Responsible hospital discharge: content validation of nurse’s activities

Alta hospitalaria responsable: validación de contenido de las actividades del enfermero

ABSTRACT

Objective:

To develop and validate a list of activities to be performed by the nurse at the responsible hospital discharge.

Method:

Content validation study. The 14 generated items were organized on a Likert scale and submitted to judges’ appreciation, using the Delphi Technique. Relevance, explicitness in the statements and the sequential order of execution were evaluated. The consensus for the answers was pre-established at 0.80 and the content validity index was calculated.

Results:

Eight professionals participated in the validation of the created list. In Delphi 1, the content validity index ranged from 0.7 (post-discharge contact and home visit scheduling) to 1.0 and in Delphi 2, a range from 0.60 (post-discharge telephone contact) to 1.0.

Conclusion:

13 of the 14 proposed activities were validated. The created list of activities can contribute to the safe discharge process, the continuity and comprehensiveness of care and, also, to the reduction of readmissions.

Keywords:
Patient discharge; Continuity of patient care; Process assessment, health care; Nursing assessment; Validation study

RESUMEN

Objetivo:

Ejecutar y validar un listado de actividades que deben realizar los enfermeros en el alta hospitalaria responsable.

Método:

Estudio de validación de contenido. Los 14 ítems producidos fueron organizados en una escala Likert y sometidos a apreciación de jueces, mediante la Técnica Delphi. Se evaluó relevancia, claridad de los enunciados y orden secuencial de ejecución. El consenso para las respuestas fue preestablecido en 0,80 y calculado el índice de validación de contenido. Resultados: Ocho profesionales participaron en la validación de la lista construida. En Delphi 1, el índice de validación de contenido varió de 0,7 (contacto post-alta y programación de visita domiciliaria) a 1,0 y en Delphi 2, se encontró variación de 0,60 (contacto telefónico post-alta) a 1,0.

Conclusión:

Fueron validadas 13 de las 14 actividades propuestas. El listado de actividades obtenido puede contribuir con el proceso de alta segura, con la continuidad e integralidad del cuidado y, también, con la reducción de reingresos en los hospitales.

Palabras clave:
Alta del paciente; Continuidad de la atención al paciente; Evaluación de procesos, atención de salud; Evaluación en enfermería; Estudio de validación

RESUMO

Objetivo:

Desenvolver e validar uma lista de atividades a serem realizadas pelo enfermeiro na alta hospitalar responsável.

Método:

Estudo de validação de conteúdo. Os 14 itens gerados foram organizados em uma escala Likert e submetidos à apreciação de juízes, através da Técnica Delphi. Avaliou-se relevância, clareza nos enunciados e ordem sequencial de execução. O consenso para as respostas foi pré-estabelecido em 0,80 e calculado o índice de validade de conteúdo dos itens.

Resultados:

Oito profissionais participaram da validação da listagem construída. Na Delphi 1, o índice de validade de conteúdo variou de 0,70 (contato pós alta e agendamento de visita domiciliar) a 1,0 e, na Delphi 2, encontrou-se variação de 0,60 (contato telefônico pós alta) a 1,0.

Conclusão:

Foram validadas 13 das 14 atividades propostas. A listagem de atividades construída pode contribuir para o processo de alta segura, a continuidade e integralidade do cuidado e, ainda, para a redução das readmissões.

Palavras-chave:
Alta do paciente; Continuidade da assistência ao paciente; Avaliação de processos em cuidados de saúde; Avaliação em enfermagem; Estudo de validação

INTRODUCTION

Discharge planning has been described as a way to qualify care and minimize the risk of complications after hospitalization1. Its early start is recommended, with an interprofessional and systemic approach, including the patient/family in decisions about care, and electing a coordinator to articulate resources and transfer information between levels of health care2. In addition, a package of measures involving standardized practices, guidelines and home monitoring for the patient/family, educational interventions with health professionals and periodic discussions between services is advocated3.

However, in the practical setting, this plan usually starts near the patient’s discharge date4) and restricted to usual care without connection with a formal process coordinator(1). Patients and family members are often not included in care planning, making it difficult the adherence and maintenance in home care(5).

