Cardiology in the Young 2015; Page 1 of 8 © Cambridge University Press, 2015

doi:10.1017/S1047951115002462

Original Article

Parent education discharge instruction program for care of

children at home after cardiac surgery in Southern India
Sandra L. Staveski,1 V. P. Parveen,2 Sai B. Madathil,2 Susan Kools,3 Linda S. Franck4
1
Cincinnati Children’s Hospital Medical Center, Research in Patient Services, Heart Institute, Cincinnati, Ohio, United
States of America; 2Amrita Institute of Medical Sciences, Amrita Lane, Kochi, Kerala, India; 3University of Virginia
School of Nursing, Charlottesville, Virginia; 4University of California San Francisco School of Nursing, San Francisco,
California, United States of America

Abstract Introduction: In many developing countries, children with CHD are now receiving surgical repair or
palliation for their complex medical condition. Consequently, parents require more in-depth discharge education
programmes to enable them to recognise complications and manage their children’s care after hospital discharge.
This investigation evaluated the effectiveness of a structured nurse-led parent discharge teaching programme on
nurse, parent, and child outcomes in India. Materials and methods: A quasi-experimental investigation compared
nurse and parent home care knowledge before and at two time points after the parent education discharge
instruction program’s implementation. Child surgical-site infections and hospital costs were compared for
6 months before and after the discharge programme’s implementation. Results: Both nurses (n = 63) and parents
(n = 68) participated in this study. Records of 195 children who had undergone cardiac surgery were reviewed.
Nurses had a high-level baseline home care knowledge that increased immediately after the discharge
programme’s implementation (T1 = 24.4 ± 2.89; T2 = 27.4 ± 1.55; p < 0.005; 30 point scale), but decreased
to near baseline (T3 = 23.8 ± 3.4; ns) 4 months after the programme’s implementation. Nurse teaching
documentation increased by 56% after the programme’s implementation. Parent knowledge scores increased
from 1.76 ± 1.4 for Cohort 1 to 3.68 ± 0.852 for Cohort 2 (p < 0.005; 0–4 scale) after the discharge programme’s
implementation. Surgical-site infections decreased from 27% in Cohort 1 to 2% in Cohort 2 (p > 0.05) after the
programme’s implementation. Conclusion: Nurse, parent, and child outcomes were improved after implementa-
tion of the structured nurse-led parent discharge programme for parents in India. Structured nurse-led parent
discharge programmes may help prepare parents to provide better home care for their children after cardiac
surgery. Further investigation of causality and influencing factors is warranted.

Keywords: Parent education; cardiac surgery; discharge

Received: 17 April 2015; Accepted: 6 October 2015

N MANY DEVELOPING COUNTRIES, CHILDREN WITH care after hospital discharge. Upon discharge, parents

