PLACE IN RETURN BOX to remove this checkout from your record. To AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 c;/CIRC/DaIeDue.p65-p.15 Abstract CONTINUITY OF CARE IMPLICATIONS FOR THE FAMILY CLINICAL NURSE SPECIALIST: A NEEDS ASSESSMENT TOOL FOR THE STUDY OF THE "DISCHARGE PLANNING" PROVIDED FOR FIRST TIME ADULT SURGICAL CLIENTS IN A 92 BED COMMUNITY HOSPITAL By Janice A. Newman Discharge planning was studied through development of an instrument designed for use in a proposed exploratory study of perceived post-discharge needs of adult clients who experience surgery for the first time. Discharge plan- ning is important in providing for continuity of care before, during and after hospitalization. Because discharge planning involves time apart from.the acute care setting, there is a need for providers outside the hospital to be involved in the discharge planning process. The Post-Discharge Needs Inventory addresses physical, emotional, and social needs anticipated to exist at discharge. Six weeks later subjects are re-interviewed to determine dis- crepancies between anticipated and actual post-discharge needs and the adequacy of the preparation received for at-home care. Findings are anticipated to highlight high needs areas, time periods that are problematic, misconceptions amenable to anticipatory teaching, and other data useful to Family Clinical Nurse Specialists in planning care for surgical clients. CONTINUITY OF CARE IMPLICATIONS FOR THE FAMILY CLINICAL NURSE SPECIALIST: A NEEDS ASSESSMENT TOOL FOR THE STUDY OF THE "DISCHARGE PLANNING" PROVIDED FOR FIRST TIME ADULT SURGICAL CLIENTS IN A 92 BED COMMUNITY HOSPITAL A NON-THESIS PROJECT Submitted to the College of Nursing Michigan State University In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE By Janice A. Newman June, 1983 To Bill, Scott, and Greg who give everything I do its meaning . ii Acknowledgments This research project would have been impossible to accomplish without the encouragement, patience and support of many to whom I wish to offer my sincere thanks. First to Diane Hawkins and her assistant, Pam Noffke, who obtained numerous articles for me and helped speed the literature review process with computer searches and frequent inquiries as to how I was progressing. Everyone at Pennock Hospital offered their understanding and encouragement, but special thanks are in order for the Nursing Office Staff who kept things going and patiently perservered while I put department projects on hold until chapter revisions were finally accept- able and an end was in sight. I wish to thank Richard Fluke, Executive Director of the hospital, for granting me time and space for the project and for not giving up on me as a Director of Nursing. Patty Knox not only provided expertise as a typist, but her interest in the project and willingness to help me meet difficult dead- lines was invaluable. Sherrie Blair and Barbara Bender were also a tremendous help with typing. Rob Hymes and Dr. John Lee tried their best to help me understand the statistical tests needed for the project and gave me confidence with their positive responses to the thruSt of my endeavor. I also wish to thank my project com- mittee, Dr. Barbara Given, Patricia Peek, MS, and Louise Selanders, MS, for their assistance in guiding me through iii the research process and helping me finish on time. Special thanks to Patty Peek, who as my major professor, helped me over several hurdles throughout my graduate education. Finally, there is no way to adequately express my appreciation to my husband, Bill, whose love, patience, cooking, shopping, attention to our sons' needs, and innu- merable other supportive activities sustained me through all phases of my education. Because he believed in me, I believed in myself and anything was possible. Our sons, Scott and Greg, contributed by being happy, responsible young men who loved their mom.no matter what. Together, as a family, we grew closer than ever and met the challenge before us. iv Table of Contents LIST OF FIGURES . CHAPTER I - THE PROBLEM . Introduction . Background of the Problem Statement of the Problem . Definition of Concepts . Discharge Planning Post-Discharge Needs First Time Adult Surgical Clients . Perception~ Continuity of Care Primary Care Purpose of the Project . Importance and Significance of the Project to Clinical Nursing Practice Scope and Delimitations of the Project . Outline of Remainder of the Project CHAPTER II - REVIEW OF LITERATURE . Overview . Conceptual Framework . Review of Research Literature Surgery Studies . Discharge Planning Studies Summary Page \dii (”WNWI—‘H 10 14 15 17 19 20 20 22 23 24 24 24 30 32 36 39 Page CHAPTER III - METHODOLOGY . . . . . . . . . . . . . . . . 41 Overview . . . . . . . . . . . . . . . . . . . . . . 41 Review of Literature . . . . . . . . . . . . . . . . 41 Operational Definitions . . . . . . . . . . . . . . 50 Physical Needs . . . . . . . . . . . . . . . . 50 Emotional Needs . . . . . . . . . . . . . . . . 51 Social Needs . . . . . . . . . . . . . . . . . 52 Home Care Instructions . . . . . . . . . . . . 53 Summary . . . . . . . . . . . . . . . . . . . . 53 Procedure Followed . . . . . . . . . . . . . . . . . 54 Recommendations for Use of the Instrument . . . . . 56 Population . . . . . . . . . . . . . . . . . . 57 Subject Solicitation . . . . . . . . . . . . . 58 Data Collection . . . . . . . . . . . . . . . . 58 Human Rights Protection . . . . . . . . . . . . 59 Findings . . . . . . . . . . . . . . . . . . . . . . 6O (HAPTERIV - SUMMARY, INTERPRETATIONS, AND IMPLICATIONS FOR NURSING . . . . . . . . . . 63 Overview . . . . . . . . . . . . . . . . . . . . . . 63 Purpose . . . . . . . . . . . . . . . . . . . . 63 Method . . . . . . . . . . . . . . . . . . . . 63 Findings . . . . . . . . . . . . . . . . . . . 64 Interpretations and Discussion . . . . . . . . . . . 67 Recommendations for Further Study . . . . u . . . . 71 Implications for Nursing . . . . . . . . . . . . . . 74 Nursing Practice . . . . . . . . . . . . . . . 75 Physical Needs . . . . . . . . . . . . . . 77 vi Page Emotional Needs . . . . . . . . . . . . . 79 Social Needs . . . . . . . . . . . . . . . 80 Home Care Instructions . . . . . . . . . . 81 Nursing Education . . . . . . . . . . . . . . . 83 Nursing Research . . . . . . . . . . . . . . . 85 Summary and Conclusions . . . . . . . . . . . . . . 87 APPENDICES A. Interviewer explanation of study to prOSpective participants . . . . . . . . . . . . 88 B. Agreement to participate in Post-Discharge Needs Assessment Study . . . . . . . . . . . . . 89 C. POST-DISCHARGE NEEDS INVENTORY — Day of Discharge . . . . . . . . . . . . . . . . 90 D. POST-DISCHARGE NEEDS INVENTORY - Six Weeks Post-Discharge . . . . . . . . . . . . 101 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . 113 vii Figure 1. Figure 2. Figure 3. List of Figures A process of human interactions Types of variables in nursing situations A process of human interactions and the impact of nursing situation variables in providing discharge planning for clients viii Page 25 27 28 CHAPTER I THE PROBLEM Introduction A major role identified with professional nursing practice is that of providing continuity of care for clients. The American Nurses' Association states that all patients/ clients in an organized health care system have a right to continuity in the health care services" (1975, p. 1). Social work and medicine also recognize the significance of continu- ity of care to their disciplines (Beale & Culley, 1981; Berns, 1980; Davidson, 1978; Schreiber, 1981; Schulman & Tuzman, 1980; Schuman, Ostfeld, & Willard, 1976), and health care literature related to all three disciplines frequently addresses the importance of aiming toward the ideal of providing total, com- prehensive care for clients, in a continuous manner, through an interdisciplinary, collaborative effort. Many factors dictate the need for health care providers to concern themselves with continuity of care. Difficult economic times, the continuing escalation of health care costs, and an increasing scarcity of health care resources force all involved in health care delivery to carefully evaluate how resources are being utilized. Increasing specialization leading to fragmentation of services can leave the client confused and in need of someone to coordinate his/her move- ment through the system. These needs are particularly evident when clients are admitted to and then discharged from acute care settings. 2 Thus, in studying the concept of continuity of care, one finds that it is frequently linked with, and often defined in terms of, discharge planning from one phase of health care service to another. Focusing on discharge planning can be useful in determining specific client needs and in developing strate- gies to meet such needs as clients episodically require vari- ous services within the health care system. Ultimately, such an assessment of needs may lead to improved continuity of care for clients and a better understanding of what continuity of care can,and should,realistically mean. A research project aimed at the development of a needs assessment tool for a specific population of clients who are to be discharged from an acute care setting can be valuable in providing greater understanding of discharge planning by placing it in a meaningful context. First time adult surgical clients typically are discharged from the hospital to conva- lesce at home. Discharge planning literature does not address needs these specific clients may experience after discharge. A needs assessment tool designed to elicit data useful in determining the role of discharge planning in meeting the needs of first time adult surgical clients, can help provide implications for practice for Family Clinical Nurse Specialists who have similar clients in their caseloads. In Chapter I background information is presented to acquaint the reader with why this project was chosen and with what the writer hopes to accomplish. Concept definitions are provided and research questions are posed. The role of 3 discharge planning in providing for continuity of care and the implications for Family Clinical Nurse Specialists are discussed in Chapter IV, based on understandings gained through this specific study of discharge planning. Background of the Problem Interest in discharge planning is far from.new and has recently intensified. Phillips (1972) notes references to problems with planning for discharge from hospitals since the early 1900's. Lurie, Pinsky and Tuzman (1981) traced the history of social work and noted that the original impetus to introduce social work into hospitals was to link medical and environmental resources and to assume responsibility for arranging and altering the environment of clients upon dis- charge. Johnson and Pachano (1981) and others refer to the impetus for discharge planning that Medicare/Medicaid legis- lation, utilization review, cost containment, and other resources utilization issues mandate. Journals of nursing, social work, and medicine have addressed discharge planning from a wide variety of perspectives. The most common themes focus on cost containment, appropriate utilization of hospital beds, decreasing lengthof stay, utilization of community resources, placing clientsin appro- priate facilities, coordinating home care efforts, providing client teaching, and determining who should do discharge planning and how it can best be implemented (Barham, 1974; Dake, 1981; Krell, 1977; LaMontagne & McKeehan, 1975; Ryan & Wassenberg, 1980). There are references relative to the needs z, of specific populations such as those of cardiac, pediatric or emergency room clients (Chapman & Harvey, 1976; Devney, 1980; Mandell, 1980). Other sources are concerned with preventing infection or readmission (Pfaff & Terry, 1980). Checklists and care plan forms are suggested to assist in the implement- ation of discharge planning (Glover, 1981; Mezzanotte, 1980). Also, clients have written about their personal experiences after discharge and their need for a better understanding of what to anticipate at home (MacMillan, 1980; Mead, 1981). Studies done in the area of discharge planning have focused on what types of discharge planning programs are being utilized (Reichelt & Newcomb, 1980), what impact early social work services have on length of stay (Boone, Coulton & Keller, 1981), and who is teaching clients prior to discharge and how well (Johnson & Pachano, 1981). There are also several references that emphasize a team approach to discharge planning (Beale & Culley, 1981; Edwards, 1978; McCarthey, 1976; Smith, Buckalew & Rosales, 1979). There is much debate in the literature as to who is responsible for discharge planning and what the process should entail. Although definitions of discharge planning tend to be similar, the way in which the definition is interpreted varies. The emphasis sometimes changes from a service meant for all clients to one of screening for those who need it, specifically, the elderly, chronically ill, and those requir- ing extended care placement or extensive community agenCy assistance (Beale & Culley, 1981; Berns, 1980; Cunningham, 1981). 5 Some writers focus on how discharge planning is or should be done (David, Hanser, Madden & Pratt, 1973; Johnson & Pachano, 1981; McKeehan, 1979; Reichelt & Newcomb, 1980; Steffel & Ride, 1978), or on why a certain discipline is best suited to coordinate discharge planning activities (Lurie, Pinsky & Tuzman, 1981; Schreiber, 1981). As Director of Nursing Services in a 92 bed community hospital, the writer has been able to observe a discharge planning program in a specific setting. Patient questionnaires utilized for quality assurance feedback by the hospital, indicate that clients perceive a need for more home care instructions. A needs assessment tool can help determine specific needs not being met by the hospital's discharge planning program and can provide insight as to how discharge planning can better be provided for clients discharged from this hospital. To help determine a specific population to study, the hospital setting, hospital statistics, and literature relative to discharge planning were reviewed. The hospital is located in a service area that includes essentially one county of approximately 625 square miles in rural south central Michigan. Its topography is characterized by scenic rolling farmlands, forest clusters, and numerous lakes. The community is surrounded by three metropolitan areas. The p0pu1ation of the county is 45,780. The county has experienced a steady growth in population over the last 30 years. The population has also been becoming increasingly older. Another 6 characteristic of the county population is that it is 98.92 white (Michigan Hospital Association Service Corporation, 1982). The average income for the county residents has risen steadily and ranks approximately 44th among 83 counties in the state. The county is dependent on neighboring counties for employment. Major employers in this county are of a manufac- turing nature, with the third ranking employer in the county being the hospital with 430 employees (Michigan Hospital Association Service Corporation, 1982). The hospital offers a variety of services including adult medical-surgical services, pediatric medical-surgical services, obstetrics, and a 24 hour a day emergency room. The medical staff numbers 35, with orthOpedics, urology, and obstetrics specialists on board. The hospital follows national patterns in terms of falling birth rates. It has also experienced drops in perinatal death rates and mortality rates (Michigan Hospital Association Service Corporation, 1982). As part of its emphasis on community service,_the hospital has a formalized discharge planning program. Discharge planning is initiated by the admitting nurse as part of the client's initial assessment and care plan. The social worker technician screens hospital census at the house supervisor's report in the morning to determine which clients might need extra assistance at discharge. Emphasis is placed on eXtended care. facility placements, home care referrals, at-home equipment needs, and clients without a family or friend support system. The client education nurse confers with the social worker technician to review clients needing extensive teaching, especially diabetics and ostomy clients. Other discharge planning needs are left to the unit nurses. Surgical clients are rarely seen by either the social worker technician or the client education nurse at the hospital. The most frequent non sex-related surgeries performed at this hospital on adult clients in 1981 were unilateral inguinal hernia repair, total cholecystectomy, and appendectomy. Standards of care and literature relative to clients having these surgeries, are primarily concerned with in-hospital needs of these clients (Luckmann & Sorensen, 1980; Neal, 1980; Phipps, Long & Woods, 1979; Tucker, Breeding, Canobbio, Paquette, Wells & Willmann, 1980). Also a review of literature relative to primary care reveals no studies specifically related to post- discharge needs of surgical clients. Therefore, clients experiencing one of the abdominal surgeries mentioned above would be helpful to study to determine if needs exist for this population that are not addressed in the literature or by the hospital's discharge planning program. Statement of the Problem Based on a review of pertinent literature and on the personal observations of the discharge planning process at the acute care setting cited above, the writer believes the concept of discharge planning needs to be put into a context that can elicit a practical understanding of what discharge planning should provide for clients. A needs assessment tool has been developed that can be utilized to answer the following questions: 1. What post—discharge needs do adult clients experienc- ing one of three abdominal surgeries (hernia repair, cholecystectomy or appendectomy) for the first time perceive are not met by the discharge planning provided to them in the setting? 