In 1986, following the release of the report ‘Making a Reality of Community Care,’ the local authorities acknowledged the advantages of care in the community setting (Health Foundation, 1986). This paper was a benchmark for addressing care in the community and acknowledging its benefits for the patients, as well as financially.
The Five Year Forward View (NHS England, 2014) established that the primary care system is the pillar of healthcare. It proposed the need for integrated care among general practice, district nursing, specialist services and social care, thus enabling a reduction in unnecessary attendance to the emergency department and facilitating timely discharge.
In 2019, the ambitious NHS Long Term Plan (NHS England, 2019), was released to target the bridge between primary and secondary care. It highlighted the pressure due to the shortage of GPs and in the district nursing service. This is mentioned by Maybin et al (2016), who described the increasing complexity of care in the community.
This drive to shift care to the community, however, has had a detrimental impact on care delivered and patient satisfaction. The King's Fund (2015) highlighted the pressures that hospitals are facing on discharge and transferring of care, such as inappropriate assessments leading to readmissions, as well as lack of communication between health and social sectors. According to Waring et al (2014), patient care during discharge planning is vulnerable due to the fragmentation of services involved.
This review methodologically explores the evidence available and highlights the lack of existing research on this subject. It discusses the drive from the NHS to bring care closer to home and its challenges. Further, it debates the issues experienced by the district nursing workforce, such as communication and lack of understanding of the district nurse's (DN) role, in caring for people at home and the hurdles following hospital discharge.
Rationale
The Queen's Nursing Institute (QNI) (2013) reported that previous acute care only delivered in the hospital is now being offered by DNs. In concordance with this, NHS England (2015) acknowledged the pivotal role of the district nursing workforce on assessing and providing care for people in the community. It highlighted how much DNs had to evolve in their roles to meet the challenging and changing needs of patients.
Despite the shift of care from secondary to primary being on the political agenda for over 30 years, there is no structure for effective discharge planning, according to Gholizadeh et al (2016). Addicott et al (2015) expressed their concerns regarding the available funding and workforce in the community setting. The Long Term Plan (NHS England, 2019), with an investment of £4.5 million towards primary care, aims to bridge the gap between primary and secondary care. Moreover, the QNI (2009) predicted that, over the following decade, the care required in the primary care sector would increase; it also stresses the decline of the district nursing workforce over the same period.
Therefore, considering the parallel on the evidence between the Government agenda to shift care into the community and the issues faced by the district nursing workforce, this extended literature review will explore the hospital discharge planning process from the district nursing perspective.
Methodology
Prior to undertaking this research, it was necessary to devise a structured framework to formulate the research question. The chosen tool was the PICO table. Methley et al (2014) stated that the PICO table narrows the search by focusing on four components: problem/population, issues/intervention, context/comparison and outcomes. This method enables the researcher to categorise the elements of the available clinical evidence.
The database used during this review were SAGE journals, Wiley Online Library, Google Scholar, Cochrane Library and the National Center for Biotechnology and Information (NCBI). Further analysis of non-UK studies was conducted by using the snowballing approach due to the scarcity of material available. This approach enabled further evidence to be sourced and explored during this review.
Nine peer-reviewed articles were identified for analysis. Cowell (2014) stated that peer reviewing reinforces the validity and reliability of data. Therefore, all the selected data were from qualitative peer-reviewed research, to strengthen the research findings. Sutton and Austin (2015) claimed that qualitative research assists researchers to explore the views and feelings of participants, hence improving understanding of the subject. Hammarberg et al (2016) highlighted the surge in the qualitative research method and its popularity in clinical settings.
Building the bridge: moving care closer to home
This section examines the selected literature regarding the Government's plan to move care from the acute setting into the community. It establishes the impact of discharge planning on how care is managed in the community setting by the district nursing workforce. Four qualitative research articles were chosen. The authors considered the need for a structured discharge planning process to achieve successful health outcomes in the community setting if the aim is to move care to the primary setting (Rytter et al, 2010; Graham et al, 2013; Nordmark et al, 2015a; Pellett, 2016) (Table 1).
