CHALLENGES RELATED to patient transitions from the hospital to home are well documented. This care transition represents a vulnerable time for patients. They must integrate new health care responsibilities while returning to everyday life. Movement from a passive role of receiving care while hospitalized to an active role in managing care can be overwhelming. Patients may need to integrate new health care needs, diet and medication changes, activity limitations, symptom monitoring, and follow-up, while returning to the nuances of managing day-to-day life.
Consequences of transition of care issues that are not well managed include readmission to the hospital, mortality, and unplanned costs. Acknowledgement of these challenges and the known consequences is widespread, but problems continue to exist. This article discusses the nurse leader's role in leveraging adaptive leadership to improve the transition from hospital to home after an individual has received care for complex medical and surgical issues.
Nurses are pivotal to an effective care transition from hospital to home. They are able to provide care coordination and patient education. However, discharge planning that facilitates these is acknowledged to be time-constrained and labor-intensive.1 Both nurses and patients report that discharge planning and patient education are elements of nursing care that are frequently missed, meaning that they are omitted and not provided when indicated.2,3 This observation by patients could impact perception of care and subsequently factor into patient experience metrics.
Nurses, especially those with fewer years of experience, are in need of tools and resources to facilitate hospital discharge experiences that lead to a successful home transition. The complex nature of patients with chronic diseases and their self-care needs requires nurses to identify, address, and prioritize unique patient needs. Nurses must employ autonomy, using judgment to act in the best interest of the patient, in order to meet his or her needs in the discharge process.4 A resource that may help nurses learn to navigate and individualize discharge planning is a mentor. Through provision of this resource, a person with which to reflect and discuss, the nurse could grow skills and experience related to discharge planning in a supportive environment.5
Many factors beyond the patient and nurse influence the discharge process. The interaction between structural factors (eg, people and tasks) and the process of patient discharge must be considered. Discharge planning may be perceived as an episodic event, when in fact it is a longitudinal process that begins on the day of admission, continues during hospitalization, and extends into a period after the patient returns home.6 Factors such as management of other comorbidities, health literacy, social support, socioeconomic status, and geographic location can all influence the patient's capacity for self-care at home, and consequently, the plans for a safe transition.
For a successful transition, patients must have the training and resources to actively assume responsibility for care, as opposed to being the passive recipient of care he or she may have been while hospitalized. For example, medication management is much different when hospitalized from home. In the hospital, it is typical for the correct medication to be brought to the patient at the correct time, while the appropriate monitoring occurs. Once home, the patient must assume responsibility for this entire process. After hospitalization, new self-care routines are often necessary. Frequent updates and changes are sometimes needed.6
The discharge process is a multifactorial process, with many interacting and intersecting parts. It can also be unpredictable, as anticipated events, such as discharge time, can change quickly. The consequences of one seemingly small change may affect multiple other parts of the discharge process. For example, a change in discharge time could impact the ability to obtain medications and supplies. Transportation plans may need to be revised and caregivers may need to adjust other commitments.
Beyond the complexities of the discharge process for an individual patient, the hospital environment is an important consideration. At the same time that the individual patient is anticipating discharge, other patients are moving through the hospital system as admissions, discharges, and transfers. Patients are experiencing changes in conditions that require the health care team to shift priorities and reallocate resources. An engaged nurse leader is able to consider the complexities of discharge planning and their connection to the local and organizational environment to discover innovative solutions.7–10
The leader seeking to improve the discharge process will not be successful if traditional, linear leadership tactics are followed. Instead, the leader must embrace complexity leadership behaviors that encompass administrative, adaptive, and enabling characteristics. Administratively, the leader must understand the nuances and needs of the organization. The adaptive leader sees the connections and relationships in the system to provoke change through the emergence of collective action. Enabling characteristics allow the leader to bring together administrative and adaptive characteristics to spark change and innovation.
Enabling leadership was key to the initiative described in this article, as it leverages the informal leader to self-organize and connect the system to the patient to optimize care.11 The complexity leader gives up some control, allowing the interconnectedness of nurse, patient, and system to emerge, while she or he provides guidance on the improvement process.12
EDUCATION RESOURCE NURSE
When the nurse leader of an inpatient adult medical-surgical unit identified negative trending of patient experience scores, she was prompted to examine and evaluate discharge readiness and barriers to the discharge process. Negative trends were noted on patient responses to questions regarding their education and readiness for care at home. These included a lack of understanding of indications for new medications and information on side effects; absence of assessment of help needed at home; possible symptoms or problems; and a paucity of overall instructions for managing care at home. About two-thirds of patient calls after discharge were related to poor understanding of discharge instructions or medications. In addition, the 30-day readmission rate for patients on this unit was trending negatively.
