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Paediatric emergency nurses’ perceptions of parents’ understanding of discharge information: A qualitative study
Australasian Emergency Care 21 (2018) 56–63
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Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
Paediatric emergency nurses’ perceptions of parents’ understanding of discharge information: A qualitative study Kodchanipa Phonpruk a,∗ , Karen Flowers b , Paul Fulbrook b,c,d , Geraldine Naughton e a
Faculty of Nursing, Suratthani Rajabhat University, Surat Thani, Thailand Faculty of Health Sciences, Australian Catholic University, Brisbane, QLD, Australia The Prince Charles Hospital, Nursing Research & Practice Development Centre, Brisbane, QLD, Australia d Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa e Faculty of Health Sciences, Australian Catholic University, Melbourne, VIC, Australia b c
a r t i c l e
i n f o
Article history: Received 5 February 2018 Received in revised form 8 May 2018 Accepted 8 May 2018 Keywords: Children Emergency medicine Parents Health literacy
a b s t r a c t Purpose: To identify paediatric emergency department nurses’ perceptions of factors influencing parents’ understanding of discharge information. Procedures: Content analysis was used to analyse data from three semi-structured focus groups with nurses from a paediatric ED. Findings: Findings were interpreted within the three domains of structure, process, and outcomes from the Donabedian model. Within the structure domain, barriers to effective provision of discharge information included inexperienced emergency department staff and time policies. Enablers included availability of interpreter services. Process-related barriers included parents’ health related behaviour and health literacy, while enablers included ensuring parents understood discharge information. Nurses’ perceptions of ineffective outcomes involved the risk of parents receiving incomplete or inappropriate information. Nurses perceived effective outcomes in quality of care were related to their professional experience and competence in being able to provide useful information to parents. Conclusion: This study investigated ED nurses’ perceptions of factors that influence parents’ understanding of discharge information. Interpreting findings within the Donabedian model provided important directions for future improvements to structure, processes and outcomes for provision of discharge information to parents leaving a paediatric ED. Ultimately, the findings from this study could inform future research to maximise the role of ED nurses in providing a high quality of discharge care for children discharged from the ED. © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
1. Background Emergency department (ED) nurses provide the first line of healthcare contact when they triage the patient. In paediatric EDs, they have multiple opportunities to engage with and support children and parents; including the provision of discharge information. Arguably, discharge information is comprised of both education and advice [1,2]. A number of factors have been identified that may limit a parent’s understanding of discharge information: parents’ level of education [3–5]; health literacy [6–8], language skills [9]; parents’ anxiety [10]; parental concern that their child is in pain [5] and inadequate communication between ED staff and parents at discharge [10].
∗ Corresponding author. E-mail address: [email protected] (K. Phonpruk).
Effective discharge information can ensure continued quality of care for a child following discharge, minimise parents’ potential confusion, and reduce possible readmissions and associated family and financial burdens [2]. Providers of discharge information are recommended to avoid the use of over medicalised words, for example using phrases such as “infection in the eyes” instead of “conjunctivitis” to explain the diagnosis; provide practical advice about caring for the child; and being sensitive of the family’s cultural context [3]. Therefore, communication between ED staff and parents may act as both an enabler and a barrier that affect the quality of discharge information provided in paediatric ED [6,10,11], and experienced ED nurses are well placed to comment on factors that influence parents’ understanding of information provided to them about their child’s care at home following discharge. The Donabedian Model applied in this study, is typically used for evaluating the quality of care in clinical practice [12,13], which can lead to enhancements in the structure (such as the physical
https://doi.org/10.1016/j.auec.2018.05.001 2588-994X/© 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
K. Phonpruk et al. / Australasian Emergency Care 21 (2018) 56–63
setting and policies), processes (such as the practices and routines) and outcomes (including patient health and satisfaction). Using the model can lead to improvements in patients’ total health care experiences [13]. 2. Procedures 2.1. Design This qualitative study used focus groups to identify ED nurses’ perceptions of factors that influence parents’ understanding of discharge information. The study adhered to the National Statement on the Conduct of Human Research in Australia and was approved by the relevant university and hospital human research ethics committees. 2.2. Setting and sample The study setting was the paediatric ED of a tertiary general hospital in south east Queensland, Australia, which treats around 20,000 child presentations annually. ED nurses were recruited using purposive sampling [14] with the support of the ED nurse unit manager. The inclusion criteria were being a Registered Nurse and working in the paediatric ED for at least three months. Participants had a diversity of experiences; providing differing perspectives, providing rich sources of data [15]. 2.3. Data collection Data were collected in August 2015. A researcher and a research assistant (RA) first contacted the ED nurse manager to explain the purpose, timeframe, and general procedures of the focus groups. The ED nurse manager then provided confidential advice about which nurses met the criteria for inclusion. Three focus groups, each with two participants, were conducted between the morning and afternoon shifts. Although it would have been ideal to have more nurses in each group, no more than two nurses were available to participate at any given time from this very busy ED. Arguably, one group of six participants [16] would have provided richer data but limited availability of ED nurses made it impractical. One to one interviews were considered, but the richness of interactions between participants, even with small numbers was deemed preferable. During the semi-structured focus groups, pre-planned, openended questions drawn from the research questions triggered discussion (Table 1). The researcher took field notes, while an RA facilitated the discussion. Sessions were recorded digitally and transcribed verbatim by the researcher within one week and confirmed by the research team. All identifying information, was removed from the transcripts. 2.4. Data analysis Qualitative content analysis was used for organising and interpreting the data to identify factors that influence parents’ Table 1 Focus group trigger questions. Trigger questions 1. What are your views on the provision of discharge information to parents in the ED that works well? 2. What are your views on the resources provided to parents? 3. What happens when parents do not seem to understand? 4. What challenges are there in the provision of discharge information to parents in the ED? 5. Is there anything else you would like to share with us on this topic?
