uncertain

Do you have friends, relatives, or neighbors close by that you feel you could call on for any of the following: Visit you to see how I.

Yes

2.

No

1.1.

Uncertain

1.

Yes

2.

No

1.1

Uncertain

Do grocery shopping

I.

Yes

2.

No

.l.

Uncertain

Do laundry

1.

Yes

2.

No

.I.

Uncertain

you are doing Transportation to doctor appointments or to take you shopping

YOUR PREFERENCES When you leave the hospital, where do you want to go? 1.

Your home

2.

A relative’s home

3.

A boarding home

4.

A transitional care/rehabilitation/extended

5.

A nursing home

care unit

When you leave the hospital, where does your family want you to go to:

NOTE:

I.

Your home

7b.

A relative’s home

3.

A boarding home

4.

A transitional care/rehabilitation/extended

5.

A nursing home

care unit

Scale steps are sequenced so that a higher number suggests “greater risk” or need for follow up care.

Figure

1

(continued).

P1ea.w

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white, and 57% were married. Education ranged from less than high school to graduate school with a median of high school diploma. Average length of hospital stay was 9.7 days with a range from 3 to 44 days (SD = 8.3 days). Potential participants were contacted 1 to 2 days after admission. The study was explained, and if they agreed to participate, they were asked to complete the DPQ. The findings indicated that elders’ self-reported ADLs on the DPQ were significantly correlated with scores on Kane’s performance ADLs (r = .66, p > ,001) thereby providing an acceptablelevel of concurrent validity for the ADL section of the DPQ. Predictive Validity If one can predict future patient behaviors or future situations from scoreson an instrument administered at an earlier time, the instrument has predictive validity (McLaughlin & Marascuilo, 1990). Because appropriate measuresof concurrent validity could not be found for the social support section of the DPQ, a visit was made to the elder’s place of residenceapproximately 2 weeks after discharge. During the interview, information was obtained on the resourcesused by elders and informal help received from family and friends. A resourcechecklist was usedto identify community services received after discharge. Elders were asked about the type and frequency of services used since discharge. Informal social support was measuredby asking participants about the types of help they had received from family and friends sincedischarge. Scoreson the ADLs sectionof the DPQ were significantly correlated with the total number of community resources used postdischarge (r = - .65, p > ,001). Personswho were more dependent shortly after hospital admission reported using a greater number of resourcesafter hospitalization. In addition, patient’s scoreson anticipated social support from family were significantly related to the support received after hospitalization (r = .58, p = .003). According to McLaughlin and Marascuilo (1990) a correlation coefficient of 0.40 and higher is indicative of validity. These findings provide a beginning level of predictive validity of the DPQ and suggestthat it may be useful in identifying postdischargeneeds. RELIABILITY

Cronbach’s alpha, which is the average interitem correlation, wasobtained for each subscaleof

METHODS

the DPQ to determine its reliability. The alpha coefficients for the subscalesrelated to ADLs (cy = .86), IADLs (o = .90), and social support (o = .87) indicate that thesesubscaleswere highly reliable. However, the alpha coefficient for the environment category (a = .60) was slightly lower. Further examination of the environment scalewith a separatesampleof elders indicated that the subscalehad three factors (neighborhood, safety, and physical environment). DISCUSSION

In interpreting the findings from this project, it is important to remember that the sample size is small and that further research is needed before generalizations can be made. However, the findings indicate that older adults are able to complete a self-administeredquestionnairesuch asthe DPQ within 1 to 3 days after admissionto a hospital for a chronic condition such as congestive heart failure, COPD, or diabetesmellitus. With shorter hospital stays, clinicians might ask eldersto complete the DPQ a day or two after admissionso the clinician would have information on elders’ perspectives on their needs. Scoresreflecting high uncertainty would alert clinicians to patients that might need closer monitoring for discharge needsor referral to social service. However, if an elder was hospitalized for longer than the 6-day average stay (National Center for Health Statistics, 1991), then it would be necessaryto have the elder complete the questionnaire a second time, closer to discharge, to more accurately assesspostdischarge needs. In addition, the DPQ might be useful to clinicians in identifying discrepanciesor inconsistenciesbetweenthe elders’ and professionals’perspectiveson the facts of the situation. For instance professionalsmay be feeding elderswho are in the hospital, but the elders might expect to be able to feed themselvesafter discharge. Allowing the elder to try eating independently before discharge might help in establishing realistic expectations. Identifying areasof disagreementbetween the elder’s and professionals’ perspectives. as well as noting responsesthat indicate uncertainty, might be particularly valuable in delineating areas that require further investigation or discussionbefore discharge. Also, reviewing the summedscore for each category can alert professionalsto situations that are characterized by uncertainty (decimals in scores indicate uncertainty). Those situations in