The inpatient adult medical-surgical unit has 36 beds. During 2017 and 2018, the average length of stay for patients was 4.7 days and the average occupancy was 81%. A variety of patient types are cared for on the unit: general medical-surgical (27%), neurosurgical (20%), otolaryngology (13%), medical neurology (12%), stroke (8%), epilepsy monitoring (6%), plastic surgery (4%), and cardiac overflow (10%).
Unique to this unit are the particular self-care challenges of patients admitted for neurology conditions, neurosurgery, or otolaryngology procedures. For example, when patients experience stroke, they often leave the hospital with vastly different physical, emotional, and cognitive functioning from they had prior to the stroke. Difficulty swallowing necessitates changes to food and fluid intake, which may even include the need to manage a new piece of equipment, such as a feeding tube. Weakness or lack of motor movement on one side of the body may impair mobility and require home modifications and adaptive equipment to remain active. Problems with speech expression can also require adaptive equipment, impair ability to express needs, and hinder communication with family and friends, the health care team, and the public at large. These are but a few of the potential impacts of stroke that require specialized discharge planning.
Individuals in the otolaryngology population often leave the hospital with head and neck wounds/scars, new feeding tubes, and/or new tracheostomies, all of which require extensive knowledge and skill to manage at home. Considerations for tracheostomy care include needs for suctioning, skin care, tie and tube changes, emergency supplies, and response to emergency situations. Wound care instructions can be detailed and specific. Patients/families must also be able to demonstrate drain care. Additionally, adaptive equipment is needed due to the patient's impaired ability to communicate via speech. While each person had a planned surgery date so that much could be done to prepare him or her ahead of hospitalization, the knowledge and skills needed posthospitalization are vast.
Due to the complexity of the hospital discharge process, the nurse leader and team understood that it was imperative to take into account a broad frame of reference, and to consider multiple factors to ensure that changes in workflow would add value.13 The unit's National Database of Nursing Quality Indicators Nursing Satisfaction Survey scores for autonomy, decision-making, and nurse-nurse interaction scores were all greater than the survey mean for the benchmark. There was the potential to leverage these positive scores to improve the discharge process. The unit leader recognized that, through autonomy, the clinical nurse could serve as an informal leader to make connections, self-organize, and allow a new process to emerge that better met patient needs. Additionally, the department of nursing had a goal to support the organization's strategic plan by outperforming the benchmarks for patient satisfaction and patient experience results. Nursing leadership aimed to enhance the patient experience through practice optimization, and development of nurse leaders at all levels. The capacity to see the connectedness between these factors and open up space for innovative solutions was needed.14
With these factors in mind, the unit leader leveraged adaptive capacity to move forward, specifically targeting flexibility and emergence. Imagining a future of an improved discharge experience, she knew it would be essential to monitor the process to make sure it was following a positive trajectory while incorporating new ideas that emerged while leveraging facilitators and addressing barriers. A key role of the leader in embracing adaptive capacity is to translate the change into a situation that the organization can understand and enculturate. The unique needs of this population and the customized discharge planning needs were chief considerations.10,13
First iteration: Quality improvement nurse
A team was formed that included clinical nurses, along with care management (RN case managers and social workers), and pharmacy. This membership represented those closest to the hospital discharge process who have the greatest understanding of opportunities and challenges. Because they work directly with patients, clinical nurses and care managers were able to communicate frequent challenges and suggestions for improvement. Pharmacists were able to help identify higher risk medication situations and engage patients in education to improve understanding, management, and adherence. The team used self-organization, leveraged discipline-specific strengths, and developed interactive relationships with colleagues not directly on the team to allow a new discharge process to emerge.
The team realized that patient education and discharge planning are known elements of missed nursing care. They can fall low on the list of responsibilities and obligations during the course of nursing work. Therefore, a plan was devised to disrupt the current unit staffing. A role was created that focused on how nurses can equip patients for self-care after hospital discharge. Without changing budget or full-time equivalents, one nurse would be dedicated to the role of a quality improvement nurse, 24 hours a day, 7 days a week. Criteria and expectations for this role were drafted. Instead of being assigned a group of patients to care for, this nurse would serve the whole unit (36 medical-surgical beds). Responsibilities were to include daily rounding and a focus on discharges and admissions. Seeing the global needs of all patients on the unit allowed the quality improvement nurse to identify patients with the biggest discharge planning and patient education needs related to medications, and to subsequently engage the pharmacist for additional support.
