I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Nurses perceptions of discharge planning in acute health care:

a case study in one British teaching hospital
Anita Atwal

MSc PhD Dip COT SROT

Lecturer in Occupational Therapy, Department of Health and Social Care, Brunel University, Middlesex, UK

Submitted for publication 26 July 2001

Accepted for publication 31 May 2002

Correspondence:
Anita Atwal,
Department of Health and Social Care,
Brunel University,
Borough Road,
Isleworth,
Middlesex TW7 5DU,
UK.
E-mail: anita.atwal@brunel.ac.uk

ATWAL A. (2002)

Journal of Advanced Nursing 39(5), 450458

Nurses perceptions of discharge planning in acute health care: a case study in one
British teaching hospital
Aim of the study. To provide an in-depth understanding of nurses perceptions of
the hospital discharge process in a London teaching hospital.
Background. Discharging patients from hospital is a key component of the nurses
role in acute health care settings. It is remarkable that despite government legislation and research, which stretches back over 20 years in both Europe and North
America, discharge planning remains problematic. Furthermore, it is an activity that
requires collaboration between health and social care agencies. In the United
Kingdom there is a new emphasis and incentive on managing acute hospital beds,
which in turn results in shorter stays in hospital. In London, discharge planners face
additional problems because of social, economic and environmental factors.
Method. Using a case study design, 19 nurses were interviewed using the critical
incident approach to obtain their perceptions of the discharge process. Direct
observation was conducted to record interactions between nurses and health care
professionals in multidisciplinary teams. In total 14 meetings were attended in elder
care and orthopaedics and 7 in acute medicine.
Findings. Aspects of the discharge process were often ignored or neglected and
assessments were rarely co-ordinated. The nursing ward handover was regarded as a
process that hindered communication. Lack of time was reported to be the biggest
barrier that affected interprofessional working and hence the co-ordination of
assessments.
Conclusion. The findings have important implications for nurses, managers and
educational establishments. It is essential that social and medical diagnoses run
parallel and that accurate information is collated and communicated within the
multidisciplinary team. Further research into the impact of time pressures on
communication, interprofessional working and the discharge process is needed.
Keywords: interprofessional, hospital discharge, teamwork communication, nurses,
ward handover

Introduction
In every health care system throughout the world, increasing patient needs and expectations continue to outstrip
available resources. Changing social policy and scarce
resources affect the delivery of health and social services,
450

and higher costs mean shorter stays in hospital. The

importance of discharge planning has increased since the
publication of the National Health Service (NHS) Plan
(Department of Health [DOH] 2000), where a clear
distinction is made between acute and intermediate care.
This document highlights the importance of freeing acute

2002 Blackwell Science Ltd

Issues and innovations in nursing practice

beds and looking at alternative and creative ways of

rehabilitating and discharging patients. Thus, in response
health care trusts must determine whether early discharge is
possible.
Discharge planning is a process that is dependent on
interprofessional collaboration between health and welfare
professionals. Working together in an interprofessional
health care arena requires competence, commitment and the
desire and will to co-operate. Nurses play a central role in
the discharge process. In addition, the named nurse is often
responsible for co-ordination of the discharge and thus needs
to understand the importance and complexities of interprofessional collaboration.
Nurses who work in London may face additional discharge
challenges. Older persons who live in London are amongst the
most deprived and experience above average levels of ill health
(Victor 1996). Housing is often problematic, particularly as
renting remains commonplace, often with poor amenities.
Kenny (1996) found that the provision of home care was 19%
higher in London than in England overall, which may be
accounted for by out-migration by younger relatives. Likewise
Victor et al. (2000) found that the absence of a family carer
was a key factor which delayed hospital discharge.

Background
In order to facilitate the discharge process it is suggested
that it should begin as early as possible, allowing potential
problems to be identified [British Geriatrics Society and
Association of Director of Social Services (BGS and ADSS)
1989, DOH 1989, Henwood 1994, Audit Commission
1995]. There is a general consensus that the process should
begin as the patient actually arrives in the Accident and
Emergency Department, but in clinical practice this rarely
occurs (Atwal 1995, Audit Commission 1995). It is essential
that discharge plans are accurate, as in many cases this
will determine whether a patient can be discharged home,
whether additional rehabilitation is required or whether a
nursing or residential home is more appropriate. Health care
professionals must take responsibility for the outcome of the
discharge plan as it is dependent on the individual skill(s) of
each member of the health care team. A survey by Bennett
et al. (1995) of older people in nursing homes found that
many had been wrongly assessed. Reed and Morgan (1999)
found that nurses did not initiate discussions with older
persons moving from hospital to a nursing or residential
home. Furthermore there was a lack of clarity over whose
responsibility it was to initiate such discussions.
Throughout the discharge process it is imperative that the
social diagnosis runs parallel with the medical diagnosis as

