KNOWLEDGE TRANSLATION IN HOSPITAL DISCHARGE PLANNING: EXPERIENCE REPORT

TRADUCCIÓN DEL CONOCIMIENTO EN LA PLANIFICACIÓN DEL ALTA HOSPITALARIA: RELATO DE EXPERIENCIA

ABSTRACT

Objective:

to report on the experience of translating knowledge into hospital discharge planning for continuity of care in the Health Care Network.

Method:

experience report of an extension project in workshop format with 29 nurses from hospitals in southern Brazil, held from May to August 2022. The extension was structured according to the conceptual model Cycle from Knowledge to Action, divided into four phases: 1) planning and organization; 2) theoretical block; 3) practical block; and 4) monitoring knowledge use. In phase 4, six participants answered the virtual questionnaire, which was made available a year after the workshop.

Results:

in phase 1, PowerPoint products, a manual and the organization of the virtual learning environment were developed. In phase 2, four meetings were held using dialogued lectures and active methodologies. In phase 3, the nurses carried out a mini-project with actions aimed at hospital discharge and based on their professional reality. In the last phase, the workshop contributed to expanding knowledge about hospital discharge planning and provoked changes, even if only specific ones, in practice for safer hospital discharges.

Conclusion:

the use of the Cycle of Knowledge to Action model for the translation of knowledge through outreach action proved to be a relevant strategy in enabling the transposition of scientific knowledge to nurses and provoking individual changes and changes in their professional practices. The model can also be replicated in other contexts.

DESCRIPTORS:
Patient discharge; Biomedical translational science; Patient care continuity; Nursing; Evidence-based clinical practice; Community-institution relations

RESUMEN

Objetivo:

relatar la experiencia de traducir conocimientos en la planificación del alta hospitalaria para la continuidad de los cuidados en la Red de Atención a la Salud.

Método:

relato de experiencia de un proyecto de extensión en formato workshop (taller) con 29 enfermeros de hospitales del Sur de Brasil, realizado de Mayo a Agosto de 2022. La extensión se estructuró siguiendo el modelo conceptual Ciclo del Conocimiento a la Acción, dividiéndose en cuatro etapas: 1) planificación y organización; 2) bloque teórico; 3) bloque práctico; y 4) monitoreo del uso del conocimiento. En la etapa 4, seis participantes respondieron al cuestionario virtual, disponible un año después del workshop.

Resultados:

en la etapa 1 se desarrollaron productos PowerPoint, manual y organización del ambiente virtual de aprendizaje. En la etapa 2 se realizaron cuatro encuentros a través de clases expositivas dialogadas y metodologías activas. En la etapa 3, los enfermeros realizaron un microproyecto con acciones dirigidas al alta hospitalaria y basadas en su realidad profesional. En la última etapa, el taller contribuyó a ampliar el conocimiento sobre la planificación del alta hospitalaria y provocó cambios, aunque puntuales, en la práctica para un alta hospitalaria más segura.

Conclusión:

el uso del modelo del Ciclo del Conocimiento a la Acción para la traducción de conocimientos a través de acciones de extensión resultó ser una estrategia relevante para permitir la transposición de conocimientos científicos a los enfermeros y provocar cambios a nivel individual y en las prácticas profesionales. El modelo también se puede replicar en otros contextos.

DESCRIPTORES:
Alta del paciente; Ciencia traslacional biomédica; Continuidad de la atención al paciente; Enfermería; Práctica clínica basada en la evidencia; Relaciones comunidad-institución

RESUMO

Objetivo:

relatar a experiência de tradução do conhecimento no planejamento da alta hospitalar para a continuidade do cuidado na Rede de Atenção à Saúde.

Método:

relato de experiência de um projeto de extensão em formato de workshop com 29 enfermeiros de hospitais no Sul do Brasil, realizado de Maio a Agosto de 2022. Estruturou-se a extensão seguindo o modelo conceitual Ciclo do Conhecimento à Ação, dividindo-se em quatro fases: 1: planejamento e organização; 2) bloco teórico; 3) bloco prático; e 4) monitoramento do uso do conhecimento. Na fase 4, seis participantes responderam ao questionário virtual, disponibilizado um ano após o workshop.