Information on this new role was communicated to staff via e-mail, huddle points, and posted flyers. (A formal education session would not be available for over 6 months and the team felt compelled to start the initiative before the formal education session.) Within 6 weeks of implementation, a number of themes emerged that guided the team forward. Patient feedback was positive—there was an appreciation for being able to see a consistent nurse. However, clinical nurses not serving in the role felt that a resource had been taken away without adding value back to the unit. This was particularly noticeable on night shift. Due to patient needs for rest, the quality improvement nurse was not effectively able to provide patient education during those hours. Collaborating partners (inside and outside of the hospital) were not available to move discharge planning needs forward. Those serving in the role of quality improvement nurse were often completing the tasks of patient discharge instead of focusing on patient education and care coordination related to discharge planning. It was also noted that the role seemed very broad and needed more definition. This information was used to improve the role and move forward in a positive way.
Second iteration: Discharge readiness nurse
Embracing the patterns, ideas, and themes that emerged during the first iteration, a name change occurred to more closely align the role with its intent. The role evolved in that it was not continued during night shift, and instead covered the hours of 7 am to 7:30 pm 7 days a week. A core group of 5 nurses served in the role. This core group supported consistency of information flow to help meet patient needs. The newly designated discharge readiness nurse took on the predischarge stroke patient satisfaction survey. Real-time responses from patients enabled the nurse to immediately make autonomous decisions to enact changes in the plan of care, patient education, and discharge processes to meet individual patient needs. This seemingly small change allowed the nurse to connect satisfaction results to autonomous nursing actions that supported a successful discharge. The discharge readiness nurse met daily with care management and the unit's team leader to identify and prioritize needs. In an effort to support care of these patients across the care continuum, this role now teaches a preoperative education course for patients who have planned spinal surgery. An online tool was created to facilitate communication among nurses serving in the role. It was integrated into the team leader tool to increase transparency and make the information available at all times.
It was during this phase that the true potential of the role began to emerge. The high autonomy scores that had been noted began to show value. Those serving in the role were able to identify targeted areas for improved processes related to patient education and discharge. The interconnectedness and importance of care across the continuum from the preoperative ambulatory setting, to the inpatient setting, and back to ambulatory care was more apparent. Changes to the preoperative spine classes were made to enhance patient understanding of the hospital stay and self-care needs after surgery. The discharge readiness nurses collaborated with a librarian to update patient education resources. Key resources were organized by specific patient populations, and a patient education station was created to provide tips for those specific populations. This change has been favorably supported by all clinical nurses, as it increased understanding and eased access to needed patient education materials. A seemingly small change has increased access and use of patient education resources. Currently, there are aggregated resources for stroke, heart failure, diabetes, tube feeding, tracheostomy, surgical drains, and surgical spine patients. Complexity leadership allowed these issues to be identified and solutions to come forward to meet needs.
At this point, the trajectory and benefits of the role were apparent. However, not enough time had passed to see the impact on patient experience scores. It is also important to note that during the time that the discharge readiness nurse role was in place, the organization also implemented a new electronic health record. This slowed the ability for the role to continue to evolve. Once the electronic health record was fully implemented, many positive benefits of the role were apparent. Patient feedback continued to be positive and clinical nurses not serving in the role began to embrace the role and see benefits. Additional gaps were identified including needs to gain a shared understanding of the role among all working on the unit, ensure better role consistency, and build stronger relationships with providers.
Third iteration: Education resource nurse
To gain a shared understanding of the role and its impact, a formal presentation on the role was given during required staff education. The title of the role was changed one more time. After the background and role details were presented, ample time for questions and discussion was allotted. Key data were presented, but storytelling was the most impactful part of the session. It was sharing of actual stories and their impact on patients and clinical nurses alike that caused the value of the role to be embraced. The team leveraged distributed leadership to share this message, making it personal, real, and realistic for the unit's nursing professionals. The time for questions and discussions embodied shared leadership characteristics to give all a voice and input into the role.
Even with a core team of nurses serving in the role, issues with consistency, communication, and workflows persisted. A standard schedule was developed where one nurse covers the role Monday, Tuesday, and Wednesday, while a second nurse covers Thursday and Friday. Two additional nurses rotate to cover Saturdays and Sundays. This has greatly improved consistency among nurses and promotes continuity of care, as the same nurse works at least 2 days in a row. While complexity leadership lives on the edge of chaos so that tension can impact change, it was important to realize the need for structure and consistency in continuity of care regarding patient education and discharge. This represents enabling leadership, which manages the intersection of administrative needs for structure within creative, adaptive solutions.