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understanding of discharge information. The structure, process, and outcome domains of the Donabedian Model of Quality of Care [17] guided the approach taken to identification and coding of categories. Nineteen categories or factors related to parents’ understanding of discharge information. The categories were further identified as barriers and/or enablers in the structure and/or process domains, or effective or ineffective outcomes in the outcome domain. 3. Findings Two themes of enablers and barriers were identified in the structure and process domains of the Donabedian Model with nine categories identified as barriers and five as enablers. Two themes were also identified under the outcome domain reflecting ineffective outcomes in parental understanding of discharge information (Table 2). Some factors could be both an enabler or a barrier depending on the situation. Some factors impacted in more than one domain. Categories collectively related to resources (six), ED staff (seven), and the children’s parents (six) (Table 3). The findings are described and explained under the three domains and supported by verbatim quotes. 3.1. Structure The structure domain of the Donabedian model [17] refers to relatively static characteristics of the settings in which the health care is delivered, which in this study, was a paediatric ED. The focus group participants identified four barriers and two enablers to parents’ understanding of discharge information in the structural features of the ED, which relate to ED staff, and resources. 3.2. Barriers Four structural barriers in the provision of discharge information were identified: inexperienced staff; time policies; lack of locally developed web-based discharge resources; and limited availability of interpreter services. These are discussed below. 3.2.1. Inexperienced staff Focus group participants commented on the inexperience of some staff in a children’s ED setting, particularly when inadequate and/or inappropriate information was provided for parents to care for their child after discharge, as reflected in this comment. Yeah, I mean even . . . um . . . some of the doctors who have not worked with children before, will be keen to give them a Panadol, Nurofen . . . If they’ve got a fever just for the sake of getting the fever down and then we have . . . (to say to parents) . . . you don’t have to do that. That’s fine (not giving medication) if they’ve got a fever and they are looking happy. (Focus group 2) Thus, a lack of specific staff experience was seen to be a potential barrier to parents’ understanding and following discharge information provided in the ED. 3.2.2. Time policies Some participants commented on how time-related pressures such as the four-hour rule imposed by the National Emergency Access Target (NEAT) policy [8] were a significant impediment to their work; specifically, in providing discharge information to parents in the paediatric ED. For example, one participant stated: Time . . . is a big one (barrier) because having the time . . . to explain, um . . . we work against the clock because we have a four-hour limit. (Focus group 3)
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Table 2 Summary of themes in the structure, process, and outcome domains. Donabedian domains
Themes
Themes
Barriers
Example quote
Enablers
Example quote
Structure
• Inexperienced staff • Time policies The lack of locally-developed web-based discharge resources • Limited availability of interpreter services
• Access to interpreter services • Access to useful discharge resources
• We do use (the) interpreter service, but yeah sometime(s). . . (it) is probably the phone service (rather than having an interpreter available on site . . . which works very well). (Focus group 2) • If it’s language, we have interpreters and we use the interpreter system. (Focus group 3) • It’s all on the website. . . which I’ve found has worked for myself in particular, probably everybody, is that having it all displayed there and then knowing that you can just go and get some and then, you know, print some off . . . (Focus group 3)
Process
• Parents’ health behaviours • Parents’ health literacy • Parents’ overall or cultural beliefs • Parents’ assumptions about information in social media • Staff providing conflicting information
• Multiple sources of information • Ensuring parents understanding of information • Follow-up appointments
Donabedian domains Outcome
Ineffective
• Yeah, I mean even . . . um . . . some of the doctors who have not worked with children before, will be keen to give them a Panadol, Nurofen . . . If they’ve got a fever just for the sake of getting the fever down and then we have . . . (to say to parents) . . . you don’t have to do that. That’s fine (not giving medication) if they’ve got a fever and they are looking happy. (Focus group 2) • Time . . . is a big one (barrier) because having the time . . . to explain, um . . . we work against the clock because we have a four- hour limit. (Focus group 3) • If we develop our own, then we have to review it. We have to update it. Whereas if they’ve got a unit that does all of that, that’s their job, that’s the only job that they have. (Focus group 3) • Sometimes it’s. . . after hours and you can use phone calls (for interpreter services). (Focus group 1) • I think that there are some parents that just . . . don’t want to know everything, they just . . . want to come here and have you fix their child and then they’ll take them home. They’re not interested. (Focus group 1) • . . . People think just to put people on antibiotics as soon as they get a runny nose and a cough. (Focus group 1) • They just still have that underlying fear of fevers for whatever reason, cultural, previous experience or whatever. (Focus group 1) • Parents do definitely do their research before they come in. like Google. . . Wikipedia, like, you know, I think that’s kind of the first thing people click on and they read all these things, those side effects or all the possible . . . Um . . . Like, worse case scenarios and they are sort of just freaking out in their heads. (Focus group 1) • I think probably inconsistency in, . . . treatment . . . it’s a little bit confusing for parents as well, if they’re told one thing by one doctor and another thing by another doctor. (Focus group 2) Example quote
• We give a lot of um, . . . patient handouts to parents who present, if it’s the first time. For example, with croup or if they have gotten any misconceptions about fevers. So, a lot of people think that fevers are dangerous then we usually give them verbal advice and then give them a fever handout afterwards. (Focus group 2) • If I’m concerned that somebody doesn’t understand then, I’ll ask them to repeat it back to me, or ask if they’ve got any questions or try and explain things in more simplistic layman’s terms rather than using medical kind of jargon. (Focus group 2) • We do try and follow up with, um, so refugees, having a (case) manager. The manager might not have come in with them. Um, we want to make sure that the manager knows. . . is aware of, of what has happened with them. (Focus group 3) Example quote
. . . or you’ve just spent, . . . 20 minutes trying to reassure a parent that what, their child’s symptoms are okay, let’s just not give a Panadol at all, and then (another medical staff member) comes in and says, oh they’ve got a fever, let’s give some Panadol. I have just done the education and, they’ve just ruined it and the parents believe the other staff member. (Focus group 2) You know, leaving without medical advice or against medical advice, that sort of thing. . . . it’s because of time, they need to get out because they have other children, they’ve got other concerns. (Focus group 3) I don’t think they’ve misunderstood what we’re saying. They just still have that underlying fear of fevers for whatever reason. . . . cultural. . . previous experience or whatever. (Focus group 1)
• Professional experience and confidence • Providing useful resources
• Inaccurate and/or incomplete Information • Parents’ time constraints • Parents’ characteristics
Effective
• We go out of our way to give them extra information, to sit down and explain, to get them . . . for asthma, for example, we want them to show us how to, how they’re doing it, tell us what their understanding is, of, you know, what they’re doing when they’re doing it. Um. So, that we find out or work out what the barriers are to them being able to troubleshoot, um, and assist them. (Focus group 3) • I think that having a properly written medical handout is much more useful for them . . . even if they don’t look at it. At least we can feel like we’ve tried to give them the right information. (Focus group 2)
The impact of NEAT on quality discharge care appeared to be a concern.
and described an example of how the absence of locally developed web-based discharge resources could be a barrier to understanding discharge information.
3.2.3. The lack of locally developed web-based discharge resources The ED Nurses identified limitations of existing resources available for parents to support care of their child following discharge
. . . Sometimes, like, um, the resource provided . . . for the parents on our QHEPS website isn’t enough and you have to actually go outside, um, to other sources to get some information. (Focus group 3)
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Table 3 Summary categories of factors influencing understanding of discharge information. Barriers/ineffective Structure
Enablers/effective Process
Outcome
Resources •Time policies •The lack of locally developed web-based discharge resources •Lack of access to Interpreter services Staff •Inexperienced staff
•Staff providing conflicting information
•Staff providing inaccurate and/or incomplete information
•Parents’ health behaviours •Parents’ lack of health literacy •Parents’ health or cultural beliefs •Parents’ assumptions about information in social media
•Parents’ time constraints •Parents’ characteristics
Structure
Process
•Access to Interpreter services •Access to useful discharge resources
•Multiple sources of information
•Ensuring parents understanding of information •Follow-up appointments
Outcome
•Staff’s professional experience and competence •Staff’s providing useful resources
Parents
Ideally, the ED nurses perceived that local resources available to parents required more information to support quality of care in discharge information. 3.2.4. Limited availability of interpreter services Some nurses shared concerns about the lack of immediately accessible interpreter services in the ED for parents with limited verbal and or written English fluency. If ED staff needed urgent services from an interpreter, they had to contact the interpreter centre service by telephone. Sometimes it’s. . . after hours and you can use phone calls (for interpreter services). (Focus group 1) Also, ED staff members who are able to interpret, may not be on shift at the appropriate time. So sometimes, we use, uh, if there’s a doctor or someone that speaks, like, Farsi or Quran or something . . ., if we’re having trouble getting an interpreter, . . . we might have to use them. (Focus group 3) However, when interpreter services were accessible, they could also be seen as an enabler for parents to receive quality discharge information, as described in the next section. 3.3. Enablers The two structural enablers that nurses discussed as enhancing the understanding of discharge information for parents were access to interpreter services and useful discharge resources. 3.3.1. Access to interpreter services Access to interpreters was viewed by participants as a support for provision of discharge information for non-English speaking parents, as reflected in the following quote. We do use (the) interpreter service, but yeah sometime(s). . . (it) is probably the phone service (rather than having an interpreter available on site . . . which works very well). (Focus group 2) If it’s language, we have interpreters and we use the interpreter system. (Focus group 3)
Perceptions of the quality of the discharge information provided by the nurses were clearly supported by the availability of interpreter services.
3.3.2. Access to useful discharge resources Again, resources previously discussed as a barrier were also a potential source of benefit to supporting discharge information. Nurses discussed the value of having multiple sources of available information (for example, their own hospital’s information, and resources from their home state government and other paediatric hospitals). The extensive range of resources was perceived as being useful for parents to access and enhance their quality of care when children were discharged to home. Access to, and convenience of electronic and readily available health information through multiple sources website was seen as a valuable resource. The ED nurses identified the ease with which they could obtain health information from this website, as reflected in the quote: It’s all on the website. . . which I’ve found has worked for myself in particular, probably everybody, is that having it all displayed there and then knowing that you can just go and get some and then, you know, print some off . . . (Focus group 3) ED nurses reported the benefits of written resources in improving their confidence that parents understood important information about their child’s care.