Resultados:

na fase 1, foram desenvolvidos produtos em PowerPoint, manual e organização do ambiente virtual de aprendizagem. Na fase 2, foram realizados quatro encontros por meio de aulas expositivas dialogadas e metodologias ativas. Na fase 3, os enfermeiros realizaram um miniprojeto com ações voltadas para a alta hospitalar e pautadas na sua realidade profissional. Na última fase, o workshop contribuiu para a ampliação do conhecimento acerca do planejamento da alta hospitalar e provocou mudanças, mesmo que pontuais, na prática para uma alta hospitalar mais segura.

Conclusão:

o uso do modelo Ciclo do Conhecimento à Ação para a tradução do conhecimento por meio da ação de extensão demonstrou ser uma estratégia pertinente ao possibilitar a transposição do conhecimento científico aos enfermeiros e provocar mudanças individuais e em suas práticas profissionais. O modelo também pode ser replicado para outros contextos.

DESCRITORES:
Alta do paciente; Ciência translacional biomédica; Continuidade da assistência ao paciente; Enfermagem; Prática clínica baseada em evidências; Relações comunidade-instituição

INTRODUCTION

Hospital discharge planning is an important action for the transition of care and the promotion of care continuity, as it makes it possible to draw up an individualized plan and ensures that patients leave the hospital at the appropriate time and with post-discharge care organized according to their needs1^-2.

Discharge planning has a slight impact on reducing the length of hospital stay3, hospital readmissions3^-4 and patient satisfaction with the care received3. However, in Brazil, it is not common for discharge planning to be carried out during the patient's hospitalization, and only specific guidance is offered on the discharge day, with little involvement from nurses5^-6. National studies indicate that among the elements for a safe transition from hospital to home is the care plan; however, this is the one that has the lowest scores in evaluations from the patients' perspective7^-8.

This highlights the need to implement strategies to ensure a safe transition from hospital to home, including the improvement of discharge planning practices in professionals' work processes, as well as in the country's health policies7^-8. To this end, there is an urgent need to develop knowledge translation, making research results accessible to potential users and applying scientific knowledge to informed decision-making and the implementation of changes in clinical practice and health policies.

Knowledge translation refers to an interactive and dynamic process that includes synthesis, dissemination, exchange and the ethical and informed application of knowledge9. It encompasses the interaction between various actors and the application in different scenarios10, with the aim of improving health, providing more efficient health services and products, while at the same time having a wide repercussion on the health system in terms of excellence and sustainability11. There are various conceptual models of knowledge translation in the literature, with the “Knowledge-to-Action Cycle” being one of the most widely used12.

To this end, a knowledge translation activity was developed through a university extension project, in the form of a workshop with nurses from different health services. This study aims to report on the experience of translating knowledge into hospital discharge planning for care continuity in the Health Care Network.

METHOD

This is an experience report on the development of the extension project entitled “Workshop on Hospital Discharge Planning: a strategy for continuity of care in the Health Care Network”, coordinated by two professors from a public university in southern Brazil. The university extension was carried out as a knowledge translation strategy at the end of an integrated research project entitled “Integration of health systems and services: analysis of the coordination of care networks, transition of care and patient safety”, based on the need to make users aware of the results of the study and engage in the implementation of new practices in health services. Thus, the extension project that gave rise to this experience report aimed to train nurses in the implementation of hospital discharge planning, providing appropriate, accessible and summarized information on the evidence on the subject and advising on the planning of actions to be implemented in the services.

The Knowledge to Action Cycle conceptual model was adopted, in which the knowledge creation cycle is subdivided into three phases and the action cycle is made up of seven stages, as shown in the circle in Figure 1. It should be noted that these stages are interactive and often take place overlapping or out of order12. University extension was organized by distributing the components of this conceptual model into four phases, as shown in Figure 1.

Figure 1 -
Phases of the extension project, according to the Cycle from Knowledge to Action. Porto Alegre, RS, Brazil, 2021.

The first phase comprised the planning and organization of the workshop, from November 2021 to March 2022. The second and third phases comprised the execution of the workshop (May 2022 to August 2022) and the fourth, the follow-up of the participants after the workshop (March 2024 to May 2024).

In the second and third phases of the workshop, the target audience was nurses who worked in hospital management or care. The inclusion criteria were: being a nurse; working in a hospital in management or care positions. Recruitment took place by means of an invitation card containing the objective, schedule and content covered in the meetings, as well as the link to sign up, posted on social networks (Instagram® and WhatsApp®). Of the 109 people who registered for the workshop, 60 were selected because they met the inclusion criteria. A total of 52 nurses took part in the meetings, of which 29 had a turnout of 75% or more. The participants came from the three southern Brazilian states.

