Factors that enhance or impede critical care nurses' discharge planning

practices
Abstrak (ringkasan)
TerjemahkanAbstrak
Any illness that is serious enough to require admission to the critical care unit will intensify the
physical and psychological effects that the patient and their significant others experience. Hence, the
discharge needs of patients admitted to critical care are unquestionably complex, diverse and
dynamic.
Utilising an exploratory descriptive approach 502 critical care nurses, identified from the Australian
College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A
31-item questionnaire was developed and distributed. A total of 218 eligible participants completed
the survey. One-to-one semi-structured interviews with 13 Victorian critical care nurses were also
conducted.
Participants reported that a lack of time was a barrier to discharge planning. Communication however,
could enhance or impede the discharge planning process in critical care. Participants considered that
the critical pathway, used in the care of cardiothoracic patients, did assist with communication of
discharge planning processes, hence enhancing the process.
While these findings provide some understanding of the factors that enhanced or impeded critical
care nurses' discharge planning practices further research is indicated. The findings reported here
may, however, provide a starting point for improving the discharge planning process in critical care.

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Characteristic

Valuea

Age (years)
25-35

53

35-44

40

>44

Number of years qualified as a critical care nurse (years)

7 or less

46

8-14

40

15 or more

14

Position title
Registered nurse

35

Clinical nurse specialist

25

Associate charge nurse

22

Nurse manager

Clinical educator

Area of specialization
General ICU

31

Coronary care

Cardiothoracic

Trauma ICU

Combined ICU

41

Model of allocation
Primary nursing

19

Patient allocation by shift

65

Other

16

Table 1 - Demographic characteristics of the sample (survey participants).

Most important factor in enhancing

Least important factor in enhancing the discharge
the discharge planning process
planning process in critical care
in critical care
Effective communication (%)

43

Planned discharge
(%)

3
8

Continuity of staff (%)

20

Continuity of staff
(%)

2
2

Planned discharges (%)

19

Available time (%)

2
1

Knowledge (%)

Knowledge (%)

1
4

Available time (%)

Effective
communication
(%)

Missing (%)

Missing (%)

Table 2 - Factors that enhance the discharge planning process in the critical care unit.

Most important factor in impeding

the discharge planning process
in critical care

Least important factor in impeding the discharge planning

process in critical care

Inadequate communication (%)

33

Continuity of staff
(%)

3
8

Unplanned discharges (%)

30

Lack of knowledge
(%)

2
1

Lack of time (%)

17

Unplanned
discharges (%)

2
0

Lack of knowledge (%)

Lack of time (%)

1
0

Continuity of staff (%)

Inadequate
7
communication (%)

Missing (%)

Missing (%)

Table 3 - Factors that impede the discharge planning process in the critical care unit.

Participant identification

Job title

Number of
years
experience
incritical care

CNSa

Graduate Certificate in Critical

Care

Nurse
educator

Graduate Diploma in Critical

Care

ACNb

10

Critical Care (hospital

certificate); Graduate Diploma
in Education

RNc

20

Critical Care (hospital

certificate)

Nurse
15
managerd

Coronary Care (hospital

certificate); Graduate Diploma
in Critical Care

CNS

11

Critical Care (hospital

certificate)

Agency
nursee

10

Qualification(s)

Coronary Care Certificate

(hospital certificate); Bachelor

of Education.
I

CNS

3(3/4)

Graduate Diploma in Critical

Care

RN

2(3/4)

Graduate Diploma in Advanced

Nursing (Critical Care)

CNS

4(1/2)

Graduate Diploma in Advanced

Nursing (Critical Care)

RN

2(3/4)

Graduate Certificate in Critical

Care

CNS

Graduate Diploma in Advanced

Nursing (Critical Care)

RN

Graduate Diploma in
Community Health; Graduate
Certificate in Critical Care

(b) ACN (associate charge

nurse) usually responsible for
coordinating patient care during
a shift.
(c) RN (registered nurse) is a
first level nurse who is licensed
to practice nursing.
(d) NM (nurse manager) is
predominately responsible for
the unit administration.
(e) Agency nurse, is a registered
nurse who is employed through
an organisation external to the
hospital, known as an agency.
Table 4 - Demographics: interview participants.
1
Introduction

There is no question that discharge planning has emerged world-wide as a complex area of practice in
the health caresystem, and is, perhaps, most complex in the critical care environment. The potential
variables that exist within thecritical care environment, such as the severity of the patient's condition,
invasive monitoring, fear, drug therapy and impaired cognition all affect patients' functional and
decisional ability and hence reduce their capacity to participate in discharge planning. The critical
care unit is a particularly difficult environment in which to assess the patient's ability, and the family's
ability, to take part in the discharge planning process. This widens the gap between the ideals of
discharge planning and reality.
As the length of hospital stays are reduced, discharge planning must move into the critical care area.
Carr (1988) argues that, by virtue of their knowledge and skills, critical care nurses are ideally suited
to begin the discharge planning process. She believes that all that is needed for the critical care nurse
to initiate the process is recognition of the importance of discharge planning.
There is no argument that the discharge needs of patients who have spent time in critical care are
complex and inter-related (Alspach, 1985; Pray and Hoff, 1992; Schlemmer, 1989). These needs
include a range of physical, psychosocial, and economic factors that require holistic management
(Daffurn et al., 1994).
Rorden and Taff's (1990) definition of discharge planning is utilised for the purposes of this paper.
They define discharge planning as "... a process made up of several steps or phases whose immediate
goal is to anticipate changes in patient care needs and whose long term goal is to insure continuity of
health care" (p.22). This multi-faceted definition describes discharge planning as a dynamic process
that involves a variety of specific skills and requires all members of the health care team to work
together in a coordinated manner to achieve mutually agreed goals and, ultimately, continuity
of care (Watts, 2004). Interestingly, Watts et al. (2005) reported that Victorian critical carenurses
were uncertain of the endpoint of the discharge planning process and argue that clarification is needed
as to whether the discharge planning process in the critical care environment is conceptualised as
preparing the patient for the next phase of care within that period of hospitalisation, or as anticipating,
planning and/or preparing health careservice provision beyond hospitalisation.
While the ideal is for the discharge planning process to commence on, or prior to, the patient's
admission to hospital (Clare and Hofmeyer, 1998; Huerta-Torres, 1998; Pray and Hoff, 1992; Williams,
1991) the literature suggests that there are a variety of reasons why this does not occur in the critical
care environment. One reason repeatedly cited is that critical care nurses usually delay discharge
planning until the patient's care needs have progressed beyond the acute stage, and their condition
has stabilised (Alspach, 1985; Carr, 1988).

Schlemmer (1989) suggests that discharge planning in the critical care environment is not consciously
overlooked bycritical care nurses but is not initiated or completed due to time constraints and high
workloads. Critical care nurses actually attended to discharge planning after the health care needs of
the critically ill patients had progressed beyond the acute state (Alspach, 1985). Carr (1988) agrees
that, for the patient hospitalised in the critical care unit, discharge planning is usually delayed until the
patient has stabilised and been transferred to a less acute care area. Life support and minute-byminute clinical changes in the patient's condition can make discharge planning a low priority and make
discharge seem far away.
Schlemmer's (1989) exploratory study aimed to identify current discharge planning processes that
exist in critical care units in the state of Washington in the USA and to identify the role of the critical
care nurse in the discharge planning processes in these units. One hundred and twenty-five
questionnaires were distributed, with a response rate of 55%. The structure of discharge planning in
the units in which the participants worked was described as unstructured by 67% of participants.
Sixty-nine percent of participants stated that their critical care units did not have written standards
outlining criteria for discharge planning in the critical care setting. Staff responsibility for the discharge
planning process varied among critical care units, with a designated discharge planner being most
frequently responsible, followed by the nurse manager. The bedside nurse had the most responsibility
for initiating post-hospital care referrals. Increased nursing workload was perceived as having the
greatest impact in delaying discharge planning in critical care units. The majority of participants did
not perceive discharge planning as a priority for critical care nurses and thought it was not practical to
implement discharge planning in the critical care unit. In general, it was perceived that discharge
planning was a process that should begin after the patient is transferred from the critical care unit.
Thompson (1985) examined discharge planning in the critical care environment in West Virginia
(USA). Questionnaires were sent to 100 randomly-selected critical care nurses to evaluate their
understanding of discharge planning and how it was accomplished. Thompson found that 70% of
participants thought that discharge planning was not applicable to their units. It should be noted that
although 100 questionnaires were distributed the actual response rate was not stated.
In a study conducted in Sydney, Australia, Daffurn et al. (1994) studied 54 patients, with a length of
stay in critical care of more than 48h, to determine functional outcome and quality of life in the weeks
after discharge. The patients were interviewed 3 months after leaving critical care. The major finding
from this study indicated that many of the patients were suffering mild to moderate sequelae. The
authors suggested that a more comprehensive discharge process was required. Leith (1998) argues
that discharge planning should not be limited to transfer from the hospital but should include planning

