Mary K. Anthony, PhD,RN 1,2 Kathleen Vidal, MSN,RN 2 Pimpanitta Jittapiriom, PhD (candidate) 1 Carolyn Kleman, MSN, RN 1 Amany Farag, PhD,RN 3 Supported by Kent State University University Hospitals Case Medical Center 1 Kent State University, 2 University Hospitals Case Medical Center, 3 University of Iowa RELATIONAL NURSING CARE: A Strategic Model Of Care To Improve Discharge Readiness and Safe Transitions

BACKGROUND Discharge represents a time that bridges the transition from hospital to home. Profile −Nearly 40 million discharges per year −Approximately 20% are readmitted within 30 days −Up to one third of these readmissions are preventable −19% have an adverse event post discharge Kent State University University Hospitals Case Medical Center

BACKGROUND Many interdisciplinary and interdisciplinary models have been designed and implemented to address the challenges of discharge. Models address structure of discharge, processes of discharge and standardization of both structure and processes. Failure of existing systems. Models of care built around relational capital may offer promise as a strategic driver in accomplishing safe discharge. Kent State University University Hospitals Case Medical Center

BACKGROUND Is discharge the most important conversation in a hospitalization? Characteristics of Discharge Communication Kent State University University Hospitals Case Medical Center

PURPOSE To assess the extent that core processes in a model of nursing care delivery explain nurse and patient perception of discharge readiness. The underpinnings of the model: To build relationships and promote information sharing. Kent State University University Hospitals Case Medical Center

METHOD Design:Cross-sectional correlational Sample:Convenience Setting: Hospital: One Healthcare System Medical Surgical Units Practicing Relationship Based Care Academic Medical Center (1)13 Community (2) 4 Rural (1) 3 Critical Access (2) 3 Kent State University University Hospitals Case Medical Center

METHOD Inclusion Criteria RN SampleWorked as bedside nurse in one of 6 hospitals within the healthcare system Worked on a medical –surgical unit where relationship based care had been practiced for at least one year Full or part time (least one day a week); PRN (if assigned to an eligible unit Permanent member of the staff Patient Sample 21 years of age Cognitively Intact Speak and Understand English Discharged home Kent State University University Hospitals Case Medical Center

RN DATA COLLECTION Hospital Liaison for each hospital Unit meeting to explain the study Survey placed in unit mailboxes Reminder Flyers posted on units at specified intervals: − The same day of survey distribution − One week after survey distribution − Two weeks after survey distribution − Three weeks after survey distribution Kent State University University Hospitals Case Medical Center

PATIENT DATA COLLECTION Data collected from patients during the same time month of RN data collection. Recruited patients who met following criteria: −Discharge within 4-6 hours −Discharged home −Consent obtained Survey was given to patient along with a envelope to place questionnaire and return to drop box on unit. Kent State University University Hospitals Case Medical Center

METHOD Response Rate RN A total of 554 surveys were distributed; 222 were returned and usable for a 40% response rate Patient Patients recruited per unit5-28 Number of patients who signed a consent 444 Number of patients who returned a survey 376 (86% return rate) Kent State University University Hospitals Case Medical Center

RN DEMOGRAPHICS UnitIndividual Mean yrs (SD) Age37.05 (4.73)36.20 (11.03) Unit Experience4.31 (2.09)7.99 ( 9.48) Experience with manager 2.20 (1.35) 2.52 ( 2.73) Kent State University University Hospitals Case Medical Center

PATIENT DEMOGRAPHICS Kent State University University Hospitals Case Medical Center Patient Sample Gender Male (n = 166)44.4% Female (n= 208)55.6% Previous Hospitalization (n = 340) 90.4% How long have you been in the hospital? 4.8 days (4.28) Range 1-36 days How many times have you been hospitalized? 74 % reported being hospitalized 1-5 times

INSTRUMENTS: Relationship Based Care (Anthony et al., 2009) 1. “Think back over the last week (7 days). In your day to day interactions, on days you worked, how often did you conduct the following activities with your assigned patients” − Admission Interview − Sit down Daily Rounds − Discharge Interview − Follow-up phone call Not at all (1) to All the time (4) 2. Nurses were asked to rank order a series of activities related to providing care. Kent State University University Hospitals Case Medical Center