2. How can these needs be determined so that future care planning can meet perceived needs? In Chapter IV interpretations relative to these questions are presented that help determine what continuity of care impli- cations these needs present for Family Clinical Nurse Specialists. These questions are useful in providing a direction that can be taken in gaining greater understanding of how to meaningfully implement broad concepts frequently referred to by health care providers. The definition of concepts to follow will begin to develop such an understanding by refining meanings as much as possible. Definition of Concepts Discharge Planning Discharge planning is an activity necessitated by move- ment from one phase of health care to another, especially admission to and then discharge from an acute care facility. It is, according to this writer, the systematicprocess provided for all clients admitted to an acute care facilityJ aimed at preparing the client for the next phase of care and ‘providingCOntinuityof care for the client before,'during, and after hospitalization. Discharge planning has been described as "a necessary element of the treatment plan for every patient admitted to a hospital" (Schreiber, 1981, p. 49). The success of treat- ment in the hospital ultimately depends on whether the client follows through with treatment or preventive measures once discharged from the hospital. Clients must understand the treatment plan and continue to take medication, follow their diet, and engage in the prescribed activity progression once at home. If a client is incapable of following through, then a responsible party must do it for him/her. Berns (1980) sheds light on the need for discharge planning for all clients by describing the post-hospital adjustment needs that are encountered by clients. These include decreased physical and mental well being, changes in family responsibilities, a different life style, employment problems, and financial difficulties as a result of illness or injury. Discharge frequently occurs when a client is only partially independent. Shulman and Tuzman (1980) define discharge planning as a systematic, organized, and centralized approach to provide continuity of care from.the time a client is admitted to a health care facility through return to the community. The American Nurses Association (1975) describes discharge planning as the part of the continuity of care process which is designed to prepare the client for the next phase of care and to assist in making any necessary arrangements for that care whether it 10 be self care, by a family member, or care by an organized health care provider. Coulton calls discharge planning a decision making process, "a process of assessing a patient's post-hospital care needs and arranging a suitable post-hospital environment. Comprehensive discharge planning considers not only physical and nursing care needs but also the patient's cognitive capacity, interpersonal relationships, emotional condition, family composition, and so forth" (1981, p. 6). Sullivan enlarges on this theme by saying, "Discharge planning is a part of an over-all program of continuity of client care and includes the family in planning, a communica- tion network before, during and after hospitalization, and an over-all monitoring system that includes the development of criteria for quality assurance and program evaluation" (1981, p. 19). It is this writer's belief that all hospital- ized patients have post-discharge needs, and nursing needs a mechanism to determine these needs so that provisions to meet them can be devised. Post Discharge Needs This project will focus on the at-home needs of adult clients experiencing surgery for the first time. The surgical procedures to be included will be appendectomy, cholecystec- tomy or unilateral inguinal hernia repair performed under general anesthesia. A definition of surgery provides a foundation for developing the meaning of the term post-discharge needs- Dorland defines surgery as "that branch of medicine which ll treats diseases, injuries and deformities by manual or operative methods" (1974, p. 1504). Beyond what surgery is in itself, it is important to consider what it means to the client. Luckmann and Sorensen (1980) describe surgery as a personal crisis for a client because any operation involves risk, expense, discomfort, emotional stress, and disruption in his usual life style. Medical textbooks allude to this aspect by discussing the importance of a "genuine bond of communication and personal responsibility" being established between the surgeon and the patient (Sabiston, 1981, p. 116). The patient must have confidence in the surgeon and in the value of what is about to happen to him, Such confidence can be developed by allowing him to participate in judgements affecting risks he will be taking, life style adjustments he may need to make, and decisions needed for his post-operative recovery. An important aspect of promoting a positive convalescence is the need to begin preparation of the client preoperatively, and for efforts to be continuous until the client's maximum physical, emotional, social and vocational capacity is attained (Hardy, 1977). The attainment of such a goal can involve the efforts of a cohesive interdisciplinary team including nurses, physicians, therapists, social workers and vocational counselors. Post-discharge needs identified in nursing standards of care references include normal incision healing, avoidance of post-surgery complications, ability to carry out activities 12 of daily living at optimal level of functioning, understand- ing of at-home plan of care (diet, activity, medication, and any other treatment instructions) and knowledge of when and where to be seen for follow-up. Also, the client should know how to obtain needed professional or community resources (Neal, 1980; Phipps, Long & Woods, 1979). Specific guidelines as to what instructions the client should be given are difficult to find in the literature. When asked how surgeons determine post-operative instruc- tions, a prominent surgeon at the hospital under study responded, "through experience and intially from one's mentor" (J. G. DenHartog, M.D., personal communication, February 7, 1983). Although six to eight weeks is generally agreed upon by surgeons as the amount of time required before normal activity can be resumed, this time period is not documented in literature. This time frame is consistent with wound healing principles, but the connection must be inferred, as it is not stated (Sabiston, 1981). No major nursing or medical references provide samples of suggested regimens for these clients beyond the general guide lines referenced above. The writer will define post-discharge needs in three broad categories; physical, emotional and social. Physical needs will focus on promotion of wound healing, pain manage- ment, adequate nutrition, appropriate activity progression, adequate rest, and prevention and reporting of complications. Emotional needs revolve around the client's temporary assumption of the sick role. According to Kasl and Cobb (1966), 13 sick role behavior involves activities undertaken by one who considers himself ill for the purpose of getting well. These activities involve receiving treatment, dependent behavior and some neglect of usual tasks. The Parsonian Model is useful for surgical clients in that surgery represents a temporary disability. The two rights and the two duties of the model are therefore applicable (Segall, 1976, p. 162). These dimensions of the sick role as outlined by Segall are: l. exemption from responsibilities related to his incapacity 2. exemption from normal social role obligations 3. obligation to work toward getting well 4. obligation to seek appropriate help to get well. Adoption of the sick role or failure to adopt it will influ- ence the emotional status of the client as well as that of his/her significant other(s) (Miller and Janosik, 1980). The client will also experience a "need to know" (Mishel, 1981; Theliacozzo & Ima, 1970). He/she will need to know what to expect, what should or should not be attempted during convalescence and why, when a health care provider should be called, what should be observed,and when a normal life style can be resumed. There is the need to know if there will be permanent life style changes necessitated by the surgery. What can be done to promote comfort and rapid ‘progress? When can sexual activity be resumed? (Robusto, 1980). Such questions are raised because the surgery is a 14 new experience for the client and many lay perspectives are available to the client that can cause confusion and concern. Other needs of post-operative surgical clients are social and vocational. The client may have expectations as to how those around him should behave regarding his/her surgery and may have concerns over loss of social contacts. Being off from work is a change that may have financial and social implications for the post-discharge client (LeMaitre & Finnegan, 1975; Miller & Janosik, 1980). Although such changes are temporary, the client may feel frustrated and concerned over any possible long term repercussions. First Time Adult Surgical Clients The population to be studied is that of male and female clients who are experiencing one of the three previously mentioned surgeries (hernia repair, cholecystectomy, or appendectomy) for the first time in their adult lifetime. Adult is defined by age, that is, between the ages of twenty 'and fifty-five years. Several stages of development will occur between twenty and fifty-five (Gould, 1978; Pesznecker, 1975; Sheehy, 1976; Stevenson, 1977), but for purposes of studying post-discharge needs after surgery, the general characteristics of adulthood will be considered sufficient. Anderson and Carter (1978) explore the meaning of adulthood and conclude that it is marked by a need to be productive and caring. Critical tasks include entering into reciprocal relationships with others, sexually, occupationally, and socially, and becoming involved in nurturance and concern 15 for others. During adulthood, a person needs to perpetuate his/her ego identity while sharing a sense of identity with others. Individuals function within family systems and accomplish both individual and family developmental tasks throughout their life span (Duvall, 1977; Miller & Janosik, 1980; Smilkstein, 1980). Adult development and learning theory and family theory must be considered when developing a method to evaluate discharge planning provided for adult clients. The Family Clinical Nurse Specialist program at Michigan State University has provided the writer with relevant theory that has been utilized in the development of the needs assessment questions. It is acknowledged that the population being considered for study will include variables that could affect the find- ings obtained, eg. education level, occupation, socio- economic status, religion, and others. Certain variables will be controlled buy many will not. Since the project involves a preliminary needs assessment tool designed for an exploratory study, precise control of the population should not be a critical factor. Subjects selected should be able to speak English so that they can adequately respond to the survey to be developed. Subjects also should not have a known chronic illness and should reside in the hospital service area . Perception The concept of perception is central to assisting clients to engage in self care (Levin, 1978). Although it is beyond 16 the scope of this project to examine the concept of self care, it is important to briefly address the fact that when a client is discharged from the hospital following a surgical procedure, the assumption is generally made that he/she will engage in such self care behavior as adherence to home care instructions pro— vided, setting personal recuperative goals, and deciding when further contact with his/her health care provider is necessary (Becker, et al., 1972). In order to behave in this manner, the client must perceive that such activities will benefit him/her and will be worth the cost, the basic tenant of the Health Belief Model (Becker, 1974). Perception for this project will be interpreted according to King's definition". . .a process of organizing, interpret- ing, and transforming information from.sense data and memory. It is a process a human transactions with environment. It gives meaning to one's experience, represents one's image of reality, it influences one's behavior" (King, 1981, p. 24). Perception is subjective, but it is also influenced by interaction with others and by feedback received (Hood, 1974). Perception is a complex concept; not an isolated independent system, but rather one that interacts with a host of other psychological systems. The perceiver actively selects information, forms hypotheses, and occasionally distorts input in order to reduce surprise or attain valued objects. Perception is an act of Categorization and, therefore, is a high mental process (Anglin, 1973). Since one's perception is related to past experiences, self concept, biological factors, educational background, and probably to socio-economic status, perception of a given event is apt to 17 vary from one person to another (King, 1981). Yet there are similarities in life experiences that make it possible to draw conclusions about universal experiences that occur for broad categories of peOple such as theories relative to the stages of adult development (Sheehy, 1976). Thus in compiling a certain population's perceptions of certain events, one can look at similarities that can be helpful in planning care and making educated predictions, while at the same time, the need for individualized approaches to clients becomes reiterated as differences in perception are noted in the data. Knowledge of perception points to the need to verify how the client views What is occuring so that appropriate planning can take place. Continuity of Care For purposes of this project continuity of care will be defined as the comprehensive support offered to clients by multiple individuals and agencies in the health care system that assures clients that attention will be paid to their total well-being, in sickness and in health; and clients will experience both coordinated movement through the health care system throughout their lifetime and a sense of stability rggarding their health care. This definition is the writer's synthesis of material reviewed on the subject and intention- ally defines the concept in its broadest sense. Henderson's well known definition of nursing supports the concept of continuity of care in that the nurse is viewed as one offering assistance to individuals, sick or well, in activities contributing to health and helping individuals be 18 as independent as possible (Henderson, 1966, p. 15). Noble states, "Patients must be supported throughout sickness and health, and the quality of life must be included among the goals of care" (1976, P. 341). Noble also discusses the fact that aspects of client care that will support the client's identity and provide meaningful stimulation and security are essential, and all providers of the client's care must adopt a uniform commitment to them. Providers responsible for care plans must utilize local resources and agencies in such a way that the effectiveness of their own services is maximized, and must also participate actively in the development and recruit- ment of additional health care resources which are required to meet client needs. Ambrose (1973) discusses continuity of care at length and is concerned that although nursing service departments in hospitals have a care plan, a client education person or department, and referrals for home care does not mean they are, in fact, providing for continuity of care. She believes that hospitals are not preparing discharged clients adequately for continuity of'care. Client teaching is a sadly neglected area in Ambrose's view. Ambrose's main concern is with the follow through of what is initiated on paper, but is not always actually carried out (1973). Pratt (1976) identifies short-comings in the provision of medical care and suggests that the family can, and should, assume responsibility for its own health care, utilizing health care professionals as needed within the family's own personal health 19 care system. This perspective dictates that health care providers supply families with information that will enable them to support their own health as much as possible, and to know how and when to utilize provider expertise as necessary. Nursing emphasizes such a perspective and provides teaching and support for clients as part of the nursing role (Brown, 1971; George, 1980; Henderson, 1969; Orem, 1980). Primary Care The Family Clinical Nurse Specialist provides services to clients within a primary care setting. Literature relative to primary care tends to view the center for the responsibility for coordination of continuity as lying within the primary care system. Primary care at its best provides an entry, screening,and referral point for the rest of the health care systemy and it can serve as a focalypoint for coordinating and monitoring the various health services that a patient may require by referring him to specialists in hospitals and following through on his later recuperative care (Andreapoulos, 1974). Andreapoulos sees primary health care as effectively dealing with an individual's problems in terms of his history, his family, his social, occupational background and the totality of his health care needs. Primary care givers, thus, are in the best position to systematically coordinate a variety of specialized care and needs. In its manpower policy for primary health care statement, the Academy of Science in 1978 defined five attributes essential to the practice of good primary care. One of these was continuity 20 of services. Continuity, as discussed in this policy statement, included not only responsibility for referrals and coordination of services, but also, responsibility for seeking continuity through such means as follow-up reminders to clients, as well as maintenance of an accurate client medical record so that continuity can be assured (report of the Institute of Medicine, 1978). Alpert and Charney (1974) identify the essential element in primary care as that of longitudinal responsibility for clients regardless of presence of absence of disease. Their emphasis on outreach and follow-up, as well as patient-centered definition of needs, point to the need for continuity in the primary care health system. Purpose of the Project The purpose of this project is to define the concept of discharge planning through the development of a needs assess- ment tool that can be utilized to collect data useful to Family Clinical Nurse Specialists in providing continuous care to their clients. From work on the project, recommenda- tions for further study can be formulated. Importance and Significance of the Project to Clinical Nursinngractice In reviewing literature relative to the practice of primary care, few references are available relative to surgical clients. The emphasis is on management of the chronically ill, acute clinical episodes of a non-emergent, non-surgical nature, health maintenance and promotion, and disease prevention. As noted earlier, surgical literature addresses the pre-operative 21 and immediate post-operative needs of these clients, but not their home-care needs. Thus this project provides a method to collect concrete data that will be helpful in planning post-hospital care for the clients selected for study. It also provides a tool to determine what nurses can do to promote continuity of care through adequate discharge planning for these clients and, in particular, enables highlighting of needs that are not, and perhaps cannot, be met by nurses in acute care settings. Thus information useful to Family Clinical Nurse Specialists who have surgical candidates in their practice settings can be obtained. This project provides a model for similar studies that can be utilized with different populations to provide further data that can help validate the unique role the Family Clinical Nurse Specialist (FCNS) holds in health care delivery, especially as related to planning care for clients admitted to, then discharged from,an acute care setting. The caring role is central to nursing practice (Lenarz, 1971; Mitchell, 1977; Repickey, 1980; Watson, 1979). Because of the nature of primary care and the focus of nursing, that is, helping individuals maximize their health so they can function in their roles (King, 1981, p. 3), the FCNS is in an excellent position to positively contribute to the discharge planning provided for surgical clients. The nature and sc0pe of nursing practice is based on a holistic approach to Man and eumhasizes wellness, promoting client and family abilities to Czope with illness, and supporting and enhancing the client's 22 own strengths and assets (School of Nursing Graduate Program Faculty, 1977). The FCNS role emphasizes such an approach, and as the FCNS utilizes a holistic framework in meeting the needs of the clients under study, the role the FCNS can play in discharge planning as a means of promoting continuity of care can be exemplified. Scope and Delimitations of the Project A needs assessment tool has been developed that can be utilized to obtain data relative to perceived post-discharge needs of first time adult appendectomy, cholecystectomy, and unilateral herniorrhaphy clients discharged from.an acute care setting. Actual data has not been collected, but a re: search design has been formulated that provides necessary preliminaries to client solicitation for study. As previously discussed, developing a tool to assess post-discharge needs of the specific population outlined is useful to the clarification of the concept of discharge plan— ning because this population's at-home needs are less obvious than those of the chronically ill, and elderly, more frequently studied. Data relative to this population's needs will thus contribute to a clearer understanding of the broad interpreta- tion of the concept under study. The project will not provide actual data, and thus is preliminary to further study. The instrument is designed for an exploratory study aimed at discovering potential unmet needs of clients. Data obtained can be used to formulate research questions and hypotheses for further study. Since the 23 population described is a specific one, it is not generalizable, and if the tool were to be used in a different setting, revi- sions would be necessary. No cause-effect relationship can be implied from this project, but groundwork will be provided for interpretations, and implications can be drawn from the inform- ation gathered in studying discharge planning and developing the needs assessment instrument. Outline of Remainder of the Project In Chapter II, literature pertinent to this project is reviewed and a conceptual framework based on King's theory of nursing is presented. An outline of the methods used in developing the needs assessment instrument is presented in Chapter III. Also, guidelines for testing instrument validity and reliability, recommendations as to how it should be used, a method for presentation of findings, and recommendations for statistical analysis are provided. Findings will be anticipa- tory only. Finally, interpretations, recommendations for further study, and implications for nursing practice are discussed in Chapter IV, especially in terms of the role discharge planning can play in providing continuity of care for clients served by Family Clinical Nurse Specialists. 