for a patient's transfer from the critical care unit to another unit within that hospital. She believes that
the barriers to providing discharge planning to patients in anticipation of transfer from the critical
care unit must be overcome. Critical care nurses have a responsibility to provide appropriate
continuity of care in order to reduce transfer anxiety in critical care patients and family members.
There is a paucity of recent literature specific to the discharge planning process in critical care. While it
is recognised that the above literature is somewhat dated, the majority of recent literature in the area,
has focused on patients' experiences of being a patient in critical care and the experiences of transfer
from the critical care environment to the general ward (Coyle, 2001; Green, 1996; McKinney and
Melby, 2002; Odell, 2000; Stein-Parbury and McKinley, 2000) and the multifunction role of the critical
care liaison nurse (Barbetti and Choates, 2003; Chaboyer et al., 2004; Green and Edmonds, 2004).
Little recent attention has been paid to nurses' understandings and beliefs of the discharge planning
process in the critical care environment.
The findings reported here are part of a larger study that aimed to explore critical care nurses'
perceptions and understanding of the discharge planning process in the health care system in the
state of Victoria, Australia, and hence gain an insight into how the discharge planning process fits into
the critical care environment from a nursing perspective. A key finding from this study was that critical
care nurses were uncertain of the endpoint of the process however there was a general emphasis on
the general movement of the patient from the critical care environment (Watts et al., 2005). In this
article, we report on the key factors participants identified as enhancing or impeding their discharge
planning practices in the critical care environment.
2
Method
2.1 Design
Utilising an exploratory descriptive approach, this study was conducted using a questionnaire
completed by 218 participants and also involved in-depth interviews with 13 critical care nurses. The
study was approved by the LaTrobe University Faculty of Health Sciences Human Ethics committee
(FHEC). Approval was also sought from and granted by the Confederation of the Australian Critical
Care Nurses (CACCN) Victorian Branch (now known as the Australian College of Critical Care Nursing
(ACCCN) Victorian Branch) research subcommittee to access their membership database in order to
recruit participants. At the time of CACCN (Victorian Branch) initial membership application and annual

membership renewal, members are asked to consent to participating in research deemed suitable by
the CACCN (Victorian Branch) research subcommittee.
2.2 Sample
The members of CACCN (Victorian Branch) provided the cohort for this study. The CACCN database
allowed identification of those members who were working in critical care areas as opposed to
members, for example, who held specialist critical care qualifications but had academic appointments
and were not working in the critical careenvironment. On the basis of the primary area of work named
by members of the CACCN renewal form (1998) 502critical care nurses were identified as working
in critical care units and were approached to participate in the study. Participants could work full-time
or part-time and have varying professional backgrounds.
2.3 Procedure
The findings reported in this paper are part of a larger study examining the discharge planning
practices and beliefs ofcritical care nurses in the Victorian health care system. Study 1 involved a
survey of 218 Victorian critical carenurses' discharge planning beliefs and practices. As no reliable and
valid tool could be found for this purpose, a new tool was developed.
The questionnaire was specifically developed and used to collect data from critical care nurses working
in the critical care environment. The development of the instrument occurred in stages. Initially,
literature searches were undertaken to determine current national and international views of the
beliefs and attitudes of nurses to discharge planning. Themes in the literature were identified. The
findings from previous research undertaken by the researcher (Watts and Gardner, in press) exploring
acute care nurses' perceptions of the discharge planning process were also drawn upon, as was
discussion with colleagues who had expertise in the area of discharge planning and critical
carenursing. Information was collated from all of these sources and used to formulate a draft
questionnaire for use in the pilot study. Questionnaires were distributed, as part of a pilot study, to
eight practicing critical care nurses, considered to be expert critical care nurses working in the
Victorian health care system. The researcher knew these participants, but they did not participate in
the study reported in this paper. In accordance with the feedback from the participants about the
wording and ordering of the questions and the adequacy of the alternatives, minor changes were
made to the wording of some questions. The category 'Pre-admission clinic' was added as a response
alternative for the two questions about the timing of discharge planning in critical care. An open-ended
question asking participants to define the discharge planning process as it relates to critical care was

added to the questionnaire. Space was made available for optional comments at three points in the
second (perceptions/experience) section of the questionnaire.
In order to assess face validity, experts were asked whether the scope of the items on the
questionnaire covered the area of discharge planning in critical care or whether items need to be
added. Informal comparison of responses to similar issues asked in related questions showed a high
degree of correlation suggesting internal reliability of the study instrument. While this study was
conducted on a heterogeneous group, critical care nurses with varying years of experience in critical
care, the reliability of the instrument was not assessed with statistical procedures. Therefore, it is
recommended that the tool should only be used in future research after further evaluation.
In-depth one-to-one interviews of a total of 13 critical care nurses allowed clarification and exploration
of findings from the questionnaire responses. Participants who received the survey were also invited to
a one-to-one interview that lasted approximately 30-40min. Twelve critical care nurses who had
participated in the survey volunteered to be interviewed, of which seven actually participated in an
interview. These nurses all had greater than 6 years of critical care experience and are identified as
Participants A-G. The researcher believed that this group of participants did not represent a substantial
sub-group of critical care nurses and an additional group of participants was therefore recruited for
interview.
As reported in the CACCN (Victorian Branch) 1998-1999 Annual Report, CACCN (Victorian Branch) had
a total membership of 682 nurses. Forty-nine percent of CACCN (Victorian Branch) members had 6-10
years experience incritical care. It was therefore considered necessary to recruit and interview
additional participants, these participants being critical care nurses with less than 6 years experience
in the critical care environment. In order to recruit this cohort of participants, professional associates
of the researcher, who had contacts working in critical care, were asked to help recruit participants by
word of mouth. It was decided to use this method of recruitment as the original request to participate
in the study via the flyer sent with the questionnaire had failed to attract interest from CACCN critical
care nurses with less than 6 years experience in critical care. The university FHEC was notified of and
approved this amendment in the project protocol, with regard to recruitment of further participants.
The recruited participants had no professional association with the researcher and were not coerced in
any way to participate in the study. Once possible participants expressed interest in taking part in the
study, names and a contact number were given by the associate to the researcher, who then contacted
the potential participants, explained the study and asked if they would participate. A further six critical
care nurses were recruited. These participants are identified as Participants H-M.

All potential participants, who expressed interest in being interviewed, were invited to an interview
that lasted approximately 30-40min, at a pre-arranged time convenient to both the researcher and the
participant. An interview schedule was utilised, consisting mainly of open-ended questions. Using the
process of funnelling (Minichiello et al., 1991) general broad questions were asked at the beginning of
the interview, then the participants were asked specific questions relating to their own discharge
planning beliefs and practices. The interviews were openly tape recorded and then transcribed. Using
the transcripts, categorisation and ordering of the information was conducted to allow the researcher
to make sense of the data. A coding system was developed to organise the data and allow
identification of themes.
3
Findings
3.1 Questionnaire
Demographic characteristics of survey participants are presented in Table 1.
3.1.1 Key factors in the discharge planning process in critical care
Table 2 profiles responses to the question 'What factor/s do you believe enhance the discharge
planning process in your unit?' Participants were asked to rank the alternatives in order from the most
important (1) to the least important (5). The table shows, for each alternative, the percentage of
participants who ranked it as (1)--most important, and, for each alternative, the percentage who
ranked it as (5)--least important. Missing refers to those cases where participants either did not
answer the question at all, or just indicated one alternative as the most important but did not rank the
other alternatives.
Just under one-half (43%) of the participants identified effective communication as the most
important factor in enhancing the discharge planning process in their unit, one-fifth (20%) of
participants rated continuity of staff as the most important factor, followed by planned discharges
(18%). A few participants (8%) identified knowledge as the most important factor and available time
was rated the most important factor by 6% of participants.
More than one-third (38%) of participants ranked planned discharges as the least important factor in
enhancing the discharge planning process in their unit. Continuity of staff was identified as the least
important factor by approximately one-fifth (22%) of the participants, 21% identified available time

and 14% knowledge. Effective communication was identified as the least important factor by only 1%
of participants.
Table 3 profiles the responses for the question 'What factor/s do you believe impede the discharge
planning process in your unit?' Participants were asked to rank the alternatives in order from the most
important (1) to the least important (5). The table shows, for each alternative, the percentage of
participants who ranked it as (1)--most important, and, for each alternative, the percentage who
ranked it as (5)--least important. Missing refers to those cases where participants either did not
answer the question at all, or just indicated one alternative as the most important but did not rank the
other alternatives.
Inadequate communication was identified as the most important factor in impeding the discharge
planning process in the critical care environment by one-third (33%) of the participants. Unplanned
discharges were identified by (approximately) another one-third (30%) of the participants as the most
important factor, followed by lack of time (17%). The remaining participants rated lack of knowledge
(9%) and continuity of staff (7%) as the most important factor in impeding the discharge planning
process in the critical care environment.
Continuity of staff was identified by over one-third (38%) of participants as the least important factor
in impeding the discharge planning process in critical care. Lack of knowledge was rated as the least
important factor in impeding the discharge planning process by approximately one-fifth (21%) of the
participants and unplanned discharges by 20%. The remaining participants identified lack of time
(10%) and inadequate communication (7%) as the least important factor in impeding the discharge
planning process in critical care.
3.2 Interviews
Demographic characteristics of the interview participants are presented in Table 4.
3.2.1 Communication of the discharge plan
The interview participants indicated that the discharge planning process was communicated in two
main ways between critical care nurses, between critical care nurses and medical staff, and
between critical care nurses and ward staff. These communications were in the form of verbal
instructions, and written documentation. The degree of written documentation of the patient's
discharge plan varied greatly, with each participant reporting a different system in the workplace.
However, in general, the interview participants focused little on the written communication of the