Table 1. Consequences of the drive to move care closer to home
| Drive to move care close to home | Issues |
|---|---|
| Lack of structured framework for hospital discharge |
|
| Premature hospital discharges |
|
Nordmark et al (2015a) conducted a qualitative and descriptive study in a Swedish district nursing team and home care organisers (social workers (SWs)). It aimed to understand the perception from both disciplines on discharge planning based on their experiences. The discharge planning process (DPP) was staged at three levels: organisation, group, and individual. The participants consensually agreed that, at an organisational level, there is an increase in discharge from hospital to the community due to the surge in ill, older patients, reduction in hospital stay and reduced number of hospital beds. According to the DNs, due to the increased need to provide care at home, an increase in the nurses' caseload was noted. DNs also reported that physicians considered DPP prematurely. Due to the pressure to release hospital beds, the DPP was ineffective in most cases, which increased the number of readmissions.
On reflecting on the group level during DPP, Nordmark et al (2015a) found a lack of collaboration between teams to manage discharge. Due to the absence of a structured framework among wards, the communication and plans for discharge become fragmented. Lastly, the individual level of DPP is affected by the lack of knowledge among hospital staff regarding the DN role. The National Institute for Healthcare and Excellence (NICE) (2016) suggested the need for a discharge coordinator or a multidisciplinary team to arrange effective hospital discharge and recommended that a healthcare professional work in conjunction to promote safe discharge. However, the DN is not mentioned among the health professionals suggested.
Graham et al's (2013) study on nurses' involvement in discharge planning used a descriptive approach to qualitative research to ascertain if the discharge risk screen (DRS) was carried out as per UK national guidelines. It found that only 23% nurses completed the DRS at admission, despite this screen being mandatory. Only 33% nurses confirmed that DRS was completed for all ward patients, and 45% agreed that, due to time constraints and pressure to discharge, DRS completion was hindered. Lastly, 18% of the participants felt that the discharge had occurred too early. This echoes the organisation-level issues described by Nordmark et al (2015a). However, Graham et al (2013) explored hospital staff nurses' viewpoints regarding DPP, whereas Nordmark et al (2015a) investigated the perceptions of DNs and SWs. Nonetheless, the health professionals shared the perception of patients being prematurely discharged.
In another study, 74% of the DNs who participated were informed of the discharge on the same day that the patient was sent home (Pellett, 2016). To strengthen the validity of the data, a web-based survey was conducted with hospital staff to understand their opinion on barriers to effective discharge planning. Both settings revealed similar data. Some 64% of the hospital staff confirmed that referral to the DN team was completed on the day of discharge. This was attributed to the pressure to discharge patients in order to manage emergency department admissions. These data agree with the findings of Nordmark et al (2015a) and Graham et al (2013), which showed that, due to the increasing demand to move care from the acute setting to the community, DPP did not occur systematically. Lastly, Pettlet (2016) recognised that both groups of professionals felt that some patients were discharged with unresolved health problems.
Taking a slightly different approach, Rytter et al (2010), aimed to analyse whether GP and DN follow-up after hospital discharge would decrease hospital readmissions. Among the 165 patients in this study, 3% were discharged without information sent to the GP. On reviewing the data, Rytter et al (2010) obtained comparable findings with Graham et al (2013) and Pellett (2016). It was acknowledged that some patients (3%) were not medically fit to be discharged, but the discharge occurred to cope with hospital demand. However, this study showed a reduction of 23% in the readmission rate after 26 weeks following hospital discharge (Rytter et al, 2010), even though. This was achieved by structured follow-up by the GPs and DNs.
The findings demonstrate the aim of organisations to fulfil the Government's plan to move care closer to home. However, it appears that this plan prevents effective hospital discharge from occurring. Conclusions from all four studies highlighted that both hospital staff and community staff perceived that patients are being discharged earlier (Rytter et al, 2010; Graham et al, 2013; Nordmark et al, 2015a; Pellett, 2016). Moreover, regardless of workflow charts for discharge planning, organisational pressure to move patient care to the community poses a threat for effective discharge to occur. According to Laugaland et al (2012), many tools and strategies are available to enhance effective hospital discharge. The literature suggests that early discharge planning, a multidisciplinary approach and active communication with community care providers decreases the numbers of failed discharges (Laugaland et al, 2012).