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which uncertainty is high may require more nursing or social work time in planning for posthospital care This preliminary work provides a basis for refining the DPQ and designing a predischarge intervention to facilitate communication in discharge planning. Because effective communication has been identified by health care professionals and patients as critical for successful discharge planning, a questionnaire such as the DPQ might be used to facilitate communication between patients, their families, and health care professionals. It is important to note that future work with larger samples is needed to obtain additional information on the factor structure of the DPQ and further examine its relationship to postdischarge outcomes. For more specific information regarding scoring of the DPQ or for copies of the instrument, please contact the investigator of this report.

Supported by the National Cenier for Nursing Research (NCNR) grant P20-NRO2300 to Sue K. Donaldson, Principal Investigator for the Center Gram on Long-Term Care ,for the Elderly, and in part by NCNR grant ROI-NR02249 to Margaret J. Bull. Address reprint requests to Margaret J. Bull. PhD, RN, School of Nursing, University of Minnesota. 6-101 HSUF, 308 Harvard St SE, Minneapolis, MN 55455. Copyright 0 1994 by W.B. Saunders Company 0897-1897l9410704-0007$5.00/0

A Review of Approaches Integrating Research and Practice

Marie

Martha

REFERENCES Berkman. B.. & Abrams, R. (1986). Factors related to hospital admission of elderly patients. Social Work, 33. 99-103. Davies, L. (1992). Instrument review: Getting the most from a panel of experts. Applied Nursing Research. 5, 194-197. Glass, R.. & Weiner, M. (1976). Seeking a social disposition for the medical patient: CAAST, a simple and objective clinical index. Medical Cure, 14, 637641. Inui. T., Stevenson, K., Plorde, D., & Murphy, I. (1981). identifying hospital patients who need early discharge planning for special dispositions. Medical Cure, 19. 922-929. Kane. R.L.. Riegler, S., Bell. R., Potter, R., & Koshland. G. (1983). Predicting the course of nursing home patients: A progress report (Report No. N-1786-NCHSR). Santa Monica, CA: Rand. Lynn, M. (1986). Determination and quantification of content validity. Nursing Research, 35, 382-385. Matz. S.. & Berke. J. (1986). Discharging catastrophic patients. Confirming Care Coordinator, 5, 34-37. McLaughlin. F.. & Marascuilo, L. (1990). Advanced nursing and health care research. Philadelphia, PA: Saunders. National Center for Health Statistics. (1991). Prevention Profile, Health, United Stares 1990. Hyattsville, MD: Public Health Service. Proctor, E.. & Morrow-Howell, N. (1990). Complications in discharge planning with Medicare patients. Health and Social Work. 15, 45-51. Wallace. D., & Steinhauer, M. (1988). An integrated approach to environmental assessment. Journal of Home Healthcare Practice. l(1). 25-34. Waters, E.J. (1980). How IO do patient discharge planning. Miami. FL: Elva Waters.

From the School of Nursing, University of Minnesota, neapolis, MN. Margaret J. Bull, PhD, RN: Associate Professor.

T. Nolan,

Min-

T

Elaine N. Hill,

Larson, and

Deborah Karen

to

McGuire,

Hailer

HE CURRENT health care climate, characterized by cost containment, new technology, and restructuring of care delivery systems, compels nursesto provide efficient and effective care. Research that examines the efficiency and effectiveness of care therefore must be appropriately disseminated,understood, incorporated, and evaluated in an ongoing process. Researchutilization is an important component of care that is frequently neglected by both students and practitioners of nursing. Numerous examplesfrom the nursing literature demonstratethat often nursesare unaware of research findings related to common clinical practices (e.g., preoperative teaching, range of motion exercises, temperature taking, coronary precautions) and therefore do not use such findings in their practice on a consistent basis (Brett, 1987; Coyle & Sokop, 1990; Ketefian, 1975; Kirchhoff, 1982; Stokes, 1981). Researchershave demonstratedthat a great many obstacles or barriers are perceived when nursesattempt to apply researchfindings to practice. The most notable obstaclesinclude limited accessto researchfindings, lack of preparation for and expertise in evaluating research reports, and institutional barriers such as lack of support from administratorsand physicians, lack of authority to implement changes, and limited time (Funk, Champagne, Wiese, & Tornquist, 1991a; Funk,