3.4. Process The process domain of the Donabedian Model [17] refers to the relatively dynamic characteristics of engagement and influences in a healthcare setting, which in this study links to providing and receiving discharge information in the ED. Four of the five barriers to parents’ understanding of discharge information in the ED processes relate to the children’s parents, the other to ED staff and two enablers relate to ED staff, and resources.
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3.5. Barriers Barriers affecting the ED processes experienced by parents including parents’ health behaviours; lack of health literacy; health and or cultural beliefs; parents’ and assumptions about information in social media; and conflicting information are described below. 3.5.1. Parents’ health behaviours The participants described two categories of observed parental behaviour that could be a barrier to understanding discharge information: parents who appeared to be disinterested, as illustrated by the following quote, I think that there are some parents that just . . . don’t want to know everything, they just . . . want to come here and have you fix their child and then they’ll take them home. They’re not interested. (Focus group 1) and parents that were perceived to be too well informed to actually listen to discharge information, as illustrated in the quote below: Some of them really know their stuff and you know, . . . they know everything (and are uninterested in hearing more). They’ve got books with them that have gotten everything that’s happened in the last few weeks. (Focus group 1) Parents’ health behaviour was discussed within the context of a barrier with parents demonstrating different and sometimes misguided understandings of the information provided by ED staff. Nurses believed that interpreting information inaccurately could potentially result in a variety of inappropriate responses to provision of the same information. 3.5.2. Parents’ lack of health literacy Nurses discussed a lack of health literacy as a barrier to parents’ understanding of advice provided in the ED. For example, parents’ frequent requests to treat their child’s viral illness with antibiotics when the prescription of antibiotics is being globally discouraged. Therefore, the requests for antibiotics were perceived by nurses to demonstrate a lack of current health knowledge. When the expected prescription for antibiotics was not forthcoming, parents’ misunderstanding of the adequacy of management and discharge information for their child could result. . . . People think just to put people on antibiotics as soon as they get a runny nose and a cough. (Focus group 1) The focus group participants discussed sub-optimal health literacy of parents as a barrier that potentially decreased the parents’ understanding of home care information provided during the discharge of a child from the ED. 3.5.3. Parents’ health and/or cultural beliefs Nurses described multiple factors influencing parents’ beliefs such as previous experiences, access to information, culture, family and/or education which, when misinformed, had the potential to impair understanding of discharge information.
children identified some difficulties. For example, parents who had already accessed health information via health and parenting websites, such as “Dr Google” could be hard to convince that their preconceived understanding of their child’s condition was misleading or inaccurate. Parents do definitely do their research before they come in, like Google. . . Wikipedia, like, you know, I think that’s kind of the first thing people click on and they read all these things, those side effects or all the possible . . . Um . . . Like, worse case scenarios and they are sort of just freaking out in their heads. (Focus group 1) Some parents’ assumption of the accuracy of all web-based resources was therefore perceived by nurses to be a major barrier to quality health care in the paediatric ED. 3.5.5. Conflicting information Conflicting information being given to parents concerned the nurses. For example, they commented on inconsistencies and confusion that arose when ED staff recommended the medication for a child that varied from advice already provided by other ED staff, including ED nurses: I think probably inconsistency in, . . . treatment . . . it’s a little bit confusing for parents as well, if they’re told one thing by one doctor and another thing by another doctor. (Focus group 2) Thus, the participants reported that inconsistent information may impact on parents’ understanding of discharge information. 3.6. Enablers Enablers to the process of effective provision of discharge information for parents included: multiple sources of information; ensuring parents understood discharge information; and nurses having a capacity to follow-up at risk patients. 3.6.1. Multiple sources of information Nurses valued having multiple sources of discharge information available to share with parents. We give a lot of um, . . . patient handouts to parents who present, if it’s the first time. For example, with croup or if they have gotten any misconceptions about fevers. So, a lot of people think that fevers are dangerous then we usually give them verbal advice and then give them a fever handout afterwards. (Focus group 2) Thus, quality discharge information for some of the nurses in the focus groups was enabled by the availability of multiple resources. 3.6.2. Ensuring parents understanding of information Nurses in the focus groups valued having opportunities to confirm parents’ understanding as a useful strategy support quality of discharge information.
They just still have that underlying fear of fevers for whatever reason, cultural, previous experience or whatever. (Focus group 1)
If I’m concerned that somebody doesn’t understand then, I’ll ask them to repeat it back to me, or ask if they’ve got any questions or try and explain things in more simplistic layman’s terms rather than using medical kind of jargon. (Focus group 2)
Nurses perceived pre-existing beliefs of parents as potentially impairing the process of understanding or following discharge information.
The ED nurses expressed some pride in their capacity to support parents by perceiving when they required additional information to properly understand the information provided.
3.5.4. Parents’ assumptions about information in social media ED nurses’ discussion on the impact of parents’ assumptions of the accuracy of social media information on parents’ care of
3.6.3. Follow-up appointments The ED nurses valued opportunities to provide additional quality in discharge care by being able to follow up appointments,
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particularly for vulnerable patients, such as refugee families, through collaboration with community-based case managers. We do try and follow up with, um, so refugees, having a (case) manager. The manager might not have come in with them. Um, we want to make sure that the manager knows. . . is aware of, of what has happened with them. (Focus group 3) Nurses perceived the follow-up appointments processes for vulnerable families as a strong enabler of the provision of quality discharge information. 3.7. Outcome The outcome domain of the Donabedian Model refers to the results of the quality of care. Factors that may compromise the effectiveness of outcomes of the provision of discharge information, parents understanding, related to parents, resources, and ED staff. 3.8. Ineffective outcomes in parental understanding of discharge information Three factors likely to compromise parents’ understanding of discharge information were: provision of incomplete or inappropriate information; parents’ time constraints and other parental characteristics as described below. 3.8.1. Provision of incomplete or inappropriate information Nurses were concerned about how parents would be able to manage their child’s care at home when they observed parents’ lack of understanding, due to ineffective health education as reflected in this quote: The asthma plan hasn’t been explained to them appropriately, so they’ve given one puff instead of the six puffs even though they’ve been given an asthma plan. I feel from that point of view we haven’t actually educated them well enough to um. . . (Focus group 2) Further the quality of resources and information provided were also a factor that could impact on the outcome of parents understanding. Sometimes the instructions aren’t necessarily clear because you can read, even if you are English speaking, you can read what’s written one way or another, so it will need (to be) interpreted. Um, you know, because maybe the grammar isn’t brilliant or the, you know. Just how it’s, it’s, it’s been written (in a confusing way). (Focus group 3) Nurses shared that if all ED staff had a more complete awareness of available resources, they could help parents have a better understanding of the discharge information. Doctors need to know that . . . that’s available. So, our doctors working both EDs, and in our adults, . . . doesn’t have freely available, um, guidelines printed. (Focus group3) The need for all staff to use evidence-based care and more directly follow existing protocols and guidelines appeared to be important to ED nurses. 3.8.2. Parents’ time constraints Nurses understood that parents could experience time pressures and need to urgently leave the ED. Parents’ own time pressures could result in a compromised understanding of discharge information.