I CHD are now receiving surgical repair or

palliation for their complex medical condition.
Consequently, parents require more in-depth
discharge education programmes to enable them to
recognise complications and manage their children’s
Correspondence to: S. L. Staveski, Research in Patient Services, Heart Institute,
3333 Burnet Avenue, Cincinnati, OH 45229-3026, United States of America.
Tel: 513-803-7636; Fax: 513-636-9765; E-mail: Sandra.staveski@cchmc.org
are required to adhere to specific discharge instruc-
tions such as proper medication administration,
provision of sufficient nutrition to augment wound
healing, maintenance of appropriate activity limita-
tions to promote sternal ossification, and application
of infection-prevention practices at home to minimise
the risk of surgical-site infections.1
Nurses are important agents in the transition from
hospital to continued recovery at home through their
2 Cardiology in the Young
discharge teaching; however, nurses often are not
taught the fundamentals of patient/parent education
or what discharge contents are important and to be
shared with parents.2 Therefore, nurse mastery of
home care instructions and specific skills for
discharge teaching are important precursors to
effective parent discharge education. Nurses often
rely only on the physician’s written discharge
summary to guide their teaching on the day of
discharge. Although the discharge summary contains
facts of the child’s hospital stay, it is likely to be
written in technical medical jargon, and often omits
important home care instructions.3,4 Inadequate
parent education results in a suboptimal transition
from hospital to home, an increase in preventable
postoperative complications, and ultimately hospital
re-admission.5
We have previously reported preliminary findings
suggesting that a structured nurse-led parent dis-
charge education programme is feasible, acceptable,
useful, effective, and sustainable for educating
parents of children after cardiac surgery in Southern
India.6 The specific aims of this investigation were
threefold: to compare nurses’ home care knowledge
and their medical record documentation before and
after the discharge programme’s implementation, to
compare the effect of the discharge programme on
parental knowledge of home care requirements before
and after the discharge programme’s implementa-
tion, and to compare child surgical outcomes – for
example, surgical-site infections, length of stay from
cardiac procedure to discharge, and primary hospitali-
sation and re-admission costs – before and after the
structured discharge programme’s implementation.
Materials and methods
Parent education discharge instruction training materials
The parent education discharge instruction program
teaches nurses how to effectively communicate
post-discharge home care information to parents in
order to improve post-cardiac surgery outcomes for
children in resource-constrained environments. The
programme is designed to enable nurses to effectively
transfer knowledge and skills to parents, as well as
other caregivers such as grandparents, and parents to
care for their children after discharge. The parent
education discharge instruction program is made up
of a computer-based discharge education training
programme for nurses, individualised bedside teach-
ing and group teaching sessions for parents, and
standardised parent educational resources designed
for both literate and low-literacy parents. Nurses are
taught the principles of parent education – that is,
how to teach – and discharge education – that is,
2015
what to teach – via a computer-based training course.
The nurses’ training course contains information on
the following: when to seek medical care, signs of
infection and infection-prevention strategies, oral care,
fingernail care, medication administration, surgical
wound care, behavioural changes after cardiac surgery,
appropriate activity restrictions and school re-entry
after cardiac surgery, nutritional requirements after
cardiac surgery, and evidence-based discharge educa-
tion strategies – for example, teach-back approach.
Parent educational resources such as handouts and
posters are accessible in English and six Indian dialects –
Hindi, Bengali, Kannada, Malayalam, Tamil, and
Telugu. A study on the description and evaluation of
the nurse-led structured discharge programme in
Southern India has been previously published.6
Research design
A quasi-experimental design was used to compare
nurse and parent home care knowledge, nursing
documentation, and child outcomes before and after
introduction of the parent education discharge
instruction program. Research approval was obtained
from the Committee on Human Research at
University of California, San Francisco, and from the
Ethics Committee at the Amrita Institute of Medical
Sciences. The principal investigator received an
exemption for retrospective medical chart review.
Research team
The research team consisted of the principal investi-
gator, hospital nurse educator, nursing director, and
the cardiac surgery unit nurse manager and they
coordinated the implementation and evaluation of
the discharge programme. The nurse educator has a
Master’s degree and is fluent in several languages
including local Indian dialects and English. The
nurse educator performed or supervised all parent
interviews.
Setting
The investigation was carried out in a paediatric
cardiac centre serving children from urban and rural
regions in Southern India, the surrounding states,
and from other countries. Approximately 700 cardiac
surgeries are performed annually at the centre,