Importance of information workflow
This segment debates the compiled evidence regarding the challenges and complexities from the DN perspective on dealing with hospital discharge. Five studies were selected from primary qualitative exploratory research. The authors argued on two factors that hinder effective discharge planning: communication and lack of understanding of the DN role (Bull and Roberts, 2001; 2010; Wilson et al, 2002; McHugh et al, 2003; O'Brien and Jack, 2010; Nordmak et al, 2015b) (Table 2).
Table 2. Poor communication on discharge planning
| Fragmented communication between hospital and DN service | Issues |
|---|---|
| Poor information exchange between primary and secondary sector |
|
| Misconception/lack of understanding of the DN role |
|
Note: DN=district nurse/district nursing
To explore the hurdles faced by the district nursing service during discharge planning, Nordmak et al (2015b) undertook robust qualitative research and descriptive statistical analysis. Some 194 hospital staff nurses and 64 DNs were invited to complete the questionnaire in this study, of where there were 129 and 42 respondents, respectively. This study provided rich data on the information exchange between the primary and secondary healthcare settings. Some 73% of the DNs provided information to the hospital staff nurses on patients' state of health, whereas only 4% of staff nurses provided this information aspect during discharge planning. These differences in information sharing were also found in other aspects, such as ongoing medication and nursing intervention. There was a higher prevalence (76%) of information sharing from the DN perspective, but only 46% staff nurses shared this information with the DNs during discharge planning.
Bull and Roberts (2001) adopted an ethnographic approach to explore proper discharge for older adults. Data were collected from two geriatric rehabilitation wards using semi-structured interviews. The disadvantage of this research was the lack of descriptive quantified figures illustrating the findings. In contrast, Nordmak et al (2015b) were able to acquire substantial data and descriptively quantify the results. Yet, Bull and Roberts (2001) identified three circles of communication: liaison between hospital staff regarding discharge planning, liaison between hospital staff and patients and their relatives and communication with the district nursing team. They found that fragmentation in communication occurs in the last circle of communication. In the first and second circles of communication, there was no involvement of the district nursing team regarding discharge planning. This evidence illustrates the figures obtained by Nordmak et al (2015b), which showed that few staff nurses would liaise with district nurses during discharge planning. Additionally, Bull and Roberts (2001) found misconception of the DN role and lack of understanding of the district nursing service to be obstacles for effective discharge planning. They made further references to the pressure that the district nursing service is experiencing due to the continuous decline in the workforce and the increasing demand to cope with the Government's aim to shift care from the hospital to the community.
In their qualitative study, McHugh et al (2003) used an interpretive approach to analyse DNs' perception of referrals from hospitals specifically for palliative care. They found that, despite the disease trajectory, 18% of participants agreed that all patients with cancer should have been referred to the DN team regardless of the disease trajectory. Further, the DNs perceived that the hospital's referrals contained minimal information related to the patient's condition and background or past medical history.
Similarly, Wilson et al (2002) used qualitative and exploratory research to investigate the importance referring cancer patients to the district nursing service. Initial consultations occurred in the hospital regarding the expectations of care in the community. A follow-up interview occurred after 4–8 weeks after discharge. Some 27 interviews were carried out before discharge and 22 after discharge; 18 patients were referred to the district nursing service and four were not. The use of this approach allowed the researchers to make a distinction among samples: unmet needs from patients not referred to the district nursing service, unmet needs from patients referred to the district nursing service and needs met by the district nursing service. The group not referred to district nursing had issues regarding the available community support. Services such as palliative care and district nursing were not mentioned during discharge planning, which led to uncertainty and anxiety during crises. The 18 patients who were referred to the district nursing team reported that they were surprised by the complexity of care delivered by DNs. These findings were similar to those of McHugh et al (2003) regarding the lack of understanding of the DN role and the district nursing service, which pose a challenge for district nurses to manage hospital discharge effectively.