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You know, leaving without medical advice or against medical advice, that sort of thing. . . . it’s because of time, they need to get out because they have other children, they’ve got other concerns. (Focus group 3) Compromised understanding as an outcome was also described in the context of ED nurses having insufficient time to check that parents had understood the information they were given: Sometimes you just get too busy. To give people adequate information and before you can get back to the bed you’re looking after, they’ve already been discharged. (Focus group 2) Nurses described their own time constraints in the ED, but also seemed sensitive to parents’ time-related pressures. 3.8.3. Parents’ characteristics The ED nurses recognised a diversity of parents’ backgrounds in discussing potential reduced quality of care outcomes relating to parent’s understanding of home care information provided during the discharge of a child from the ED. I don’t think they’ve misunderstood what we’re saying. They just still have that underlying fear of fevers for whatever reason. . . . cultural . . . previous experience or whatever. (Focus group 1) Therefore, independent of resources and how experienced the ED nurses were in helping parents understand information, parents’ characteristics could challenge communication. 3.9. Effective outcomes in parental understanding of discharge information Two factors were identified as being important to effectively providing discharge information to parents: (i) the professional experience and competence of the ED staff and (ii) the provision of useful resources. 3.9.1. Professional experience and competence Nurses in the focus groups felt their professional competence was important in the effectiveness of providing information and the outcome of parents’ understanding of that information. We go out of our way to give them extra information, to sit down and explain, to get them . . . for asthma, for example, we want them to show us how to, how they’re doing it, tell us what their understanding is, of, you know, what they’re doing when they’re doing it. Um. So, that we find out or work out what the barriers are to them being able to troubleshoot, um, and assist them. (Focus group 3) Therefore, the ED nurses perceived that their training and their competence was helpful to ensuring parents’ understanding of discharge information. 3.9.2. Providing useful resources Having additional resources, such as pamphlets, was considered important to complement the verbal information provided to parents. Such resources helped nurses feel effective about how they were supporting parents’ understanding of their child’s health and healthcare needs. I think that having a properly written medical handout is much more useful for them . . . even if they don’t look at it. At least we can feel like we’ve tried to give them the right information. (Focus group 2) Therefore, ED nurses believed having additional resources could reinforce the likely outcome that discharge information would improve parents’ understanding of their child’s care at home.
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Nurses’ perceptions of the causes of ineffective outcomes for understanding discharge information related to unclear communication, pressures relating to time and time policies, and parental characteristics that limited their understanding. Nurses perceived effective outcomes in quality of care aligned to their own professional experience and competence in being able to provide useful resources to promote parents understanding.
4. Discussion Multiple factors related to parents’ understanding of discharge information were identified in this study which concerned verbal and written communication with parents and between staff and the role of the ED Nurse. The quality of care in ED settings can depend on patients receiving appropriate written and verbal instructions [4]. Incomplete health communication can compromise patient care [6,9] as communication is a key factor in patient understanding [18,19] and an important skill of specialist ED nurses [20]. In this study, nurses took pride in their capacity to help parents understand more about their child’s condition, provide accurate information, and suggest appropriate care for this child at home. Also, providing additional printed resources for parents accessing children’s EDs is seen as an opportunity to increase parents’ understanding in child health [3,8]. Nurses in our study believed in their capacity to help parents when they were afforded opportunities to follow-up with families after a child was discharged from the ED. Appropriate follow-up appointment is essential to optimise outcomes after discharge from the ED when nurses perceive additional care may be required [10]. These nurses were experienced in supporting children with high needs, including children from refugee families. Refugee children are a vulnerable group who require culturally appropriate, trauma sensitive services, continuity of care and follow up to support parents’ understanding of a child’s health needs [11]. Even though this type of follow up appointment on discharge information appeared to be a rare opportunity for ED nurses, they perceived success in communicating with these vulnerable families. Other examples of ED nurses’ pride in communication skills included their stated capacity to explain and educate on asthma management, know when and how to communicate using interpreters and check with parents around their understanding of information provided. These ED nurses’ perceptions of competence in communication and their sensitivity to cultural diversity highlight professional practices well aligned to the International Standards of Care for Children in Emergency Departments [3]. Implications for ED nursing practice from this study include a recommendation to consider commencing the provision of discharge information as part of the discharge process from triage to the waiting and departure stages. ED nurses could encourage parents to think about what might be needed in caring for this child and continue a discharge related discussion within communication that occurs during waiting times. This discussion could include inform parents to return to the triage station if their child’s condition deteriorates, and most importantly quality control checks for understanding prior to parents leaving the ED with their child [21,22]. Therefore, for ED nurses to practice effective communication and education skills to maximise their expertise in discharge planning. Ultimately, ED nurses can be of great assistance in ensuring parents understand the information they receive about their child’s care at home. Finally, there is potential for an increased role for ED nurses in directly discharging children with higher triage scales (three to five) as these triage categories could open educational opportunities for child health promotion; which would save time and resources for the ED medical staff.
5. Conclusion Through application of the Donabedian Model, this study identified barriers to and enablers of parents’ understanding of discharge information which were linked to communication, resources, staff competencies and time constraints as well as characteristics of the parents. Clear, consistent, and accurate communication appears as important as the availability of high quality supportive resources to assist parents’ understanding of discharge information. While dealing with time pressures and managing the other complexities of the ED can make discharge planning difficult, ED nurses described satisfaction with the quality of their work when they were afforded the time to check parents’ understanding. Findings from this study can be used to support the specific role of nurses in providing quality information to parents as part of a child’s treatment and discharge from a paediatric ED. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest The authors certify that this study has neither been published in whole or in part elsewhere nor is under consideration elsewhere. The authors declare that there is no conflict of interests regarding the publication of this paper. Contribution KP made a substantial contribution to the conception, design, data collection and interpretation. KF and PF also substantially contributed to the conception, design, and interpretation of data. GN contributed to the conception, design, data collection and interpretation. All authors shared in critically revising the manuscript before providing their final approval for publications. Acknowledgements The staff of the paediatric emergency department are acknowledged for their support and participation. References [1] The Australasian College for Emergency Medicine. Quality standards for emergency departments and other hospital-based emergency care services; 2015. Available at: https://acem.org.au/getattachment/74975862-1d4a-4ae7a95e-4b6d806aefb0/Preliminaries.aspx [accessed 06.05.17]. [2] Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to standard written instructions improved caregivers’ understanding of their child’s emergency department visit, plan, and follow-up: a randomized controlled trial. Pediatr Emerg Care 2013;29(6):699–704. [3] Al-Harthy N, Sudersanadas KM, Al-Mutairi M, Vasudevan S, Bin Saleh G, Al-Mutairi M, et al. Efficacy of patient discharge instructions: a pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Fam Community Med 2016;23(3):155–60. [4] Gozdzialski A, Schlutow M, Pittiglio L. Patient and family education in the emergency department: how nurses can help. J Emerg Nurs 2012;38(3):293–5. [5] Chappuy H, Taupin P, Dimet J, Claessens YE, Treluyer JM, Cheron G, et al. Do parents understand the medical information provided in paediatric emergency departments? A prospective multicenter study. Acta Paediatr 2012;101(10):1089–94. [6] Samuels-Kalow M, Stack A, Porte S. Effective discharge communication in the emergency department. Ann Emerg Med 2012;60(2):152–9.
K. Phonpruk et al. / Australasian Emergency Care 21 (2018) 56–63 [7] Samuels-Kalow M, Hardy E, Rhodes K, Mollena C. “Like a dialogue”: teach-back in the emergency department. Patient Educ Counsel 2016;99(4):549–54. [8] Ismail S, McIntosh M, Kalynych C, Joseph M, Wylie T, Butterfield R, et al. Impact of video discharge instructions for pediatric fever and closed head injury from the emergency department. J Emerg Med 2016;50(3):e177–83. [9] Samuels-Kalow M, Stack A, Porte S. Parental language and dosing errors after discharge from the pediatric emergency department. Pediatr Emerg Care 2013;29(9):982–7. [10] Curran J, Bishop A, Plint A, MacPhee S, Zemek R, Chorney J, et al. Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol. BMC Health Serv Res 2017;17(1):1–7. [11] Akinsola B, Cheng J, Zmitrovich A, Khan N, Jain S. Improving discharge instructions in a pediatric emergency department impact of a quality initiative. Pediatr Emerg Care 2017;33(1):10–3. [12] Ayanian JZ, Markel H. Donabedian’s lasting framework for health care quality. N Engl J Med 2016;375(3):205–7. [13] Moore L, Lavoie A, Bourgeois G, Lapointe J. Donabedian’s structure-process-outcome quality of care model: validation in an integrated trauma system. J Trauma Acute Care Surg 2015;78(6):1168–75. [14] Kumar R. Research methodology. 4th ed USA: SAGE; 2014.