Discharge planning in acute health care

this enables an holistic approach to discharge planning,

ensures that the appropriate referrals are made and enables
discharge plans to be formulated. However there is evidence
that suggests that the social aspects of the discharge process
are often ignored or neglected (Audit Commission 1992,
Oktay et al. 1992, King & MacMillan 1994, NHS Executive
1994). Mistiaen et al. (1997) found that 37% of patients who
were discharged home from an acute setting had one or more
unmet needs 1 week after discharge. A study by Waters et al.
(2001) is more encouraging because they found that there
were fewer unmet needs for older persons discharged in the
1990s than in the 1980s.
Interprofessional collaboration has been acknowledged as
an essential part of discharge planning because discharge
problems are caused by poor communication and co-ordination between hospital based and community based professionals (Gregory 1992, Wilson 1998, McKenna et al. 2000,
Bull & Roberts 2001). Problems are exacerbated by
involvement of different agencies, professionals and carers
(both formal and informal) because each party has a specific
responsibility for specific aspects of health and social care
(Audit Commission 1995, 1997, Proctor et al. 1996, Healy
et al. 1999).
The primary nurse is often responsible for co-ordinating
multidisciplinary assessments and thus needs to understand
the role of each team member. Research by Armitage and
Kavanagh (1996) and McKenna et al. (2000) suggests that
the nurses role in the discharge process requires further
clarification. Nurses are often responsible for making referrals to other members of the multidisciplinary team. The
referral process allows members of the multidisciplinary team
to manage aspects of the patients care. It is where interprofessional liaison comes into its own and when interprofessional relationships are at their most strained. Victor et al.
(2000) suggested that late referrals to members of the
multidisciplinary team could be a factor in causing delays
in hospital discharge. In addition the research found that
a nurse co-ordinated team made the fewest referrals for
multidisciplinary assessments. Indeed, the assessment part of
the discharge process is punctuated by decision-making at
crucial stages, as the referral process can be broken down into
three areas who, why, and when (Cass 1978).
To gain an accurate picture of the patient it is essential that
the results of the assessments are co-ordinated and that joint
goals are set. McKenna et al. (2000) suggest that nurses
have failed to improve communication and documentation in
discharge planning despite the publication of research by
Skeet (1975) identifying similar problems. Likewise, Payne
et al. (2000) found that nurses did not regard paperwork as
being a having the same status as patient care. It is often

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

451

A. Atwal

difficult to retrieve information from other agencies as

different records are maintained by various health care
providers.
In the literature there is considerable evidence that interprofessional collaboration influences the discharge process. It
is essential to determine nurses likes and dislikes of the
discharge process in order to identify what strategies need to
be implemented to ensure best practice.

orthopaedics. The main difficulties were that patients being

admitted to hospital by the on-call medical team were often
confused, medically unwell and situated in many different
areas of the hospital, including the Accident and Emergency
Department. It would not have been possible to ascertain the
informed consent of patients and members of the team prior
to team meetings.

Data collection

The study
Aims
The aims of the study were:
to explore nurses perceptions of discharge planning;
to identify the type of interactions which occurs in multidisciplinary team meetings and its impact on discharge
planning.

Methods and design

A case study design was selected as this enabled in-depth
understanding of discharge planning. Robson (1993, p. 5)
defines a case study as A strategy for doing research which
involves an empirical investigation of a particular contemporary phenomenon within its real context using multiple
sources of evidence. Nineteen nurses working in the acute
physical health care setting were interviewed using the critical
incident approach, a qualitative research methodology
developed by Flanagan (1954). A direct observational study
was carried out in elder care, orthopaedics and acute
medicine to record interactions of multidisciplinary team
members and their impact on discharge decision-making.
Sample
The sample was taken from nurses working on acute wards.
The nurses who participated included nine from orthopaedics, six from acute medicine and four from elder care.
A convenience sample was used to recruit research participants, who were invited to participate by responding to
posters, letters and talks.
Ethical issues
Ethical clearance was obtained by meeting the criteria set by
the Hospital Ethics Committee. Prior to seeking the consent
of nurses to participate in the research it was essential to gain
the support of nurse managers and trust managers. For the
observational study it was imperative to gain the consent of
all health care professionals. I was unable to gain ethical
approval to video record ward rounds in acute medicine and
452