Responsible discharge is foreseen in Brazilian legislation(6) and can be understood as a process of transition from hospitalized patient care to other levels of health care, especially to Primary Care. This care continuity model considers the participation and development of patient/family autonomy over care; the articulation between the different points of the network and the adoption of de-hospitalization mechanisms(6).

The nurse plays a central role in ensuring the continuity of treatment and patient safety in self-care, leading, and coordinating this process. In this way, he/she acts as a mediator in interprofessional actions, paying attention to the needs and concerns of the patient/family(7). In planning the discharge, this professional manages, together with the interprofessional team, situations that require greater demand for care at home(8), including chronic conditions, palliative care and the use of devices and equipment for health(9).

Although the transition from hospital discharge care (responsible) is legitimized, each hospital institution establishes its own workflow. Thus, the diverse activities performed by nurses during the discharge plan may differ between health institutions. Although there is an international reference(10) regarding the activities performed by nurses in the discharge plan, no studies have been identified, so far, addressing this model (responsible discharge), proposed nationally, for the continuity of care after hospitalization. Therefore, it is necessary to map and obtain expert consensus for the Brazilian reality.

The findings presented here constitute an initial part of a broaden investigation called “Transfer of care at hospital discharge: time dedicated by nursing and process effectiveness”, from a master’s program, and is linked to the research group Management of Health and Nursing Services (Gestão de Serviços de Saúde e de Enfermagem - GESTSAÚDE). The present study seeks to clarify the question: What activities should nurses perform in the responsible discharge process? Are they validated by experts? And for that, it aims to develop and validate a list of activities to be performed by the nurse during the responsible hospital discharge.

METHOD

This study of content validation followed the two stages proposed in the literature(11), that is, the development stage (here called activity mapping) and the judgment and quantification stage. In the first, there was identification of the construct (responsible hospital discharge) with a search in the literature and development of a list of activities/items to be performed by nurses during the discharge process. Next, a group of judges assessed the relevance of the generated items (qualitative part) and the content validity index of items (I-CVI) was calculated (quantitative part) based on the proportion of agreement of experts.

Content validity enables to verify whether the items that compose a scale (activities) adequately represent the construct under analysis(12). Activities, in this study, are considered the specific actions or behaviors of the nursing team, in the unfolding of an intervention, to achieve results(10).

Sources of information for the mapping of discharge activities were: a) Ordinance No. 3390 of the Ministry of Health on guidelines for the organization of the hospital component of the Health Care Network (Rede de Atenção à Saúde - RAS)(6) and the planning manual and management of discharges prepared by the investigated institution; b) the Nursing Interventions Classification (NIC) Discharge Plan (7370)(10); c) international standards and recommendations on discharge planning(2-4); and, d) other scientific production on the subject(5,13-15), among others.

The list created from these multiple sources, removing duplications, followed the chronological order of the stages of responsible discharge. The 14 items generated were organized on a four-point Likert scale, avoiding the neutral point. The scores for each item were: 1. strongly disagree, 2. disagree, 3. agree, and 4. strongly agree.

The items sequentially addressed the identification of eligibility criteria, communication with the physician about the expected discharge date, responsible discharge planning with the interprofessional team, collection of information from the patient and their family, insertion and guidance of these in home care, record in medical records, team coordination, formalization of counter-referral and post-discharge actions to solve identified problems.

The form generated by mapping activities was inserted into the Google Forms application, allowing for auto-completion. In the initial part, after explaining the research objectives, it was used the Free and Informed Consent Form (FICF) to mark acceptance, space for personal and professional data of the participants, ending with 14 activities proposed in the Likert format.

To validate the content of the generated list, the Delphi technique was used. In it, structured questionnaires are presented sequentially to a group of professionals (judges) with specific knowledge on a particular subject, in search of consensus. The number of phases varies in each study, but it is usually between two and four(16).

As eligibility criteria to compose the group of judges, it was considered a performance of at least one year in the process of responsible hospital discharge and/or scientific production related to the subject. The researchers were located on the Lattes Platform on the website of the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq). As for the other professionals, through referral by peers or managers of nursing services.

The judges were contacted by email with a link to access the online form. Reminders were sent when they exceeded the 15-day filing deadline. Appraisal was requested regarding the relevance of the content and wording of each activity (item) of the responsible discharge, evaluating whether they presented relevance, explicitness in the statements and sequential order of execution(16). Also, that they justified their choice and presented suggestions for improvement, if deemed necessary. Data collection took place between April and August 2020.