including newborns and children up to 19 years of
age. The cardiac surgery unit has ~45 inpatient
cardiac surgery beds in multi-bed rooms serving
low-income families.
Sample
The present study included non-random, conve-
nience samples of parents of children who underwent
cardiac surgery, nurses caring for children after
 Staveski et al: Parent education discharge instruction program
cardiac surgery, and medical records of children who
had cardiac surgery before and after implementation
of the discharge programme. All nurse and parent
patients either spoke in English or communicated
through an interpreter. Exclusion criteria were as
follows: parents of a child nearing end-of-life, and/or
children and the families of children cared for in
private rooms outside the cardiac surgery unit – that
is, high-income families.
Measures
The Nursing Mastery test and the Parent Mastery test
used in this investigation were developed for and
used in the initial parent education discharge
instruction program investigation.6 These tools have
not yet received formal reliability and validity
testing. The Nursing Mastery test is a 30-item
questionnaire to assess nurses’ knowledge of
discharge content essential for parents to know before
caring for their child after discharge.6 The Nursing
Mastery test’s questions were multiple-choice or true/
false type questions. Total scores were calculated and
based on a 0–30 point scale. Learning domains
included the following: when to seek medical care,
signs of infection and infection-prevention strategies,
oral care, fingernail care, medication administration,
surgical wound care, behavioural changes after
cardiac surgery, appropriate activity restrictions and
school re-entry after cardiac surgery, nutritional
requirements after cardiac surgery, and evidence-
based home care teaching methods.6
The Parent Mastery test is a four-item ques-
tionnaire developed by the research team to measure
parents’ knowledge of important aspects of their
child’s postoperative care at home after paediatric
cardiac surgery in India.6 Learning domains included
the following: when to seek medical care, signs of
infection, oral care, and fingernail care. Total scores
were calculated and based on a 0–4 point scale and
the proportion of individual correctly answered
questions reported.
Evidence of nurses’ documentation of parent
discharge teaching completion was reviewed each
week on nursing audit forms (Yes/No) for this
investigation during the first 4 months after the
discharge programme’s implementation. In addition,
medical records were evaluated for the presence of
parent discharge teaching in nursing notes (Yes/No)
to corroborate the nursing discharge documentation
on the study audit forms.
The medical records of children after cardiac
surgery were examined for demographic and clinical
characteristics; five dichotomous (Yes/No) items
were evaluated and they included the following:
developmental delay, presence of any genetic
3
syndrome, other major medical illnesses, presence of
pulmonary hypertension, and history of prematurity.
In addition, two continuous variables were examined:
baseline oxygen saturation and baseline haematocrit
levels. Finally, calculation of surgical risk using the
Risk Adjusted Classification for Congenital Heart
Surgery was evaluated.7 All data were corroborated
with the International Quality Improvement
Collaborative database.
Children’s medical records were examined for the
presence of surgical-site infections during hospitalisa-
tion and verified by the International Quality
Improvement Collaborative database. The managers of
the International Quality Improvement Collaborative
database perform 30-day follow-up calls to assess for
development of surgical-site infections after hospital
discharge and these data were included in the analysis.
Data collection occurred during summer and monsoon
months, because those are historically the months with
the highest rates of surgical-site infections.
In total, four variables were evaluated in child
medical records and the financial database included
the following: length of time from surgical procedure
to discharge, primary hospitalisation costs, occur-
rence of re-hospitalisation after paediatric cardiac
surgery, and re-admission costs for nursing care and
bed utilisation.
Study procedures
The principal investigator and the supporting non-
governmental organisation, Children’s HeartLink,
provided hospital leadership support for adopting the
parent education discharge instruction program as
their standard of care based on a previous pilot study at
another facility in Southern India, demonstrating its
acceptability, feasibility, utility, and sustainability.6
Before the discharge programme’s implementation,
parents in Cohort 1 (at T1) who consented to partici-
pate in the study were approached within 48 hours of
their child’s anticipated discharge to complete the
Parent Mastery test.6 Parents completed either a paper
copy of the Parent Mastery test or were interviewed by
the nurse educator, who transcribed their responses
verbatim.
After 30 Cohort 1 Parent Mastery tests were
completed, Cohort 1 nurse patients who consented to
participate in the study completed the Nurse Mastery
test at two time points before (T1) and immediately
after training (T2).6 All the nurses in the cardiac
surgery unit, except for two who were on leave, were
educated using the discharge programme. After 90%
of the nursing staff received training, members of the
project team role-modelled 10 individualised and
group teaching sessions of the parent education
discharge instruction program’s teaching in the
4 Cardiology in the Young 2015