discharge plan rather, they raised many issues in relation to verbal communication of the discharge
plan.
3.2.1.1 Verbal communication between critical care nurses
The majority of participants thought that the discharge plan was communicated verbally
between critical care nurses and that there was little formal written communication. Verbal
communication regarding the discharge plan occurred principally between senior members of staff
especially at 'hand-over' time, and the bedside nurse was not necessarily involved.
Participant B explained that discharge planning is communicated in two ways in her work place:
verbally and by documentation. However, as discussed below, for cardiothoracic patients, there is a
tendency for nurses to utilise thecare path that has a space clearly devoted to discharge planning,
with team leaders playing a principal role in communicating the discharge plan. It was reported that
the team leaders have a series of handover cards, which are used as the basis for subsequent verbal
communication of the discharge plan "I think there is a heading 'discharge' but it is more to do with
the date and time ..." (Participant B). In comparison, discharge planning for the general ICU patient is
once again communicated through the team leader's notes and the nursing care plan, however, there
is no heading on the care plan assigned to discharge planning. This suggests that senior members of
staff, rather than the bedside nurses, are the key stakeholders in the discharge planning process.
Participant F explained that a similar means of communication occurred in her unit:
It's both, the critical pathway, that's what I'm trying to think of, the first page of that actually has a lot
of information about the patient, their family and the physiotherapist ... The other part of the process
is that the team leaders, the person in charge of each shift, actually also hands over a lot of
information and that's kept on a card system (Participant F).
3.2.1.2 Verbal communication between critical care nurses and medical staff
There was a perception by some participants that, in reality, critical care nurses have little control over
the discharge planning process. As to who determines when the patient is going to be discharged, the
participants reported that this was a physician's decision:
I'd have to say mostly the doctors. It's probably a medical decision (Participant J).
It was reported that in the workplace this occurred due to dominance of the doctors and the
associated issue of power and control, and/or the urgent need to admit another patient. Participants
consistently indicated that physicians play a major role in decisions to admit or transfer patients

in critical care units and this occurred in both the public and private health care sectors. Frustration
with the whole process was displayed, and the need to make the process a more collaborative effort
was recognised:
... usually what happens is that they do their round, they say okay "you're ready to go to the ward
and we've got someone, somewhere, who had just had an arrest, who can we get out of here"? And
that's usually your discharge plan, who can we get out of here and how quickly can we get them out
(Participant G).
3.2.1.3 Verbal communication between critical care nurses and ward staff
In this study, there was no consistency in responses with regard to communication between critical
care nurses and ward nursing staff. Whether ward staff met the patient prior to discharge from critical
care and admission to the ward appeared to depend on the individual ward policy and in some cases
on the individual patient.
Participants reported that ward staff were more likely to be involved at an earlier stage if the patient
was classified as 'long-term', and this increased the likelihood of involvement of ward staff prior to the
discharge of the patient fromcritical care. However, only a few participants indicated that this in fact
was routine:
Yes, we would routinely do that for all the long term [patients], so the people who have been in for
about two weeks or more, we involve the ward staff (Participant C).
In my experience, the patient going out to the ward is the first time the ward sees them ... if the ward
staff have met the patient in the first instance [a ward patient who has been admitted to ICU] they will
generally, I find, follow them through. If they haven't, they don't come in to see what we've got
because they are too busy dealing with what they've got (Participant D).
Sometimes (Participant B)
Participants reported that although a discharge report was forwarded to the wards the specific nursing
information conveyed varied, as did the member of the nursing staff who was responsible for
supplying the information.
3.2.2 Written documentation

The additional written documentation perceived to be associated with discharge planning was clearly
considered the major barrier to the process in the critical care environment. Participants thought that
there was already considerable documentation to attend to when caring for a critically ill patient, for
example, the constant documentation of observations, fluid status, and drug administration.
Documentation associated with discharge planning was perceived to be an added burden, especially in
light of its perceived limited value, especially when the patient is acutely ill:
You know we have a lot of documentation to do, we have the routine data collection and then you
have to write what you normally do, so it is asking a lot for people to add another document ...
especially if they don't value it (Participant C).
However, on further investigation there was perceived to be a lack of specific documentation related to
the discharge planning process as illustrated in the following response:
There's very little documentation ... our written communication is quite poor. But organisationally it is
quite good; the unit managers meet each morning and discuss things like potential discharge from ICU
to the wards so there is forward planning in that way ... the communication is not fantastic, ... we
have no written plan for discharge (Participant C).
Participant K reported that the discharge plan was actually documented on the day of discharge and
up until this time significant events were documented, however, the effectiveness of the discharge
plan depended very much on the premise "If you have time, please fill it out, especially if you know
the patient". This response summarised key elements of all responses in that the timing of the
formulation of the discharge plan was ad hoc and there was an emphasis on significant events:
When it's really busy and you're just happy to do all the care, sometimes the paperwork is the last
thing that gets done, gets forgotten, maybe not picked up by someone else (Participant K).
3.2.3 Tools available
Clinical pathways have been implemented in some of the critical care settings in which the participants
worked, to assist with the management of cardiothoracic and coronary care patients, and, according to
the participants' responses, the implementation had been successful. The discharge plan is built into
the clinical pathway document, hence this had enhanced discharge planning in this cohort of patients
admitted to critical care. In contrast, there are few clinical pathways available for the general
intensive care patient, as it is perceived to be too difficult to predict thecare they will require due to
the critical nature and related unpredictability of their illness. The second group of interview
participants (with less than 6 years experience in the critical care environment) reported that clinical

pathways had only just been introduced into the ward where the majority of the participants worked,
consequently only the first group of interview participants' comments were considered with regard to
available tools.
These participants reported utilising clinical pathways when caring for cardiothoracic patients, but
none of them reported using clinical pathways when caring for the general intensive care patient. The
clinical pathway was considered to be a vehicle that improved discharge planning for the
cardiothoracic patients because of the very nature of having the necessary steps documented and the
requirement of ticking and signing the step on its completion, as illustrated by the following
responses:
I think our cardiac patients are well catered for, and in having the critical pathway it is all there you
know, you can't ignore it, it has to be ticked and signed ... but in our general patients you know ... it
is a variable kind of thing ... so you can't put policies in place (Participant B).
Cardiac is easy, the intensive care patients are difficult and, as I said there are, there's few care maps
set aside for the intensive care patient, that's much more ad hoc on a needs day-to-day basis ...
(Participant E).
Participant C expressed her concern regarding the reliance nurses have on clinical pathways and the
danger that nurses would blindly follow the pathway without considering the individual nature of the
patient in regard to their discharge planning requirements, "... there is no conscious planning going on
because the document is there and people don't have to think about it".
3.2.4 Time available
A reason why the discharge planning process was not considered a priority in the initial phase of the
patient's admission to critical care was a perceived lack of time to engage in discharge planning.
Participants reported lack of time on two levels--time demands due to the patient's critical physical
condition and time demands due to overall high workloads. First, participants consistently reported
that it was not possible to engage in the discharge planning process because they were caught up with
the acute aspects of the patient's condition and hence they did not have time to undertake discharge
planning. The discharge planning process received some consideration when the patient's condition
was considered not life threatening, as illustrated by the following quote:
...you're busy, you know, with the physical problems ... that are life threatening issues, and I suppose
when you reach the discharge planning stage, um, it's not so acute ... (Participant A).