Statistical analysis was conducted using the software The SAS System for Windows (Statistical Analysis System), version 9.2 (SAS Institute Inc, 2002-2008, Cary, NC, USA). It included descriptive analysis of categorical variables (absolute frequency and percentage) and numerical (mean (M) and standard deviation (SD), median (MD) and quartile (Q1 and Q3).

In the quantitative analysis of the answers, the I-CVI was evaluated, that is, the proportion of agreement in each of the items (activities) in the list was measured among the evaluators (group of judges). This index is measured considering the number of items that received ratings of 3 and 4 divided by the number of judges(12). These authors advocate that in this process, an ordinal scale becomes a dichotomous scale (valid content x invalid content) and, therefore, the I-CVI must be adjusted using the modified kappa (K^*) to avoid random agreement(12).

Thus, for each of the 14 items of the different Delphi phases, the probability of agreement by chance (pc), the item content validity index (I-CVI) and the modified kappa (K^*) were calculated. The minimum agreement value of 0.80 was adopted, as recommended(12). For the interpretation of the Kappa, the following values ​​were used: ≤ 0.40 (poor), 0.40 - 0.59 (moderate), 0.60 - 0.74 (good) and >0.74 (excellent)(17).

Anticipating data collection, the project was submitted to the Research Ethics Committee of the study institution - CAAE08412019.4.0000.5415 and opinion No. 3.198.240/2019. Participants were accepted by signing the FICF using the submitted form.

RESULTS

From the invited professionals, eight returned the questionnaires. The evaluators were female, with a mean age of 36.1 (SD=6.9; range 24-43) years and working time (seven clinical nurses and one manager) of 11.2 (SD=6.6; range 1-20) years; five had a specialization and three a master’s degree.

The Delphi application occurred in two phases. In Delphi 1, shown in Table 1, the mean agreement on the nurse’s activities ranged from 3.2 (contact after discharge and scheduling a home visit) to 4.0 (eligibility criteria; information collection; patient-family communication and teaching of equipment handling).

Table 1 -
Means and medians of the answers obtained from the judges about the nurse's activities at hospital discharge responsible in Delphi phase 1. São José do Rio Preto, São Paulo, Brazil, 2020

Activities	M	SD	Md	Q1	Q3
1. Eligibility Criteria	4.0	0.0	4.0	4.0	4.0
2. Medical contact and discharge forecast	3.9	0.3	4.0	4.0	4.0
3. Therapeutic project	3.9	0.3	4.0	4.0	4.0
4. Information collection	4.0	0.0	4.0	4.0	4.0
5. Elaboration of discharge plan	3.6	0.7	4.0	3.5	4.0
6. Patient/family communication	4.0	0.0	4.0	4.0	4.0
7. Professional team coordination	3.7	0.5	4.0	3.5	4.0
8. Documentation and referrals	3.7	0.5	4.0	3.5	4.0
9. Information sharing	3.7	0.5	4.0	3.5	4.0
10. Patient/family guidance	3.9	0.3	4.0	4.0	4.0
11. Teaching of equipment handling	4.0	0.0	4.0	4.0	4.0
12. Post-discharge contact	3.2	0.9	3.5	2.5	4.0
13. Scheduling home visit	3.2	1.2	4.0	2.5	4.0
14. Discharge Plan Effectiveness	3.6	0.7	4.0	3.5	4.0

• M: mean: SD: standard deviation; Md: median; Q1 and Q3: quartiles.

In this same phase, the I-CVI ranged from 0.7 (post-discharge contact and scheduling home visit) to 1.0 (criteria, discharge forecast, therapeutic project, information collection and sharing, documentation, patient/family communication and guidance, equipment handling and team coordination). The K^* values ranged from 0.72 to 1.0 - considered excellent (Table 2).