INSTRUMENTS Perception Of Readiness For Discharge Nurse Perception of Readiness Nurse Perception of Quality Care (Aiken, 2002) Nurses rated confidence in patients ability to manage care at time of discharge Confident (1) to Not Confident at All (4) (reverse scored) Patient Perception of Readiness Patient Readiness for Discharge (Weiss, 2006) 7-item instrument Responses on the RHDS are on an 11-point summated numeric rating scale Not at All (0) to Totally (10) Kent State University University Hospitals Case Medical Center

RELATIONSHIP BASED CARE Relationship Based Care UnitIndividual M (SD) Admission Interview4.39 (.58)4.39 (1.63) Daily Sit down Round3.93 (.98)3.81 (1.69) Discharge Interview 3.68 (.84) 3.55 (1.85) Importance of Discharge (mean Rank) 5.19 (.95)7.42 (1.80) Kent State University University Hospitals Case Medical Center

RANK ORDER OF NURSING CARE ACTIVITIES Nursing Activity Rank Order (1 is most important) Unit Level M (SD) Individual Level M (SD) Discharge Planning7.27 (.75)7.42 (1.8) IV Care3.66 (.71)3.79 (1.7) Complete update interview profile7.41 (.66)7.48 (1.8) Sit down with patient5.84 (.95)5.81 (2.2) Patient Education5.19 (.80)5.11 (1.7) Treatments3.91 (.78)3.78 (1.7) Charting5.64 (.96)5.63 (2.2) Conversation with patient3.61 (1.00)3.61 (2.3) Passing Medications2.17 (.73)2.15 (1.6) Kent State University University Hospitals Case Medical Center

READINESS FOR DISCHARGE UnitIndividual Perception of Readiness for Discharge M (SD) Patient (0-10) 8.11 (.53) 8.13 (1.43) RN (1-4) 2.73 (.26) 2.70 (.61) Kent State University University Hospitals Case Medical Center

RESEARCH QUESTIONS 1.What are the relationships among: a.RN perception of readiness and patient perception of readiness for discharge? b.Readiness for discharge (patient and nurse) with core processes of relationship based care and their relative importance? 2.Based on univariate analysis, what is the explanatory power of a relationship based model of care on nurse and patient readiness for discharge? Kent State University University Hospitals Case Medical Center

RELATIONSHIP OF DISCHARGE READINESS Kent State University-University Hospitals Case Medical Center RN Perception of Patient Readinessp Patient Perception of Readiness.20.35

CORRELATION RN Perception of Readiness for Dischargep Conducting Admission Interview Conduct Daily Sit Down Rounds Conduct Discharge Interview Importance of: Discharge Planning Patient Education Sit Down with Patient Conversation with patient Kent State University-University Hospitals Case Medical Center

CORRELATION Patient Perception of Readiness for Discharge p Conducting Admission Interview Conduct Daily Sit Down Rounds Conduct Discharge Interview Importance of: Discharge Planning Patient Education Sit Down with Patient Conversation with patient Kent State University-University Hospitals Case Medical Center

RN PERCEPTION OF PATIENT READINESS FOR DISCHARGE (N = 23) Betat p Admission Interview Sit down rounds Discharge Interview Importance of Discharge Planning Model R 2 =.38, F 4, 18 = 2.80 p =.057 * p<.05, * * p <.01 ***p <.001 Kent State University University Hospitals Case Medical Center

PATIENT PERCEPTION OF PATIENT READINESS FOR DISCHARGE (N = 23) Betat p Admission Interview Sit down rounds Discharge Interview Importance of Discharge Planning Model R 2 =.23, F 4, 18 = 1.36 p =.28 * p<.05, * * p <.01 ***p <.001 Kent State University University Hospitals Case Medical Center

CONCLUSIONS RN sample, the sit down rounds and relative ranking of discharge planning were important to their perception that patients were ready for discharge. Patient sample, the admission interview and relative ranking of discharge planning were to their perception of being ready for discharge. What is in common is that both the admission interview and sit down rounds involve focused conversations. The small sample likely accounted for moderate effects to be nonsignificant. Kent State University University Hospitals Case Medical Center

IMPLICATIONS Discharge Information −What helps patients manage this complex information? −What helps patients make sense of complex information? −What helps them differentiate information? What is the discussion around structured conversation with relational conversation in managing discharge? Kent State University University Hospitals Case Medical Center