Observation of interactions in multidisciplinary meetings

Using a nonparticipant observation approach, I observed and
recorded interactions that occurred in multidisciplinary
meetings. Whilst the observations focused on all members of
the multidisciplinary team, this paper reports those that were
specific to nursing and discharge planning. Two elder care
consultants (A and B), two orthopaedics consultants (C and D)
and one acute medicine consultant (consultant E) participated
in the research. Multidisciplinary team meetings occurred
weekly and on a specific day of the week. I observed how each
professional participated in the team meetings and the content
of the discussions. All 19 participants were observed.
Seven meetings with consultant A and seven meetings with
consultant B were attended, all of which were videorecorded. The length of meetings varied considerably with
consultant As lasting on average 50 minutes and consultant
Bs lasting on average two and a half hours. Nurses,
occupational therapists, physiotherapists, doctors and social
workers attended these meetings.
I attended seven bedside multidisciplinary meetings with
consultant D and seven meetings with consultant E, and
interactions were recorded. The orthopaedic team visited
each patient and reviewed them at the bedside. The rounds
occurred every week at 8:00 a.m. and were attended by
occupational therapists, physiotherapist, doctors and nurses.
Depending on the number of patients who needed to be
reviewed, the meeting could last between 30 and 90 minutes.
I attended 14 meetings in total in acute medicine, and
recorded interactions. No formal multidisciplinary meetings
occurred in this setting. One consultant participated in the
research. Acute medicine is organized so that each ward has
patients from different consultants and consequently medical
teams visit numerous wards and the Accident and Emergency
Department to review the patients. Only doctors and nurses
attended these meetings, and their length was dependent on
the number of patients.
Critical incident approach
The critical incident approach is unique in that it does
not measure satisfaction or dissatisfaction, but discloses

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

Issues and innovations in nursing practice

individuals likes or dislikes, and allows subjects to talk about

the events they consider important (Jones 1988). It is therefore an extremely useful guide to illustrate what changes may
need to be made. The approach is described by Flanagan
(1954, p. 327) as a method for collecting direct observations of human behaviour in such a way as to facilitate their
potential involving practical problems.
Critical incidents can be collected from either direct
observation or retrospective accounts. It is a flexible technique that has been adapted to evaluate patient perceptions
of nursing care (Grant & Hryack 1985, Norman et al. 1992)
and to evaluate performance (Flanagan et al. 1963, Cormack
1983, Benner 1984).
The criteria outlined by Flanagan (1954) must be applied
to determine what is a critical incident. This is defined as Any
observable human activity that is sufficiently complete in
itself to permit inferences and predictions to be made about
the act (Flanagan 1954, p. 327). It must occur in a situation:
Where the purpose or the intent of the act seems fairly clear to the
observer and where its consequences are sufficiently definite to leave
little doubt concerning its effect (Flanagan 1954, p. 327).

The critical incident technique was piloted with five female

health professionals (two occupational therapists and three
nurses). All were known to me and consented to participate
in the pilot study. I attended in total six multidisciplinary
meetings (two each in elder care, orthopaedics and acute
medicine) in order to become familiar with group values,
norms, rules, and culture, this also enabled research participants to familiarize themselves with both the aims of the
research and with me.
The themes of the interviews focused on nurses likes and
dislikes of the discharge process. Participants were asked to
describe and reflect upon the discharge process in the trust, to
give narratives from practice, recall incidents when discharge
planning did or did not go well, and explore and reflect on
factors which impacted on the discharge process and their
own role.
Interviews in the main study were approximately 4560
minutes long and took place between 1998 and 1999. All
were tape-recorded. It was important to allow enough time
for participants to warm up sufficiently prior to the
interview as this provides a relaxed atmosphere.
In addition I ensured that the following criteria had been
met when collecting the incidents: Is the actual behaviour
reported? Was it observed by the reporter? Were all relevant
factors in the situation given? Has the reporter made a
definite judgement regarding the criticalness of the behaviour? Has the reporter made it clear just why she or he
believes the behaviour was critical.