O'Brien and Jack (2010) also adopted an ethnographical approach to examine hospital discharge among palliative patients. Their data were similar to those of Wilson et al (2002): they found that both services felt the need for the DN to be involved in the early stages during discharge planning due to the complexities and unpredictabilities in palliative care. Khoen and Nair (2019) introduced the medical order for scope of treatment (MOST), a standardised framework for palliative patients in hospital. This assessment tool encompasses all aspects of palliative care, including safe discharge home with tailored care according to patient needs. They saw a reduction in acute episodes and decline in hospital admissions, as patient preferences were fulfilled and community providers were fully aware of patients' condition, disease trajectory and prognosis. This enabled them to establish effective care in the community.
The literature evidences the importance of communication between hospital and community providers during the discharge process. It highlighted the lack of information during discharging planning (Bull and Roberts, 2001; Nordmak et al, 2015b) and the discrepancies regarding the level of data exchange between the settings. This failure in communication remains the underpinning issue faced by the district nursing service to manage hospital discharge. Moreover, the challenges encountered by DNs to deliver effective palliative care following hospital discharge have been highlighted. Communication continues to present obstacles for efficient care provided in the community setting for palliative patients (Wilson et al, 2002; McHugh et al, 2003; O'Brien and Jack, 2010). Lastly, safe discharge is vital for continuity of care in the community setting; nevertheless, the literature shows the negative impact of misunderstanding regarding the DN role and service specification.
Conclusion
This review showed a surge in hospital discharge figures into the community, in line with the Government's aim of shifting care into the community. However, this move can have a detrimental impact on patients and the community health workforce. Due to pressures to hasten hospital discharge and manage hospital workflow, fragmentation occurs during discharge planning, which hinders effective transition of care between settings.
Moreover, the literature highlighted DNs as promoters of care closer to home and as the providers of tailored care in community settings. It confirmed the vital work provided by this workforce. According to the data, fragmentation in communication between hospital staff and DNs, as well as misconceptions surrounding district nursing services, creates barriers to efficient transition of care. Finally, misconceptions regarding the DN role among hospital staff further add to the challenges around effective management of hospital discharge.
Fragmented or insufficient information related to patients' hospital stay delays prompt action from DNs. Moreover, it increases office time on liaison to ensure correct and accurate information sharing, thus, restricting face-to-face time with patients. Additionally, the misconception regarding the DN role creates false expectations for patients. This can be a barrier to rapport building between DNs and patients, which naturally affects patient and health professional relationships. These issues hinder the performance of the district nursing workforce from managing hospital discharge.
Recommendations for practice
- There is a need for improvement in communication between hospital staff and district nursing teams. A traffic light system would highlight the degree of need for the district nursing service to be involved in hospital discharge planning
- Education of medical and nursing staff regarding the role of the DN would help them recognise the need for appropriate involvement of district nursing teams during discharge planning
- Promotion of integration between the primary and secondary sectors via seminars or webinars to discuss failed discharge or case studies could improve the rapport between health professionals in these settings and improve understanding of the DN role
- Discharge buddies-that is, one DN and one hospital staff member-could be nominated to liaise or coordinate discharge from wards or other acute settings.
KEY POINTS
- There is a continuous increase on district nursing caseload to manage the drive from the government to bring care closer to home
- Communication and fragmented communication hurdle the district nurse to safely manage hospital discharge
- There is a lack of understanding from the primary care sector regarding the district nurse role and its remits
- There is a scarcity of robust frameworks to manage transition of care from the acute to the community setting.
CPD REFLECTIVE QUESTIONS
- What is the role of the district nurse during the hospital discharge planning process?
- Consider the increasing demand to provide care closer to home; what information is necessary during the discharge planning for an effective discharge?
- How can the district nursing workforce improve their profile across the secondary care sector?