cardiac surgery unit. Nurses then assumed respon-

sibility for providing discharge teaching to parents,
with support and coaching from the study team.
Consecutive medical records of 90 children –
unmatched with parent patients – were accrued.
Demographic information and clinical character-
istics, presence of surgical-site infections, and
number of days from cardiac surgical procedure to
discharge before implementation of the discharge
programme were collected. Data were corroborated
with the International Quality Improvement
Collaborative database and no discrepancies were
found. A convenience subset of child medical records
were accrued from a separate database and data on Figure 1.
length of stay from cardiac procedure to discharge, Study design.
primary hospitalisation costs, and re-admission costs
were collected.
The nurse manager examined nursing documenta-
examination of statistical significance was based on
tion for evidence of discharge teaching each week
meeting the assumptions for parametric or non-
between T1 and T3. The nurse educator and nurse
parametric statistics. A p-value <0.05 was considered
manager also incorporated the computer-based nurse
to be significant.
parent education discharge instruction training into
the orientation for new nurses hired for the cardiac
surgery unit. Parent
Parent patients in Cohort 2 and consecutive child
medical records (unmatched) were accrued 4 months Mann–Whitney U-tests were performed on Parent
after the discharge programme’s implementation. Mastery test scores, Cohorts 1 and 2. The Fischer
Parents in Cohort 2 completed the Parent Mastery exact test was used and the proportion of parents who
test.6 A subset of nurse patients in Cohort 1 com- correctly answered questions in the Parent Mastery
pleted the Nurse Mastery test at 4 months after the test was determined.
discharge programme’s implementation (T3). Newly
hired nurses in Cohort 2 – consisting of cardiac
surgery nurses hired after the initial study training –
Nurse
completed the Nursing Mastery test for the first time. Nursing Mastery test scores at T3 and Risk Adjusted
A second sample of 105 children’s medical records for Congenital Heart Surgery scores were determined.
(Cohort 2) was accrued. Data were verified with the Wilcoxon’s Signed Rank test was used to examine
International Quality Improvement Collaborative Cohort 1 Nurse Mastery test scores at T1 and T2. A
database. A second convenience subset of child subset of Cohort 1 with Nurse Mastery test scores
medical records was evaluated for length of stay from at T1, T2, and T3 was evaluated using the
cardiac procedure to discharge, and the financial Friedman test.
database was re-queried for primary hospitalisation
costs and re-admission costs for these children
(see Fig 1). Medical and financial records
The Amrita Institute of Medical Sciences’ infection Independent samples Student’s t-tests were performed
control department was queried for monthly surgical- on continuous variables such as days from cardiac pro-
site infection rates in the hospital’s paediatric cardiac cedure to discharge, oxygen saturation, haematocrit
surgery population, and the proportion of surgical- levels, and primary hospitalisation and re-admission
site infection rates within a 6-month time period was costs. The Fisher exact test was used to examine the
calculated for Cohorts 1 and 2. proportion of medical records with appropriate
discharge documentation in nursing notes.
Analysis
Data were entered into SPSS (IBM SPSS Statistics Surgical-site infections
Version 22.0; Armonk, New York, United States of The Fisher exact test was utilised to examine the
America). All the data were expressed as means and proportion of children with surgical-site infections in
standard deviation units for consistency; however, Cohorts 1 and 2.
 Staveski et al: Parent education discharge instruction program 5

Results

p-value

0.865

<0.001
There were 63 nurse patients in this study (Cohort
1 = 45, Cohort 2 = 18). Each cohort included 90% of
nurses working in the cardiac surgery unit at that
time point; the remaining 10% were on leave. None

23.39 (3.3)

3.68 (0.9)
of the nurses declined participation; however, there
was attrition, and this was reflected in the smaller
Cohort 1 sample size at T3 (n = 10).

3
Initial testing of mean nursing knowledge scores
(0–30 scale) between T1 and T2 showed an
improvement from 24.4 (SD = 2.89) to 27.4 (SD =
1.55) (Wilcoxon’s Signed Rank test, p < 0.005);

—
2
Table 1. Comparison between pre- and post-parent education discharge instruction program implementation, nurse and parent total knowledge scores.

Time points
however, the scores essentially returned to baseline

Cohort 2
when evaluated 4 months after the programme’s
implementation in the subset of nurses who were still

—
actively employed at the hospital. This subset had

1
mean knowledge score at T1 of 23.4 (SD = 2.41),
28.1 (SD = 1.37) at T2, and 23.8 (SD = 3.4) at T3. In
addition, there were 18 newly hired nurses, who