24 CHAPTER II REVIEW OF LITERATURE Overview The available literature on the concept of discharge planning is primarily descriptive or didactic in nature. The writer has been able to determine from the volume of material available, an overall understanding of the state of the art, but research studies to document the process and outcome of discharge planning programs meant to provide continuity of care for hospitalized surgical clients are limited. After presentation of the conceptual framework for the project, the writer will acquaint the reader with specific information about research literature related to the concept under study. Studies relative to the methodology utilized in developing the post-discharge needs assessment instrument will be dis- cussed in Chapter III. Conceptual Framework It is the writer's intent to broaden nursing's understand- ing of the concept of discharge planning through a needs assess- ment tool developed for a specific population. King's theory of nursing is helpful in developing a model to demonstrate the relationship between perception, insult of surgery and the discharge planning process. King's (1981) view of nursing is that of a process of actions, reactions, interaction, and transactions, the ultimate goal of which is helping individ- uals maintain health so they can function in their roles. King's 25 theory provides a way to understand human beings (clients and nurses) as individuals interacting with each other within a variety of environments, roles, past experiences, and concrete situations. In order for the nurse to assist a client to be able to function in his/her role, the nurse and the client muSt match perceptions as to what is needed, so that together they can set and achieve goals for the client. King believes all behavior is a form of communication and each person involved in an interaction responds to the input from the other. Figure 1 demonstrates how transactions occur in nursing situations, according to King. ---------------- Feedback--------------- I Perception W / JUdgment I Action \ . , / Client Action a Perception 1- --------------- Feedback --------------- Nurse Reaction-9Interaction-’Transaction . * Figure 1. A Process of Human Interactions. *Adapted from King, I. A theory for nursing, New York, John Wiley & Sons, 1981, p. 61 26 In the development of her theory, King (1971) established types of variables that are useful in examining the relation- ships to be studied in this project. These variables are depicted in Figure 2. It is beyond the scope of this project to examine these variables in depth, but they must be acknowledged in order to determine their involvement in the concept of discharge planning. Figure 3 and the discussion following,utilize King's nursing situation variables and the process of human interaction in depicting the role of percep- tion and interaction in providing discharge planning for the adult clients targeted for study in this project. In order for the nurse and the client to set and achieve mutual goals aimed at helping the client maintain health, the impact of the nursing situation variables on nurse and client perceptions must be recognized. In the case of first time surgical clients, discharge planning can follow the impact of surgery and can ultimately lead to continuity of care for the client, over time. This becomes possible when nurse and client share their perceptions of the impact of the variables, thus interacting and making transaction possible (see Figure 3). King's view of health is an important component of her theory relative to this project (1981, p. 8). According to King, human beings have three fundamental health needs: 1. Usable health information at a time when they require it and are able to use it (underlining emphasis, the writer's). 2. Preventive care. 3. Care when they cannot help themselves. Nurse Variables Perception Goals Values Needs Expectations Education and Experience Factors Knowledge and skills Past achievement Present performance FUture goals Situational Variables Social Institutions Structure Goals Groups Functions Physical resources Economic resources Climate Figure 2. Types Client Variables Perception Goals Values Needs Expectations Abilities Changes in Health Status 27 Nurse Behaviors Communication Interpersonal relationships Application of knowledge Promotion of health Care given in illness Client Behaviors Knowledge about health maintenance Adjustment to health problem Performance of activities of daily living of variables in nursing situations. Communication Interpersonal relationships Application of knowledge Compliance with information and instructions provided * *Adapted from King, I. Toward a theory for nursing, New York, John Wiley & Sons, 1971, p. 45. 28 Situational Variables V Nurse I --------------- Feedback ----------------- Variables Perception Client I Reaction-9Interaction->Transaction U I l I I l l Behaviors ’////;,Judgment : I . Nurse Action : | l l I I l | l l I Client Action Discharge I Planning Client Judgment Variables Q '1‘ I Perception 1 Nurse 'I : Behaviors --------------- Feedback ................. A Situation Variables Changes in Health Status Figure 3. A process of human interactions and the impact of nursing situation variables in providing discharge planning for clients.* *Adapted from.King, I. A theory for nursing, New York, John Wiley & Sons, 1981, p. 61 29 King's definition of health, "dynamic life experiences by a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living" (1981, p. 5),a11udes to the need for nurses to be cognizant of the various impacts on clients and how to assist clients to utilize their own strengths in making appropriate adjustments. As discussed earlier in defining perception, many factors influence how an individual will organize and interpret information and utilize it affecting behavior. What has occur- red in a person's life to date, what he or she believes in and is striving for, what is important and worthwhile to the person, the extent and content of his or her understanding and knowledge will influence how the individual perceives a new life event. Both the nurse and client come to the nursing situation with their own personal backgrounds, roles, resources and skills. In the situation they share their perceptions with each other and together attempt to deal with the immedi- ate situational variable of the client's surgery. Discharge planning, as defined earlier, can occur only if perceptions are shared and matched so that realistic goals can be set for the client's self care at home. If discharge planning occurs, the stage is set for continuity of care because the client will feel secure in knowing he/she will have a resource person to contact when questions arise, that he/she knows how and when to contact the resource established, 30 and that he/she possesses some initial knowledge of what to expect and how to cope at home. The needs assessment tool developed in this project can help determine how, when, and by whom discharge planning should be accomplished to best assure continuity of care for the post- surgical clients targeted by this project. It is the writer's belief that the acute care staff cannot fully provide for one of King's fundamental health needs, that is the provision of timely information. It is also difficult for the in- hospital staff to adequately provide the interaction that King's theory suggests is necessary for transaction and ultimately for adequate discharge planning to occur. In studying this population's perceptions of at-home needs and how they were, or were not, met by the hospital discharge planning program, an aspect of King's theory will be tested, and the FCNS will have information useful to planning care for these clients. Review of Research Literature A literature review relative to the concept of continuity of care produced references primarily concerned with discharge planning. Research studies on discharge planning tend to focus on early identification of clients who need discharge planning, impact of discharge planning on length of stay, how discharge planning is organized, effectiveness of discharge planning programs, and home care programs aimed at shortening length of stay (Boone, Coulton & Keller, 1981; Dawson & Stern, 1973; Carson & Collins, 1976; Inui et al., 1981; Johnson & Pachano, 31 1981; Lindenberg & Coulton, 1980; Prescott et al., 1979; Reichelt & Newcomb, 1980; Schuman et al., 1976; Smith, 1977). As noted earlier, much of the literature on discharge planning focuses on elderly clients, need for use of extended care facilities or community resources, and the role of various health professionals, including acute care staff nurses, public health nurses, social workers, and physicians in the discharge planning process. In reviewing literature on the three surgeries involved in this project, the writer found studies relative to pain management (Johnson & Rice, 1974; Welkg 1982), self regulatory processing and recovery (Wood & Pesut, 1981), effects of information on emotional response (Hartfield, Cason & Cason, 1981; Johnson, Fuller, Endress & Rice, 1978; Ziemer, 1983), and specific surgical management issues such as nutritional support, use of drains with cholecystectomy and use of iodine to prevent wound infection (deJong, Vierhout & vanVroonhoven, 1982; Kirkpatrick, Dahn, Hynes & Williams, 1981; Trowbridge, 1982). Several non-research nursing care articles were available on surgical dressings, advice regarding sexual activity after surgery, nutritional management, and compli- cations prevention (Cooper & Schumann, 1979; Ennis & Andrassy, 1980; Pfaff & Terry, 1980; Robusto, 1980). Medical-surgical nursing texts and nursing standards of care address post-discharge concerns in a general way (Neal, 1980; Phipps et al., 1979). Home care studies assessing clinical outcomes for clients sent home earlier than usual 32 (Gerson & Collins, 1976; Prescott, Ruckley, Garraway & Cuthbertson, 1979) look at home care from the perspective of early post-operative responses of clients sent home versus those of patients kept in the hospital. A search of liter- ature in the area of primary care such as, Continuing Education for the Family Physician, Nurse Practitioner, Journal of Family Practice, and Primary Care failed to produce references relative to the surgeries under investigation. Although no research studies are available that directly deal with at-home needs of appendectomy, cholecystectomy, or hernia clients, several studies address aspects of this problem and are useful to review. Also, some research studies relative to the discharge planning process are related to this project and are important to consider. Surgery Studies Gerson and Collins (1976) studied the clinical function of surgical clients receiving part of their post-operative care at home instead of remaining in the hospital for the traditional length of stay. Clinical function was measured in terms of discomfort, infection, delay in healing, and operative compli- cations. The p0pu1ation consisted of 583 clients undergoing one of five surgeries; varicose vein stripping, herniorrhaphy, cfrolecystectomy, anal and rectal surgery, or abdominal 'hysterectomy. Clients were randomly assigned to a home care, exPerimental group, or a control, normal length of stay group, over a period of 13 months. No apparent differences in rates 0f untoward events were found between the two groups, but 33 there were problems with execution of the study which limit its validity. Half the clients assigned to the home care group did not actually receive home care referral, thus creating a control group that was twice as large as the experimental group. The authors conclude that, if the results prove replicable, early discharge could be considered for clients based on psychosocial function, client desire, economic reasons, and effective utilization of hospital beds, since clinical functions will be the same whether the clients are kept in the hospital or sent home for post-operative recovery. In the presentation of the above findings, other items of value to this project were found. First, clients reported symptoms at a much higher rate than the physicians examining clients noted. Second, herniorrhaphy clients had the fewest untoward events. Third, the home care group utilized a nurse coordinator "to arrange all home care services and monitor continuity of care" (Gerson & Collins, 1976, p. 520). Fourth, the most frequent untoward events reported were pain, tiredness, and, by the cholecystectomy clients, low spirits. Prescott, Ruckley, Garraway and Cuthbertson (1979) conducted a similar study in Scotland using 60 clients under- going varicose vein and hernia surgery and found no major differences in functional outcome between groups randomly assigned to those receiving after care in the hospital, in a convalescent hospital, or at home. An interesting finding in this study was the significantly higher percentage of clients who slept well at home versus those in either hospital setting. 34 Use of pain medication did not vary significantly between groups, and client and provider's satisfaction with care was similar in all situations. Cultural differences need to be considered in evaluating this study in terms of application to American clients. Wells (1982) and Johnson and Rice (1974) studied pain. Wells' research concerned the effect of relaxation training on post-operative abdominal pain. She concluded that there was less psychological distress for the experimental group of clients than the control group clients all of whom had cholecystectomies, but no significant difference physiologically. The small sample size of six clients in each group used makes further study of this relationship necessary. In the Johnson study, a carefully controlled laboratory study utilizing 52 male subjects 18-25 years old, the findings suggest that clients who receive a partial description of a sensation they may experience will have as much reduction of stress as those receiving a complete description of the sen- sation. The pain sensation was produced by inflating a blood pressure cuff on the subjects' arms for five minutes. An attempt to duplicate findings using clinical situations as opposed to experimental would be useful in applying the find- ings to post-surgical clients. A study of 58 cholecystectomy and 57 herniorrhaphy clients by Johnson, Fuller, Endress and Rice (1978) was designed to replicate their previous findings that preoperative information significantly reduces length of post-operative hospitalization 35 and also the time after discharge before clients ventured from home. The new study contains some changes in methodology, but these were well documented by the researchers, and the effects on the findings were acknowledged. The p0pulation was carefully screened and randomly assigned to five experi- mental groups, each having a different combination of inform— ation-giving methods employed. Each surgery was tested separately. Complete data was available on the cholecystec- tomy sample, but not on the herniorrhaphy sample. The find- ings did replicate the original study and suggest that inform- ation-giving bolsters coping strategies that the client uses both in the hospital and after discharge. The researchers note that studying recovery from surgery is complicated by many intervening factors and, firm conclusions, even after replication, would be premature. However, the findings of the study are helpful in supporting the writer's assumption that timely information-giving is an important variable in post-operative recovery. Studies done on the effects of pre-operative procedure information on post-operative procedure coping report mixed findings (Hartfield et al., 1981; Ziemer, 1983) and serve a limited purpose for this project. However, Silva's (1979) study on the effects of orientation information on spouses' anxieties and attitudes toward hospitalization and surgery, could have relevance for how post-discharge information will affect anxieties and attitudes towards the at-home recovery period. The study used the Solomon four group design involving 36 random assignment of 32 male and 16 female subjects to one of four groups: a pre-tested experimental group, a pre- tested control group, an unpre—tested experimental group, and an unpretested control group in a 338 bed hospital setting. This design facilitated control over the effects of pre- testing and reduced threats to internal and external validity. Anxiety was measured by The State Anxiety Inventory and attitude towards hospitalization and surgery, and by Silva's Spouse Perception Scale, adapted from Palmer's (1963) Patient's Perception Scale. Analysis of variance, analysis of co—variance, and chi square tests were used to analyze the data. Silva thoroughly discusses inconsistencies in her findings, and her recommendations for further study include suggestions as to how the factors involved could be controlled. Silva's conclusion that structured nursing intervention may positively alter spouse response to surgery, suggests the need to further test this premise, and the study itself emphasizes the need to include families in information-giving, along with clients. Discharge Planning Studies Schuman, Ostfeld and Willard (1976) found that discharge planning from an acute care facility could be improved by assigning individual nurses the responsibility for detecting client needs and formulating care plans for both in-hospital and after-hospital care. The study utilized criteria based measures of adequacy of discharge plans, adequacy of client knowledge, and client satisfaction. The study compared clients discharged pre and post a new discharge planning 37 program instituted on one medical teaching ward in a large metropolitan hospital. The study took place over a three month time period,and few variables were controlled. All clients being discharged from the one ward were included. Sixty clients were interviewed