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[15] Richardson-Tench M, Taylor B, Kermode S, Roberts K. Research in nursing: evidence for best practice. 5th ed. South Melbourne, Vic.: Cengage Learning; 2014. [16] Hennink MM, Hutter I, Bailey A. Qualitative research methods. London: SAGE; 2011. [17] Donabedian A. The quality of care: how can it be assessed? JAMA 1988;121:1743–8. [18] International Federation for Emergency Medicine. In: Medicine IFFE, editor. International standards of care for children in emergency departments. West Melbourne, VIC: International Federation for Emergency Medicine; 2012. p. 2012. [19] Curran J. Discharge instructions for parents in the context of pediatric emergency care: a narrative review. BMC Health Serv Res 2014;14(Suppl. 2):20. [20] Ak M, Cinar O, Sutcigil L, Congologlu ED, Haciomeroglu B, Canbaz H, et al. Communication skills training for ED nurses. Int J Med Sci 2011;8(5): 397–401. [21] Kourkouta L, Papathanasiou IV. Communication in nursing practice. Mater Socio-Med 2014;26(1):65–7. [22] Innes K, Jackson D, Plummer V, Elliott D. Emergency department waiting room nurse role: a key informant perspective. Australas Emerg Nurs J 2017;20(1):6–11.
Contents lists available at ScienceDirect
Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec
Paediatric emergency nurses’ perceptions of parents’ understanding of discharge information: A qualitative study Kodchanipa Phonpruk a,∗ , Karen Flowers b , Paul Fulbrook b,c,d , Geraldine Naughton e a
Faculty of Nursing, Suratthani Rajabhat University, Surat Thani, Thailand Faculty of Health Sciences, Australian Catholic University, Brisbane, QLD, Australia The Prince Charles Hospital, Nursing Research & Practice Development Centre, Brisbane, QLD, Australia d Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa e Faculty of Health Sciences, Australian Catholic University, Melbourne, VIC, Australia b c
a r t i c l e
i n f o
Article history: Received 5 February 2018 Received in revised form 8 May 2018 Accepted 8 May 2018 Keywords: Children Emergency medicine Parents Health literacy
a b s t r a c t Purpose: To identify paediatric emergency department nurses’ perceptions of factors influencing parents’ understanding of discharge information. Procedures: Content analysis was used to analyse data from three semi-structured focus groups with nurses from a paediatric ED. Findings: Findings were interpreted within the three domains of structure, process, and outcomes from the Donabedian model. Within the structure domain, barriers to effective provision of discharge information included inexperienced emergency department staff and time policies. Enablers included availability of interpreter services. Process-related barriers included parents’ health related behaviour and health literacy, while enablers included ensuring parents understood discharge information. Nurses’ perceptions of ineffective outcomes involved the risk of parents receiving incomplete or inappropriate information. Nurses perceived effective outcomes in quality of care were related to their professional experience and competence in being able to provide useful information to parents. Conclusion: This study investigated ED nurses’ perceptions of factors that influence parents’ understanding of discharge information. Interpreting findings within the Donabedian model provided important directions for future improvements to structure, processes and outcomes for provision of discharge information to parents leaving a paediatric ED. Ultimately, the findings from this study could inform future research to maximise the role of ED nurses in providing a high quality of discharge care for children discharged from the ED. © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
1. Background Emergency department (ED) nurses provide the first line of healthcare contact when they triage the patient. In paediatric EDs, they have multiple opportunities to engage with and support children and parents; including the provision of discharge information. Arguably, discharge information is comprised of both education and advice [1,2]. A number of factors have been identified that may limit a parent’s understanding of discharge information: parents’ level of education [3–5]; health literacy [6–8], language skills [9]; parents’ anxiety [10]; parental concern that their child is in pain [5] and inadequate communication between ED staff and parents at discharge [10].
∗ Corresponding author. E-mail address: [email protected] (K. Phonpruk).
Effective discharge information can ensure continued quality of care for a child following discharge, minimise parents’ potential confusion, and reduce possible readmissions and associated family and financial burdens [2]. Providers of discharge information are recommended to avoid the use of over medicalised words, for example using phrases such as “infection in the eyes” instead of “conjunctivitis” to explain the diagnosis; provide practical advice about caring for the child; and being sensitive of the family’s cultural context [3]. Therefore, communication between ED staff and parents may act as both an enabler and a barrier that affect the quality of discharge information provided in paediatric ED [6,10,11], and experienced ED nurses are well placed to comment on factors that influence parents’ understanding of information provided to them about their child’s care at home following discharge. The Donabedian Model applied in this study, is typically used for evaluating the quality of care in clinical practice [12,13], which can lead to enhancements in the structure (such as the physical
https://doi.org/10.1016/j.auec.2018.05.001 2588-994X/© 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
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setting and policies), processes (such as the practices and routines) and outcomes (including patient health and satisfaction). Using the model can lead to improvements in patients’ total health care experiences [13]. 2. Procedures 2.1. Design This qualitative study used focus groups to identify ED nurses’ perceptions of factors that influence parents’ understanding of discharge information. The study adhered to the National Statement on the Conduct of Human Research in Australia and was approved by the relevant university and hospital human research ethics committees. 2.2. Setting and sample The study setting was the paediatric ED of a tertiary general hospital in south east Queensland, Australia, which treats around 20,000 child presentations annually. ED nurses were recruited using purposive sampling [14] with the support of the ED nurse unit manager. The inclusion criteria were being a Registered Nurse and working in the paediatric ED for at least three months. Participants had a diversity of experiences; providing differing perspectives, providing rich sources of data [15]. 2.3. Data collection Data were collected in August 2015. A researcher and a research assistant (RA) first contacted the ED nurse manager to explain the purpose, timeframe, and general procedures of the focus groups. The ED nurse manager then provided confidential advice about which nurses met the criteria for inclusion. Three focus groups, each with two participants, were conducted between the morning and afternoon shifts. Although it would have been ideal to have more nurses in each group, no more than two nurses were available to participate at any given time from this very busy ED. Arguably, one group of six participants [16] would have provided richer data but limited availability of ED nurses made it impractical. One to one interviews were considered, but the richness of interactions between participants, even with small numbers was deemed preferable. During the semi-structured focus groups, pre-planned, openended questions drawn from the research questions triggered discussion (Table 1). The researcher took field notes, while an RA facilitated the discussion. Sessions were recorded digitally and transcribed verbatim by the researcher within one week and confirmed by the research team. All identifying information, was removed from the transcripts. 2.4. Data analysis Qualitative content analysis was used for organising and interpreting the data to identify factors that influence parents’ Table 1 Focus group trigger questions. Trigger questions 1. What are your views on the provision of discharge information to parents in the ED that works well? 2. What are your views on the resources provided to parents? 3. What happens when parents do not seem to understand? 4. What challenges are there in the provision of discharge information to parents in the ED? 5. Is there anything else you would like to share with us on this topic?