Parent (n = 37)
Nurse (n = 18)
received parent education discharge instruction
training as part of their orientation in Cohort 2, and
they had a mean score of 23.4 (SD = 3.33). There was
no significant difference between the Nursing Mas-
tery test scores for nurses in Cohorts 1 and 2 at T3
(p = 0.865) (see Table 1).
The proportion of documented discharge teaching
in medical records for Cohort 1 before the discharge

p-value

<0.001
0.753
programme’s implementation was 53% (23/43). This
increased to 95% in Cohort 2 (52/55, Fisher’s exact
test, p < 0.005). There were 46 discharge audits
performed by the nurse manager on a weekly basis
during the 4-month period after the discharge pro-
23.8 (3.4)

gramme’s implementation that revealed 100%

adherence with the discharge teaching documenta-
—

tion standards. These audit results were indepen-

3

dently confirmed by the principal investigator during

medical record examination and were found to have
100% adherence with documentation in nursing
notes of patient medical records.
27.4 (1.5)
28.1 (1.4)

There were 68 parent patients (Cohort 1 = 30,

—

Cohort 2 = 38); two parents declined to participate in

2

the study, and two parents in Cohort 1 later declined

Mann–Whitney U Cohort 2 nurses and parents.

to complete the Parent Mastery test. Baseline mean

Friedman’s Cohort 1 time points 1, 2, and 3.

Parent Mastery test scores were 1.76 (SD = 1.4; 0–4

Time points

Wilcoxon’s Cohort 1 time points 1 and 2.

scale) for Cohort 1 and 3.68 (SD = 0.852) for Cohort

Reported values are in mean (SD) units.
24.4 (2.9)
23.4 (2.4)
1.76 (1.4)
Cohort 1

2 after the discharge programme’s implementation

(p < 0.005). The proportion of parents correctly
1

answering individual questions improved after the

p-value significant = 0.05.

discharge programme’s implementation – Q1: 50

versus 97%, Q2: 62 versus 97%, Q3: 24 versus 84%,
Q4: 41 versus 89%; Fisher’s exact test, all p < 0.005.
Subset (n = 10)
Parent (n = 29)
Nurse (n = 45)

The medical records of 195 children in Cohorts 1

and 2 were examined for baseline characteristics and
presence of surgical-site infections (Cohort 1 = 90;
Cohort 2 = 105). There were no differences in
6 Cardiology in the Young 2015

baseline demographic and clinical characteristics
between Cohorts 1 and 2 (see Table 2). A subset of
Cohorts 1 and 2 was evaluated for length of stay from
cardiac surgical procedure to discharge and cost of
primary hospitalisation and re-admission (Cohort
1 = 61; Cohort 2 = 68).
The overall percentage of children with surgical-
site infections in Cohort 1 was 26.7%, and the
percentage of children in the post-implementation
cohort (Cohort 2) with surgical-site infections was
1.9% (p < 0.005). Further analysis was performed
comparing surgical-site infection rates for the same
months – that is, June to December – in 2011 and
2012, and there was a significant reduction in
surgical-site infections between the two matched
periods – that is, 20 surgical-site infections out of
390 procedures from June to December in 2011
versus five surgical-site infections out of 400 proce-
dures from June to December in 2012 (p = 0.002)
(see Table 3).
There was no significant difference in the length
of hospitalisation from cardiac procedure to
discharge between cohorts (Cohort 1 M = 12.3 days,
SD = 7.62; Cohort 2 M = 12.9 days, SD = 9.19;
p = 0.342) or in the cost of primary hospitalisation –
pre-implementation M = $3252 United States dol-
lars, SD = 1726; post-implementation M = $3524
United States dollars, SD = 1393, p = 0.571). There
were three re-admissions for children in Cohort 1
with a mean re-admission cost of $4420 United
States dollars (SD = 6752). There were five
re-admissions for children in Cohort 2 with a mean
re-admission cost of $600 United States dollars
(SD = 1140).
Discussion
This investigation evaluated relationships between
nurse, parent, and child outcomes before and after
implementation of the parent education discharge

Table 2. Child characteristics (n = 195)