Table 2 -
Content Validity Index and modified Kappa regarding the answers obtained from the judges about the nurse’s activities during the responsible hospital discharge in Delphi phase 1. São José do Rio Preto, São Paulo, Brazil, 2020

Activities	pc	I-CVI	K*
1. Eligibility criteria	0.004	1.00	1.00
2. Medical contact and discharge forecast	0.004	1.00	1.00
3. Therapeutic project	0.004	1.00	1.00
4. Information collection	0.004	1.00	1.00
5. Elaboration of discharge plan	0.031	0.87	0.87
6. Patient/family communication	0.004	1.00	1.00
7. Professional team coordination	0.004	1.00	1.00
8. Documentation and referrals	0.004	1.00	1.00
9. Information sharing	0.004	1.00	1.00
10. Patient/family guidance	0.004	1.00	1.00
11. Teaching of equipment handling	0.004	1.00	1.00
12. Post-discharge contact	0.109	0.75	0.72
13. Scheduling home visit	0.109	0.75	0.72
14. Discharge Plan Effectiveness	0.031	0.87	0.87

• pc: probability of random agreement; I-CVI: item content validity index; K^*: Modified Kappa.

From the answers obtained in the first questionnaire, changes were made in the second version of the list of activities. In view of the justifications pointed out by the judges, some terms were included or revised for better explicitness of the statements. It was opted for the inversion of items 5 and 6, considering that the communication and inclusion of the patient/family in the planning of discharge must precede the registering in medical records or electronically, thus following a chronology in the dynamics of the process. The evaluation of the effectiveness of the discharge plan (item 14) was validated, but with extensive reservations by the judges, and thus, it was decided to reformulate it. In this second moment, only five judges returned the answers to the questionnaires.

In the Delphi phase 2 (Table 3), the mean agreement on the nurse’s activities ranged from 2.8 (post-discharge telephone contact) to 4.0 (discharge forecast, therapeutic project, patient/family guidance and communication, team coordination and scheduling home visit).

Table 3 -
Means and medians of the answers obtained from the judges about the nurse’s activities at responsible hospital discharge in Delphi phase 2. São José do Rio Preto, São Paulo, Brazil, 2020

Activities	M	SD	Md	Q1	Q3
1. Eligibility criteria	3.8	0.4	4.0	4.0	4.0
2. Medical contact and discharge forecast	4.0	0.0	4.0	4.0	4.0
3. Therapeutic project	4.0	0.0	4.0	4.0	4.0
4. Information collection	3.6	0.5	4.0	3.0	4.0
5. Patient/family communication	4.0	0.0	4.0	4.0	4.0
6. Elaboration of discharge plan	3.8	0.4	4.0	4.0	4.0
7. Professional team coordination	4.0	0.0	4.0	4.0	4.0
8. Documentation and referrals	3.8	0.4	4.0	4.0	4.0
9. Information sharing	3.6	0.5	4.0	3.0	4.0
10. Patient/family guidance	4.0	0.0	4.0	4.0	4.0
11. Teaching of equipment handling	3.8	0.4	4.0	4.0	4.0
12. Telephone contact after discharge (up to 7 days)	2.8	0.8	3.0	2.0	3.0
13. Scheduling home visit *	4.0	0.0	4.0	4.0	4.0
14. Identification/solving post-discharge problems	3.8	0.4	4.0	4.0	4.0

• M: mean: SD: standard deviation; Md: median; Q1 and Q3: quartiles; ^* for patients with greater demand for care needs (use of equipment/devices or care with greater technical complexity).

As for the results of the I-CVI, from Delphi phase 2 (Table 4), all items received a value of 1.0, except for item 12 related to telephone contact after discharge, which obtained a value of 0.60; The K^* values ranged from 0.42 (moderate) -1.0 (excellent).

Table 4 -
Content Validity Index and modified Kappa regarding the answers obtained from the judges about the nurse’s activities during the responsible hospital discharge in Delphi phase 2. São José do Rio Preto, São Paulo, Brazil, 2020

Activities	pc	I-CVI	K*
1. Eligibility criteria	0.031	1.00	1.00
2. Medical contact and discharge forecast	0.031	1.00	1.00
3. Therapeutic project	0.031	1.00	1.00
4. Information collection	0.031	1.00	1.00
5. Patient/family communication	0.031	1.00	1.00
6. Elaboration of discharge plan	0.031	1.00	1.00
7. Professional team coordination	0.031	1.00	1.00
8. Documentation and referrals	0.031	1.00	1.00
9. Information sharing	0.031	1.00	1.00
10. Patient/family guidance	0.031	1.00	1.00
11. Teaching of equipment handling	0.031	1.00	1.00
12. Telephone contact after discharge (up to 7 days)	0.313	0.60	0.42
13. Scheduling home visit *	0.031	1.00	1.00
14. Identification/solving post-discharge problems	0.031	1.00	1.00

• pc: probability of random agreement; I-CVI: item content validity index; K^*: modified kappa; ^*for patients with greater demand for care needs (use of equipment/devices or care with greater technical complexity).