In the fourth workshop phase, nurses who had completed the minimum course load (75%) were invited to complete an online questionnaire after one year of the workshop to monitor the use of the knowledge acquired. The exclusion criterion was not working in nursing after the workshop. At this stage, an invitation to take part in the study was sent by e-mail, which contained the purpose of the research and the Informed Consent Form (ICF). After the invitation, three reminders were sent, 15 days apart, and six nurses returned them. After the participants agreed to the informed consent form, the data was collected virtually, from March to May 2024, using a questionnaire on Google Forms, consisting of closed questions to characterize the participants and open questions that addressed the workshop's contributions to professional practice and the application of the knowledge acquired in practice. The data obtained in phase four was analyzed using content analysis13, which was carried out in three phases: pre-analysis; exploration of the material; treatment of the data; and interpretation. To guarantee anonymity, the participants in phase four were identified by the letter P followed by a cardinal number in ascending order as the questionnaires were received.

In order to describe this experience report, the results have been organized according to the four phases of the Knowledge to Action Cycle that encompass the development of the workshop. The study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul and the Extension Commission of the same institution.

RESULTS

First phase: planning and organizing the workshop

The workshop was planned and organized from November 2021 to April 2022 and covered the knowledge creation cycle of the conceptual model. Initially, the five questions recommended by the model's authors¹² were used when planning activities to meet the needs of potential knowledge users, as shown in Chart 1.

Chart 1 -
Planning the extension project. Porto Alegre, RS, Brazil, 2021.

Questions	Adapted answers for planning the extension project
What should be disclosed?	Contribution of discharge planning to care continuity and strategies to strengthen the nurses' role in the discharge process in health services.
For whom?	Nurses who manage and assist hospital services.
By whom?	Research professors with academic expertise and nurses with practical experience in the field.
How?	Interactive workshop, with theoretical and practical activities, enabling the exchange of experiences between formulators and users of knowledge.
With what effect?	Change in the knowledge or practice of nurses in the hospital discharge process and implementation of discharge planning in hospitals.

In order to ascertain and synthesize existing knowledge, studies resulting from the integrated research project, other relevant productions on the subject2^,6^,14^-17 and recent review studies were used18^-20. The knowledge from these materials was refined and served as the basis for constructing the educational modules to be used in the workshop. The aim was to make scientific knowledge more accessible, cohesive and useful to participants, explaining recommendations for developing improvements in hospital discharge processes and facilitating the use of evidence in decision-making. Tools were prepared in PowerPoint and manual format, and a virtual teaching and learning environment was organized on the Moodle Academic platform.

Second phase: theoretical workshop block

The theoretical block consisted of 15 hours and aimed to provide the participants with information on hospital discharge planning and continuity of care in the Health Care Network. The stages of identifying the problem, determining the gaps between knowing and doing, and adapting knowledge to the local context, referring to the Cycle from Knowledge to Action12, were developed alternately in synchronous and asynchronous workshop activities.

The synchronous activities consisted of four weekly two-hour meetings, remotely via Google Meet, using dialogued lectures and active learning methodologies. Interactive and collaborative tools such as videos, word clouds and collaborative walls were used. The content covered, as well as the corresponding stage of the Cycle from Knowledge to Action in each meeting, are shown in Figure 2.

Figure 2 -
Description of the workshop meetings. Porto Alegre, RS, Brazil, 2021.

At the end of the theoretical block’s last meeting, the group was asked the following question: based on what we've discussed today, what would you do differently tomorrow? This question generated discussions about the resources available for using scientific recommendations in the participants' workplaces.

The asynchronous activities aimed to deepen the knowledge covered in each synchronous meeting. The teachers made scientific articles and videos available on the Moodle Academic platform at the end of each meeting.

Third phase: practical workshop block

The practical block lasted five hours and aimed to exercise the knowledge obtained in the theoretical block and assess the barriers and facilitators to the use of knowledge in the practical reality of nurses, stimulating the adaptation of discharge planning strategies and the implementation of interventions in their work processes, corresponding to two stages of the Cycle from Knowledge to Action. It was proposed that a mini-project be drawn up for the participants' place of work, with possible actions for hospital discharge with a view to care continuity in the HCN.