Cohort 1 Cohort 2
Characteristics n = 90 n = 105 p-value

RACHS-1 2.46 (± 0.942) 2.51 (± 0.989) 0.714

Pre-operative Hct 39.2 (± 8.536) 41.1 (± 8.686) 0.728
Adm sat 88.5 (± 13.206) 87.19 (± 16.029) 0.196
DTDFP 12.26 (± 7.262) 12.94 (± 9.19) 0.342
Sex (male) 43 (48%) 59 (56%) 0.242
Prematurity 3 (3%) 4 (4%) 0.859
Genetic syndrome 9 (12%) 11 (12%) 0.912
Non-cardiac illness 4 (5%) 3 (3%) 0.563
PAH 24 (26%) 23 (25%) 0.439
Developmental delay 7 (8%) 4 (4%) 0.238
RACHS-1 = Complexity Score (1-6, increasing complexity) Mann-Whitney U; Pre-operative Hct = pre-operative hematocrit,
independent sample t-test; Adm Sat = admission oxygen saturation, independent sample t-test; DTDFP = days to discharge
from procedure, independent sample t-test; PAH = pulmonary arterial hypertension (and other dichotomous variables)
Mann-Whitney U

Table 3. Surgical site infection rates 2011 and 2012

2011 2012
Number of SSI per 100 Number of SSI per 100
Month cases cases SSI rate cases cases SSI rate