Second, inadequate time was also perceived to be a factor in limiting discharge planning when it was
considered that the unit as a whole was busy:
... if the unit was working at greater than 70 percent capacity, discharge planning became such a low
priority that eventually it just faded and disappeared again (Participant G).
While lack of time was recognised by participants as a key factor contributing to inconsistencies in how
well patients are prepared for discharge from the critical care environment, only one participant
offered a possible strategy to improve this situation. This participant suggested that bedside nurses
needed to be given time to reflect on their patients' needs. Thus, it was perceived that the nurse
required time, away from the bedside, to consider the patient's discharge needs without having to deal
with all other bedside issues:
...I think it's probably a time and experience thing. That people have things to deal with at the bedside
and don't often get to step away from the bedside (Participant H).
4
Discussion
In this paper, reporting of findings of the questionnaire survey and interview data may appear
unbalanced, with the second given a higher profile in spite of a small sample size. This is attributed to
specific questions being asked in the questionnaire while the interviews generated considerable
discussion in the topic area. However, both the survey and interview participants consistently reported
that communication is an important factor in either enhancing or impeding the discharge planning
process in critical care.
The interview participants considered the written documentation associated with the discharge
planning process an additional burden. The written nursing care plan has long been considered the
tool to communicate patient careneeds with regards to planning and implementing the
required care and subsequently promoting continuity of care. However, in reality, there are problems
associated with the use of care plans. For example, many nurses show poor compliance with their use,
often documentation is incomplete and there are perceived inefficiencies in the use of nurses' time
(Twardon and Gartner, 1993). These are all factors identified by the study
participants. Critical pathways were reported as a tool that enhanced communication of the discharge
plan specifically for the cardiothoracic patient.

Participants reported verbal communication regarding the discharge planning process in critical care as
taking place primarily between senior members of staff, often to the exclusion of the bedside nurse.
Just how effective verbal or written communication of the discharge plan is between nursing staff at
the bedside appears to relate directly to the commitment of the individual nurse. It was also
suggested, by some participants, that there was a lack of interest among bedside nurses in
communicating the discharge plan. These findings highlight the need for an improved communication
process between critical care nursing staff, and as such, a starting point may be to improve critical
care nurses' knowledge of the discharge planning process and the importance of communicating the
plan to other members of the health care team. Rorden and Taff (1990) suggest that well-constructed
documentation, which clearly outlines the patient's discharge plan, is essential in order to prevent
potential problems, such as inadequate verbal communication among critical care nurses. This finding
and that from the survey, of continuity of staff being ranked as the second most important factor that
enhances the discharge planning process, may be indicative of the shortage of critical care trained
nurses in Victoria (de Sales and Ogle, 1999). This shortage has been paralleled by a decline in the
number of permanent staff working in critical care units in Victoria, and an increase in the number of
part-time and agency staff.
The major theme that arose from discussion of communication of the discharge plan between critical
care nurses and medical staff was that the participants felt that, in reality, they had little control of the
discharge planning process. While it was reported that it was a medical decision to determine when a
patient was to be discharged, participants were clearly frustrated with the perceived lack of
collaboration between medical and nursing staff underpinning the discharge planning process in critical
care. While Oddi and Huerta (1990) believe that it is the physician who must have the final say in
deciding which patient requires admission or transfer from the critical care unit, Clausen (1984)
argues that a discharge planning model that continually seeks physicians' orders and permission can
limit nurses' initiatives. Such a model may in fact encourage nurses to blame doctors for the nurses'
poor planning and allow nurses to shirk their responsibility in discharge planning. Dawson (1993)
believes that if nurses are removed from the decision making process, resentment will occur.
The participants reported communication between critical care staff and ward staff as variable. There
was no consistent policy of involvement of ward staff, prior to the discharge of the critical care patient
to the general ward, within organisations or between organisations. It appeared that whether ward
staff visited a patient in the critical care environment, prior to transfer to the general ward, was
dependent on the individual ward nurse. It was also more common for ward staff to visit the patient
in critical care prior to transfer if the ward staff knew the patient, or in other words a relationship

already existed. This perhaps then discriminated against patients and their families where no prior
relationship had been established.
While the survey participants ranked unplanned discharges as the second major factor that impedes
the discharge planning process in critical care, the interview participants consistently reported a lack
of time as a barrier to engaging in discharge planning in the critical care environment. A lack of time
was largely attributed to dealing with the many acute aspects of the patient's condition and, at times,
a busy environment compounded this. This finding is consistent with the finding in Schlemmer's
(1989) study that discharge planning is often not initiated or completed by the critical care nurse
because of time constraints. Interestingly, 17% of the interview participants reported lack of time as
the most important factor that impedes the discharge planning process in critical care. The finding of
unplanned discharges against the finding of inadequate time may be attributed to the type of unit
participants worked in and the predictability of patient transfer, for example, a general
intensive care unit or a cardiothoracic unit.
If we return to Rorden and Taff's (1990) definition of discharge planning it is difficult to know how
members of the health care team can work together in a coordinated manner to achieve mutually
agreed upon goals and, ultimately, continuity of care if inadequate communication is perceived to be a
major factor that both enhances and impedes the discharge planning process in critical care. Because
discharge planning contributes to the provision of continuity ofcare for patients (Alspach, 1985;
Hartigan and Brown, 1985; Zarle, 1989) the findings reported here from the survey and interviews
suggest that continuity of care for patients admitted to the critical care environment warrants further
research.
Of the 502 critical care nurses invited to participate in the interviews, 12 volunteered initially to
participate (seven of whom were subsequently interviewed). One can only speculate about why such a
small number of critical carenurses offered to participate. Possible reasons might include a reluctance
to spend time outside work hours involved with research, or perhaps the critical care nurses did not
want to be interviewed one-to-one. Other reasons might be that the topic area was not of interest,
was considered to be of a low priority to nurses working in the clinical area, or the topic was not
perceived to be of relevance to critical care nurses.
All of the initial seven participants, who participated in the in-depth interviews, had extensive
experience with critical care patients and considerable knowledge of discharge planning in the critical
care environment. They were able to articulate their experience from their perspective during the indepth semi-structured interviews, thus fulfilling Streiner and Norman (1995) criteria of key
informants. However, while key informants are able to provide particularly useful information, a major

limitation is that their perspective may be distorted or biased (Patton, 1990). In this study, the
additional perspectives provided by the six participants with less than 6 years experience in critical
care, reduced the potential distortion of results.
5
Limitations
Because this study is an exploratory descriptive study, future research is needed to investigate the
practice of discharge planning in critical care. It is acknowledged that a descriptive study cannot
answer the question of cause and effect. It is also acknowledged that, as a whole, the nurses who
participated may not be entirely representative ofcritical care nurses practising in Victoria. Therefore,
the results might have been more generalisable if critical carenurses who are not members of CACCN
(Victorian Branch) had also been surveyed.
6
Conclusion
Participants' years of critical care experience did not appear to have significance in regard to the
findings of this study. Two key factors that enhanced or impeded the discharge planning process in
the critical care environment were communication and time available. While survey participants
identified communication as both the most important factor enhancing and impeding the discharge
planning process, the principal modes of communication of the discharge planning process discussed
by interview participants were verbal and written documentation. Verbal communication was
considered on three levels, communication between critical care nurses, between critical care nurses
and medical staff, and between critical care nurses and ward nurses. Communication at all three levels
was found to be problematic and in need of review at ward level.
These findings provide some understanding of the two key factors that impact on critical care nurses'
ability to engage in the discharge planning process in the critical care environment. However, it is
perhaps more important to recognise that these factors are relatively unchanged from those reported
in the 1980's (Alspach, 1985; Carr, 1988; Schlemmer, 1989). Further research is therefore indicated
to examine these factors in more depth. These findings may, however, form part of the basis for
improving the discharge planning process in the current critical care

strak (Ringkasan)
TerjemahkanAbstrak
Setiap penyakit yang cukup serius untuk meminta masuk ke unit perawatan kritis
akan mengintensifkan efek fisik dan psikologis yang pasien dan lain-lain
pengalaman yang signifikan mereka. Oleh karena itu, kebutuhan pemulangan
pasien dirawat di perawatan kritis tidak diragukan lagi kompleks, beragam dan
dinamis.
Memanfaatkan pendekatan deskriptif eksploratif 502 perawat perawatan kritis,
diidentifikasi dari Australian College of Critical Care Nursing (ACCCN) (Victoria)
Database diundang untuk berpartisipasi dalam penelitian ini. Sebuah kuesioner 31item dikembangkan dan didistribusikan. Sebanyak 218 peserta yang memenuhi
syarat menyelesaikan survei. Satu-ke-satu wawancara semi-terstruktur dengan 13
Victoria perawat perawatan kritis juga dilakukan.
Peserta melaporkan bahwa kurangnya waktu adalah penghalang untuk
melaksanakan perencanaan. Komunikasi Namun, bisa meningkatkan atau
menghambat proses perencanaan debit dalam perawatan kritis. Peserta menilai
bahwa jalur kritis, yang digunakan dalam perawatan pasien kardiotoraks, apakah
membantu dengan komunikasi proses perencanaan debit, maka meningkatkan
proses.
Sementara temuan ini memberikan beberapa pemahaman tentang faktor-faktor
yang meningkatkan atau menghambat praktek perencanaan debit perawatan
perawat kritis 'penelitian lebih lanjut ditunjukkan. Temuan yang dilaporkan di sini
mungkin, bagaimanapun, memberikan titik awal untuk meningkatkan proses
perencanaan debit dalam perawatan kritis.
Teks Lengkap
TerjemahkanTeks Lengkap
Aktifkan Navigasi Istilah pencarian
Karakteristik Valuea
Umur (tahun)
25-35 53
35-44 40
> 44 7
Jumlah tahun memenuhi syarat sebagai perawat perawatan kritis (tahun)
7 atau kurang 46
8-14 40
15 atau lebih 14
Judul Posisi
Terdaftar perawat 35
Perawat klinis spesialis 25
Asosiasi biaya perawat 22
Perawat Manajer 7
Klinis pendidik 7
Bidang spesialisasi
ICU umum 31