on the day of discharge before the new program was instituted and 60 after it was in place. Chart reviews were also utilized. The sample was primarily from the lower socio-economic levels, and clients were hospitalized with chronic diseases. Despite limitations in methodology, the study raises pertinent issues for nursing's involvement in discharge planning through client responses that indicate a need for matching of the client's environment to his/her capabilities upon discharge. Johnson and Pachano (1981) studied client teaching prior to discharge by surveying 37 nurses and 82 former clients in a 220 bed acute care community hospital over a period of one year. The study had several limitations, especially in terms of the client population, which included all clients except newborns and those that signed out against medical advice. Findings must, therefore, be regarded cautiously, but provide rudimentary evidence that perhaps there is great discrepancy between what clients believe they know and what nurses believe clients know. The findings also indicate that clients believe physicians are their primary source of information while nurses see themselves, dietitions, or themselves, with physicians, as the primary source. Another study that focuses on the importance of understanding 38 needs from the client's point of view, was one dealing with admission needs assessment. Porter, Moschel, Liederman and Pope (1977) randomly selected 20 adult medical-surgical clients that were hospitalized on a non-emergency basis. None had been hospitalized within three years prior to the study. A 44 item questionnaire was administered within a 24 hour period of admission to each subject either in the admitting office or in their hospital room. Questions were concerned with information a person might want to know upon admission. Items involved client roles, rights and obligations of clients, physical environment issues, care giver items, and rules and routines issues. The findings indicated a high priority given by clients to rules and routines, followed by physical sur— roundings, then care giver items and, lastly, client role concerns. The study was limited in design, and offers only crude information that must be studied further. No attempt was made to compare the data with what the nurses felt was important for clients to know, but it was implied that nurse perceptions may vary from client perceptions, and thus, assessing client view of needs, assists nursing to better know what information should be provided to clients. As stated earlier,other research studies on discharge planning have been done, but there are few empirical studies, their relevance to the post-discharge needs of adult surgical clients is limited, and their contribution to understanding continuity of care has already been discussed. Studies have indicated that effective discharge planning can reduce length 39 of hospital stay and that clients discharged from hospitals have been found to have needs that are recognized in the hos— pital but are not met at home (Boone, Coulton & Keller, 1981; Lindenberg & Coulton, 1980). The writer believes further exploration of post-discharge needs will assist Family Clinical Nurse Specialists in planning improved approaches to care, especially in terms of providing continuity. Summary A conceptual framework based on King's theory of nursing was presented. If nurses and clients match perceptions in nursing situations through action, reaction and interaction, transaction, or mutual goal setting, can ultimately take place. In the case of clients who are experiencing a first time surgery, such a transaction can be considered discharge planning. Family Clinical Nurse Specialists can utilize information gained from studying the discharge planning process and the perceived at—home needs of surgical clients in improving the care they provide for these clients. Following the conceptual framework, a review of research studies relevant to appendectomy, cholecystectomy and herniorrhaphy clients' post-discharge needs and also to the concept of discharge planning was presented. No studies were found that directly deal with at-home needs of the clients under study, but research relative to clinical function post- operatively, pain,and the effects of information-giving were helpful in providing background information useful in develop- ing the needs assessment tool to be presented in Chapter III. 40 Research on the discharge planning process is limited, and this project will thus help expand nursing's understanding of the concept, discharge planning, and how to best provide it for clients. 41 CHAPTER III METHODOLOGY Overview The purpose of this project is to provide greater under- standing of the concept of discharge planning through synthesis of material found in professional literature and, empirically, through a needs assessment tool developed for a specific popula- tion. Data obtained from the tool develoPed could be useful to Family Clinical Nurse Specialists in providing continuity of care in their practices for the types of clients chosen for the study. Further discussions of the implications for nursing can be found in Chapter IV. The concepts under study and a review of related literature have previously been presented. In this chapter the needs assessment tool that has been developed (Post-Discharge Needs Inventory) is described and a proposed method for its use is offered. Recommendations for data analysis are suggested, and the writer's expectations as to possible findings are presented. Review of Literature Several instruments aimed at assessing client perception of needs are available in the literature. Such instruments were useful to the writer in the development of the Post-Discharge Needs Inventory (PDNI) found in Appendix C. However, the post-discharge needs as defined in Chapter I were not completely addressed by any one instrument reviewed. Thus, the PDNI represents an original instrument that is based on synthesis 42 of material found in other studies conducted for related, but different, purposes than that of this project. Bruhn and Trevino (1979) sought to develop a method for determining client's perceptions of their health needs. The Health Needs Assessment Questionnaire developed by Bruhn and Trevino uses Becker's Health Belief Model as a conceptual frame- work and focuses on four categories of health needs based on literature review, discussions with laymen and health care professionals, and their own personal experiences as clients. The four categories are: 1. Identification and verification; need to know if sick or not. 2. Knowledge; need to know what can be done to get well and implications of illness. 3. Treatment; need to know if illness can be treated. 4. Support; need to talk to someone who understands. Bruhn and Trevino utilized previous research in developing their instrument but did not develop a research design to test their own instrument. Therefore, no validity and reliability data is available, and the instrument needs further testing before it can be confidently utilized in future research. The instrument is intended to assist health care practitioners in developing the client/practitioner relationship with new clients. Mandell (1980) conducted a crude post-discharge follow-up study aimed at determining post-discharge problems experienced at home by pediatric clients. For six months, follow-up tele- phone calls were made between 48 hours and one week after children 43 were discharged from the hospital to determine: 1. b4») 5. The child's progress at home. Parent's understanding of child's illness. Special care being given to child at home. Questions parents had regarding medications, activity, treatments, diet, operative site (if applicable), diagnostic test results, different symptoms experienced at home. Any other concerns parents wished to discuss. The pOpulation was not controlled, and the findings must be regarded cautiously. However, the following findings provided an indication of post-discharge concerns that could potentially exist for adult surgical clients: 1. Families had questions related to changes that had occurred in the client since discharge. Families expressed concern about new circumstances that had arisen in the home situation that had not been anticipated, such as the child feeling better and wanting to be more active than discharge instructions recommended. There were concerns that no one seemed to be coordinat- ing the care of the whole child; each provider was interested in some aspects of care but not others, and the lack of a coordinator left families unsure of whom they should call when they had general questions about their child's care at home. An exploratory study by Wood and Pesut (1981) was designed 44 to determine what self-regulatory mental processes clients use during recovery from surgery. A small sample (26 subjects) and broad population criteria (any surgical intervention, age 22-72, male and female clients) were utilized. The researchers acknowledge that future studies will require refinements in methodology. The data was collected through a one-time, open- ended taped interview using the question, "As you think about your recovery experience, are you aware of things you have done to help yourself feel better or get better?” (Wood and Pesut, 1981, p. 264). Despite its limitations, the study is of value for this project because it utilized holistic principles and is based on self-care literature and the psychophsyiologic relation- ship described by Selye (1976), Pelletier (1977) and others. Wood and Pesut found that clients engaged in self-initiated physical activities, such as walking, doing as much for them— selves as possible, and repositioning themselves to decrease discomfort; external distraction activities, like television, reading, and puzzles; internal distraction activities such as fantasizing, daydreaming, and visual imagery, especially regard- ing the future; and self-initiated interactions with staff, visitors, other clients and using the telephone as a means to foster their own recovery process. Clients also compared them- selves to other clients as a means to encourage themselves regarding their progress. The role of uncertainty in producing stress in hospital- ized clients was studied by Mishel (1981). A carefully construct- ed scale, the Mishel Uncertainty in Illness Scale (MUIS), was 45 developed and validated through three replicative studies. The scale tapped uncertainty related to: Symptomatology Diagnosis Treatment Relationship with care givers LI'IJ-‘UJNI—I Planning for the future. A significant correlation was found between uncertainty and stress, and Mishel's scale appears to be a useful tool in assessing factors that can affect recovery. In this project the MUIS is helpful in developing questions related to the client's emotional needs since a need to know was identified in Chapter I as an assumed post-discharge need of the clients to be studied. Bergner and Bobbitt (1981) present the final revision of the Sickness Impact Profile (SIP), a behaviorally based measure of health status. After six years of study, the SIP was found to be highly reliable for subjects in varying age, sex, and educational groupings and at different levels of sickness and dysfunction (test-retest reliability of 0.92 and internal consistency of 0.94). The SIP measures the impact of sickness through subjects' degree of difficulty with 12 categories of daily living activities: 1. Sleep and rest 2. Eating 3. Work 4. Home management 46 Recreation and pastimes Ambulation Mobility . Body care and movement \oooxroxua Social interaction 10. Alertness behavior 11. Emotional behavior 12. Communication. Several of these areas were defined in Chapter I as potential post-discharge needs of surgical clients, particularly social interaction, sleep, diet, performing usual work, home management, and emotional reactions. As a well documented measure, the SIP is useful in formulating questions for the study of post— discharge needs of surgical clients, but some of the categories of the SIP are intended for a population of clients with chronic illness, eg. communication, mobility, and alertness behavior. Three scales available in Volume I of Instruments for measuring nursing practice and other health care variables (Ward and Lindeman, 1979) were useful in examining methods to determine post-Operative needs. The limitation of all these scales for this project is the emphasis on the early, in-hospital pre and post operative phase of the surgical experience. The three scales reviewed include: 1. Patient Recovery Inventory (PRI) - Wolfer, Eisler, and Diers 2. Patient's Perception Scale (PPS) - Palmer 3. Post-Operative Convalescence Questionnaire (PCQ) - Elms. 47 The PRI (Eisler, Wolfer & Diers, 1972) was designed to elicit a client's own evaluation of his/her physical condition while recovering from elective surgery in the hospital. It is a 15 item self-reporting 6 point scale (very poor, poor, fair, good, very good, excellent). It is completed by the client for a series of days, and individual ratings are summed for a total score for each day. The items rate specific physical functions such as appetite and strength, and one item is related to the psychosocial sphere regarding whether or not anything upsetting has happened either in or out of the hospital. Pearson correla- tions were computed between the total score derived from the instrument and the Social Desirability Score (SDS) and with nurses' ratings for each day clients were in the hospital. Correlations between the PRI and the SDS were -0.06 to -0.32 and with the nurses' ratings, 0.67 to 0.69, based on the responses of 50 clients. Reliability and validity of the instrument has not been established, and the instrument is aimed at early post-operative responses only. The PPS (Palmer, 1963) measures adult client's perceptions related to impending surgery. It is a 46 item self-reporting scale using a Likert type rating system. The items are grouped into 13 categories: 1. Confidence in ability of the family to maintain itself Faith in God Competence of care-givers Body integrity U'I-DUJN Acceptance of need for surgery 48 Financial security Understanding and support of others Dependence - independence \DCDNO‘ Post-operative living patterns 10. Expectations about surgery 11. Self-awareness 12. Anesthesia 13. Painful procedures. Responses are scored by assignment of points to the agree- disagree continuum and is interpreted as favorable perceptions toward surgery (high score) versus unfavorable perceptions toward surgery (low score). The instrument was not based on any specific theory. Several sources of information were used to solicit items, and the final instrument was tested using a population of 50 hospitalized adult clients scheduled for general surgery. Using the Kuder-Richardson method, a reliability coefficient of 0.884 was obtained, and using the Spearman-Brown formula, 0.939. Content validity was tested using a panel of three judges considered experts in medical surgical nursing, psychiatric nursing, and nursing research. The PPS is useful for adaptation from impending surgery perceptions to post-surgical perceptions to a limited degree because several of the 13 areas apply after discharge as well, such as body integrity, financial security, understanding and support of others, self-awareness, dependence/ independence, and post—Operative living patterns. The reliability of the PPS cannot be generalized to such adaptation due to the change from a pre-surgery to a post-surgery perspective, however, 49 and the PPS questions survey attitude toward surgery more than needs associated with surgery. The PCQ elicits information in four areas following surgery: Physical complaints Physical independence Social interaction and diversional activity bWNI—I Emotional response. These areas are all addressed in the writer's definition of post-discharge needs, but the focus of the PCQ is on in-hospital perception. The survey contains 46 items that describe possible experiences the surgical client could have in the hospital. The subject answers according to forced choice responses, and the PCQ is designed to be administered by an interviewer. Approximate- ly 15 to 20 hours are suggested to train interviewers in the use of the tool. Testing of the survey was done in one study using 60 clients with a wide variety of surgical procedures. Reliability and validity are not clearly established. The PCQ was useful to the writer as a reference, but questions were not considered for adaptation. In summary, several previously developed instruments have been found that study aspects of perceived needs expressed by various client pOpulations. Although none specifically address perceived needs of first time adult appendectomy, cholecystec- tomy or herniorrhaphy clients, each instrument reviewed contri- buted in part to the development of the PDNI, which is designed to ascertain perceived needs of this specific population. The operational definitions to follow will include references to 50 the various instruments utilized in formulating the questions in the Post—Discharge Needs Inventory. Operational Definitions As outlined in Chapter I, the PDNI has been developed to elicit data relative to perceived physical, emotional, and social needs of adults experiencing,for the first time, one of three abdominal surgeries. These needs will be measured at two time periods following the client's surgery; at discharge and after six weeks at home. The client's perception of his/her prepara- tion for at—home care will also be assessed by the PDNI. Physical Needs Physical needs normally experienced after abdominal surgery include pain management, wound healing problems and concerns such as how the incision looks and how to promote healing, potential difficulty with recommended diet, activity and/or rest, potential difficulty with understanding home care instructions, and potential difficulty knowing what and to whom to report signs of complications (Gerson & Collins, 1976; Neal, 1980; Phipps, Long 8 Woods, 1979). Questions 11-31 of the PDNI .