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Provider Opinions and Experiences Regarding Development of a Social Support Assessment to Inform Hospital Discharge: The Going Home Toolkit

Wallace, Andrea PhD, RN; Papke, Todd PhD; Davisson, Erica MSN, RN; Spooner, Kara MSN; Gassman, Laura MHA, BSN, RNC-EFM

doi: 10.1097/NCM.0000000000000234

Purpose of Study: Despite over three decades of research linking social support and optimal health outcomes, social support is not systematically assessed or addressed during clinical care. This study sought input from health care providers to inform the design of an intervention intended to facilitate assessment of social support in a way that could aid in anticipatory planning during the process of hospital discharge.

Primary Practice Setting(s): Using a purposive sampling strategy, data were collected from providers in two acute care settings serving rural patients, one academic and one community based. Opinions about what an assessment of social support would seek to accomplish, what is currently done and by whom, and the preferred format for delivery were elicited during a series of individual and group interviews. During phase two, feasibility was assessed with three inpatient nurses over 3 clinical days. Field notes were analyzed throughout the project using rapid data analysis techniques.

Results: Health care providers endorsed the creation of an assessment and stated that target users would include all members of the discharge team (e.g., clinical nurses, case managers, discharge coordinators, hospitalists, and specialty care). They identified the need for a patient–family resource (vs. a traditional provider-facing assessment). Participants stated that, although both the information collected and the interview process would meet a need to increase patient engagement in inpatient settings, competing clinical demands would require a tool that was easily completed by patients and family and seen as directly informing clinical activities. To this end, although focusing on the eventual development of an electronic tool seemed valuable, a hard-copy resource was considered more feasible for patient use at the present time. The preliminary test of the resulting hard-copy “Going Home Toolkit” demonstrated potential feasibility and usefulness during clinical practice.

Implications for Case Management Practice: There is need for not only assessing patients' supportive networks during discharge planning, but to do so in a way that would facilitate directed communication between, and engagement with, team members, patients, and families. Especially in light of new legislation focusing on involvement of caregivers, a tool such as the “Going Home Toolkit” may facilitate important conversations about, and planning around, patients' supportive resources at home.

Andrea Wallace, PhD, RN, is an Associate Professor at the University of Utah College of Nursing and School of Medicine. Dr. Wallace's clinical research focuses on narrowing gaps in health outcomes for those living with chronic illnesses while understanding how interventions can be feasibly administered during routine service delivery.

Todd Papke, PhD, is a Technology Innovations Scientist at the University of Iowa College of Nursing. He serves as a technology consultant in both research and education initiatives, and focuses on improving data aggregation, reporting, and research processes as part of the Evidence-Based Practice and Quality group at UIHC.

Erica Davisson, MSN, RN, is a PhD candidate, research assistant, and guest lecturer at the University of Iowa. In addition, she continues to work part-time as a staff nurse at UIHC. Ms Davisson's research focuses on staff nurses' decision making during discharge planning for patients with heart failure.

Kara Spooner, MSN, is Medical Surgical Nursing Unit Director at Mercy Medical Center, Clinton, Iowa. In that role, she builds on 12 years of nursing experience. Prior to her role as a unit director, she worked as a Clinical Development Specialist assisting with nursing orientation and educational opportunities for staff.

Laura Gassman, MHA, BSN, RNC-EFM, serves as Director of Clinical Professional Development, Quality and Magnet Coordinator at Mercy Medical Center. In these positions, she leads teams who provide curriculums for leadership, clinical mastery, infection prevention, and metric-driven outcomes. She has been instrumental in facilitating simulation education, research studies, advancement programs, and Magnet designation.

Address correspondence to Andrea Wallace, PhD, RN, The University of Utah College of Nursing, Annette Poulson Cumming Building Rm 5635, 10 South 2000 East, Salt Lake City, UT 84112 (

The University of Utah College of Nursing, Annette Poulson Cumming Building Rm 5635, 10 South 2000 East, Salt Lake City, UT 84112-5880, The University of Iowa College of Nursing, 50 Newton Road, Iowa City, IA 52242, Mercy Medical Center, Clinton, Iowa, 1410 N. 4th St., Clinton, IA 52732.

Funding for this work was provided by the University of Iowa Office of Engagement and Outreach.

The authors report no conflicts of interest.

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