Perawatan koroner 7
Kardiotoraks 9
Trauma ICU 3
Gabungan ICU 41
Model alokasi
Keperawatan primer 19
Pasien alokasi oleh pergeseran 65
Lainnya 16
Tabel 1 - Karakteristik demografi sampel (peserta survei).
Faktor yang paling penting dalam meningkatkan proses perencanaan debit dalam
perawatan kritis Least faktor penting dalam meningkatkan proses perencanaan
debit dalam perawatan kritis
Komunikasi yang efektif (%) 43 debit Rencana (%) 38
Keberlanjutan staf (%) 20 Kontinuitas staf (%) 22
Debit yang direncanakan (%) 19 Tersedia waktu (%) 21
Pengetahuan (%) 8 Pengetahuan (%) 14
Tersedia waktu (%) 6 Komunikasi yang efektif (%) 1
Hilang (%) 4 Hilang (%) 4
Tabel 2 - Faktor-faktor yang meningkatkan proses perencanaan debit di unit
perawatan kritis.
Faktor yang paling penting dalam menghambat proses perencanaan debit dalam
perawatan kritis Least faktor penting dalam menghambat proses perencanaan debit
dalam perawatan kritis
Komunikasi tidak memadai (%) 33 Kontinuitas staf (%) 38
Debit yang tidak direncanakan (%) 30 Kurangnya pengetahuan (%) 21
Kurangnya waktu (%) 17 pembuangan terencana (%) 20
Kurangnya pengetahuan (%) 9 Kurangnya waktu (%) 10
Keberlanjutan staf (%) 7 yang tidak memadai komunikasi (%) 7
Hilang (%) 4 Hilang (%) 4
Tabel 3 - Faktor-faktor yang menghambat proses perencanaan debit di unit
perawatan kritis.
Peserta identifikasi Job Jumlah judul tahun mengalami incritical perawatan
Kualifikasi (s)
Sebuah Graduate Certificate CNS 6 dalam Perawatan Kritis
B Perawat pendidik 6 Graduate Diploma dalam Perawatan Kritis
C ACNb 10 Critical Care (sertifikat rumah sakit); Graduate Diploma dalam
Pendidikan
D RNC 20 Critical Care (sertifikat rumah sakit)
E Perawat managerd 15 Koroner Perawatan (rumah sakit sertifikat); Graduate
Diploma dalam Perawatan Kritis
F CNS 11 Critical Care (sertifikat rumah sakit)
H Badan nursee 10 Sertifikat Perawatan Koroner (sertifikat rumah sakit); Sarjana
Pendidikan.
Saya SSP 3 (3/4) Graduate Diploma dalam Perawatan Kritis

J RN 2 (3/4) Graduate Diploma dalam Advanced Nursing (Critical Care)

K CNS 4 (1/2) Graduate Diploma dalam Advanced Nursing (Critical Care)
L RN 2 (3/4) Graduate Certificate dalam Perawatan Kritis
M CNS 5 Graduate Diploma in Advanced Nursing (Critical Care)
N RN 1 Graduate Diploma di Kesehatan Masyarakat; Graduate Certificate dalam
Perawatan Kritis
(B) ACN (biaya perawat associate) biasanya bertanggung jawab untuk
mengkoordinasikan perawatan pasien selama pergeseran.
(C) RN (perawat terdaftar) adalah seorang perawat tingkat pertama yang berlisensi
untuk praktek keperawatan.
(D) NM (perawat manager) didominasi bertanggung jawab atas administrasi satuan.
(E) Badan perawat, adalah seorang perawat terdaftar yang dipekerjakan melalui
organisasi eksternal ke rumah sakit, yang dikenal sebagai agen.
Tabel 4 - Demografi: peserta wawancara.
1
Pengantar
Tidak ada pertanyaan bahwa perencanaan debit telah muncul di seluruh dunia
sebagai daerah kompleks latihan di caresystem kesehatan, dan, mungkin, yang
paling kompleks dalam lingkungan perawatan kritis. Variabel potensial yang ada
dalam lingkungan perawatan thecritical, seperti tingkat keparahan kondisi pasien,
pemantauan invasif, ketakutan, terapi obat dan gangguan kognisi semua
mempengaruhi kemampuan fungsional dan putusan pasien dan dengan demikian
mengurangi kapasitas mereka untuk berpartisipasi dalam perencanaan pulang. Unit
perawatan kritis adalah lingkungan yang sangat sulit di mana untuk menilai
kemampuan pasien, dan kemampuan keluarga, untuk mengambil bagian dalam
proses perencanaan pulang. Ini memperlebar kesenjangan antara cita-cita
perencanaan debit dan realitas.
Sebagai panjang tinggal di rumah sakit berkurang, perencanaan debit harus pindah
ke daerah perawatan kritis. Carr (1988) berpendapat bahwa, berdasarkan
pengetahuan dan keterampilan, perawat perawatan kritis ideal untuk memulai
proses perencanaan pulang. Dia percaya bahwa semua yang diperlukan untuk
perawat perawatan kritis untuk memulai proses pengakuan akan pentingnya
perencanaan pulang.
Tidak ada argumen bahwa kebutuhan debit pasien yang telah menghabiskan waktu
dalam perawatan kritis sangat kompleks dan saling terkait (Alspach, 1985; Berdoa
dan Hoff, 1992; Schlemmer, 1989). Kebutuhan ini mencakup berbagai faktor fisik,
psikososial, dan ekonomi yang membutuhkan manajemen holistik (Daffurn et al.,
1994).
Rorden dan Taff (1990) definisi perencanaan debit digunakan untuk keperluan
makalah ini. Mereka mendefinisikan perencanaan debit sebagai "... suatu proses
yang terdiri dari beberapa langkah atau tahapan yang segera tujuannya adalah
untuk mengantisipasi perubahan kebutuhan perawatan pasien dan yang jangka
panjang tujuannya adalah untuk memastikan kesinambungan pelayanan
kesehatan" (p.22). Definisi multi-faceted ini menjelaskan debit perencanaan sebagai

proses dinamis yang melibatkan berbagai keterampilan khusus dan memerlukan

semua anggota tim kesehatan untuk bekerja sama secara terkoordinasi untuk
mencapai tujuan yang disepakati bersama dan, pada akhirnya, kontinuitas
perawatan (Watts, 2004). Menariknya, Watts et al. (2005) melaporkan bahwa
carenurses kritis Victoria yang pasti dari titik akhir dari proses perencanaan debit
dan berpendapat bahwa klarifikasi diperlukan apakah proses perencanaan debit
dalam lingkungan perawatan kritis dikonseptualisasikan sebagai mempersiapkan
pasien untuk tahap berikutnya perawatan dalam yang periode rawat inap, atau
mengantisipasi, perencanaan dan / atau mempersiapkan penyediaan careservice
kesehatan di luar rumah sakit.
Sementara yang ideal adalah untuk proses perencanaan pulang untuk dimulai pada
atau sebelum, masuk pasien ke rumah sakit (Clare dan Hofmeyer, 1998; HuertaTorres, 1998; Berdoa dan Hoff, 1992; Williams, 1991) literatur menunjukkan bahwa
ada berbagai alasan mengapa hal ini tidak terjadi di lingkungan perawatan kritis.
Salah satu alasan berulang kali dikutip adalah bahwa perawat perawatan kritis
biasanya menunda perencanaan debit sampai kebutuhan perawatan pasien telah
melampaui tahap akut, dan kondisi mereka telah stabil (Alspach, 1985; Carr, 1988).
Schlemmer (1989) menunjukkan bahwa perencanaan pulang dalam lingkungan
perawatan kritis tidak sadar diabaikan perawat perawatan bycritical tetapi tidak
diinisiasi atau diselesaikan karena keterbatasan waktu dan beban kerja yang tinggi.
Perawat perawatan kritis sebenarnya hadir untuk melepaskan perencanaan setelah
kebutuhan perawatan kesehatan pasien sakit kritis telah berkembang di luar negara
akut (Alspach, 1985). Carr (1988) setuju bahwa, untuk pasien dirawat di unit
perawatan kritis, perencanaan debit biasanya ditunda sampai pasien telah stabil
dan telah dipindahkan ke daerah perawatan yang kurang akut. Mendukung
kehidupan dan perubahan klinis menit-demi-menit dalam kondisi pasien dapat
membuat debit perencanaan prioritas rendah dan membuat debit tampak jauh.
(1989) studi eksplorasi Schlemmer yang bertujuan untuk mengidentifikasi proses
perencanaan debit saat ini yang ada di unit perawatan kritis di negara bagian
Washington di Amerika Serikat dan mengidentifikasi peran perawat perawatan kritis
dalam proses perencanaan debit pada unit-unit ini. Seratus dua puluh lima
kuesioner yang dibagikan, dengan tingkat respon dari 55%. Struktur perencanaan
debit di unit di mana peserta bekerja digambarkan sebagai tidak terstruktur dengan
67% dari peserta. Enam puluh sembilan persen dari peserta menyatakan bahwa
unit perawatan kritis mereka tidak memiliki standar yang menguraikan kriteria
untuk perencanaan pulang dalam pengaturan perawatan kritis tertulis. Tanggung
jawab staf untuk proses perencanaan debit bervariasi antara unit-unit perawatan
kritis, dengan perencana debit ditunjuk menjadi yang paling sering bertanggung
jawab, diikuti oleh manajer perawat. Perawat samping tempat tidur memiliki paling
bertanggung jawab untuk memulai arahan perawatan pasca-rumah sakit.
Peningkatan beban kerja keperawatan dianggap sebagai memiliki dampak terbesar
dalam menunda perencanaan debit di unit perawatan kritis. Mayoritas peserta tidak
menganggap perencanaan debit sebagai prioritas bagi perawat perawatan kritis
dan berpikir itu tidak praktis untuk menerapkan perencanaan debit di unit