(see Appendix C) are designed to determine client needs in these areas. The Sickness Impact Profile (Bergner & Bobbitt, 1981), which measures the degree of difficulty with activities of daily living using behavioral criteria, provided the rationale for inclusion of questions relating to difficulties post-surgical clients might encounter with specific activities at home. 51 Adaptations of parts of the SIP can be found in questions 19-25. Wood and Pesut's (1981) use of an open-ended question aimed at determining how clients utilize self-regulatory mental processes during recovery from surgery influenced the construc- tion of question 15. A review of the Patient Recovery Inventory, the Patient Perception Scale, and the Post-Operative Convalescence Questionnaire provided reference relative to the general needs anticipated to exist for clients undergoing surgery. Although these scales are concerned with the early, in-hospital aspect of the surgical experience rather than the post-discharge phase, several identified needs carry over into the after-hospitaliza- tion time period and have been included in the tool, eg. pain management, wound healing concerns, diet, and activity. Emotional Needs Several sources were utilized in developing questions in the emotional sphere, and for this project, emotional needs will include expectations and feelings the client will experience related to his/her temporary assumption of the sick role, concern over lack of knowledge or understanding related to the surgery and/or the temporary changes it has created, and the need for support from others during convalescence (Kasl & Cobb, 1966; Mishel, 1981: Segall, 1976). Bruhn and Trevino's (1979) Health Needs Assessment Question- naire was developed to provide a broad perspective of clients' perceptions of their own health needs. This perspective is reflected in the variety of emotional concerns addressed by questions 32-46 of the PDNI. 52 The specific concerns relate to the four dimensions of the sick role outlined in Chapter I (see page 13) as reflected in questions 32-39, and to the role of uncertainty in producing stress as studied by Mishel (1981). Questions 40-46 deal with the client's perception of a concern over needing to know about various aspects of the recovery period that are related to Mishel's five categories of uncertainty identified earlier; a need to know what to expect (symptomatology), what should or should not be attempted and why (diagnosis, treatment), when a health care provider should be called (relationship with care givers), and what lifestyle changes might be necessary because of surgery (planning for the future). Social Needs Social needs for this project are defined in terms of the client's expectations of how those around him/her should behave regarding his/her surgery, potential temporary social withdrawal, potential loss of social contacts and/or missing out on social events, potential financial stress, and potential role strain related to being unable to perform normal activities for a period of time (LeMaitre & Finnegan, 1975; Miller & Janosik, 1980). The Sickness Impact Profile (Bergner & Bobbitt, 1981) was utilized in formulating questions 47-59. Items were also gener- ated for this section by review of the Patient Perception Scale (Palmer, 1963) and Bruhn and Trevino's (1979) Health Needs Assessment Questionnaire, which reinforced including items adapted from the SIP. 53 Home Care Instructions Questions 60-68 of the PDNI are concerned with how the client perceives the home care instructions given to him/her before discharge from the hospital. Questions deal with who provided instructions, what was provided and when, and how instructions were given. Mandell's (1980) follow-up study of pediatric clients identified client concerns relative to the need for one person to coordinate care so that questions can be directed comfortably. Questions 66-68 can help determine the client's perception of who such a care coordinator should be and how that person can help meet post-discharge needs. The questions in this section are also designed to elicit information relative to the assumption that timely information giving is important to the post-discharge recovery of surgical clients (Johnson et al., 1978; Silva, 1979). The readminis- tration of the instrument in six weeks is aimed at obtaining data that can be used to formulate hypotheses for further study relative to the best times to provide clients with information helpful to them during convalescence. 'Summary Operational definitions of the four sections of the PDNI were provided. It must be emphasized that this project is intended as an exploratory study only. It is designed to gather information relative to a needs area found to be lack- ing specific attention in the literature. For this reason, the definitions represent a synthesis of a variety of perspec- tives related to, but not specifically designed for, the study 54 of post-discharge needs of surgical clients. These definitions provide a framework for surveying surgical clients in terms of needs that can be anticipated to exist for them based on avail- able literature. However, a broad perspective is taken to allow for discovery of unanticipated needs as well, and there is no intent to provide conclusions about these clients needs; only information about such needs that can be useful in providing direction for further research and nursing practice. Procedure Followed The Post-Discharge Needs Inventory was developed by the writer using the operational definitions previously outlined. Demographic areas were then selected to screen for significant differences related to potential intervening variables. Ques- tions 1-10 of the instrument address these variables. The instrument was given to the hospital social worker technician, six registered nurses working at the hospital, and six staff physicians for comment and further suggestions. ‘Minor revisions were made, and the revised version was submitted to two statisticians for further recommendations regarding the construction of the instrument, sample size, categorizing and analyzing data, and presentation of data. The PDNI is to be administered by trained interviewers who can help subjects interpret questions and can probe for meaningful responses (see interviewer instructions, Appendix C). Inter-rater reliability will need to be tested using correlation to determine the degree of consistency between interviewers. High correlations (above 0.80) will indicate acceptable 55 consistency. A panel, such as that used to initially respond to and revise the instrument, should categorize items after the interviewers have done so to provide another test of reliabil- ity through testing for correlation between rater and non-rater interpretations of subjects' responses. If inter-rater correlations are below 0.80, interviewers will be questioned by the researcher to help determine possible discrepancies in the method of administration of the instrument and/or questions the interviewer has about the procedure. The researcher will also reinterview a sample of the subjects interviewed by each rater and compare her own data with that originally obtained. Assistants can be given necessary clari- fication instructions and/or further training, or can be replaced if a personal bias or problem is found to exist. The instrument itself will also be re-examined to see if the problem can be traced to wording of questions or instructions. If correlations remain low after retraining and modifications, the researcher will need to utilize less assistants or do all interviewing herself and extend the time of the study. At the six week post-discharge interview, the instrument to be readministered will have wording changes that will reflect a hindsight perspective of the questions being asked (see Appendix D). It is acknowledged that expectation questions become actuality questions and represent measurement of a different entity. For the prupose of this project, however, it is useful to determine the potential discrepancies between expectations and actual occurrences in order to make anticipatory 56 teaching more meaningful, and to obtain as much information about post-discharge needs of surgical clients as possible. Recommendations for Use of the Instrument The instrument should be pretested by administering it to 10 to 20 subjects within the setting who are similar to those who will be participating in the study. Such a pretest can help determine the clarity, research adequacy, and freedom from bias of the instrument before it is used in the study. Suggest- ions elicited by the reactions and responses to the pretest can be incorporated into the instrument, and a second pretest run if extensive revisions are found to be needed (Polit & Hungler, 1978). The panel of professionals who initially reviewed the instrument could be utilized to judge if the responses to the questions address the intended concerns (content validity), and if language difficulties or response biases are evident. Appro- priate revisions can be suggested by the panel and incorporated into the instrument before it is used in the actual study. For purposes of the pretest, the instrument need only be adminis- tered at discharge. Reliability can be tested from the study data using Cronbach's coefficient alpha (Crano and Brewer, 1973). Items in each section will be tested for correlation with other items within the section. Items which do not correlate at 0.80 or greater will be deleted from analysis or analyzed separately. Permission to use the instrument in a research project in the setting selected should be obtained from the hospital's governing board or Human Subjects Protection Committee. The 57 researcher will then need to select and train two assistants to help administer the survey. Two half-day sessions should be allowed for training, with additional time provided if the interviewers cannot demonstrate comfort and competence with the procedure. The assistants will need to be available throughout the time frame of the study because the same inter- viewer is to administer the instrument at six weeks post- discharge as at discharge. Population The subjects for the study are to be hospitalized adult clients who experience one of three abdominal surgeries; appendectomy, cholecystectomy, or herniorrhaphy. The surgery is to be a first surgical experience for the client. Clients are to be between the ages of 20 and 55 and can be either male or female. Participants must be able to speak English, have no history of psychiatric or chronic illness, and reside in the hospital service area. The surgery is to be performed under general anesthesia, and major complications such as peritonitis, pneumonia, or an extended hospital stay due to wound infection following surgery will disqualify a partici- pant from the study. The sample will include all clients meeting the above criteria who are hospitalized in the setting described in Chapter I over a one-year period. Based on hospital statistics, it should be possible to obtain a sample of 150 to 200 subjects in suCh a time frame. A sample of this size should assist in providing enough data to determine meaningful categories of 58 needs. The effects of extraneous variables, such as demographic variables, can also be lessened by providing for as large a sample as possible. Subject Solicitation The social worker technician receives a daily report on all new admissions. She will be instructed to screen for clients meeting the above criteria and to notify the researcher that a potential participant has been admitted. The researcher, or one of her trained assistants, will then arrange to contact the client to explain the study and solicit agreement to partici- pate (see explanation of study form, Appendix A and agreement to participate form, Appendix B). Data Collection A list of participants will be kept in the house supervi- sor's office so that the researcher, or assistants, can be notified when a participant is to be discharged. The interview- er will verbally administer the PDNI to the participant in a 'quiet, private location on the day of discharge and will arrange, with the client, a home visit in six weeks time. During the home visit, the interviewer will readminister the PDNI (with appropriate changes to make the questions retrospective) and note any observable problems in the home setting. The visit is to be kept short, and advice giving is to be avoided. If problems are noted or the client asks questions relative to his/her care, such problems or questions will be referred to an apprOpriate provider, eg. the client's 59 family care provider, the client's surgeon, or if necessary, to an emergency care facility. The researcher will have briefed house staff in advance of the study so that such referrals will be handled expeditiously and feedback will be available from the provider to whom the client is referred. Interviewers will record questions asked, problems observed, and feedback from referrals on the PDNI form under the inter- viewer's comments section. This data will be summarized by the research team and utilized in the interpretation of data. Outliers and data discrepancies might be explained by variables found in the comments. Needs not addressed by the instrument itself might also surface in the questions asked by subjects or the problems noted. Human Rights Protection Subject participation in the study is to be strictly vol- untary,and potential participants will be informed of this fact when they are contacted about the study. Subjects will have the purpose of the study fully explained to them.and will be told that they have the right to withdraw from.the study if they wish without their care being affected in any way. Parti- cipants will also be told that there will be no direct benefit for them from participation in the study, but results of the study upon its completion will be available to them, if they desire. Subjects will sign an agreement form indicating they voluntarily have agreed to participate and understand what is required of them. To facilitate record keeping and to personal- ize contacts with participants, the client's name and date of 60 discharge will be recorded on the form, but will be discarded once the second interview has taken place in order to preserve confidentiality of responses. Findings Since this is an exploratory study, findings will be informational rather than demonstrating any cause-effect rela- tionships, and analysis of findings will focus on determining high needs areas, unanticipated needs, and possible relation- ships between needs and situational or demographic variables, using the scores obtained for the various needs sections. Open-ended questions will be analyzed separately. Responses to open-ended questions will be examined to determine possible categories and also for unanticipated needs. Frequency tables ‘will then be used to determine high needs categories. Questions were constructed to allow for sum scoring as much as possible, but open-ended questions were included to allow respondents latitude to express needs freely and to provide for the possibility of discovering potential needs not recognized in current literature. As an exploratory instrument, the PDNI is designed to provide a means to uncover data rather than to utilize date to support Specific pre-determined hypothesized relationships. The researcher and assistants will categorize data as it is obtained and will group similar responses to open-ended questions to obtain a workable number of categories that can be arranged in frequency table form. All refusals to partici- pate in the study will be documented and the number of refusals 61 reported in the summary of findings. Also, subjects who with- draw from the study prior to the six week interview will be reported. Descriptive statistics will be used to describe the sample. Scaled questions in each section will be summed so that each participant receives a physical needs, an emotional needs and a social needs score. High scores will indicate high need in that Sphere. These scores can then be tested for correlation with type of surgery and with the two time periods the instrument was administered (at discharge and six weeks after discharge) using the Pearson Product Moment correlation with ordinal level data and chi square with categorical data. The Pearson Product Moment correlation is used when both variables are expressed as continuous scores (Crano & Brewer, 1973). Such correlations could be calculated between physical needs scores, for example, at discharge and physical needs scores at six weeks after discharge. Analysis of variance could be used to determine correlation between type of surgery (three categories) and the three needs areas (physical, emotional, social). Demographics statistics can be correlated with the physical, emotional, and social needs scores using Pearson Product Moment with continuous scores, such as age, and chi square with categorical data, such as sex or occupation, to observe for relationships between certain demographics and high needs areas. Any relationships noted could be used as hypotheses in future studies that could specify a more stringent study design. For example, older age groups might demonstrate higher physical 62 needs scores and lower social needs scores than younger age groups. The home care instructions questions will be reported separately. There will not be a score for this section that can be statistically correlated with the other section needs scores, but the data will be categorized and visually examined for high frequency responses that can be useful in hypothesiz- ing the usefulness of various approaches to home care instruction. For example, if participants with high needs tend to state that they were given only verbal instructions and.thomewith low needs, written instructions, an experimental study could be designed to test the relationship of type of instructions given to post-discharge needs found. Significant differences and high percentage responses will be noted in the summary of findings as well as any irregulari- ties in the data collection process. Implications for practice will be based on inferences that can be drawn from the quantity and types of needs found. It is anticipated that the partici- pants will have unanswered questions when they leave the hospital and will experience even more questions at a signifi- cant point of time during the recovery period. The Family Clinical Nurse Specialist will find this data useful in plan- ‘ ning strategies of care for post-surgical clients. In Chapter IV, interpretations of findings and implications for practice will be explored further. 63 CHAPTER IV SUMMARY, INTERPRETATIONS, AND IMPLICATIONS FOR NURSING Overview In this chapter a brief review of the purpose, method, and findings of the project is presented. Interpretations and recom- mendations for further study are offered. Finally,implications for nursing research, education, and practice are discussed. Purpose The purpose of this project was to expand understanding of the concept of discharge planning through the development of a needs assessment tool designed to determine post-discharge needs perceived by first time adult appendectomy, cholecystectomy, or herniorrhaphy clients discharged from a community hospital. The instrument developed can be utilized to elicit data useful in determining areas needing further study, and also, in plan- ning care for surgical clients. In gaining improved understand- ing of discharge planning, nurses will be better able to provide for continuity of care for clients. "Method The Post-Discharge Needs Inventory (PDNI) was developed by the writer based on several needs assessment instruments available in professional literature and a review of literature relative to discharge planning and the surgeries involved in the Study. Three categories of needs are addressed by the survey; physical needs, emotional needs and social needs. A fourth 64 section of the survey is concerned with home care instructions received by the client, and the client's perception of the ade- quacy of instructions provided. The instrument was reviewed by a social worker technician, and nurses and physicians in the hospital under study. Two statisticians were consulted for further refinements. It was recommended that the instrument be pretested using a small sample in the setting under study. A review panel and appropriate statistical tests were suggested. The population is to consist of male and female clients between the ages of 20 to 55, hospitalized for one of the three surgeries outlined earlier. Subjects should not have experienced surgery before. Findings Intended as an exploratory study, the project can be util- ized as a means to gather information useful in determining needs areas for the clients under Study and possible relationships between needs and other variables. Inferences can be drawn from the quantity and types of needs found. The reviewers of the instrument did not test it with clients directly, but based on their personal experiences with surgical clients in the past and/or their own surgical episodes, expressed anticipation that clients would have unanswered questions at the time of discharge and during convalescence at home. Such questions would concern the client's rate of recovery, whether or not specific activities should be undertaken, wound healing time, who to call with "trivial" questions, clients' unexpected reactions and/or annoyance with others at home, frustration 65 over not knowing about aspects of their convalescence, possible pressures from.normal work accumulating, and not feeling pre- pared at discharge time for their care at home. Both the re- viewers and the writer believe data will indicate that 1) a discrepancy will exist between what clients anticipate their convalescence needs will be and what they actually experienced in six weeks time, and 2) there will be a certain time period that proves to be particularly discouraging for clients during convalescence. Gerson and Collins' (1976) findings that early discharge frOm the hospital did not lead to increased untoward events in terms of discomfort, infection, delay of healing or operative compli- cations, points to the possibility that length of stay could possibly be safely decreased from a clinical standpoint. However, in their study, a nurse coordinator arranged all home care services and monitored continuity of care, indicating the prob- able need for such a care provider in order for hospital stay to be shortened safely. Also, Gerson and Collins found the most frequent needs to be pain, fatigue and, with cholecystectomy clients, low spirits, indicating needs areas that might score high using the PDNI. The study of cholecystectomy and herniorrhaphy clients' responses to pre-operative information by Johnson, Fuller, Endress and Rice (1978), indicated that pre-operative information signi- ficantly reduced length of hospital stay and decreased length of time after discharge before clients ventured from.home.