The participants were divided into 15 groups according to their place of work. Two synchronous remote meetings of two hours each were held for each group, with the teachers acting as mediators. Through brainstorming, the groups were encouraged to identify the potentialities and difficulties in relation to hospital discharge according to their professional context, mapping flows, internal resources and external resources, and also identifying the priority and essential elements for defining the objective and actions of the mini-project. Models of mini-projects and management tools (5W2H Matrix), which were built during the planning stage of the extension, were made available so that participants could structure the planning of their actions.

Each group worked according to their experience of hospital discharge planning and the knowledge obtained from the theoretical block. Preparing the mini-projects was challenging, as there were a variety of themes developed, including the development of structured discharge plans, educational materials for patients and their families, as well as improvements to processes already in place, such as monitoring quality indicators and recording the date of expected discharge in a nursing shift instrument. At the end of the workshop, the groups presented their mini-projects, which was a time for collaboration and discussion of different forms that were appropriate and feasible in the local context.

Fourth phase: monitoring knowledge use

One year after the workshop, the use of the knowledge acquired by the participants was monitored. A total of six female nurses aged between 32 and 52 took part in this phase. Two had a master's degree, three a doctorate and one a specialization. Five nurses were from Rio Grande do Sul and one from Santa Catarina. As for the position held by the professionals at the time of collection, two worked in management, two in care and two in teaching.

From the data analysis, the category emerged: Workshop contributions to nurses and their professional practice.

The workshop expanded the nurses’ knowledge of hospital discharge planning by familiarizing them with the practices carried out in hospitals that had structured hospital discharge management services coordinated by nurses, and also through the exchange of interprofessional experiences.

It added to knowing the practices of liaison nurses from other institutions (P1).

[…] the workshop helped to identify opportunities for actions that nurses can develop in the hospital service to improve the transition of care at discharge, [...] it was also interesting to interact with professionals from other services to find out what is already being developed in practice and the interface with theory (P5).

[…] with the exchange of experience we had during the course, and especially with fellow nurses from hospitals where our patients are transferred daily, I was able to understand this working dynamic and plan this process better (P4).

[...], improved knowledge about care continuity, interaction with colleagues through the teaching modality adopted in the workshop. [...] the workshop allowed me to broaden my knowledge and share it in the classroom [...] (P6).

Not all the nurses put into practice the knowledge acquired during the workshop and the proposal developed in the practical block, for reasons such as lack of human resources and dependence on other colleagues.

[…] no [the mini-project proposal was implemented]. Because it depended on the actions of colleagues at the place of action itself, which was the maternity ward (P2).

[…] it [the mini-project proposal] was implemented, but it was not possible to maintain it due to the marked shortage of human resources at the hospital (P3).

However, we did see the implementation of different actions aimed at responsible discharge and also the debate on essential elements of the transition of care.

Every day [I use the knowledge from the workshop]. Especially in the multi-professional rounds where we focus on defining post-discharge procedures (P3).

[…] they are being used for safer discharge from hospital. We have improved the design and feedback of the Internal Regulation Center, where we provide guidance and information to patients and their families on the progress of hospital admission management (P4).

[...] I am able to discuss with the hospital’s managers and multidisciplinary team the transition analysis carried out and opportunities for qualification, within the conditions of the service [...] and about a de-hospitalization protocol that is in the construction phase for implementation in the service and suggest important points, such as post-discharge assessment and follow-up (P5).

DISCUSSION

Discussions about the knowledge translation have been highlighted in Brazil and Latin America. Although there is often an interest in producing knowledge to improve the quality of the services offered by the Unified Health System in Brazil, there are still few examples of knowledge translation actions developed in universities and health services. However, there are several international models that can facilitate the knowledge application in practice, and it is necessary to choose the one that best fits the context of each study and service11.

The choice to carry out the action of translating knowledge through an extension project was due to the university's commitment to sharing the knowledge acquired through teaching and research developed at the institution with the external public. A similar experience was reported in an extension project in which knowledge about urgency and emergency was translated through the dissemination and exchange of knowledge between nursing professionals and teachers21. Based on a commitment to changing reality, university extension is a resource used within universities that enables interaction between teachers, students and the community21, and can be an innovative way of getting closer to relevant social demands, synthesizing evidence and helping to use scientific knowledge in practice.

The Knowledge to Action Cycle model, which was used in this study, has Canadian origins and is recommended by the World Health Organization12 and used in a variety of areas and countries, including Cameroon22, India23, Australia24 and the United States25. The model is very comprehensive and complete, following stages from the creation of knowledge to its application, evaluation of results and maintenance12. As with other research26, this study used some of the proposed stages.