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understanding of discharge information. The structure, process, and outcome domains of the Donabedian Model of Quality of Care [17] guided the approach taken to identification and coding of categories. Nineteen categories or factors related to parents’ understanding of discharge information. The categories were further identified as barriers and/or enablers in the structure and/or process domains, or effective or ineffective outcomes in the outcome domain. 3. Findings Two themes of enablers and barriers were identified in the structure and process domains of the Donabedian Model with nine categories identified as barriers and five as enablers. Two themes were also identified under the outcome domain reflecting ineffective outcomes in parental understanding of discharge information (Table 2). Some factors could be both an enabler or a barrier depending on the situation. Some factors impacted in more than one domain. Categories collectively related to resources (six), ED staff (seven), and the children’s parents (six) (Table 3). The findings are described and explained under the three domains and supported by verbatim quotes. 3.1. Structure The structure domain of the Donabedian model [17] refers to relatively static characteristics of the settings in which the health care is delivered, which in this study, was a paediatric ED. The focus group participants identified four barriers and two enablers to parents’ understanding of discharge information in the structural features of the ED, which relate to ED staff, and resources. 3.2. Barriers Four structural barriers in the provision of discharge information were identified: inexperienced staff; time policies; lack of locally developed web-based discharge resources; and limited availability of interpreter services. These are discussed below. 3.2.1. Inexperienced staff Focus group participants commented on the inexperience of some staff in a children’s ED setting, particularly when inadequate and/or inappropriate information was provided for parents to care for their child after discharge, as reflected in this comment. Yeah, I mean even . . . um . . . some of the doctors who have not worked with children before, will be keen to give them a Panadol, Nurofen . . . If they’ve got a fever just for the sake of getting the fever down and then we have . . . (to say to parents) . . . you don’t have to do that. That’s fine (not giving medication) if they’ve got a fever and they are looking happy. (Focus group 2) Thus, a lack of specific staff experience was seen to be a potential barrier to parents’ understanding and following discharge information provided in the ED. 3.2.2. Time policies Some participants commented on how time-related pressures such as the four-hour rule imposed by the National Emergency Access Target (NEAT) policy [8] were a significant impediment to their work; specifically, in providing discharge information to parents in the paediatric ED. For example, one participant stated: Time . . . is a big one (barrier) because having the time . . . to explain, um . . . we work against the clock because we have a four-hour limit. (Focus group 3)
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Table 2 Summary of themes in the structure, process, and outcome domains. Donabedian domains
Themes
Themes
Barriers
Example quote
Enablers
Example quote
Structure
• Inexperienced staff • Time policies The lack of locally-developed web-based discharge resources • Limited availability of interpreter services
• Access to interpreter services • Access to useful discharge resources
• We do use (the) interpreter service, but yeah sometime(s). . . (it) is probably the phone service (rather than having an interpreter available on site . . . which works very well). (Focus group 2) • If it’s language, we have interpreters and we use the interpreter system. (Focus group 3) • It’s all on the website. . . which I’ve found has worked for myself in particular, probably everybody, is that having it all displayed there and then knowing that you can just go and get some and then, you know, print some off . . . (Focus group 3)
Process
• Parents’ health behaviours • Parents’ health literacy • Parents’ overall or cultural beliefs • Parents’ assumptions about information in social media • Staff providing conflicting information
• Multiple sources of information • Ensuring parents understanding of information • Follow-up appointments
Donabedian domains Outcome
Ineffective
• Yeah, I mean even . . . um . . . some of the doctors who have not worked with children before, will be keen to give them a Panadol, Nurofen . . . If they’ve got a fever just for the sake of getting the fever down and then we have . . . (to say to parents) . . . you don’t have to do that. That’s fine (not giving medication) if they’ve got a fever and they are looking happy. (Focus group 2) • Time . . . is a big one (barrier) because having the time . . . to explain, um . . . we work against the clock because we have a four- hour limit. (Focus group 3) • If we develop our own, then we have to review it. We have to update it. Whereas if they’ve got a unit that does all of that, that’s their job, that’s the only job that they have. (Focus group 3) • Sometimes it’s. . . after hours and you can use phone calls (for interpreter services). (Focus group 1) • I think that there are some parents that just . . . don’t want to know everything, they just . . . want to come here and have you fix their child and then they’ll take them home. They’re not interested. (Focus group 1) • . . . People think just to put people on antibiotics as soon as they get a runny nose and a cough. (Focus group 1) • They just still have that underlying fear of fevers for whatever reason, cultural, previous experience or whatever. (Focus group 1) • Parents do definitely do their research before they come in. like Google. . . Wikipedia, like, you know, I think that’s kind of the first thing people click on and they read all these things, those side effects or all the possible . . . Um . . . Like, worse case scenarios and they are sort of just freaking out in their heads. (Focus group 1) • I think probably inconsistency in, . . . treatment . . . it’s a little bit confusing for parents as well, if they’re told one thing by one doctor and another thing by another doctor. (Focus group 2) Example quote
• We give a lot of um, . . . patient handouts to parents who present, if it’s the first time. For example, with croup or if they have gotten any misconceptions about fevers. So, a lot of people think that fevers are dangerous then we usually give them verbal advice and then give them a fever handout afterwards. (Focus group 2) • If I’m concerned that somebody doesn’t understand then, I’ll ask them to repeat it back to me, or ask if they’ve got any questions or try and explain things in more simplistic layman’s terms rather than using medical kind of jargon. (Focus group 2) • We do try and follow up with, um, so refugees, having a (case) manager. The manager might not have come in with them. Um, we want to make sure that the manager knows. . . is aware of, of what has happened with them. (Focus group 3) Example quote
. . . or you’ve just spent, . . . 20 minutes trying to reassure a parent that what, their child’s symptoms are okay, let’s just not give a Panadol at all, and then (another medical staff member) comes in and says, oh they’ve got a fever, let’s give some Panadol. I have just done the education and, they’ve just ruined it and the parents believe the other staff member. (Focus group 2) You know, leaving without medical advice or against medical advice, that sort of thing. . . . it’s because of time, they need to get out because they have other children, they’ve got other concerns. (Focus group 3) I don’t think they’ve misunderstood what we’re saying. They just still have that underlying fear of fevers for whatever reason. . . . cultural. . . previous experience or whatever. (Focus group 1)
• Professional experience and confidence • Providing useful resources
• Inaccurate and/or incomplete Information • Parents’ time constraints • Parents’ characteristics
Effective
• We go out of our way to give them extra information, to sit down and explain, to get them . . . for asthma, for example, we want them to show us how to, how they’re doing it, tell us what their understanding is, of, you know, what they’re doing when they’re doing it. Um. So, that we find out or work out what the barriers are to them being able to troubleshoot, um, and assist them. (Focus group 3) • I think that having a properly written medical handout is much more useful for them . . . even if they don’t look at it. At least we can feel like we’ve tried to give them the right information. (Focus group 2)
The impact of NEAT on quality discharge care appeared to be a concern.
and described an example of how the absence of locally developed web-based discharge resources could be a barrier to understanding discharge information.
3.2.3. The lack of locally developed web-based discharge resources The ED Nurses identified limitations of existing resources available for parents to support care of their child following discharge
. . . Sometimes, like, um, the resource provided . . . for the parents on our QHEPS website isn’t enough and you have to actually go outside, um, to other sources to get some information. (Focus group 3)
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Table 3 Summary categories of factors influencing understanding of discharge information. Barriers/ineffective Structure
Enablers/effective Process
Outcome
Resources •Time policies •The lack of locally developed web-based discharge resources •Lack of access to Interpreter services Staff •Inexperienced staff
•Staff providing conflicting information
•Staff providing inaccurate and/or incomplete information
•Parents’ health behaviours •Parents’ lack of health literacy •Parents’ health or cultural beliefs •Parents’ assumptions about information in social media
•Parents’ time constraints •Parents’ characteristics
Structure
Process
•Access to Interpreter services •Access to useful discharge resources
•Multiple sources of information
•Ensuring parents understanding of information •Follow-up appointments
Outcome
•Staff’s professional experience and competence •Staff’s providing useful resources
Parents
Ideally, the ED nurses perceived that local resources available to parents required more information to support quality of care in discharge information. 3.2.4. Limited availability of interpreter services Some nurses shared concerns about the lack of immediately accessible interpreter services in the ED for parents with limited verbal and or written English fluency. If ED staff needed urgent services from an interpreter, they had to contact the interpreter centre service by telephone. Sometimes it’s. . . after hours and you can use phone calls (for interpreter services). (Focus group 1) Also, ED staff members who are able to interpret, may not be on shift at the appropriate time. So sometimes, we use, uh, if there’s a doctor or someone that speaks, like, Farsi or Quran or something . . ., if we’re having trouble getting an interpreter, . . . we might have to use them. (Focus group 3) However, when interpreter services were accessible, they could also be seen as an enabler for parents to receive quality discharge information, as described in the next section. 3.3. Enablers The two structural enablers that nurses discussed as enhancing the understanding of discharge information for parents were access to interpreter services and useful discharge resources. 3.3.1. Access to interpreter services Access to interpreters was viewed by participants as a support for provision of discharge information for non-English speaking parents, as reflected in the following quote. We do use (the) interpreter service, but yeah sometime(s). . . (it) is probably the phone service (rather than having an interpreter available on site . . . which works very well). (Focus group 2) If it’s language, we have interpreters and we use the interpreter system. (Focus group 3)
Perceptions of the quality of the discharge information provided by the nurses were clearly supported by the availability of interpreter services.