‘ It can be anticipated, based on this study, that clients will express 66 a desire to receive information prior to surgery and again prior to discharge, and will indicate the usefulness of information they were given when they are interviewed after six weeks at home. Silva's (1979) conclusion from her study of the effects of orientation information on spouses' anxieties and attitudes toward hospitalization and surgery, (that structured nursing intervention may positively alter spouse response to surgery), suggests that clients responding to the PDNI may indicate a need for orientation information, not only for themselves, but also for their families. From Schuman, Ostfeld and Willard's study (1976) of a discharge planning program in an acute care facility, the inference can be made that in the present study, it will be found that the discharge planning program at the hospital under study is less than adequate in terms of the presence of un- answered questions and a feeling of not being prepared for discharge on the part of the sample to be surveyed. Since discharge planning improved, as measured by criteria based measures of adequacy of discharge plans, adequacy of client knowledge, and client satisfaction, when individual nurses were assigned responsibility for detecting client needs, hypotheses can be formulated relative to the role of the Family Clinical Nurse Specialist in discharge planning. Other findings that might be anticipated based on the literature include 1) clients may express that they believe physicians are their primary source of information (Johnson and Pachano, 1981), and 2) a higher priority might be placed 67 on physical needs than emotional or social (Porter et al., 1977). Interpretations and Discussion In studying discharge planning, it was found that the literature emphasizes client placement and utilization of community resources and client teaching for clients with identified high needs levels, such as the elderly and chron- ically ill. This emphasis is understandable, but is not con- sistent with the American Nurses' Association's statement that fill clients have a right to continuity of care in an organized health care system (American Nurses' Association, 1975). Surgical clients are typically discharged to convalesce at home after a brief hospital stay, and literature relative to these clients' post-discharge needs is limited. It was there- fore determined that it would be helpful to study the perceived post-discharge needs of a specific population of surgical clients. The PDNI was developed to determine what post-discharge needs adult clients experiencing a first surgery (an appendectomy, cholecystectomy, or herniorrhaphy) identify as not being met by the discharge planning provided for them in the hospital setting, and to provide data useful to nursing in planning post-‘ discharge care for these clients. If the data to be collected supports the anticipated find- ing that there will be discrepancies between what clients anticipate at discharge and what needs they identify as actually existing after six weeks at home, nursing intervention in the form of anticipatory guidance can be considered a useful strategy to help minimize misconceptions and enhance client 68 coping abilities. AS a form of problem solving that aims to prepare the client to deal with problems or accomplish goals at some time in the future (Pridham, Hansen, and Conrad, 1977), anticipatory guidance can help surgical clients plan for their convalescence and determine, in advance, how they will cope with both the expected and the unexpected events that may occur after discharge. Pridham, Hansen and Conrad also stress the importance of the clinician's availability in providing anticipatory guidance in situations that elicit fear or dis- comfort. A long-term, continuing relationship enhances the provision of anticipatory care through reinforcement of the positive effects of planning and through new problem identi- fication, as necessary, over time. Since literature on the post-discharge course and needs of hernia, appendectomy, and cholecystectomy clients is sparse, there is no documentation of a time after surgery that is particularly frustrating or difficult for these clients. However, all the reviewers stated that clients had reported such discouragement or difficulty at both one and three weeks after discharge. In an informal poll of available individuals who had had any surgery, the writer found the same two time periods mentioned. Data will be needed to confirm or reject the hypothesis that clients experience such plateaus during their recovery period. If the data supports this potential finding, Family Clinical Nurse Specialists can plan follow-up care of these clients accordingly, utilizing calls or home visits at the identified difficult time periods. 69 Should data from the PDNI support Gerson and Collins (1976) findings discussed earlier, the FCNS could play an instrumental role in reducing hospital length of stay for surgical clients by providing the nurse coordinator role identified by Gerson and Collins. The nurse would also be able to help the client anticipate and plan strategies for dealing with pain, fatigue and low spirits, such as diversion, appropriate use of medi- cations, appropriate exercise and rest patterns, arranging for needed assistance,and getting out of the house and making social contacts as soon as possible. Other findings, if supported, would establish the need for pre-operative information giving to both clients and family members and would hopefully, clarify what type of inform- ation would be most helpful to clients. From the mixed results relative to the effects of pre-operative teaching that can be found in the literature (Hartfield et al., 1981; Ziemer, 1983), it is unclear as to what clients find most helpful at what point in time. Further study is needed, and use of the PDNI may contribute data helpful in clarifying this issue. Also, if clients do in fact state that physicians are their primary source of information as Johnson and Pachano (1981) found, the FCNS will need to develop strategies to build client confidence in the nurse as a resource person. Such strategies will be discussed further in the nursing implications section. Comparisons between the sections of the PDNI can help interpret which area(s) needs particular attention in planning post-discharge care for surgical clients; physical, emotional 70 or social. As an exploratory study, the project is designed to provide data that can potentially demonstrate common patterns of responses or a wide variety of responses. Potential re- lationships with demographic variables may surface which will need further study such as a relationship between number of young children and difficulty getting rest, or a relationship between age and concern over how the incision looks. Lacking specific discussion of this population's post-discharge needs in the literature, it is difficult to predict responses in advance, but based on the observations of the reviewers, an emphasis on physical concerns would be anticipated. Hernia clients have been found in previous studies to have fewer post-operative complaints than other types of surgery (Gerson and Collins, 1976; Johnson et al., 1978),so a relationship between type of surgery and needs scores might be anticipated. The PDNI is designed to allow for diverse responses in each section so that potential unanticipated needs can be uncovered. Interpretation of responses will have to consider a possible rationale for the response before the data can be utilized in planning future studies or strategies for care. For example, if a client indicated he/she expects to need an excessive amount of rest at home, possible reasons for such a response will need to be explored before conclusions can be reached. Perhaps a family member experienced a complex surgery and required excessive rest, and the client is assuming the same will be true for him/her. In the emotional needs section, it will be important to 71 interpret the "need to know" questions in relationship to the unanswered questions asked for in the home care instructions section. The strength of the client's need to know can be interpreted by his/her consistency in responding to questions directed at this potential need. Emotional and social needs will have to be interpreted in terms of the client's family situation also. If the client was recently divorced or there has been family stress or change, the responses to the questions in both the emotional and social sections may be skewed toward a high needs score. Home situation circumstances will need to be considered in interpreting the home care instructions responses also. For instance, a client who has a friend or relative who is a nurse or physician may feel more secure at discharge and may not express any need for discharge instructions. Recommendations for Further Study As stated in Chapter III, it is recommended that the PDNI be pretested and revisions made based on the data obtained. The refined instrument should then be utilized in the study design proposed. Limitations of the instrument and/or the study design can be determined following the completion of data collection, analysis, and interpretation. It is hypothesized that the clients under study will 1) identify needs not addressed by the discharge planning provided for them, 2) will state different identified needs in hindsight than could be anticipated at discharge, 3) type of surgery and possibly age and family circumstances will be 72 related to types of needs identified, and 4) there will be certain time periods identified by clients as most trouble- some during convalescence. It is anticipated that from the data generated by the study, more specific hypotheses can be generated. At this preliminary stage of the study several limita- tions are anticipated. 1. The study is exploratory only, and it will not be possible to state firm conclusions or cause-effect relationships. The surgical experience of clients may be influenced by variables not addressed in the study design such as the surgeon performing the procedure. In the particular setting targeted for the study, the surger- ies will all be performed by one of two surgeons who practice together. However, there are distinct differences in each of the surgeon's approach to clients and to their practice of medicine that perhaps should be accounted for in future studies. Discharge planning done by nurses may need to take into account physician differences in approach to post-discharge care. The instrument wording may be unclear or misleading to clients. The sample will be essentially all white in race, limiting generalizability. The variety of types of questions may limit scoring 73 accuracy and the statistical tests that can be utilized in analyzing the data obtained. 6. The potential for subject withdrawal before both interviews can be completed could limit conclusions that can be reached regarding possible discrepancies between anticipated versus actual needs perceived by clients. 7. There may be interaction between physical, emotional, and social needs (Williamson, 1978). A post-study follow-up on a random.sample of the popula- tion studied may be helpful in determining respondent reaction to the instrument. Possible problems that may be identified include instrument too long, repetitive, or unclear. Other future studies recommended include replication studies on different populations to 1) increase the informa- tional data available relative to the concepts under study and to 2) further examine the reliability and validity of the PDNI. The proposed study could be viewed as a pilot study for determining the potential value of the PDNI as a useful instrument for the study of post-discharge needs. Based on the anticipatory findings discussed earlier in this chapter, other studies might address the relationship of anticipatory guidance provided to surgical clients and reduced length of stay. Identified needs could be incorporated in an experimental study that would provide for anticipatory guidance to be given to the experimental group and not to a control group with length of stay used as the outcome measure. 74 Nurse perceptions of post-discharge needs compared to client perceptions of post-discharge needs is another area that requires further study. The PDNI could be administered to nurses as well as clients, and the data analyzed for signifi- cant difference. Also, a study designed to provide a measure- ment of the effectiveness of pre, during, and post-hospital- ization care by a FCNS in terms of reduced length of hospital stay and fewer post-discharge complications is recommended. Implications for Nursing The discharge planning program at the hospital under study demonstrates a particular gap for the clients targeted for study. Other settings might have a more comprehensive program for surgical discharges, thus this project is limited to what was found in the literature and observed in one setting. However, nurse clinicians have surgical clients in their caseloads. As a provider whom the client knows, and with whom the client has established a relationship, the Family Clinical Nurse Specialist may well be in the best position to develOp strategies to provide the information the client will need after discharge from the hospital, at the times the client can best utilize such information. As Dawson and Stern (1973) imply, acute care nurses' priorities are not synchronized with the issue of discharge planning and continuity of care for a variety of reasons, including: 1. No sense of responsibility for the client once he/she is outside the hospital 2. Lack of communication with community nurses 75 3. ‘More immediate pressing needs of other acute care clients 4. Difficulty discerning needs for care that do not involve technical nursing skills. As a provider who focuses on the family as a unit of care, the FCNS can also help alleviate the shortcomings in health care identified by Pratt (1976) in Chapter I. The FCNS supplies families with information that will enable them to utilize their own strengths to full advantage in supporting their efforts towards maximizing the health of the client and the family system. Further discussion of implications for nursing will be divided into implications for practice, education,and research. Special attention is paid to the role of the Family Clinical Nurse Specialist in providing care for the clients under study, as well as emphasizing that this role must be complementary to the discharge planning efforts of acute care nursing personnel. NursingrPractice In order to coordinate the smooth transition of the client through the various levels of the health care system, the FCNS will need to move out of the primary care setting and into the acute care setting (Miller, 1981). In so doing, a communi- cation linkage will occur between acute care staff nurses and primary care family nurse clinicians. As a leader, the FCNS can foster a collaborative team effort focused on the client and his family and what needs to be done so that continuity of care can be assured. This interface among nurses can be a positive step forward not only in assuring continuity of care 76 for clients, but also, in fostering needed unity within the nursing profession. To accomplish a collaborative effort will not be an easy matter, however, since it will involve a change in how discharge planning is presently being handled. The FCNS will thus need to be a change agent as well. According to Gossman (1974), the role of change agent involves analyzing the need for change and the organization's ability to accept change. The change agent is an analyst, facilitator, salesman, and catalyst. Bennis (1979) sees the change agent as one concerned with organizational improvement, develOpment, and enhancement. Several roles are adopted by the change agent according to Bennis, including researcher, trainer, consultant, counselor, teacher, and/or manager. The challenge for the FCNS is to help provide a positive incentive to the acute care setting to look at discharge planning as part of continuity of care, and to accept the FCNS as the provider in an ideal posi- tion to coordinate efforts to assure continuity of care for surgical clients once they are discharges from the hospital. The FCNS must work with acute care nursing staff so that the efforts both expend in discharge planning are complementary. Contact- ing the Director of Nursing Services and utilizing written notes that brief acute care staff on pertinent information about clients can facilitate such a complementary effort. Obtaining privileges at the hospital will also be helpful in providing the opportunity for the FCNS to contribute to the client's written record. Within the practice setting, the FCNS can utilize the 77 information obtained from this project to plan specific care strategies for clients and their families. Based on King's (1981) perception model, the FCNS will be aware of the need to determine what the client's perceptions and expectations relative to an impending surgical experience are, so that the nurse's perceptions can be matched to those of the client during the interaction that takes place between them and appropriate planning and goal setting can take place. The problem solving approach to anticipatory guidance described earlier can thus be employed (Pridham et al., 1977). One method to determine client perceptions would be to use a shortened version of the PDNI. The nurse could use the client's responses to assess whether the client appears to ' have reasonably accurate expectations or is overly optimistic or pessimistic. Knowing from the study findings what needs are commonly perceived by clients having surgery for the first time, the nurse can introduce information prior to surgery that the client can utilize in devising his/her own coping Strategies with events as they occur. Also knowing when clients usually are most discouraged, the nurse can plan a follow-up call or visit during that time period. Each section of the PDNI will provide information that can be helpful in planning care strategies. Some potential findings and how they might be applied in the practice setting follow. ‘Physical'Needs It is anticipated that post-surgical clients will have needs relative to pain relief, incision care, and appropriate 78 activity level (Gerson & Collins, 1976; Phipps, Long & Woods, 1979; Prescott et al., 1979). The nurse can assist the client with management of these