Discharge planning in acute health care

Data analysis
The interview and observation data were fully transcribed
and content analysis undertaken. Transcripts from the
observations were analysed by identifying the types of
interaction in multidisciplinary meetings and which professional participated in each interaction. To ensure reliability
another researcher worked independently on samples of the
data to identify categories, which were then discussed to
reach consensus.
The first step in analysis of interviews was to conceptualize
the data by breaking down each sentence into something that
represented an incident (Strauss & Corbin 1990). Codes were
applied to a group of words and ideas in order to categorize
them together. These codes were assertiveness, confidence,
time constraints, skills, knowledge and expertise. Once
particular phenomena in the data were identified, their labels
were grouped together, which is referred to as categorizing.
Categories that emerged were each given a name, and those
that were related to one another were merged.
Checking codes, an essential part of qualitative content
analysis, improved the objectivity of the research data. It
enabled me to ascertain whether there was agreement
regarding the definition of a code(s) and whether it needed
to be expanded or rectified. This event took place as soon as
the categories were formulated. Two independent judges
performed the interrater agreement testing. One was an MSc
student in research methods whilst the second was a senior
occupational therapist. Separately, they coded five pages of
transcription. The two coded passages were then compared
and disagreements amongst the two judges were discussed.
To ascertain the rate of intercoder agreement the number of
agreements was divided by the total number of agreements
and disagreements. It is recommended that intercoder agreement should be between 80% and 95% (Miles & Huberman
1994). Initially the two coders had only 65% agreement. The
process was repeated until the two coders reached the
standard required. The same procedure was repeated twothirds of the way through the study to ensure that a high
agreement between the two coders was maintained (83%).

Findings
Interprofessional discharge education and training
There was considerable evidence that the expertise of
professionals affected the management of patients. There
was no evidence from the observational study of health care
professionals educating other professionals about their role
and/or the discharge process. Discussions in the observational

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

453

A. Atwal

study demonstrated how expertise influenced the outcome for

patients. For example, over a 3-week period the orthopaedic
team were attempting to manage the discharge of a patient
who required a hoist. The meeting began with the team
awaiting the delivery of a hoist, which had been ordered by
a newly qualified occupational therapist. However on arrival
the hoist would not fit under the bed. The delay in provision
of the hoist was reported by a staff nurse (orthopaedics) who
had difficulty understanding why delays occurred:
It is costing thousands of pounds to keep this woman here in a bed
with acute nursing care on this ward. You could have paid for that
hoist in 4 daysI just dont understand why they cant say take a
little bit of this budget and give it to them so she can buy a bloody
hoist and she wouldnt be blocking the bed. But you cant do that,
can you? I dont understand that.

Another staff nurse (orthopaedics) was acutely aware of the

different levels of expertise and expressed concern that during
the nursing handover nurses did not question information
that they did not comprehend. Professionals in all three
specialities reported that discharge skills were learnt when
qualified and not as a student. There were numerous ways of
acquiring these skills, and one was learning through experience. A staff nurse (medicine) reported that she learnt about
discharge planning only after being involved in a problematic
discharge that had a disastrous outcome. Another staff nurse
(medicine) outlined the role that experienced nurses had in
developing junior nurses:
Unfortunately you do have some people who are slightly timidand
you have to push themIf you feel that this person is at risk of going
home too early then stand your ground.

For junior professionals, discharge planning was viewed as a

process that was extremely challenging. A staff nurse
(orthopaedics) described her initial feelings:
So when I was qualified I went to my first ward. There was like this
ocean in front of me. and I wondered whether or not I could
discharge this patient safely or no, was like whether I could cross the
channel. If I got across I thought, Thank God for that. Can I do
another one?

in all three specialities the consultants were the leaders of the

medical team and members of the medical profession tended
to speak first and most convincingly on all issues. In elder
care a sincere effort was made to discuss social aspects as
opposed to the medical problems. At the medical postadmission ward round the social history was rarely asked for or
even volunteered, although this may have reflected the focus
of their meeting, which was to review the medical management of acutely ill patients. Similarly interactions from the
orthopaedic ward rounds focused on the medical management, although conservative efforts were also made to discuss
social aspects.
A staff nurse (medicine) reported that on the ward rounds
it was disheartening to report that a patient could not be
discharged, whilst a staff nurse (orthopaedics) reported that it
was often difficult to state opinions if they were different
from those of other team members: It is horrible when that
happens because you dont like to say, I think they are safe
to go home when everybody else is disagreeing, sort of
thing. A staff nurse (orthopaedics) stated:
Sometimes you are made to feel humiliated in putting across the
fact that the patient has got medical problems rather than orthopaedic problemsBut then some consultants do make you justify and
there and then make you feel small and or say, Well, basically this is
a trauma ward. There is nothing wrong with this patient. We need
this bed. The patient has to go.