January 46 5 10.86 64 1 1.56

February 47 5 10.64 50 1 2.00
March 45 1 2.22 58 0 0
April 71 4 5.63 70 2 2.85
May 56 3 5.63 61 1 1.63
June 56 6 10.71 50 1 2.00
July 50 3 6.00 64 2 3.12
August 45 1 2.22 52 0 0
September 57 8 14.03 52 0 0
October 61 1 1.64 63 0 0
November 61 0 0 67 1 1.49
December 60 1 1.67 52 1 1.92
Pre-implementation data collection April 2012
Post-implementation data collection September 2012
 Staveski et al: Parent education discharge instruction program
instruction program at a hospital in Southern India.
We found that nurses had a high level of baseline
discharge knowledge and that their knowledge scores
increased immediately after participating in the
discharge programme’s instruction, returning to
baseline 4 months after programme implementation.
There was a significant and sustained increase in
nursing discharge documentation after implementa-
tion of the discharge programme with almost all
parents receiving discharge teaching 4 months after
the programme’s implementation. In addition, there
was a significant increase in parent knowledge scores
in Cohort 2. Finally, our findings indicate that chil-
dren in Cohort 2 had fewer surgical-site infections
compared with Cohort 1 and a trend in lower
re-admission costs, but no difference in length of stay
between cardiac procedure and discharge or primary
hospitalisation costs.
The parent education discharge instruction
program taught nurses discharge content and
evidence-based methods of discharge teaching.
Nursing mastery of important discharge content and
teaching methods are central to parents’ ability to
learn the discharge content;5 yet, little is known
about what constitutes nursing mastery of discharge
content or how to enhance the use of effective teach-
ing methods by nurses in developed or developing
countries. Our findings suggest that nurses in one
hospital in a developing country have reasonable
knowledge about home care for children with CHD
after cardiac surgery, and that knowledge can be
increased with instruction, but is not sustained
without further intervention. Further research is
needed to develop better strategies for sustaining the
knowledge gained in educational sessions and to
better understand the relationships between knowl-
edge and skillfully communicating that knowledge
in effective discharge teaching.
This investigation found a substantial and
sustained increase in nursing documentation of
discharge teaching to parents. Reviewing patient
records for evidence of discharge teaching and for the
robustness of the documentation provides insight
into a nurse’s clinical practice. The use of doc-
umentation audits may have enhanced acceptance of
this new care standard by nurses because the audits
served as a reminder of the practice change and were
closely monitored by their direct supervisor. This was
one of the strategies described by Wang et al8 in their
systematic review of 77 papers on the quality of
nursing documentation and interventions to enhance
documentation. At present, regulatory compliance
expectations are increasing in India, and as a
consequence there is a growing effort to enhance the
quality of nursing documentation, which may have
contributed to the increase in nursing discharge
7
documentation practices during the study period.9
Further research is warranted to better understand
the relationship between the quality of discharge
documentation and the quality of discharge teaching
performed.
This investigation found a significant improve-
ment in parent knowledge about home care after
implementation of the discharge programme. In her
systematic review, Lerret5 described parent education
as essential for parents to comprehend their child’s
home care needs, as well as to ensure their adherence
to discharge recommendations. Our study findings
suggest that the parent education discharge instruc-
tion program developed specifically for parents in
resource-constrained environments may have pro-
vided parents with improved knowledge to care for
their child at home. Further research is needed to
determine whether greater parent knowledge is
associated with fewer preventable complications in
children such as surgical-site infections.
Surgical-site infection following surgical inter-
vention for children with CHD has been cited as a
major source of morbidity, mortality, and financial
cost in a number of studies.10,11 Surgical-site infec-
tions represent a spectrum of disease ranging from
superficial infections to deep sternal wound infections
known as mediatinitis, and is a major cause of
increased length of hospital stay.10 There are no
studies documenting increased length of stay or the
costs of surgical-site infections in Indian hospitals;
however, given that <5% of Indian children have
medical insurance that covers CHD, such complica-
tions may have a significant impact on families’
financial status.12 Reducing preventable complica-
tions is a valuable contribution to the lives of children
with CHD. In addition, the negative impact of
prolonged hospitalisation or re-admission on
throughput within paediatric cardiac centers and the
ability to provide surgical interventions for children
with CHD are significant considerations.13 Our
findings suggest that surgical-site infection preven-
tion education provided to parents through the
parent education discharge instruction program could
be associated with a reduction in surgical-site infec-
tions and deserve further study in a multi-site trial.
Hurried teaching, ineffective learning, compli-
cated home care needs, and caregiver stress can lead to
hospital re-admissions.14 Although there was a small
number of re-admissions to the cardiac surgery unit,
there was a trend towards lower re-admission costs
after parent education discharge instruction program
implementation. Further research is warranted to
determine whether providing parents with surgical-
site infection prevention education influences
adherence with specific home care instruction and
reduces re-admission costs.
8 Cardiology in the Young
The findings from this study should be considered
in light of its limitations. Our study collected data
from a non-random, convenience sample from a
single site and was exploratory in nature, using a
quasi-experimental design. Contextual factors may
have influenced the results, such as a surgical-site
infection quality improvement project that was
completed 2 months before initiation of this study.
Further limitations associated with the evaluation of
re-admissions included incomplete data due to
parents seeking care at a hospital closer home or
financial considerations. In addition, nurses and
parents were reluctant to provide their socio-
demographic data. Finally, there was significant
turnover in nursing staff in the cardiac surgery unit,
which is not uncommon in resource-constrained
environments. All these factors are sources of poten-
tial bias and limit the generalisability of the study.
Nonetheless, given the paucity of literature on struc-
tured nurse-led parent discharge training programmes
in resource-constrained environments, this exploratory
study provides insight to inform future research.
Although nursing knowledge improved immedi-
ately after implementation of the parent education
discharge instruction program, nurse mastery scores
returned to their baseline high-level mastery scores
4 months after the education programme. After
implementation of the parent education discharge
instruction program, there was an increase in
re-admissions; however, these re-admissions were less
costly than re-admissions before the home care
instruction programme’s implementation. A struc-
tured nurse-led parent discharge programme in a
resource-constrained environment may have a posi-
tive influence on nurse, parent, and child outcomes.
Further investigation is warranted for examining
direct relationships and causality. A structured
nurse-led parent discharge programme may be useful
in preparing parents for home care. If shown to have
proven positive effects, this programme could be
more broadly applied to other children with complex
illnesses in resource-constrained environments.
Acknowledgements
The authors acknowledge and thank the following
individuals and organisations for their generous
support in the development of the parent education
discharge instruction materials, (in alphabetical
order): Estelle Brouwer, MPA; Children’s HeartLink;
Lizzy DeVita, illustrator and graphic designer;
Justine Kidd, RN; Jeff Paurus, RN; Pam Sagan, RN;
Shanthi Sivanandam, MD; WiRED International;
Bistra Zheleva, MBA. This work was performed
while Sandra Staveski was a doctoral candidate at the
University of California, San Francisco.
2015
Financial Support
This research received no specific grant from any
funding agency, commercial, or not-for profit sectors.
Conflicts of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to
this work comply with the ethical standards of rele-
vant international guidelines on human experi-
mentation entitled international compilation of
human research studies and with the Helsinki
Declaration of 1975, as revised in 2008, and has been
approved by the institutional committees of the
University of California, San Francisco, and Amrita
Institute of Medical Sciences.
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