needs through anticipatory guidance of what can normally be expected, reassurance that the recov- ery period takes time but is limited in duration, and that certain behaviors can be utilized to cope. Although the nurse will want the client to understand how and when to use prescribed medications for pain, alternative methods of pain management such as distraction, positioning, relaxation techniques, and gradual increases in physical activity should be offered both before surgery and throughout the convalescent period. An understanding of how wound healing takes place can help the client make sound decisions as to how his/her wound is progressing. Specific guidelines regarding activities to be avoided and for how long should be explained with a rationale, eg. sexual activity should not be resumed until the wound has developed substantial tensile and burst strength, usually in approximately 4 weeks (Robusto, 1980). Periodic contacts with the client (during first week home, at about three weeks post-discharge, and at about six weeks) will aid in discussing appropriate activity progression by making it fit the client's present need. During the anticipatory teaching time, the nurse can also explore potential needs related to stairs, housework, child care, and other such home situations of potential concern to the client. Together the nurse and client can explore options such as relatives who can help, tasks that can be delayed, and 79 time management ideas such as napping at the same time as the young children do. The nurse's knowledge of the upcoming surgery, of possible resources, and of practical suggestions will help the client see the nurse as his/her primary resource person and will facilitate the nurse's effort to coordinate care for the client through this communication channel estab- lished with the client. If referrals will be needed for the client, they can be initiated before the surgery takes place, providing for a smooth transition after hospitalization. Emotional Needs Emotional needs are expected to be expressed in terms of a need to be temporarily relieved of normal expectations, to receive attention, to feel an obligation to help self get well, and to feel a need to know what to expect (Kasl & Cobb, 1966; Miller & Janosik, 1980; Mishel, 1981; Thellacozzo & Irna, 1970; Segall, 1976). Anticipatory understanding of the probable occurrence of these feelings can assist the client in accepting responsibility for his/her own way to handle such feelings (Green, 1979). Timing will be important in addressing the "need to know" aspect of the client's post-discharge course. If too much specific information is provided prior to surgery when the client is tense and anxious, it is doubtful that it will all be useful to the client. Using the data from the study, the nurse can present material as the client is apt to need it. For example, the client will want to know specific activities that should be avoided during the first week as he is leaving 80 the hospital such as sexual activity, lifting items over a certain weight, and driving. At the end of the first week a call to help the client assess what new activities can be added would help the client feel in better control of his at-home care and progress. Social Needs The stage of development and social situation of the client may influence his/her needs in this area tozigreat extent, but all clients are anticipated to experience needs in terms of understanding temporary changes in relationships, effects on normal social and work activities, and possible financial stress (Anderson & Carter, 1978; Miller & Janosik, 1980; LeMaitre & Finnegan, 1975; Sheehy, 1976; Smilkstein, 1980). The nurse's rapport with the client will facilitate assessment of such needs, and the client can again be counseled through anticipatory teaching and timely contacts based on the nurse's understanding of probable concerns the client is apt to experience. For example, if the client is employed and will be returning to work, anticipatory counseling at approximately the fifth week (or one week before returning to work) will be more helpful than discussing issues related to work when the client is first leaving the hospital. The client's family will also experience needs due to the changed circumstances the client's surgery necessitates. Other family members may temporarily have to assume aspects of the client's normal role and may feel over-burdened and stressed. Concern for the client's well being by family members may 81 affect normal dispositions and responses. Family members, like the client, can benefit from infommation provided by the nurse in a timely manner. Knowing what to expect, what is common, what preparations should be made in advance of surgery, helps family members lower their anxiety level and facilitates coping with the convalescent period (Silva, 1979). The nurse's interest in the needs of family members will strengthen the family's belief in itself as a system and promote use of its own resources and strengths (Miller & Janosik, 1980). Home Care Instructions Based on the writer's observations and the reviewers' comments, it is anticipated that clients will state that they have been given instructions relative to their follow-up appointment with their surgeon, how to take prescribed medi- cation and vague activity instructions such as "avoid heavy lifting" and "do what you feel able to do". Most instructions will be given on the day of discharge and will be verbal, with some items written. Clients will probably state that their physician gave them instructions and will not identify unanswered questions at discharge, but will at the 6 week interview. The FCNS can play a major role in discharge planning for the client by discussing post—hospital planning before surgery with the client and establishing that the nurse can, and should, be the contact person for the client. It will be important for the nurse to establish rapport with the hospital staff nurses, with the social worker, and with the physicians so 82 that the nurse's role can be seen as a facilitative one. The pre, during, and after visit approach by one care-giver can make continuity of care and coordination of care a reality, but the nurse will need to be alert to what the client has been told by others, and must communicate with the other professionals involved in the client's care as much as possible (Deakers, 1972; Tebbitt, 1981). Knowing the common physical, emotional, and social needs discussed earlier, the FCNS can plan visits and anticipatory teaching according to questions the client and his/her family are likely to have and at the times such assistance will most likely be needed and best able to be utilized. It is important, however, for the nurse to assess the individual client and family's unique expectations so that assistance can be offered in helping the client and family develop expectations that are as realistic as possible. This can be accomplished by offering what is known about others' experiences so the client can apply such information to his/her own situation. Also the nurse needs to be available to assist the client to cope when actual experiences are different from expectations, through offering concrete suggestions for coping such as the pain management strategies discussed earlier. The various locations the FCNS will see the client; in the office before surgery, in the hospital after surgery, and at home or in the office after discharge from the hOSpital, will facilitate the nurse's ability to offer support to the client and the family as well as providing a feeling that there is continuity to the care 83 being provided. As the client's resource person, advocate, and primary care provider, the FCNS will need to refer the client as necessary and keep the physician, staff nurses, and social worker informed of any problems that occur. Information being taught to clients should be shared with staff nurses so that there can be consistency in what the client is taught, and unique circumstances can be mutually discussed. The goal of client education is a smooth post-discharge recovery for the client, possible earlier discharge, and improved continuity of care. NursingiEducation The conceptual framework utilized in this project was based on King's (1981) theory of nursing and the importance of interaction between nurse and client in matching perceptions so that mutual care goals can be set. As stated in Chapter II, use of King's theory in this study provides an opportunity to test her theory in a particular context. Such theory test- ing is important in providing a sound theoretical basis for what is both taught and practiced in the nursing profession. Another way of viewing King's perceptual model is to express matching perceptions through interaction as involve- ment with clients. Mitchell states, "Unless the nurse becomes involved with the patient, the nursing process becomes merely a mechanical, intellectual exercise in collecting, sifting, and analyzing data." (1977, p. 58). Providing continuity of care for clients depends on involvement and understanding the 84 client from his perspective so that planning care can be a mutual nurse/client process. Nurses must teach clients what clients need, not what the nurse thinks clients need. The present study helps provide data to increase the nurse's understanding of common needs experienced by first time surgical clients that can be helpful in understanding prob- able perceptions these clients may hold. Such understanding is helpful in the development of nursing curricula. Discharge planning and continuity of care need to be included in nursing education both for nurses who will practice in acute care settings and for the advanced practice nurse in primary care settings. The FCNS role needs to emphasize the importance of follow-up and adequate communi- cation with acute care settings so that continuity of care can be accomplished. The FCNS curricula perhaps Should encourage students to spend some clinical time in acute care settings during the course of study, and students should include surgical clients in their caseloads. This emphasis can be promoted outside of the profession as well, particularly from a cost-effectiveness perspective. Further studies can demonstrate the role of discharge planning, follow-up, and continuity of care in reducing length of hospital stay and reducing readmissions and/or complications after discharge. Nursing curricula can incorporate the find- ings from such studies in continuing to develop the clinician role. Staff development and life long education programs for 85 nurses should also include discharge planning concerns. The FCNS can facilitate the acceptance of the role of the nurse in advanced practice by promoting the value of complementary efforts by primary care nurses and acute care nurses in dis- charge planning. By working together to plan for a smooth transition for clients from hospital to home, nurses in both settings can learn a great deal about each other as well as improving the continuity of care clients receive. Nursing Research Several suggestions have been offered relative to future research related to this study. A summary follows. 1. Approach the hospital targeted for study and arrange to carry out the study as designed. 2. Utilize findings from above study to refine the PDNI and the study design. 3. Devise an evaluation of the PDNI that can obtain data from participants to be used to improve the instrument. 4. Consider controlling for possible interveningvariables that have not been controlled in this study, such as the surgeon performing the procedure. 5. Design replication studies for different populations to create a greater pool of data relative to post- discharge needs and to establish the reliabiltiy and validity of the instrument. 6. Based on findings from several exploratory studies, develop experimental studies to answer questions such as: 10. 11. 86 a) Does care by a Family Clinical Nurse Specialist reduce hospital length of stay for surgical clients? b) Does anticipatory teaching reduce post-discharge needs of surgical clients? c) Do nurses and surgical clients hold similar perceptions of post-discharge needs, and is there a positive relationship between similarity of perceptions and reduced length of stay and post-discharge concerns? Design a study that would compare the effectiveness of discharge planning provided by hospital staff with that of clinical specialists. According to McKeehan (1979), using nursing diagnoses in discharge planning facilitates communication among providers and enhances continuity of care. A study could be designed to test this hypothesis. A study might be useful to test the hypothesis that post surgical clients experience frustration at one and three weeks post discharge from.the hospital. Other relationships that could be tested include number of small children increases difficulties encountered during the post-discharge recovery period, and stage of adult development influences areas of needs empha- sized after surgery. Design a study to determine if inclusion of family members in discharge planning decreases length of stay and post-discharge concerns and complications. 87 Summary and Conclusions The writer has studied the concept of discharge planning. A post-discharge needs assessment instrument has been developed and recommended for use in a specified research design that would provide descriptive data relative to perceived needs of adult clients discharged from a 92 bed community hospital following one of three abdominal surgeries; appendectomy, cholecystectomy, or herniorrhaphy. Such a study is needed to provide a meaningful context for a broad, difficult to demonstrate concept. The project offers a means to collect data useful to providing such a context, and also such data can assist Family Clinical Nurse Specialists in considering new approaches to the care they provide for the surgical clients in their practices. The writer has learned that broad concepts such as discharge planning and continuity of care are difficult to measure, but believes this project has offered one means to attempt to do so, while providing information useful for specific applications in providing nursing care. Data collection is needed to fully determine the usefulness of the tool developed, but a foundation has been established for further study. APPENDICES APPENDIX A Interviewer Explanation of Study to Prospective Participants 88 Appendix A Interviewer Explanation of Study to Prospective Participants I am , a nurse researcher working on a project aimed at improving the continuity of care people receive from health care providers, and especially, from nurses. I would like to talk with you about what you expect your conval- escence from surgery to be like, and what questions and concerns you have about caring for yourself at home. Your responses will be kept confidential by grouping your responses with those of others who have had surgery, and names will not be used in any of the tabulations. Information obtained from this study will be used to improve the services we can offer to people when they leave the hospital after surgery. Our discussion may take approximately 1/2 to one hour and will take place the day you are scheduled to leave the hospital. We will contacting you again in 6 weeks to ask you Similar questions once you have been home for a while to see if, in hindsight, you had questions and concerns you could not anticipate as you were leaving the hospital. Would you be interested in participating in this project? Thank you for your help. Janice Newman, R.N., B.S.N. Candidate for M.S.N. Michigan State University College of Nursing APPENDIX B Agreement to Participate in Post-Discharge Needs Assessment Study 89 Appendix B Agreement to Participate in Post-Discharge Needs Assessment Study I, , understand what is (Print name andphone number) required of me as participant in this study, and voluntarily agree to take part. I have had an opportunity to ask questions of who will be interviewing me, and I understand that I can withdraw from the study at any time if I wish. There will be no direct benefit to me from participation in this study, no effect on the care I receive if I choose not to participate, and I can request information about the results if I desire. (Signature of participant) (Date) Janice Newman, R.N., B.S.N. Candidate for M.S.N. Michigan State University College of Nursing. APPENDIX C Post-Discharge Needs Inventory (Day of Discharge) 90 Appendix C POST-DISCHARGE NEEDS INVENTORY (Day of Discharge) Date Client's name Interviewer Client ID# INTERVIEWER INSTRUCTIONS: See attached sheet and notes throughout the questionnaire. First I will be asking you some questions about yourself that will help us determine which groups of people share similar needs. INTERVIEWER NOTE: Circle appropriate response or write in when a line is provided. 1. What is your age? 2. Sex: Male Female 3. Race: White Black Hispanic Other (Specify) 4. Marital status: Single Married Divorced Remarried Widowed Other (Specify) 5. How many living children do you have in each of the following categories? None ____ Infant-4I____ 5-12 ____ 13-19 p____20 & older ____ 6. What is the highest level of education you have completed? Less than 7th grade High School graduate Completed 9th grade Tech/BusinesS/Trade Some High School Post-grad/Professional 7. Which of the following best describes your occupation? Unemployed Housewife Unskilled position 4 Skilled Clerical Technical Professional 10. 91 In which of the following ranges does your yearly income fall? Less than 10,000 20,000-24,999 10,000-14,999 25,000-29,999 15,000-19,999 30,000-34,999 35,000 & over What type of surgery did you have? Appendectomy Hernia Cholecystectomy Other (Combination-Specify ) Have you ever been hospitalized before? Yes No If yes, why? The next group of questions have to do with how you expect to feel and manage at home. Answer as best you can predict. There are no right or wrong answers. INTERVIEWER NOTE: Circle appropriate response or write in when 11. 12. a line is provided. How much pain are you experiencing related to your surgery? None Very little Some A great deal What was used to manage your pain while you were in the hospital? Medication Position Change Distraction Other (Specify) INTERVIEWER NOTE: Encourage specifics if client can elaborate l3. l4. and note here How well has your pain been controlled while in the hospital? Very well Well Fair Poorly Very poorly How much pain do you anticipate experiencing at home? None Very little Some A great deal 92 15. What do you think you will be able to do to manage pain at home? INTERVIEWER NOTE: Take medication, watch TV, talk to friends, etc.. 16. How well do you expect to be able to manage pain at home? Very well Well Fair Poorly Very poorly If less than fair, why? INTERVIEWER NOTE: Will be alone, don't like to take medicine, had difficulty in the hospital, etc.. 17. What concerns do you have about how your surgical incision looks? None A little Some Concerned Quite concerned If concerned, why? INTERVIEWER NOTE: Will leave a scar. larger than expected, too wide, etc.. 18. Do you have questions about how to care for your incision? Yes No If so, what do you need to know? INOte # ofquestions ) INTERVIEWER NOTE: What activities will strain, what clothes will bother it, etc.. 19. Do you have questions about what you should eat at home? Yes No If so, what do you need to know? (Note # of questions ) INTERVIEWER NOTE: Is roughage important, do I need extra protein, etc. . 