The social history was not regarded as an important factor

that needed to be communicated at either the nursing
handover or multidisciplinary team meeting I dont think
that the full social history is given until the day before the
patient is discharged (staff nurse orthopaedics). The low
priority placed on the importance of social history may be
influenced by professional reluctance to be associated with
this relatively unscientific task.
In an elder care multidisciplinary team meeting a consultant outlined her perception of the discharge process to
members of the multidisciplinary team. This highlighted the
role responsibilities of professionals and the absence of care
management in the initial information gathering process:
The first part in discharge planning in my mind is what had gone on
before. That is my understanding of discharge planning. You have

Social history and discharge planning

got to have the information from beforeThe OTs do a lot of it, so

The type of information, given in multidisciplinary meetings

is of considerable significance in the discharge decisionmaking process. Communication is an important part of the
process as it allows professionals to give and ask for opinions,
defend themselves, find out where they stand in relation to
others, and formulate a discharge plan. It was observed that

454

do the care managers once they become involved. But of course we

wait 6 weeksso that is no good so it has to be OTs, doctors and
nurses. Not physiosBut it is where we constantly fail.

Nurses in orthopaedics and acute medicine admitted to

failing to collect social information directly from patients
once they arrived on the ward. Nurses in orthopaedics and

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

Issues and innovations in nursing practice

acute medicine stated that this information was difficult to

obtain from trauma patients or those who were confused and
consequently it was then forgotten about and left incomplete.
As a result they relied on information from Accident and
Emergency or medical notes. A staff nurse (medicine) highlighted the fact that people who were admitted often did not
have a next of kin, or know their name and address.

Interprofessional working
It was observed that nurses and members of the multidisciplinary team did not attend multidisciplinary meetings when
faced with other pressing priorities. A staff nurse (medicine)
reported that other professionals often arrived on the ward
at the most inconvenient times and expected her to drop
everything and communicate with them. Then she would
have to spend time phoning the social work department for
the outcome of the assessment:
If you are really busy and the whole place is bedlam and the care
manager walks onto the ward you just think, Oh God no! and you
know that you are going to have to talk and you know that you are
going to have to spend time and often you dont have it. It is an
inconvenience and, you know, an hour later you are phoning them up
trying to get them to come up to the ward so you can speak to them.
But if they come at a time when you are not expecting them it is

Discharge planning in acute health care

willing to give and receive information. However, a staff

nurse (medicine) reported that communication with doctors
occurred when they required information: We approach
them and ask them what they are doing. Another staff
nurse (medicine) reported: But on day to day things I
generally dont keep in touch. It is only when something
changes or something is directly affecting what I am doing.
Nurses in orthopaedics expressed frustration that communication with occupational therapists was a one-way process
only, although this opinion was contradicted by another staff
nurse (orthopaedics), who believed that she received more
information from occupational therapists and physiotherapists than from her nursing colleagues. One reason for this
may be her commitment to the benefits of interprofessional
working.
Care managers, occupational therapists and doctors in
acute settings were criticized by nurses for not interacting
without being chased or badgered, which they described as
an extremely time-consuming process. The greatest number
of complaints in relation to care management was about the
number of calls that were not returned, and the fact that these
people were perceived as only coming to the ward when
specifically asked. An elder care ward manager admitted that,
due to lack of time, a ward clerk was asked to collate
information from care managers about patients.

bedlam and you just cringe.

One staff nurse (medicine) reported that communication was

dependent on her relationship with members of the multidisciplinary team. During the course of the research two
consultants formally introduced new members and welcomed
them into their team. In some instances professionals were
not formally introduced, whilst on other occasions care
managers and occupational therapists acted as the broker:
You know, you might hand over to the physio in the morning and
it just depends if it is somebody you personally get on with or not
whether you communicate with them throughout the day or notIt
depends on how well you know them and how long you have known
them.