The final list of the 13 validated activities to be performed by nurses at the responsible hospital discharge is presented in Chart 1.

Chart 1 -
Activities to be performed by the nurse at hospital discharge validated by the judges. São José do Rio Preto, São Paulo 2021

ACTIVITIES
1	To identify eligibility criteria for responsible discharge of the patient through active bedside search.
2	To discuss with the physician the hospital discharge forecast.
3	To establish the therapeutic project and the discharge plan with the multidisciplinary team.
4	To collect information from the patient (main caregiver, health care network in the municipality, clinical conditions, family composition, and necessary care at home, among others), facilitating and restricting factors for continuing care at home.
5	To communicate and involve the patient and/or family member/caregiver in the discharge plan.
6	To elaborate the discharge plan and its documentation in medical records or electronically.
7	To align the communication process and coordinate actions between the multidisciplinary team.
8	To document the necessary referrals, reference and counter-reference guide, home oxygen process and others for the social worker.
9	To share information with the city of origin related to clinical conditions, care, family nucleus, among other information relevant to the process.
10	To guide the patient and family/caregiver about the necessary care and measures after hospital discharge, verbally and/or in writing.
11	To teach the patient and family member/caregiver how to handle equipment and/or special materials for the necessary care at home, reviewing and certifying their understanding.
12	To schedule and conduct home visits for patients with greater demand for care needs (use of equipment/devices or care with greater technical complexity).
13	To identify problems after hospital discharge, by telephone or on a home visit, and establish a care plan to resolve them, involving the primary care unit of reference, when necessary.

• Source: Elaborated by the authors.

DISCUSSION

This investigation had the purpose of develop and validate a list of activities performed by the nurse during the responsible hospital discharge. The multiple sources of information used, bringing together international and national, institutional guidelines and recommendations and research findings on the subject allowed the mapping, in sequential order of execution, of 14 activities that are part of this process.

A group of eight professionals, selected using the Delphi technique, participated in the content validation of the created list. This multi-phase interactive method for reaching consensus is considered practical, allowing the inclusion of a large number of experts, eliminating geographic barriers and preserving anonymity(16). Due to the influence of the composition of the group of professionals on the results obtained and the possibility of bias in the research(16), special attention was given to the knowledge and professional experience of the participants, prioritizing those with clinical practice, in public and private institutions, together to patients in palliative care, in a situation of chronicity and care with greater care complexity, in the process of responsible discharge.

In the Delphi 1 phase, mean scores and high I-CVI were obtained for most activities, showing high agreement between the judges. Of the 14 activities listed, ten presented maximum I-CVI and Kappa^* (1.0). This highlights aspects such as identification of eligibility criteria; contact with the physician to forecast hospital discharge; establishment of the therapeutic project with the multidisciplinary team, collection of information from the patient to verify the facilitating and restricting factors for the continuation of care at home; patient/family communication and guidance; professional team coordination; documentation, referrals and information sharing with the city of origin and teaching of equipment handling are incorporated in the professional’s daily routine.

Studies have shown(7,15,18) that the nurse is directly linked to the coordination of the responsible discharge process, actively participating in the alignment of the interprofessional team in the elaboration of the therapeutic project. In this way, it searches among the team members, those involved, specifically, in the demand of each patient/family, according to the use of devices and care complexity, for articulation with the city of origin and continuation of care at home. Activities aimed at health education for both the patient and family/caregiver were identified as the most performed by nurses who work in the transition of care(18). The importance of choosing the right time - preferably at admission or in the first days of hospitalization - has been highlighted(2,4,18).

