Patient information at discharge—A study of a combined approach

Abstract

Objective

To describe patients’ perceptions of a new information procedure related to going home after urological surgery. This procedure, developed in an action research project, included a discharge talk with the nurse and an information booklet for the patients to keep.

Methods

A convenience sample of 99 patients responded to a survey sent home 1 week after discharge (return 78.6%). The Patient Information and Nurse Interaction Scale (PINI) was used for data collection.

Results

The sample were mostly male (81%), older (mean 71.9 years), and hospitalised on average less than 4 days. Patients who got the booklet had significantly more favourable perceptions on information received (p < 0.05) on 11 of 21 items, and 91% said they would not have managed very well at home without it.

Conclusion

The patients who received the booklet knew more about what might happen to them, were less uncertain and had fewer concerns when going home.

Practice implications

The combination of standardised written information and a talk with the nurse where patients participated in individualising the information appears to have had a significant impact on self-management at home.

Introduction

In general, patients ask for more information than they receive and generally it is for more individualised information. Relevant information delivered in a way that brings understanding is important for both patients and relatives. The significance of patient education before hospital admission, tests, and treatment is well documented with regard to its positive effect on satisfaction with care, psychological distress, and length of stay [1], [2], [3]. The need to improve the information given at discharge is documented in several studies [4], [5], [6]. In Norway, it is prescribed by law that patients have the right to receive information about their health status and treatment choices [7]. Norwegian studies on patients’ view on their hospital stay have repeatedly reported the least satisfaction with information and communication with discharge information receiving the lowest score [8], [9], [10].

Structural changes in health care delivery, such as decreased length of hospital stay, more frequent use of day surgery, and treatment in outpatient clinics, have a dramatic effect on the time available for patient education. This is especially problematic with regard to discharge information. As a consequence, patients may leave the hospital without sufficient knowledge about how to manage their care at home and things to look for related to treatment effect and signs of complications. A national survey in England in which 4226 surgical patients participated reported that close to one-third of the patients said it would have helped them to know more about how to manage at home, 37% wanted more information about side-effects of medication, and many were uncertain about what would be normally expected to occur [5]. Knowledge about possible complications, symptom management, pain relief, consequences of daily living, and wound care are all high priorities for surgical patients [11], [12], [13], [14], [15], [16], [17], [18]. Other important things are sleep, the progress of activity, appetite, and psychological reactions after discharge [19], [20]. In the elderly, information about how to manage care when returning home is often judged to be insufficient [21], [22], [23]. Lack of information may lead to re-admission and more frequent use of health services in the community [21], [24], [25]. It has been reported that patients have most concerns 1 week after discharge [26]. Naylor and colleagues documented in a randomised clinical trial the effect of planned systematic discharge information for elders with common medical and surgical diagnoses [21]. For example, fewer persons in the intervention group were readmitted and the time span from discharge to re-admission was longer compared to the control group. Thus, well planned discharge information may have economic effects in addition to the increased potential for patients’ self-care management at home [6], [21], [27].

Most of the patient education before and after contact with the hospital is in the form of written information. A key issue is whether this is understandable to patients and their relatives [28], [29], [30], [31], [32], [33]. Understanding is decreased by difficult language, if it does not correspond with patients’ current knowledge level, and when too much information is in a small font size and lack of space between information [34].

On two urological wards in a university hospital in Norway an action research project was carried out in the period 1999–2003. The focus was on improving information for patients undergoing transurethral resection (TUR), a surgical procedure for problems in both the prostate and bladder. For these most frequent diagnoses, no guidelines existed on the wards for giving patients specific information. A major concern for the nurses was the lack of guidelines as well as the quality of their interaction with patients. The process of this action research is published elsewhere as well as the outcomes of a new procedure for patient information for TUR-patients [35], [36]. This previous research had guidelines for written information to be sent to the patient at home before surgery, guidelines for the nurses’ admission talks and their style of communication with patients.

The present study explored the TUR-patients’ perceptions related to new guidelines for discharge information which included a discharge talk with the nurse and a written information booklet. The booklet was developed by nurses on the ward and based on their expert knowledge about what to observe after TUR, what problems may arise in the postoperative period, and how to deal with this. The content was in accordance with research on discharge information and patients’ learning needs after hospital stay (11–15, 17, 19–20). As recommended for written material to the elderly population, font 14 was used since TUR-patients’ mean age is above 70 years [34].

The four-page booklet in everyday language, included observations, appropriate actions, and advice on what to do if certain changes in the patient's condition occurred; telephone numbers in case questions or concerns arose. It addressed food, fluid, constipation, urination, bleeding, activity, sexual life, and possible complications such as urinary infection, serious bleeding, etc. Examples are given in Fig. 1. Below each section of standardised information, an open space was left for the nurse and patient to fill in relevant individual issues during the discharge talk. An example is the directive to drink 2 l of fluid each day. This had to be modified and individualised for patients with specific cardiac conditions.

Guidelines for the information process were developed. During the admission talk with the nurse, the patient received the booklet to read, and a sticker in the patient's journal was signed and dated by the nurse. The discharge talk took place prior to or on the discharge day. After concluding this interactive session, addressing and individualising the content of the booklet, it was signed by both patient and nurse and a copy was made for the patient's record while the patient kept the original to take home. The nurse signed and dated the sticker.

Action research aims at permanent change of practice through practitioners’ active participation in all phases of the project. The nurses had defined the problem and the actions to be taken, and also created the booklet and the guidelines (35). They knew the new procedure. The head nurse supervised its implementation and coached new nurses on the ward, while the researchers were not involved in this process.

The research questions for this study were:

• How do TUR-patients judge the information received while hospitalised?

• What are TUR-patients’ views on interaction between the nurses and the patients?

• What are TUR-patients’ perceptions about how to take care of themselves after discharge?