perawatan kritis. Secara umum, itu dianggap bahwa perencanaan debit adalah
proses yang harus dimulai setelah pasien dipindahkan dari unit perawatan kritis.
Thompson (1985) meneliti perencanaan debit dalam lingkungan perawatan kritis di
Virginia Barat (USA). Kuesioner dikirim ke 100 dipilih secara acak perawat
perawatan kritis untuk mengevaluasi pemahaman mereka tentang perencanaan
debit dan bagaimana hal itu dilakukan. Thompson menemukan bahwa 70% dari
peserta berpikir bahwa perencanaan debit tidak berlaku untuk unit mereka. Perlu
dicatat bahwa meskipun 100 kuesioner yang dibagikan tingkat respons yang
sebenarnya tidak dinyatakan.
Dalam sebuah penelitian yang dilakukan di Sydney, Australia, Daffurn et al. (1994)
meneliti 54 pasien, dengan lama tinggal dalam perawatan kritis lebih dari 48 jam,
untuk menentukan hasil fungsional dan kualitas hidup dalam minggu-minggu
setelah pulang. Para pasien diwawancarai 3 bulan setelah meninggalkan perawatan
kritis. Temuan utama dari studi ini menunjukkan bahwa banyak pasien menderita
ringan sampai sedang gejala sisa. Para penulis menyarankan bahwa proses
discharge yang lebih komprehensif diperlukan. Leith (1998) berpendapat bahwa
perencanaan debit tidak harus dibatasi untuk mentransfer dari rumah sakit, tetapi
harus mencakup perencanaan untuk transfer pasien dari unit perawatan kritis ke
unit lain di dalam rumah sakit itu. Dia percaya bahwa hambatan untuk
menyediakan perencanaan pulang pada pasien dalam mengantisipasi transfer dari
unit perawatan kritis harus diatasi. Perawat perawatan kritis memiliki tanggung
jawab untuk memberikan kontinuitas perawatan yang tepat untuk mengurangi
perpindahan kecemasan pada pasien perawatan kritis dan anggota keluarga.
Ada kekurangan literatur terbaru khusus untuk proses perencanaan debit dalam
perawatan kritis. Meskipun diakui bahwa sastra di atas agak tanggal, mayoritas
literatur terbaru di daerah, telah difokuskan pada pengalaman pasien menjadi
pasien dalam perawatan kritis dan pengalaman transfer dari lingkungan perawatan
kritis ke bangsal umum (Coyle 2001, Hijau, 1996; McKinney dan Melby, 2002; Odell,
2000; Stein-Parbury dan McKinley, 2000) dan peran multifungsi perawat
penghubung perawatan kritis (Barbetti dan Choates, 2003;. Chaboyer et al, 2004;
Hijau dan Edmonds, 2004). Perhatian baru-baru ini sedikit telah dibayarkan kepada
pemahaman dan keyakinan dari proses perencanaan debit perawat di lingkungan
perawatan kritis.
Temuan yang dilaporkan di sini merupakan bagian dari penelitian yang lebih besar
yang bertujuan untuk mengeksplorasi persepsi perawatan perawat kritis dan
pemahaman tentang proses perencanaan debit dalam sistem perawatan kesehatan
di negara bagian Victoria, Australia, dan karenanya memperoleh wawasan tentang
bagaimana proses perencanaan debit cocok dengan lingkungan perawatan kritis
dari perspektif keperawatan. Temuan utama dari studi ini adalah bahwa perawat
perawatan kritis yang pasti dari titik akhir dari proses namun ada penekanan umum
pada gerakan umum pasien dari lingkungan perawatan kritis (Watts et al., 2005).
Dalam artikel ini, kami melaporkan peserta faktor kunci yang diidentifikasi sebagai
meningkatkan atau menghambat praktek perencanaan pulang mereka dalam
lingkungan perawatan kritis.

2
Metode
2.1 Desain
Memanfaatkan pendekatan deskriptif eksploratif, penelitian ini dilakukan dengan
menggunakan angket yang diisi oleh 218 peserta dan juga terlibat dalam
wawancara mendalam dengan 13 perawat perawatan kritis. Studi ini disetujui oleh
Universitas Fakultas LaTrobe Ilmu Kesehatan Komite Etika Manusia (FHEC).
Persetujuan juga dicari dari dan diberikan oleh Konfederasi Perawat Australia Critical
Care (CACCN) Cabang Victoria (sekarang dikenal sebagai Australian College of
Critical Care Nursing (ACCCN) Cabang Victoria) penelitian subkomite untuk
mengakses database keanggotaan mereka dalam rangka untuk merekrut peserta .
Pada saat CACCN (Cabang Victoria) aplikasi keanggotaan awal dan perpanjangan
keanggotaan tahunan, anggota diminta untuk menyetujui berpartisipasi dalam
penelitian yang dianggap cocok oleh CACCN (Cabang Victoria) subkomite penelitian.
2.2 Contoh
Para anggota CACCN (Cabang Victoria) disediakan kohort untuk penelitian ini.
Database CACCN diperbolehkan identifikasi para anggota yang bekerja di daerah
perawatan kritis sebagai lawan anggota, misalnya, yang memegang kualifikasi
perawatan spesialis kritis tetapi memiliki janji akademik dan tidak bekerja di
careenvironment kritis. Berdasarkan area utama kerja yang ditunjuk oleh anggota
dari bentuk pembaharuan CACCN (1998) perawat perawatan 502critical
diidentifikasi sebagai bekerja di unit perawatan kritis dan didekati untuk
berpartisipasi dalam penelitian ini. Peserta bisa bekerja full-time atau paruh waktu
dan memiliki berbagai latar belakang profesi.
Prosedur 2.3
Temuan yang dilaporkan dalam makalah ini merupakan bagian dari penelitian yang
lebih besar memeriksa praktek perencanaan debit dan keyakinan ofcritical perawat
perawatan dalam sistem perawatan kesehatan Victoria. Studi 1 melibatkan survei
terhadap keyakinan dan praktik perencanaan debit 218 Victoria carenurses kritis '.
Karena tidak ada alat yang handal dan valid dapat ditemukan untuk tujuan ini, alat
baru dikembangkan.
Kuesioner secara khusus dikembangkan dan digunakan untuk mengumpulkan data
dari perawat perawatan kritis bekerja di lingkungan perawatan kritis.
Pengembangan instrumen terjadi secara bertahap. Awalnya, pencarian literatur
yang dilakukan untuk menentukan pandangan nasional dan internasional saat ini
keyakinan dan sikap perawat untuk debit perencanaan. Tema dalam literatur
diidentifikasi. Temuan dari penelitian sebelumnya yang dilakukan oleh peneliti
(Watts dan Gardner, dalam press) mengeksplorasi persepsi perawatan perawat akut
proses perencanaan debit juga ditarik atas, seperti diskusi dengan rekan-rekan yang
memiliki keahlian di bidang perencanaan debit dan carenursing kritis . Informasi
yang dikumpulkan dari semua sumber dan digunakan untuk merumuskan
rancangan kuesioner untuk digunakan dalam studi percontohan. Kuesioner
dibagikan, sebagai bagian dari studi percontohan, delapan berlatih perawat
perawatan kritis, dianggap ahli perawat perawatan kritis bekerja dalam sistem