The activities “Post-discharge contact” and “Scheduling home visit”, both with I-CVI of 0.75 and K^* of 0.72, did not reach the minimum value of agreement established (I-CVI ≥ 0.80)(12). According to the reports of the judges, these activities are relevant for the continuation of care. However, for some, they should be performed by Primary Health Care (PHC), that is, the city of origin of the patient; for others, only for patients with greater demand for care at hospital discharge.

In the Delphi second round, there was a consensus among the judges regarding the performance by the nurse of “Scheduling home visit” (activity 13) and “Identification of post-discharge problems” (activity 14), both with I-CVI and K^* 1.0. The change in the wording and scope of actions seems to have been decisive for agreement. Thus, scheduling and conducting the home visit was limited to the inclusion of patients with greater demand for care needs (use of equipment/devices or care with greater technical complexity).

“Identification of post-discharge problems” originated from the restructuring of the activity “Assessing the effectiveness of the discharge plan”, approved in Delphi phase 1, but with many questions from the judges. Although they agreed with the importance of this assessment as a way to avoid failures in the process and establish improvements, they were concerned about the operationalization. Thus, in the new wording, there was greater specification incorporating actions such as the identification of problems after hospital discharge and the establishment of a care plan for their resolution. Also, the way it could happen - via telephone or on a home visit - and involving the reference PHC unit, when necessary.

It seems contradictory that the home visit reached a consensus among the judges, but not the monitoring of the patient/family through telephone contact, up to seven days after discharge, to clarify doubts and reinforce guidance- I-CVI 0.60 and K^*0 .42. This can be explained, in part, by the number of judges being reduced to five in Phase 2, despite several reminders sent. Monitoring the patient/family through telephone contact and home visits greatly contributes to post-discharge care outcomes(14).

The workload and the consequent limitation of time for interprofessional communication makes the discharge process vulnerable, impacting the quality of guidance and information for the transition of care(14,18). To strengthen the articulation between Hospital Care and PHC, some countries such as Canada(19), Spain(15) and Portugal(20) adopted the “liaison nurse” model. This professional coordinates the discharge process, sharing information between the two levels of care, conducting care planning, educational activities and monitoring the patient/family’s care needs(19).

In Brazil, some initiatives in this sense are already emerging(21). They would also be of great value as a way to reduce the workload of nurses in hospitalization units, since the coordination of the senior responsible process takes time and they are already overloaded with care and management actions.

The reduction in the number of judges in the Delphi 2 phase could be considered a limitation of the study. However, there are no established criteria in the literature for the number of professionals in the group composition(16). Three experts are considered as the minimum acceptable number for measuring content validity(12). Interest and commitment are considered aspects that favor the retention of judges during the phases(12).

Also, the non-validation of one of the activities could have led to a third Delphi phase. This did not occur due to the loss of judges given the health situation caused by the COVID-19 pandemic and the time limit for conducting the study. The Delphi 2 phase was conducted during the COVID-19 pandemic, with a major impact on practice scenarios and on the workload, physical and emotional safety of health professionals. The judges were mostly clinical nurses. It is assumed, in this technique, that the number of questionnaire rounds (phases) continues until the group consensus is obtained or the number of questionnaire answers decreases.

The diversity of practice contexts, organization and work dynamics of the judges contributed to a list of activities in accordance with the reality of Brazilian health institutions. The validated mapping, in sequential order of performing the activities, can be used as a checklist to guide the planning and assessment of the hospital discharge system with proposals for improvements. It also allows the assessment of the time dedicated by the nurse in conducting the various stages of responsible discharge and measurement of the workload to adapt the staff. In this way, it contributes to the process of safe and humanized discharge, the continuity and comprehensiveness of care, and also to the reduction of readmissions and hospital expenses.

CONCLUSION

13 of the 14 activities proposed for responsible hospital discharge were validated. “Conduct monitoring of the patient/family through telephone contact within seven days after hospital discharge to clarify doubts and reinforce guidance”, did not obtain a pre-established consensus for the answers. Further research is recommended with a greater number of nurses, active in the responsible discharge process, to study the feasibility of hospital nurse to monitor the patient/family after hospitalization.

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Publication Dates

• Publication in this collection
  23 May 2022
• Date of issue
  2022

History

• Received
  18 Feb 2021
• Accepted
  22 Sept 2021