The planning phase of the workshop, covering the Knowledge Creation Cycle, was fundamental for adapting the knowledge to the target audience that would take part in the activity, producing the teaching materials that would be used in the subsequent phases. This is an important activity for selecting evidence through filters and making the most valid and useful knowledge available to users12.

The theoretical and practical blocks were organized to make up part of the stages of the action cycle, making it possible to disseminate knowledge, adapt it to the local context of the participants and select interventions. The remote format helped to have participants from different states and realities, favoring the exchange of experiences. In addition to these benefits, the authors of a study that carried out a workshop virtually also reported the advantages of low cost, time optimization, greater adherence and participation by nursing professionals27. However, it is worth mentioning that the diversity of experiences and realities of the participants made it difficult to conduct the construction of the mini-projects and deepen the proposals for action in health institutions. On another occasion, it would be relevant to develop activities in specific institutions, according to the local context and with more commitment from the service's leaders.

In the phase of monitoring knowledge use, it was identified that the workshop expanded nurses' knowledge of discharge planning, with some changes in behavior and practices at an individual and interprofessional level. However, organizational barriers were also observed, which prevented the implementation of more collective actions, since they depend on institutional interest in adopting the products and recommendations generated. This highlights the importance of engaging stakeholders and decision-makers in the institutions for the successful knowledge translation and implementation10^,12.

Although the stages of evaluating the impact and maintaining the use of knowledge were not carried out in this study, there is an opportunity for future activities that can measure the results of the changes and provide reinforcements for maintaining the actions in the medium and long term. Furthermore, it is important that researchers take on a social commitment to ensure that the knowledge use is sustained, evaluated and monitored26.

One of the limitations of the study was the participants' low response rate to the questionnaire in the fourth phase, which limited the understanding of the workshop's contributions to professional practice and the application of the knowledge acquired after the end of the outreach action. It is believed that the low uptake was due to the time lag between the knowledge translation phase and data collection for the monitoring phase, so the time between these phases could be reduced. Despite this, it can be seen that the large number of people registered for the workshop, as well as the high level of participation by nurses at the meetings, indicates the interest of health professionals in the Unified Health System in developing strategies to improve hospital discharge and care continuity, which is a step forward in establishing priorities and encouraging changes in health service practices.

CONCLUSION

Adopting the conceptual model Cycle of Knowledge to Action for the translation of knowledge through the outreach action proved to be a pertinent strategy, as it enabled the planning and systematization of this action and also transposed scientific knowledge about discharge planning and continuity of care to nurses working in different realities, enabling these professionals to broaden their knowledge on the subject and change their behaviour and practices at an individual and interprofessional level.

However, organizational barriers prevented the implementation of collective actions, demonstrating the need for management strategies to structure services aimed at managing hospital discharge and changing the institutional culture so that discharge is not just understood as the end of hospitalization, but as a process that needs to be planned to promote continuity of care in the HCN. In addition, there is an imminent need to build a care transition policy to support the implementation of hospital discharge management.

The contribution of this study is the possibility of using the conceptual model Cycle of Knowledge to Action in other contexts as a way of translating knowledge, in order to equip professionals who work in practice and also to fulfill one of the objectives of the triad of federal public universities, extension action.

ACKNOWLEDGMENT

We thank Professor Elizabeth Bernardino, Associate Professor at the Federal University of Paraná, and Me. Jociele Gheno, a nurse from the Nossa Senhora da Conceição Hospital (HNSC), for collaborating in giving talks at the workshop about their experiences in Discharge Management at the Federal University of Paraná's Hospital de Clínicas Complex and the Conceição Hospital Group in Porto Alegre, respectively.

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NOTES

• FUNDING INFORMATION

  The study received financial support from the National Council for Scientific and Technological Development (CNPq) (Process No. 433997/2018-4).

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul, opinion n. 6.696.363, Certificate of Presentation for Ethical Appraisal 76885924.6.0000.5347.

• TRANSLATED BY

  Leonardo Parachú.

Edited by

EDITORS

Associated Editors: Gisele Cristina Manfrini, Ana Izabel Jatobá de Souza.

Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  11 Nov 2024
• Date of issue
  2024

History

• Received
  18 June 2024
• Accepted
  19 Aug 2024