However, when relationships were strained between nurses

and doctors communication decreased:
It is the same with the doctorsit is often quite tense between you
and that stops you from communicatingI cant be bothered to go
and speak to you. (staff nurse medicine)

One staff nurse (acute medicine) was of the opinion that the
effectiveness of communication was dependent on its
importance to the communicators. Nurses in all three
specialities valued communication where both parties were

Nursing handover
The shift patterns of nurses can be detrimental to maintaining
interprofessional communication and continuity of care. The
nursing handover is an important part of nursing and
interprofessional communication and is used as a tool to
co-ordinate patient care. In general the ward was considered
a central focus for interprofessional communication; however, staff nurses in medicine and in orthopaedics reported
that communication is lacking on the ward. A staff nurse
(medicine) and a care manager (acute) compared communication on the wards to Chinese whisper and a staff nurse in
orthopaedics echoed this opinion: By the time that it had got
to the night shift it is forgotten about.

Discussion
The interviews showed that a social history is not collected on
admission and there is considerable delay in collecting this
information throughout the discharge process. If accurate
and credible information were collected on admission and
shared with other members of the team then many discharge
potential problems might be alleviated. The research data
support the findings of McBride (1995) and the Audit

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

455

A. Atwal

Commission (1995) that this rarely occurs in practice.

Williams and Fitton (1988) concluded that 58% of
unplanned re-admissions could have been prevented if more
effective action had been taken in the preparation and timing
of discharge.
It is essential that nurses adopt a strongly patient-focused
role. Mackay (1997, p. 176) found that nurses were often
reluctant to voice their opinions even if it was a Matter of life
and death. Manias and Street (2001) found that nurses often
found it very difficult to present relevant patient issues
during medical ward rounds. Furthermore, very rarely did
they introduce a new problem into the discussion. Gair and
Hartery (2001) suggest that reducing medical dominance
within a team will in turn encourage its members to voice
opinions. Throughout the discharge process it is imperative
that the social diagnosis runs parallel with the medical
diagnosis. This ensures a holistic approach to discharge
planning, ensures that the appropriate referrals are made, and
enables discharge plans to be formulated. However, there is
evidence to suggest that the social aspects of the discharge
process are often ignored or neglected. This supports the
findings of the Audit Commission (1992), Oktay et al.
(1992), King and MacMillan (1994) and NHS Executive
(1994). It was also reflected in multidisciplinary meetings
where health care professionals are reluctant to discuss social
issues. Similarly, Rintala et al. (1986) found that on a
multidisciplinary ward in a rehabilitation setting the physical
content of interactions was overemphasized (65%) whilst the
psychosocial area was underemphasized (14%).
Data from the research showed that interprofessional
relationships were strained, and this is consistent with the
findings of Benson and Ducanis (1995), Birchall (1997),
Burke et al. (2000) and Dalley and Sim (2001). The involvement of different health care professionals and agencies may
in fact lead to discharge delays. Thus it important to adhere
to the principles of patient-focused care by ensuring that the
numbers of professionals involved in the discharge process
are reduced.
Whilst nursing handover is an important aspect of the
discharge process, the data showed that it was the key area
where information was miscommunicated. Thus it is essential
nurses spend time both giving and receiving accurate information about patients social and medical status. Research by
Payne et al. (2000) found that nursing handovers in elder
care were routinized, given at high speed, and emphasized
biomedical factors and the physical aspects of care. Whilst
my data showed an absence of interprofessional discharge
education and training, it is important to note that current
health care policy advocates interprofessional education as a
means of improving relationships (DOH 2000). There is little
456

evidence, however, that demonstrates its effectiveness in

clinical practice (Zwarenstein 2000). Whilst nurses in my
study did not identify specific factors which contributed to
successful discharges, it is evident that educational and health
and social care institutions all have an important role to play.
I suggest that undergraduate nursing, health and social care
educational establishments should provide an interprofessional discharge module, which would equip students with
discharge and team-working skills. Placement education
should enable students to put theory into practice and hence
become competent discharge planners prior to starting
practice.