perawatan kesehatan Victoria. Peneliti tahu peserta ini, tetapi mereka tidak
berpartisipasi dalam penelitian yang dilaporkan dalam makalah ini. Sesuai dengan
umpan balik dari para peserta tentang kata-kata dan pemesanan pertanyaan dan
kecukupan alternatif, perubahan kecil yang dilakukan pada kata-kata dari beberapa
pertanyaan. Kategori 'Pre-masuk klinik' ditambahkan sebagai alternatif respon
untuk dua pertanyaan tentang waktu perencanaan debit dalam perawatan kritis.
Sebuah pertanyaan terbuka meminta peserta untuk menentukan proses
perencanaan debit yang berkaitan dengan perawatan kritis telah ditambahkan ke
kuesioner. Ruang dibuat tersedia untuk komentar opsional di tiga titik di kedua
(persepsi / pengalaman) bagian dari kuesioner.
Dalam rangka untuk menilai validitas wajah, para ahli ditanya apakah lingkup item
pada kuesioner meliputi bidang perencanaan debit dalam perawatan kritis atau
apakah item perlu ditambahkan. Perbandingan informal tanggapan terhadap isu-isu
serupa ditanyakan dalam pertanyaan terkait menunjukkan tingkat tinggi korelasi
menunjukkan reliabilitas internal instrumen penelitian. Meskipun studi ini dilakukan
pada kelompok heterogen, perawat perawatan kritis dengan berbagai pengalaman
bertahun-tahun dalam perawatan kritis, keandalan instrumen ini tidak dinilai
dengan prosedur statistik. Oleh karena itu, disarankan agar alat seharusnya hanya
digunakan dalam penelitian masa depan setelah evaluasi lebih lanjut.
Dalam mendalam satu-ke-satu wawancara dari total 13 perawat perawatan kritis
memungkinkan klarifikasi dan eksplorasi temuan dari respon kuesioner. Peserta
yang menerima survei juga diundang untuk wawancara one-to-one yang
berlangsung sekitar 30-40 menit. Dua belas perawat perawatan kritis yang telah
berpartisipasi dalam survei sukarela untuk diwawancarai, yang tujuh benar-benar
berpartisipasi dalam sebuah wawancara. Perawat ini semua memiliki lebih dari 6
tahun pengalaman perawatan kritis dan diidentifikasi sebagai Peserta AG. Peneliti
percaya bahwa kelompok ini peserta tidak mewakili karena itu sub-kelompok besar
perawat perawatan kritis dan kelompok tambahan peserta direkrut untuk
wawancara.
Sebagaimana dilaporkan dalam CACCN (Cabang Victoria) 1998-1999 Laporan
Tahunan, CACCN (Cabang Victoria) beranggotakan total 682 perawat. Empat puluh
sembilan persen CACCN (Cabang Victoria) anggota memiliki 6-10 tahun mengalami
perawatan incritical. Oleh karena itu dianggap perlu untuk merekrut dan
mewawancarai peserta tambahan, peserta tersebut menjadi perawat perawatan
kritis dengan kurang dari 6 tahun pengalaman dalam lingkungan perawatan kritis.
Untuk merekrut kohort ini peserta, rekan profesional peneliti, yang memiliki kontak
yang bekerja di perawatan kritis, diminta untuk membantu peserta merekrut dari
mulut ke mulut. Diputuskan untuk menggunakan metode perekrutan sebagai
permintaan asli untuk berpartisipasi dalam penelitian ini melalui selebaran yang
dikirim dengan kuesioner telah gagal untuk menarik minat dari perawat CACCN
perawatan kritis dengan kurang dari 6 tahun pengalaman dalam perawatan kritis.
Universitas FHEC diberitahu dari dan disetujui perubahan ini dalam protokol proyek,
sehubungan dengan perekrutan peserta lanjut. Peserta yang direkrut tidak memiliki
hubungan profesional dengan peneliti dan tidak dipaksa dengan cara apapun untuk

berpartisipasi dalam penelitian ini. Setelah peserta mungkin menyatakan minatnya

untuk mengambil bagian dalam studi, nama dan nomor kontak yang diberikan oleh
asosiasi kepada peneliti, yang kemudian menghubungi calon peserta, menjelaskan
studi dan bertanya apakah mereka akan berpartisipasi. Selanjutnya enam perawat
perawatan kritis direkrut. Peserta ini diidentifikasi sebagai Peserta HM.
Semua calon peserta, yang menyatakan minatnya untuk diwawancarai, diundang
untuk wawancara yang berlangsung sekitar 30-40 menit, pada pra-diatur waktu
yang tepat untuk kedua peneliti dan peserta. Jadwal wawancara digunakan,
terutama terdiri dari pertanyaan terbuka. Menggunakan proses menyalurkan
(Minichiello et al., 1991) pertanyaan yang luas umum diminta pada awal
wawancara, maka peserta diminta pertanyaan spesifik yang berkaitan dengan
keyakinan perencanaan debit mereka sendiri dan praktek. Wawancara secara
terbuka direkam dan kemudian ditranskrip. Menggunakan transkrip, kategorisasi
dan pemesanan informasi ini dilakukan untuk memungkinkan peneliti untuk
memahami data. Sebuah sistem pengkodean dikembangkan untuk mengatur data
dan memungkinkan identifikasi tema.
3
Temuan
3.1 Kuesioner
Karakteristik demografi peserta survei disajikan pada Tabel 1.
3.1.1 Faktor kunci dalam proses perencanaan debit dalam perawatan kritis
Tabel 2 profil tanggapan terhadap pertanyaan 'Apa faktor / s yang Anda percaya
meningkatkan proses perencanaan debit di unit Anda? " Peserta diminta untuk
menentukan peringkat alternatif dalam urutan dari yang paling penting (1) sampai
yang kurang penting (5). Tabel menunjukkan, untuk setiap alternatif, persentase
peserta yang peringkat sebagai (1) - yang paling penting, dan, untuk setiap
alternatif, persentase yang peringkat sebagai (5) - paling tidak penting. Hilang
mengacu pada kasus-kasus di mana peserta baik tidak menjawab pertanyaan sama
sekali, atau hanya menunjukkan salah satu alternatif sebagai yang paling penting,
tetapi tidak peringkat alternatif lain.
Hanya di bawah satu-setengah (43%) dari peserta mengidentifikasi komunikasi
yang efektif sebagai faktor yang paling penting dalam meningkatkan proses
perencanaan debit di unit mereka, seperlima (20%) peserta dinilai kelangsungan
staf sebagai faktor yang paling penting, diikuti oleh debit yang direncanakan (18%).
Beberapa peserta (8%) mengidentifikasi pengetahuan sebagai yang paling penting
faktor dan tersedia waktu dinilai faktor yang paling penting dengan 6% dari peserta.
Lebih dari sepertiga (38%) peserta peringkat debit direncanakan sebagai faktor
paling penting dalam meningkatkan proses perencanaan debit di unit mereka.
Keberlanjutan staf diidentifikasi sebagai faktor paling penting oleh sekitar seperlima
(22%) dari peserta, 21% diidentifikasi waktu yang tersedia dan 14% pengetahuan.
Komunikasi yang efektif diidentifikasi sebagai faktor paling penting dengan hanya
1% dari peserta.
Tabel 3 profil tanggapan untuk pertanyaan 'Apa faktor / s yang Anda percaya
menghambat proses perencanaan debit di unit Anda? " Peserta diminta untuk

menentukan peringkat alternatif dalam urutan dari yang paling penting (1) sampai
yang kurang penting (5). Tabel menunjukkan, untuk setiap alternatif, persentase
peserta yang peringkat sebagai (1) - yang paling penting, dan, untuk setiap
alternatif, persentase yang peringkat sebagai (5) - paling tidak penting. Hilang
mengacu pada kasus-kasus di mana peserta baik tidak menjawab pertanyaan sama
sekali, atau hanya menunjukkan salah satu alternatif sebagai yang paling penting,
tetapi tidak peringkat alternatif lain.
Komunikasi tidak memadai diidentifikasi sebagai faktor yang paling penting dalam
menghambat proses perencanaan debit dalam lingkungan perawatan kritis oleh
sepertiga (33%) dari peserta. Debit direncanakan diidentifikasi oleh (kurang-lebih)
sepertiga lainnya (30%) dari peserta sebagai faktor yang paling penting, diikuti oleh
kurangnya waktu (17%). Para peserta yang tersisa dinilai kurangnya pengetahuan
(9%) dan kontinuitas staf (7%) sebagai faktor yang paling penting dalam
menghambat proses perencanaan debit dalam lingkungan perawatan kritis.
Keberlanjutan staf diidentifikasi oleh lebih dari sepertiga (38%) peserta sebagai
faktor paling penting dalam menghambat proses perencanaan debit dalam
perawatan kritis. Kurangnya pengetahuan dinilai sebagai faktor paling penting
dalam menghambat proses perencanaan debit sekitar seperlima (21%) dari peserta
dan pembuangan yang tidak direncanakan sebesar 20%. Para peserta yang tersisa
mengidentifikasi kurangnya waktu (10%) dan komunikasi yang tidak memadai (7%)
sebagai faktor paling penting dalam menghambat proses perencanaan debit dalam
perawatan kritis.
3.2 Wawancara
Karakteristik demografi peserta wawancara disajikan pada Tabel 4.
3.2.1 Komunikasi rencana debit
Para peserta wawancara menunjukkan bahwa proses perencanaan debit
dikomunikasikan dalam dua cara utama antara perawat perawatan kritis, antara
perawat perawatan kritis dan staf medis, dan antara perawat perawatan kritis dan
staf bangsal. Komunikasi ini berada dalam bentuk instruksi lisan, dan dokumentasi
tertulis. Tingkat dokumentasi tertulis rencana debit pasien sangat bervariasi,
dengan masing-masing peserta pelaporan sistem yang berbeda di tempat kerja.
Namun, secara umum, para peserta wawancara terfokus sedikit pada komunikasi
tertulis rencana debit lebih, mereka mengangkat isu-isu yang berkaitan dengan
komunikasi verbal dari rencana debit.
3.2.1.1 Komunikasi verbal antara perawat perawatan kritis
Mayoritas peserta berpikir bahwa rencana debit dikomunikasikan secara verbal
antara perawat perawatan kritis dan bahwa ada sedikit komunikasi tertulis formal.
Komunikasi verbal mengenai rencana debit terjadi terutama antara anggota senior
staf terutama di 'tangan-over' waktu, dan perawat samping tempat tidur belum
tentu terlibat.
Peserta B menjelaskan bahwa perencanaan pulang dikomunikasikan dengan dua
cara di tempat kerjanya: lisan dan dengan dokumentasi. Namun, seperti dibahas di
bawah, untuk pasien kardiotoraks, ada kecenderungan bagi perawat untuk
memanfaatkan thecare jalan yang memiliki ruang yang jelas ditujukan untuk debit