3.3.2. Access to useful discharge resources Again, resources previously discussed as a barrier were also a potential source of benefit to supporting discharge information. Nurses discussed the value of having multiple sources of available information (for example, their own hospital’s information, and resources from their home state government and other paediatric hospitals). The extensive range of resources was perceived as being useful for parents to access and enhance their quality of care when children were discharged to home. Access to, and convenience of electronic and readily available health information through multiple sources website was seen as a valuable resource. The ED nurses identified the ease with which they could obtain health information from this website, as reflected in the quote: It’s all on the website. . . which I’ve found has worked for myself in particular, probably everybody, is that having it all displayed there and then knowing that you can just go and get some and then, you know, print some off . . . (Focus group 3) ED nurses reported the benefits of written resources in improving their confidence that parents understood important information about their child’s care.
3.4. Process The process domain of the Donabedian Model [17] refers to the relatively dynamic characteristics of engagement and influences in a healthcare setting, which in this study links to providing and receiving discharge information in the ED. Four of the five barriers to parents’ understanding of discharge information in the ED processes relate to the children’s parents, the other to ED staff and two enablers relate to ED staff, and resources.
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3.5. Barriers Barriers affecting the ED processes experienced by parents including parents’ health behaviours; lack of health literacy; health and or cultural beliefs; parents’ and assumptions about information in social media; and conflicting information are described below. 3.5.1. Parents’ health behaviours The participants described two categories of observed parental behaviour that could be a barrier to understanding discharge information: parents who appeared to be disinterested, as illustrated by the following quote, I think that there are some parents that just . . . don’t want to know everything, they just . . . want to come here and have you fix their child and then they’ll take them home. They’re not interested. (Focus group 1) and parents that were perceived to be too well informed to actually listen to discharge information, as illustrated in the quote below: Some of them really know their stuff and you know, . . . they know everything (and are uninterested in hearing more). They’ve got books with them that have gotten everything that’s happened in the last few weeks. (Focus group 1) Parents’ health behaviour was discussed within the context of a barrier with parents demonstrating different and sometimes misguided understandings of the information provided by ED staff. Nurses believed that interpreting information inaccurately could potentially result in a variety of inappropriate responses to provision of the same information. 3.5.2. Parents’ lack of health literacy Nurses discussed a lack of health literacy as a barrier to parents’ understanding of advice provided in the ED. For example, parents’ frequent requests to treat their child’s viral illness with antibiotics when the prescription of antibiotics is being globally discouraged. Therefore, the requests for antibiotics were perceived by nurses to demonstrate a lack of current health knowledge. When the expected prescription for antibiotics was not forthcoming, parents’ misunderstanding of the adequacy of management and discharge information for their child could result. . . . People think just to put people on antibiotics as soon as they get a runny nose and a cough. (Focus group 1) The focus group participants discussed sub-optimal health literacy of parents as a barrier that potentially decreased the parents’ understanding of home care information provided during the discharge of a child from the ED. 3.5.3. Parents’ health and/or cultural beliefs Nurses described multiple factors influencing parents’ beliefs such as previous experiences, access to information, culture, family and/or education which, when misinformed, had the potential to impair understanding of discharge information.
children identified some difficulties. For example, parents who had already accessed health information via health and parenting websites, such as “Dr Google” could be hard to convince that their preconceived understanding of their child’s condition was misleading or inaccurate. Parents do definitely do their research before they come in, like Google. . . Wikipedia, like, you know, I think that’s kind of the first thing people click on and they read all these things, those side effects or all the possible . . . Um . . . Like, worse case scenarios and they are sort of just freaking out in their heads. (Focus group 1) Some parents’ assumption of the accuracy of all web-based resources was therefore perceived by nurses to be a major barrier to quality health care in the paediatric ED. 3.5.5. Conflicting information Conflicting information being given to parents concerned the nurses. For example, they commented on inconsistencies and confusion that arose when ED staff recommended the medication for a child that varied from advice already provided by other ED staff, including ED nurses: I think probably inconsistency in, . . . treatment . . . it’s a little bit confusing for parents as well, if they’re told one thing by one doctor and another thing by another doctor. (Focus group 2) Thus, the participants reported that inconsistent information may impact on parents’ understanding of discharge information. 3.6. Enablers Enablers to the process of effective provision of discharge information for parents included: multiple sources of information; ensuring parents understood discharge information; and nurses having a capacity to follow-up at risk patients. 3.6.1. Multiple sources of information Nurses valued having multiple sources of discharge information available to share with parents. We give a lot of um, . . . patient handouts to parents who present, if it’s the first time. For example, with croup or if they have gotten any misconceptions about fevers. So, a lot of people think that fevers are dangerous then we usually give them verbal advice and then give them a fever handout afterwards. (Focus group 2) Thus, quality discharge information for some of the nurses in the focus groups was enabled by the availability of multiple resources. 3.6.2. Ensuring parents understanding of information Nurses in the focus groups valued having opportunities to confirm parents’ understanding as a useful strategy support quality of discharge information.
They just still have that underlying fear of fevers for whatever reason, cultural, previous experience or whatever. (Focus group 1)
If I’m concerned that somebody doesn’t understand then, I’ll ask them to repeat it back to me, or ask if they’ve got any questions or try and explain things in more simplistic layman’s terms rather than using medical kind of jargon. (Focus group 2)
Nurses perceived pre-existing beliefs of parents as potentially impairing the process of understanding or following discharge information.
The ED nurses expressed some pride in their capacity to support parents by perceiving when they required additional information to properly understand the information provided.
3.5.4. Parents’ assumptions about information in social media ED nurses’ discussion on the impact of parents’ assumptions of the accuracy of social media information on parents’ care of
3.6.3. Follow-up appointments The ED nurses valued opportunities to provide additional quality in discharge care by being able to follow up appointments,
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particularly for vulnerable patients, such as refugee families, through collaboration with community-based case managers. We do try and follow up with, um, so refugees, having a (case) manager. The manager might not have come in with them. Um, we want to make sure that the manager knows. . . is aware of, of what has happened with them. (Focus group 3) Nurses perceived the follow-up appointments processes for vulnerable families as a strong enabler of the provision of quality discharge information. 3.7. Outcome The outcome domain of the Donabedian Model refers to the results of the quality of care. Factors that may compromise the effectiveness of outcomes of the provision of discharge information, parents understanding, related to parents, resources, and ED staff. 3.8. Ineffective outcomes in parental understanding of discharge information Three factors likely to compromise parents’ understanding of discharge information were: provision of incomplete or inappropriate information; parents’ time constraints and other parental characteristics as described below. 3.8.1. Provision of incomplete or inappropriate information Nurses were concerned about how parents would be able to manage their child’s care at home when they observed parents’ lack of understanding, due to ineffective health education as reflected in this quote: The asthma plan hasn’t been explained to them appropriately, so they’ve given one puff instead of the six puffs even though they’ve been given an asthma plan. I feel from that point of view we haven’t actually educated them well enough to um. . . (Focus group 2) Further the quality of resources and information provided were also a factor that could impact on the outcome of parents understanding. Sometimes the instructions aren’t necessarily clear because you can read, even if you are English speaking, you can read what’s written one way or another, so it will need (to be) interpreted. Um, you know, because maybe the grammar isn’t brilliant or the, you know. Just how it’s, it’s, it’s been written (in a confusing way). (Focus group 3) Nurses shared that if all ED staff had a more complete awareness of available resources, they could help parents have a better understanding of the discharge information. Doctors need to know that . . . that’s available. So, our doctors working both EDs, and in our adults, . . . doesn’t have freely available, um, guidelines printed. (Focus group3) The need for all staff to use evidence-based care and more directly follow existing protocols and guidelines appeared to be important to ED nurses. 3.8.2. Parents’ time constraints Nurses understood that parents could experience time pressures and need to urgently leave the ED. Parents’ own time pressures could result in a compromised understanding of discharge information.