Relationships with key provider groups have been strengthened with the presence of the education resource nurse at daily neurosurgery bedside rounds, weekly neurosurgery interdisciplinary rounds, and stroke rounds. A consistent team of nurses serving in the education resource nurse role allows for trending of gaps or inconsistencies in patient education. The education resource nurses have taken accountability for moving toward resolution when issues are identified. Through collaboration with provider teams, proactive planning occurs related to supplies and medications to facilitate the discharge process. An example of this is creation and implementation of a discharge packet for neurosurgery patients that aims to decrease surgical site infections. While not one of the intended roles of the education resource nurse, it is through these collaborations that inconsistencies in unit supplies related to patient care have been identified and resolved. By working with supply chain management, consistent supplies can now be provided throughout the continuum of care.
The education resource nurse promotes the essential role of an educator for all clinical nurses on the unit. To maintain each nurse's role in education, an Educator of the Month is identified from among the clinical nurses. This highlights an outstanding nurse whose work with educating patients has had a positive impact. This has been crucial in demonstrating that patient education is not just the role of the education resource nurse. It is the role of every nurse who interacts with patients.
This disruption to current staffing was not seen as favorable to all clinical nurses. Increased workload and job strain were brought forward as concerns. The role of the leader in this circumstance was to be intimately involved as an active listener and transparent communicator. As a result of constant monitoring and communication at multiple levels (patients, clinical nurses, care management, and providers), and a commitment to appropriate and timely response to emerging situations, the role is now embraced and has clearly added value.
Another challenge has come forward as a result of this project's success. Other hospital units have heard about this role and have sought to utilize the resource. For example, when a patient is admitted to a different unit with a tracheostomy, the education resource nurse is contacted to assist with care. Often, the education resource nurse is not contacted until the last minute (ie, right before discharge). It has been difficult to meet this patient need, as the resource is dedicated to one nursing unit, and the education resource nurse has competing priorities. Discussion has begun on how this role might be utilized in other areas of the hospital. The complexity leader must leverage the emergence of this role to enhance care in other areas while not detrimentally affecting current efforts.
The sustained impact of the intervention on patient experience scores is yet to be fully known, as results are still pending. Informal feedback from patients during leadership rounds is positive and there are demonstrated examples of how nurse autonomy has been leveraged to facilitate the success of the role.
Preliminary 30-day readmission data are trending favorably for the primary patient types that the unit cares for: neurology, neurosurgery, and otolaryngology. The rate was 9.10% in the 6 months prior to the start of the project, 8.70% during the quality improvement nurse and discharge readiness nurse iterations of the project, and 7.50% during the first 3 months of the education resource nurse role. See Figure 1 for details.
Patient experience results have been variable in response to the addition of this evolving role. When considering the 2 highest ratings for each item, scores increased related to instructions for care at home, understanding of how to manage health needs, and indications for new medications. However, gains were not realized for education related to medication side effects, discussion of help needed at home, and potential signs and symptoms. See Figures 2 and 3 for details. The team is in the process of evaluating ways to improve scores that have not seen gains while maintaining the positive trajectory in other patient experience and readmission data.
The ability of the leader to open up adaptive capacity and provide an environment that leverages nurse autonomy through enabling leadership principles has led to considerable improvement in the early stages of the project. Utilizing the autonomy and expertise of the clinical nurse who most closely interacts with the patient in a space that allows for self-organization has resulted in a new role that is seen as beneficial by both patients and the health care team.
Limitations of the work are related to the narrow scope of the project. Because it involved only one hospital unit, it is unknown whether similar results would occur elsewhere. However, this role has drawn the attention of others in the organization along with discussion of potential applicability in other units. Successful implementation in other areas will require a leader who sees the interconnectedness of patients, employees, and the system in allowing for individualization of the role to best fit the needs of other areas. A one-size-fits-all approach to this role will likely prove detrimental.
This disruptive innovation in the staffing model, the education resource nurse, is showing value. The continued success of this role is dependent on its ability to adapt and evolve as changes in health care and nursing emerge. Creation of the role has been an enjoyable journey that is only just beginning. The original impetus of doing the right things for the patient remains apparent through all of the changes and adjustments. Through flexibility, the changes have only strengthened the role. The implementation of the education resource nurse highlights the need for adaptive capacity of nurse leaders, as they respond to an ever-shifting health care environment.