perencanaan, dengan pemimpin tim memainkan peran utama dalam

mengkomunikasikan rencana debit. Dilaporkan bahwa pemimpin tim memiliki
serangkaian kartu serah terima, yang digunakan sebagai dasar untuk komunikasi
verbal berikutnya dari rencana debit "Saya pikir ada judul 'debit' tetapi lebih
berkaitan dengan tanggal dan waktu. .. "(Peserta B). Sebagai perbandingan,
perencanaan pulang untuk pasien ICU umum sekali lagi dikomunikasikan melalui
catatan pemimpin tim dan rencana asuhan keperawatan, bagaimanapun, tidak ada
judul pada rencana perawatan yang ditugaskan untuk melaksanakan perencanaan.
Hal ini menunjukkan bahwa anggota senior staf, daripada perawat samping tempat
tidur, adalah pemangku kepentingan utama dalam proses perencanaan pulang.
Peserta F menjelaskan bahwa alat yang sama komunikasi terjadi di unit-nya:
Ini baik, jalur kritis, itulah yang saya sedang mencoba untuk memikirkan, halaman
pertama yang benar-benar memiliki banyak informasi tentang pasien, keluarga
mereka dan fisioterapis ... Bagian lain dari proses ini adalah bahwa tim pemimpin,
orang yang bertanggung jawab dari setiap shift, sebenarnya juga menyerahkan
banyak informasi dan yang disimpan pada sistem kartu (Peserta F).
3.2.1.2 Komunikasi verbal antara perawat perawatan kritis dan staf medis
Ada persepsi oleh beberapa peserta yang, dalam kenyataannya, perawat perawatan
kritis memiliki sedikit kontrol atas proses perencanaan pulang. Siapa menentukan
kapan pasien akan dipulangkan, para peserta melaporkan bahwa ini adalah
keputusan dokter:
Saya harus mengatakan sebagian besar dokter. Ini mungkin keputusan medis
(Peserta J).
Dilaporkan bahwa di tempat kerja ini terjadi karena dominasi para dokter dan isu
terkait kekuasaan dan kontrol, dan / atau kebutuhan mendesak untuk mengakui
pasien lain. Peserta secara konsisten menunjukkan bahwa dokter memainkan peran
utama dalam keputusan untuk mengakui atau mentransfer pasien di unit perawatan
kritis dan ini terjadi baik di sektor kesehatan publik dan swasta. Frustrasi dengan
seluruh proses ditampilkan, dan kebutuhan untuk membuat proses upaya lebih
kolaboratif diakui:
... Biasanya apa yang terjadi adalah bahwa mereka melakukan putaran mereka,
mereka mengatakan apa-apa "Anda siap untuk pergi ke bangsal dan kita punya
seseorang, di suatu tempat, yang baru saja penangkapan, yang bisa kita keluar dari
sini" ? Dan itu biasanya rencana debit Anda, yang bisa kita keluar dari sini dan
seberapa cepat kita bisa mendapatkan mereka keluar (Peserta G).
3.2.1.3 Komunikasi verbal antara perawat perawatan kritis dan staf bangsal
Dalam penelitian ini, tidak ada konsistensi dalam tanggapan berkaitan dengan
komunikasi antara perawat perawatan kritis dan staf bangsal perawatan. Apakah
staf bangsal bertemu pasien sebelum meninggalkan perawatan kritis dan masuk ke
bangsal tampaknya tergantung pada kebijakan lingkungan individu dan dalam
beberapa kasus pada masing-masing pasien.
Peserta melaporkan bahwa staf lingkungan lebih cenderung terlibat pada tahap
awal jika pasien diklasifikasikan sebagai 'jangka panjang', dan ini meningkatkan
kemungkinan keterlibatan staf bangsal sebelum pembuangan perawatan

fromcritical pasien. Namun, hanya beberapa peserta menunjukkan bahwa ini

sebenarnya adalah rutin:
Ya, kami secara rutin akan melakukan itu untuk semua jangka panjang [pasien],
sehingga orang-orang yang telah di selama sekitar dua minggu atau lebih, kita
melibatkan staf lingkungan (Peserta C).
Dalam pengalaman saya, pasien pergi ke bangsal adalah pertama kalinya bangsal
melihat mereka ... jika staf bangsal telah bertemu pasien dalam contoh pertama
[pasien bangsal yang telah dirawat di ICU] mereka akan umumnya, saya
menemukan, mengikuti mereka melalui. Jika mereka tidak memiliki, mereka tidak
datang untuk melihat apa yang kita punya karena mereka terlalu sibuk berurusan
dengan apa yang mereka punya (Peserta D).
Kadang-kadang (Peserta B)
Peserta melaporkan bahwa meskipun laporan debit diteruskan ke bangsal informasi
keperawatan spesifik disampaikan bervariasi, seperti yang dilakukan anggota staf
perawat yang bertanggung jawab untuk memberikan informasi tersebut.
3.2.2 Dokumentasi tertulis
Dokumentasi tertulis tambahan dirasakan terkait dengan perencanaan debit jelas
dianggap sebagai penghalang utama proses dalam lingkungan perawatan kritis.
Peserta berpikir bahwa sudah ada dokumentasi yang cukup untuk mengurus ketika
merawat pasien sakit kritis, misalnya, dokumentasi konstan pengamatan, status
cairan, dan pemberian obat. Dokumentasi yang terkait dengan perencanaan debit
dianggap menjadi beban tambahan, terutama mengingat nilai terbatas dirasakan,
terutama ketika pasien akut sakit:
Anda tahu kami memiliki banyak dokumentasi yang harus dilakukan, kita memiliki
pengumpulan data rutin dan kemudian Anda harus menulis apa yang biasanya Anda
lakukan, sehingga meminta banyak bagi orang untuk menambahkan dokumen
lain ... terutama jika mereka tidak menghargai itu (Peserta C).
Namun, penelitian lebih lanjut dianggap ada menjadi kurangnya dokumentasi
spesifik yang berhubungan dengan proses perencanaan debit seperti yang
diilustrasikan pada respon berikut:
Ada sangat sedikit dokumentasi ... komunikasi tertulis dari kami sangat miskin. Tapi
secara organisasi cukup baik; para manajer unit bertemu setiap pagi dan
mendiskusikan hal-hal seperti potensi debit dari ICU ke bangsal sehingga ada
perencanaan ke depan dengan cara yang ... komunikasi tidak fantastis, ... kita tidak
punya rencana tertulis untuk discharge (Peserta C).
Peserta K melaporkan bahwa rencana debit sebenarnya didokumentasikan pada
hari debit dan sampai saat ini peristiwa penting yang didokumentasikan, namun,
efektivitas rencana debit sangat tergantung pada premis "Jika Anda punya waktu,
silakan mengisinya, terutama jika Anda tahu pasien ". Tanggapan ini diringkas
elemen kunci dari semua tanggapan dalam waktu penyusunan rencana debit ad hoc
dan ada penekanan pada peristiwa penting:
Ketika itu benar-benar sibuk dan Anda hanya senang melakukan semua perawatan,
kadang-kadang dokumen adalah hal terakhir yang akan dilakukan, akan dilupakan,

mungkin tidak dijemput oleh orang lain (Peserta K).

3.2.3 Alat yang tersedia