Limitations of the study

The study was carried out in one health care trust and thus
represents the opinions and actions of these staff only. Thus it
is suggested that it should be repeated in other health care
settings.
Medical consultants were reluctant to participate in the
research, the reasons given for refusal ranging from organizational ones, to those of disinterest, or failure to acknowledge the relevance of the research. However issues of relative
status may have been a factor, in that I am an occupational
therapists and not a doctor.

Conclusion
Nurses play a key role in discharge planning and are best
placed to deliver patient-centred care. As a component of the
mentoring of junior nurses, senior nurses need to ensure that
discharge skills continue to develop. Discharge planning is a
complex process that involves many different agencies and
health and social care professionals. As co-ordinators of care,
nurses need to ensure that they understand how health and
social care agencies function. They need to be committed to
the principles of team-working and allow sufficient time for
interprofessional and intraprofessional communication. They
need to value their own vital contribution to effective and
efficient interprofessional working. It is imperative that
nurses value the social aspects of patient care and that this
is seen as an integral part of the discharge process.

Acknowledgements
I wish to thank the nursing staff who took part in this study.
The research was possible due to a PhD studentship funded
by the School of Health, Biological and Environmental
Sciences at Middlesex University. I would like to thank
Kay Caldwell (Principal Lecturer at the School of Health,

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

Issues and innovations in nursing practice

Biological and Environmental Sciences, Middlesex University, London), and Christine Craik (Director of Undergraduate Occupational Therapy, Brunel University, London)
for their support and encouragement.

References
Armitage S. & Kavanagh K. (1996) Hospital nurses perceptions of
discharge planning for medical patients. Australian Journal of
Advanced Nursing 14, 1623.
Atwal A. (1995) The management of fallers who attend an Accident
and Emergency Department. Unpublished MSc Thesis, South Bank
University, London.
Audit Commission (1992) Lying in Wait: the Use of Medical Beds in
Acute Hospitals. HMSO, London.
Audit Commission (1995) United They Stand Coordinating Care for
Elderly Patients with a Hip Fracture. HMSO, London.
Audit Commission (1997) The Coming of Age. HMSO, London.
Benner P. (1984) From Novice to Expert Excellence and Power in
Clinical Nursing Practice. Addison-Wesley, California.
Bennett M., Smith E. & Millard P. (1995) The Right Person? The
Right Place? An Audit of the Appropriateness of Nursing Home
Placements Post Community Care. Department of Geriatric
Medicine, St Georges Hospital Medical School, London.
Benson L. & Ducanis A. Nurses perceptions of their role and role
conflicts. Rehabilitation Nurse 20, 204211.
Birchall J.L. (1997) Patient-focused care: anatomy of a failure.
Holistic Nursing Practice 11, 1729.
British Geriatric Society for the Health of the Aged (1989) Joint
Statement of Professional Associations, Discharge to the Community of Elderly Patients in Hospital. British Geriatrics Society
and Association of Director of Social Services, London.
Bull M.J. & Roberts J. (2001) Components of a proper
hospital discharge for elders. Journal of Advanced Nursing 35,
571581.
Burke D., Herrman H., Evans M., Cockram A. & Trauer T. (2000)
Educational aims and objectives for working in multidisciplinary
teams. Australasian Psychiatry 8, 336339.
Cass S. (1978) The effects of the referral process on hospital patients.
Journal of Advanced Nursing 3, 563569.
Cormack D. (1983) Psychiatric Nursing Described. Churchill
Livingstone, Edinburgh.
Dalley J. & Sim J. (2001) Nurses perceptions of physiotherapists as
rehabilitation team members. Clinical Rehabilitation 15, 380389.
Department of Health (1989) Health Circular HC(89) 5: Discharge
of Patients from Hospital. HMSO, London.
Department of Health (2000) The NHS Plan. A Plan for Investment.
A Plan for Reform. HMSO, London.
Flanagan J.C. (1954) The critical incident approach. Psychological
Bulletin 51, 327359.
Flanagan J.C., Gosnell D. & Fivars G. (1963) Evaluating student
performance. American Journal of Nursing 63, 9699.
Gair G. & Hartery T. (2001) Medical dominance in multidisciplinary
teamwork: a case study of discharge decision-making in a geriatric
assessment unit. Journal of Nursing Management 9, 311.
Grant N.K. & Hryack N. (1985) How can you find out what patients
think about their care? Canadian Nurse 81, 51.