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You know, leaving without medical advice or against medical advice, that sort of thing. . . . it’s because of time, they need to get out because they have other children, they’ve got other concerns. (Focus group 3) Compromised understanding as an outcome was also described in the context of ED nurses having insufficient time to check that parents had understood the information they were given: Sometimes you just get too busy. To give people adequate information and before you can get back to the bed you’re looking after, they’ve already been discharged. (Focus group 2) Nurses described their own time constraints in the ED, but also seemed sensitive to parents’ time-related pressures. 3.8.3. Parents’ characteristics The ED nurses recognised a diversity of parents’ backgrounds in discussing potential reduced quality of care outcomes relating to parent’s understanding of home care information provided during the discharge of a child from the ED. I don’t think they’ve misunderstood what we’re saying. They just still have that underlying fear of fevers for whatever reason. . . . cultural . . . previous experience or whatever. (Focus group 1) Therefore, independent of resources and how experienced the ED nurses were in helping parents understand information, parents’ characteristics could challenge communication. 3.9. Effective outcomes in parental understanding of discharge information Two factors were identified as being important to effectively providing discharge information to parents: (i) the professional experience and competence of the ED staff and (ii) the provision of useful resources. 3.9.1. Professional experience and competence Nurses in the focus groups felt their professional competence was important in the effectiveness of providing information and the outcome of parents’ understanding of that information. We go out of our way to give them extra information, to sit down and explain, to get them . . . for asthma, for example, we want them to show us how to, how they’re doing it, tell us what their understanding is, of, you know, what they’re doing when they’re doing it. Um. So, that we find out or work out what the barriers are to them being able to troubleshoot, um, and assist them. (Focus group 3) Therefore, the ED nurses perceived that their training and their competence was helpful to ensuring parents’ understanding of discharge information. 3.9.2. Providing useful resources Having additional resources, such as pamphlets, was considered important to complement the verbal information provided to parents. Such resources helped nurses feel effective about how they were supporting parents’ understanding of their child’s health and healthcare needs. I think that having a properly written medical handout is much more useful for them . . . even if they don’t look at it. At least we can feel like we’ve tried to give them the right information. (Focus group 2) Therefore, ED nurses believed having additional resources could reinforce the likely outcome that discharge information would improve parents’ understanding of their child’s care at home.
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Nurses’ perceptions of the causes of ineffective outcomes for understanding discharge information related to unclear communication, pressures relating to time and time policies, and parental characteristics that limited their understanding. Nurses perceived effective outcomes in quality of care aligned to their own professional experience and competence in being able to provide useful resources to promote parents understanding.
4. Discussion Multiple factors related to parents’ understanding of discharge information were identified in this study which concerned verbal and written communication with parents and between staff and the role of the ED Nurse. The quality of care in ED settings can depend on patients receiving appropriate written and verbal instructions [4]. Incomplete health communication can compromise patient care [6,9] as communication is a key factor in patient understanding [18,19] and an important skill of specialist ED nurses [20]. In this study, nurses took pride in their capacity to help parents understand more about their child’s condition, provide accurate information, and suggest appropriate care for this child at home. Also, providing additional printed resources for parents accessing children’s EDs is seen as an opportunity to increase parents’ understanding in child health [3,8]. Nurses in our study believed in their capacity to help parents when they were afforded opportunities to follow-up with families after a child was discharged from the ED. Appropriate follow-up appointment is essential to optimise outcomes after discharge from the ED when nurses perceive additional care may be required [10]. These nurses were experienced in supporting children with high needs, including children from refugee families. Refugee children are a vulnerable group who require culturally appropriate, trauma sensitive services, continuity of care and follow up to support parents’ understanding of a child’s health needs [11]. Even though this type of follow up appointment on discharge information appeared to be a rare opportunity for ED nurses, they perceived success in communicating with these vulnerable families. Other examples of ED nurses’ pride in communication skills included their stated capacity to explain and educate on asthma management, know when and how to communicate using interpreters and check with parents around their understanding of information provided. These ED nurses’ perceptions of competence in communication and their sensitivity to cultural diversity highlight professional practices well aligned to the International Standards of Care for Children in Emergency Departments [3]. Implications for ED nursing practice from this study include a recommendation to consider commencing the provision of discharge information as part of the discharge process from triage to the waiting and departure stages. ED nurses could encourage parents to think about what might be needed in caring for this child and continue a discharge related discussion within communication that occurs during waiting times. This discussion could include inform parents to return to the triage station if their child’s condition deteriorates, and most importantly quality control checks for understanding prior to parents leaving the ED with their child [21,22]. Therefore, for ED nurses to practice effective communication and education skills to maximise their expertise in discharge planning. Ultimately, ED nurses can be of great assistance in ensuring parents understand the information they receive about their child’s care at home. Finally, there is potential for an increased role for ED nurses in directly discharging children with higher triage scales (three to five) as these triage categories could open educational opportunities for child health promotion; which would save time and resources for the ED medical staff.
5. Conclusion Through application of the Donabedian Model, this study identified barriers to and enablers of parents’ understanding of discharge information which were linked to communication, resources, staff competencies and time constraints as well as characteristics of the parents. Clear, consistent, and accurate communication appears as important as the availability of high quality supportive resources to assist parents’ understanding of discharge information. While dealing with time pressures and managing the other complexities of the ED can make discharge planning difficult, ED nurses described satisfaction with the quality of their work when they were afforded the time to check parents’ understanding. Findings from this study can be used to support the specific role of nurses in providing quality information to parents as part of a child’s treatment and discharge from a paediatric ED. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest The authors certify that this study has neither been published in whole or in part elsewhere nor is under consideration elsewhere. The authors declare that there is no conflict of interests regarding the publication of this paper. Contribution KP made a substantial contribution to the conception, design, data collection and interpretation. KF and PF also substantially contributed to the conception, design, and interpretation of data. GN contributed to the conception, design, data collection and interpretation. All authors shared in critically revising the manuscript before providing their final approval for publications. Acknowledgements The staff of the paediatric emergency department are acknowledged for their support and participation. References [1] The Australasian College for Emergency Medicine. Quality standards for emergency departments and other hospital-based emergency care services; 2015. Available at: https://acem.org.au/getattachment/74975862-1d4a-4ae7a95e-4b6d806aefb0/Preliminaries.aspx [accessed 06.05.17]. [2] Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to standard written instructions improved caregivers’ understanding of their child’s emergency department visit, plan, and follow-up: a randomized controlled trial. Pediatr Emerg Care 2013;29(6):699–704. [3] Al-Harthy N, Sudersanadas KM, Al-Mutairi M, Vasudevan S, Bin Saleh G, Al-Mutairi M, et al. Efficacy of patient discharge instructions: a pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Fam Community Med 2016;23(3):155–60. [4] Gozdzialski A, Schlutow M, Pittiglio L. Patient and family education in the emergency department: how nurses can help. J Emerg Nurs 2012;38(3):293–5. [5] Chappuy H, Taupin P, Dimet J, Claessens YE, Treluyer JM, Cheron G, et al. Do parents understand the medical information provided in paediatric emergency departments? A prospective multicenter study. Acta Paediatr 2012;101(10):1089–94. [6] Samuels-Kalow M, Stack A, Porte S. Effective discharge communication in the emergency department. Ann Emerg Med 2012;60(2):152–9.
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