Discharge planning in acute health care

Gregory M.F. (1992) Planning safe discharge from hospital the
importance of interprofessional collaboration and communication.
Journal of Interprofessional Care 6, 133139.
Healy J., Thomas A., Seargeant J. & Victor C. (1999) Assessing the
Post-Hospital Care Needs of Older People. Policy Studies Institute,
London.
Henwood M. (1994) Hospital Discharge Workbook: A Manual on
Hospital Discharge Practice. Department of Health, London.
Jones M.P. (1988) Not how many but why. A qualitative approach to
customer relations. Health Service Management 86, 175177.
Kenny D. (1996) Estimating Levels of Need Among Older People in
London. Report for the Kings Fund Commission. London
Research Centre, London.
King C. & MacMillan M. (1994) Documentation and discharge
planning for elderly patients. Nursing Times 90, 3133.
Mackay L. (1997) Conflict in Care Medicine and Nursing. Chapman &
Hall, London.
Manias E. & Street A. (2001) Nursedoctor interactions during
critical care ward rounds. Journal of Clinical Nursing 10, 442
450.
McBride R.C. (1995) An audit of current discharge arrangements and
their effectiveness on elderly care wards and community nursing
services together with aspects of client satisfaction. Journal of
Nursing Management 3, 1924.
McKenna H., Keeney S., Glenn A. & Gordon P. (2000) Discharge
planning: an exploratory study. Journal of Clinical Nursing 9,
594601.
Miles M.B. & Huberman A.M. (1994) Qualitative Data Analysis,
2nd edn. Sage, Thousand Oaks, CA.
Mistiaen P., Duijnhouwer E., Wijkel D., de Bont M. & Veeger A.
(1997) The problems of elderly people at home one week after
discharge from an acute care setting. Journal of Advanced Nursing
25, 12331240.
National Health Service Executive (1994) The Patients Progress
Towards a Better Service. HMSO, London.
Norman I.J., Redfern S.J., Tomalin D.A. & Oliver S. (1992) Developing Flanagans critical incident technique to elicit indicators of
high and low quality nursing care from patients and their nurses.
Journal of Advanced Nursing 17, 590600.
Oktay J.S., Steinwachs D.M., Mamon J., Bone L.R. & Fahey M.
(1992) Evaluating discharge planning services for elderly people
access, complexity and outcome. Health and Social Work 17, 290
298.
Payne S., Hardey S. & Colemanan P. (2000) Interactions between
nurses during handovers in elderly care. Journal of Advanced
Nursing 32, 277285.
Proctor E.K., Howell-Morrow N. & Kaplan S.J. (1996) Implementation of discharge plans for chronically ill elders discharged
home. Health and Social Work 21, 3040.
Reed J. & Morgan D. (1999) Discharging older people from hospital
to care homes: implications for nursing. Journal of Advanced
Nursing 29, 819825.
Rintala D.H., Hanover D., Alexander J.L., Robert W., Sanson-Fisher
R.W., Willems E.P. & Halstead L.S. (1986) Team care: an analysis
of verbal behaviour during patient rounds in a rehabilitation hospital. Archives of Physical and Medical Rehabilitation 67, 18122.
Robson C. (1993) Real World Research. Blackwell Publishing,
Oxford.

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458

457

A. Atwal
Skeet M. (1975) Home from Hospital. The Results of a Survey
Conducted Among Recently Discharged Hospital Patients. Kings
Fund Centre, London.
Strauss A. & Corbin J. (1990) Basics of Qualitative Research. Sage,
Newbury Park, CA.
Victor C.R. (1996) Broken down by age and sex: an examination of
old age in the inner city. In Home Care (Guez D. ed.), Sedi, Paris,
pp. 85101.
Victor C.R., Healy J., Thomas A. & Seargeant J. (2000) Older
patients and delayed discharge from hospital. Health and Social
Care in the Community 8, 443452.

458

Waters K., Allsopp D., Davidson I. & Dennis A. (2001) A sources of

support for older people after discharge from hospital: 10 years on.
Journal of Advanced Nursing 33, 575582.
Williams E.I. & Fitton F. (1988) Factors affecting early unplanned
readmissions of elderly patients to hospital. British Medical
Journal 297, 784787.
Wilson J. (1998) Proactive risk management: documentation of
patient care. British Journal of Nursing 7, 797798.
Zwarenstein M. (2000) Whats so great about collaboration. British
Medical Journal 320, 10221023.

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 450458