20. Who will be preparing meals at home? 93 21. How do you expect your appetite to be at home? Excellent Good Fair Poor Very poor 22. How many hours of rest per day do you anticipate needing at home? During the first week After 3 weeks After 6 weeks 23. To what degree are you concerned about doing tasks around the home? Not Somewhat Don't Concerned Very Concerned Concerned KnOW’ Concerned If concerned, what tasks do you expect to be a problem? INTERVIEWER NOTE: Vacuuming, bending, lifting the children, etc.. 24. How much interference with getting rest do you expect? None Very little A little Some A great deal 25. What normal daily physical activities do you expect to be able to do? Today After 1 week After 3 weeks After 6 weeks INTERVIEWER NOTE: Take a shower, care for the children, drive, clean house, etc.. 26. What medications has your physician prescribed for you? Do you have any questions about the medications prescribed? Yes No If yes, what questions? (Note # Of questions ) INTERVIEWER NOTE: What are they for, how to take them, can they be taken with my other medications, etc.. 94 27. What treatments has your physician prescribed for you? Do you understand what you are supposed to do? Yes No If not, what don't you understand? INTERVIEWER NOTE: What to put in the soak water, how often to change dressings, how long to continue dressing changes, etc. 28. If you need help with household tasks, is there someone avail- able to help you? Yes No 29. What kinds of problems would prompt you to contact a health care professional for help? INTERVIEWER NOTE: Incision looks red, feeling tired, cannot con- trol pain, wonder if can do a certain activity, etc. 30. Who would you contact? 31. When are you scheduled to see your surgeon for follow-up visits? In one In two In six Don't Other (Specify) Week Weeks Weeks Know ' INTERVIEWER NOTE: Circle more than one if client has been given more than one appointment. For the next series of questions, tell me if you strongly agree, agree, don't know, disagree or strongly disagree with the state- ments I read to you. Be as honest as you can and remember there are no right or wrong answers. We are interested in how you expect to feel about these things at home. INTERVIEWER NOTE: Elaborate as necessary if client doesn't seem to understand, e.g. #32 - my husband will need to take care of the baby for a few days. Circle one response for each question. 32. I expect my responsibilities around the home to be done by others during my convalescence. Strongly Agree Don't Disagree Strongly Agree Know Disagree 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 95 I expect to be somewhat irritable and demanding at times. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect my family and friends to understand my feelings. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect my family and friends to pay attention to me while I'm recovering. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect to be content to stay at home during my convalescence. Strongly Agree Don't Disagree Strongly Agree Know Disagree I will find it difficult to ask for help if I need it. Strongly Agree Don't Disagree Strongly Agree Know Disagree I feel I have an obligation to help myself get well by doing things for myself that will promote my comfort and speed my recovery. Strongly Agree Don't Disagree Strongly Agree Know Disagree I feel I have an obligation to seek help in getting well, whenever necessary. Strongly Agree Don't Disagree Strongly Agree Know Disagree I feel a need to know what kind of progress I can expect during the next few weeks. Strongly Agree Don't Disagree Strongly Agree Know Disagree I feel a need to know what activities I Should attempt and why or why not. Strongly Agree Don't Disagree Strongly Agree Know Disagree I am concerned about whom I Should call if I am having any problems while recovering at home. Strongly Agree Don't Disagree Strongly Agree Know Disagree 43. 44. 45. 46. 96 I am concerned about knowing what symptoms are important to tell a nurse or doctor about. Strongly Agree Don't Disagree Strongly Agree Know Disagree I feel a need to know when I can expect to be back to normal. Strongly Agree Don't Disagree Strongly Agree Know Disagree I am concerned about knowing if I will have to alter my life- style in some way because of my surgery even after my recovery is complete. Strongly Agree Don't Disagree Strongly Agree Know Disagree 1 have questions regarding when it is advisable to resume sexual activity once I am home. Strongly Agree Don't Disagree Strongly Agree Know Disagree The next group of questions have to do with the effects your surgery might have on your relationships with others and on your work. Again, indicate whether you strongly agree, agree, don't know, disagree, or strongly disagree with each statement. INTERVIEWER NOTE: Circle one response for each question and 47. 48. 49. 50. clarify any statements the client doesn't understand. I expect my family and friends to be overprotective of me. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect my family and friends to ignore me more than I would like. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect to miss out on some important social events because of my surgery. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expect to lose contact with my friends during my recovery. Strongly Agree Don't Disagree Strongly Agree Know Disagree 51. 52. 53. 54. 55. 56. 57. 58. 59. 97 Family and friends will give me advice I won't really want and I will find it irritating. Strongly Agree Don't Disagree Strongly Agree Know Disagree I will want to be alone more than usual. Strongly Agree Don't Disagree Strongly Agree Know Disagree I will not be able to keep up with my normal activities and will find the pressure frustrating. Strongly Agree Don't Disagree Strongly Agree Know Disagree My surgery will create a financial strain on me and/or my family. Strongly Agree Don't Disagree Strongly Agree Know Disagree People around me will understand how I feel and what my temp- orary needs are. Strongly Agree Don't Disagree Strongly Agree Know Disagree When I return to work (or normal activities around the home), my co-workers (family) will be sensitive to my need to talk about my surgery. Strongly Agree Don't Disagree Strongly Agree Know Disagree When I return to work (or normal activities around the home), my co-workers (family) will be understanding of my need to gradually get back to full capacity. Strongly Agree Don't Disagree Strongly Agree Know Disagree People will treat me as if nothing has happened. Strongly Agree Don't Disagree ,Strongly Agree Know Disagree When I return to work (or normal activities around the home). I will be far behind and have to catch up. Strongly Agree Don't ”Disagree Strongly Agree Know Disagree 98 These last few questions are concerned with how you have been helped to prepare for your care at home. We are interested in how you feel we can best help you make the transition from hOSpital to home and from recovering to back to normal. INTERVIEWER NOTE: Circle apprOpriate response or write in when a line is provided. Encourage client to be as specific as possible. 60. Has anyone discussed with you the subjects we have talked about so far? Yes No If so, who? 61. What kinds of things have been discussed? INTERVIEWER NOTE: Medications to take, activity restrictions (note how specific, e.g. not lifting anything heavier than 10 lbs. vs. no heavy lifting), appointments, etc. 62. When did such a discussion take place? Before Soon after Yesterday Today No discussion Surgery Surgery INTERVIEWER NOTE: May circle more than one, if applicable. 63. How were you given information regarding your care at home? Verbally Written Both verbal No instructions And written Given Other (Specify) 64. Who gave you information about your care at home? Nurse Doctor Social No one Other (Specify) Worker ‘ 65. Do you have any unanswered questions as you are about to be discharged from the hospital? Yes No If so, what questions? (Note # of questions ) INTERVIEWER NOTE: When can I drive, can I go up and down stairs etc. 99 66. Who would you feel most comfortable asking these questions? Nurse Doctor Social Other (Specify) Not Sure Worker INTERVIEWER NOTE: If the client seems to feel that more than one person should be asked, you can note that here. Try to obtain a rank order if the client can state. 67. Do you feel prepared to go home? Yes No Why or why not? INTERVIEWER NOTE: Good instructions, still have questions, no one at home to help, still feel weak, etc. 68. Are there any ways someone could have helped you feel more ready to go home? Yes No If so, explain. INTERVIEWER NOTE: Spoke with me sooner, been more specific, given a name to call, etc. Thank you for your help with this project. I will be in touch with you in six weeks for a follow-up session as I explained earlier. Let me double check how to reach you (phone # or address). Best wishes for a speedy recovery. Interviewer's Comments: 100 POST-DISCHARGE NEEDS INVENTORY Interviewer Instructions Establish rapport with the client before beginning questioning. Use probes as indicated by examples given and as you feel needed to obtain as much information as possible from the open-ended questions. Familiarity with the survey in advance is vital to a smooth interview. Circle appropriate answer when a choice is provided or write in, as indicated. Sex and race can be entered by observation rather than questioning client, unless there is doubt. Explain any questions the client seems unsure about. Use the interviewer comments section or the margins to note any unusual responses, e.g. client cries or refuses to answer. Also note situational or environmental observations such as home ex- ceptionally unkempt or family arguments prevalent. If the client asks questions and you need to refer him/her, note the nature of the question and to whom you referred in the comments section. Also include any feedback you receive from providers to whom you referred the client and/or family members. Remember: - Conduct the interview in a private room - Explain the study thoroughly to the client - Have the client Sign the consent form - Thank the client for his/her time and help with the study - Fill in the comments section, as necessary - Note the amount of time you spend with the client (in the comments section). APPENDIX D Post-Discharge Needs Inventory (Six Weeks Post-Discharge) 101 Appendix D POST-DISCHARGE NEEDS INVENTORY (Six weeks Post-Discharge) Date Client's Date of Discharge Interviewer Client ID# INTERVIEWER INSTRUCTIONS: See attached sheet and notes throughout the questionnaire. Let's review the information you gave me six weeks ago to be sure I have it accurate. INTERVIEWER NOTE: Circle apprOpriate response or write in when a line is provided. 1. What is your age? 2. Sex: Male Female 3. Race: White Black Hispanic Other (Specify) 4. Marital status: Single Married Divorced Remarried Widowed Other (specify) 5. How many living children do you have in each of the following categories? None Infant-4 5-12 13-19 20 & older 6. What is the highest level of education you have completed? Less than 7th grade High School graduate Completed 9th grade Tech/Business/Trade Some High School Post-grad/Professional 7. Which of the following best describes your occupation? Unemployed Housewife Unskilled position Skilled Clerical Technical Professional 10. 102 In which of the following ranges does your yearly income fall? Less than 10,000 20,000-24,999 10,000-14,999 25,000-29,999 15,000-19,999 30,000 & over What type of surgery did you have? Appendectomy Hernia Cholecystectomy Other (Combination-Specify ) Have you ever been hospitalized before? Yes No If yes, why? Now that you have been home six weeks, let's review how you have felt and managed after having had surgery. Answer as best you can recall, and provide as much specific information as possible. INTERVIEWER NOTE: Circle appropriate response or write in when 11. 12. a line is provided. How much pain are you experiencing related to your surgery now? None Very little Some A great deal What was used to manage your pain while you were in the hospital as you recall now? Medication Position Change Distraction Other (specify) INTERVIEWER NOTE: Encourage specifics if client can elaborate 13. 14. and note here How well was your pain controlled while in the hospital? Very well Well Fair Poorly Very poorly How much pain have you experienced at home? None Very little Some A great deal 103 15. What were you able to do to manage pain at home? INTERVIEWER NOTE: Take medication, watch TV, talk to friends, etc. 16. HOW‘Well were you able to manage pain at home? Very well Well Fair Poorly Very poorly If less than fair, why? INTERVIEWER NOTE: was alone, didn't like to take medicine, had had difficulty in the hospital, etc. 17. What concerns did you have about how your surgical incision looked? None A little Some Concerned Quite concerned If concerned, why? INTERVIEWER NOTE: Will leave a scar larger than expected, too wide, etc. 18. Did you have questions about how to care for your incision? Yes No If so, what did you need to know? (Note # oquuestions client has ) INTERVIEWER NOTE: What activities will strain, what clothes will bother it, etc. 19. Did you have questions about what you should eat at home? Yes No If so, what did you need to know? (Note # of questions ) INTERVIEWER NOTE: Was roughage important, did I need extra protein, etc. 20. Who has prepared meals at home? 104 21. How has your appetite been at home? Excellent Good Fair Poor Very poor 22. How many hours of rest per day did you need at home? During the first week After 3 weeks After 6 weeks 23. To what degree were you concerned about doing tasks around the home? Not Somewhat Don't Concerned Very Concerned Concerned Know Concerned If concerned, what tasks were you concerned about? INTERVIEWER NOTE: Vacuuming, bending, lifting the children, etc. 24. How much interference with getting rest did you experience? None Very little A little Some A great deal 25. What normal daily physical activities were you able to do? First day After 1 week After 3 weeks After 6 weeks INTERVIEWER NOTE: Take a shower, care for the children, drive, clean house, etc. - 26. What medications did your physician prescribe for you? Did you have any questions about the medications prescribed? Yes No If yes, what questions? (Note # of questions ) INTERVIEWER NOTE: What were they for, how to take them, could they be taken with my other medications, etc. 105 27. What treatments did your physician prescribe for you? Did you understand what you were supposed to do? Yes No If not, what didn't you understand? INTERVIEWER NOTE: What to put in the soak water, how often to change dressings, how long to continue dressing changes, etc. 28. If you needed help with household tasks, was there someone available to help you? Yes No 29. What kinds of problems prompted you to contact a health care professional for help? INTERVIEWER NOTE: Incision looked red, felt tired, could not control pain, wondered if could do a certain activity, etc. 30. Who did you contact? 31. When were you scheduled to see your surgeon for follow-up visits? In one In two In six Don't Other (Specify) __ Week Weeks Weeks Know ' " ' INTERVIEWER NOTE: Circle more than one if client was given more than one appointment. For the next series of questions, tell me if you strongly agree, agree, don't know, disagree or strongly disagree with the state- ments I read to you. Be as honest as you can and remember there are no right or wrong answers. We are interested in how you felt about these things at home. INTERVIEWER NOTE: Elaborate as necessary if client doesn't seem to understand, e.g. #32 - my husband needed to take care of the baby for a few days. Circle one response for each question. 32. I expected my responsibilities around the home to be done by others during my convalescence. Strongly Agree Don't Disagree Strongly Agree Know Disagree 33. 34. 35. 36. 37. 106 I felt somewhat irritable and demanding at times. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expected my family and friends to understand my feelings. Strongly Agree Don't Disagree Strongly Agree Know Disagree I expected my family and friends to pay attention to me while I was recovering. Strongly Agree Don't Disagree Strongly Agree Know Disagree I was content to stay at home during my convalescence. Strongly Agree Don't Disagree Strongly Agree Know Disagree I found it difficult to ask for help when I needed it. Strongly Agree Don't Disagree Strongly Agree Know Disagree INTERVIEWER NOTE: Use "Don't Know" if client didn't need any 38. 39. 40. 41. help. I felt I had an obligation to help myself get well by doing things for myself that would promote my comfort and speed my recovery. Strongly Agree Don't Disagree Strongly Agree Know Disagree I felt I had an obligation to seek help in getting well, whenever necessary. Strongly Agree Don't Disagree Strongly Agree Know Disagree I felt a need to know what kind of progress I could expect during the past Six weeks. Strongly Agree Don't Disagree 'Strongly Agree Know Disagree I felt a need to know what activities I should attempt and why or why not. Strongly Agree Don't Disagree Strongly Agree Know Disagree 42. 43. 44. 45. 46. 107 I was concerned about whom I should call if I had any problems while recovering at home. Strongly Agree Don't Disagree Strongly Agree Know Disagree I was concerned about knowing what symptoms were important to tell a nurse or doctor about. Strongly Agree Don't Disagree Strongly Agree Know Disagree I felt a need to know when I could expect to be back to normal. Strongly Agree Don't Disagree Strongly Agree Know Disagree I was concerned about knowing if I would have to alter my lifestyle in some way because of my surgery even after my recovery is complete. Strongly Agree Don't Disagree Strongly Agree Know Disagree I had questions regarding when it is advisable to resume sexual activity once I was home. Strongly Agree Don't Disagree Strongly Agree Know Disagree The next group of questions have to do with the effects your surgery had on your relationships with others and on your work. Again, indicate whether you strongly agree, agree, don't know, disagree, or stongly disagree with each statement. INTERVIEWER NOTE: Circle one response for each question and 47. 48. 49. clarify any statements the client doesn't understand. Family and friends were overprotective of me. Strongly Agree Don't Disagree Strongly Agree Know Disagree Family and friends ignored me more than I liked. Strongly Agree Don't Disagree 'Strongly Agree Know Disagree I lost contact with my friends during my recovery. Strongly Agree Don't Disagree Strongly Agree Know Disagree 50. 51. 52. 53. 54. 55. 56. 57. 58. 108 I missed out on some important social events because of my surgery. Strongly Agree Don't Disagree Strongly Agree Know Disagree Family and friends gave me advice I didn't really want and I found it irritating. Strongly Agree Don't Disagree Strongly Agree Know Disagree I wanted to be alone more than usual. Strongly Agree Don't Disagree Strongly Agree Know Disagree I was not able to keep up with my normal activities and found the pressure frustrating. Strongly Agree Don't Disagree Strongly Agree Know Disagree My surgery created a financial strain on me and/or my family. Strongly Agree Don't Disagree Strongly Agree Know Disagree People around me understood how I felt and what my temporary needs were. Strongly Agree Don't Disagree Strongly Agree Know Disagree' When I returned to work (or normal activities around the home), my co-workers (family) were sensitive to my need to talk about my surgery. Strongly Agree Don't Disagree Strongly Agree Know Disagree When I returned to work (or normal activities around the home), my co-workers (family) were understanding of my need to gradually get back to full capacity. Strongly Agree Don't Disagree ,Strongly Agree Know Disagree People treated me as if nothing had happened. Strongly Agree Don't Disagree Strongly Agree Know Disagree 59. 109 When I returned to work (or normal activities around the home), I was far behind and had to catch up. Strongly Agree Don't Disagree Strongly Agree Know Disagree Now that you have your recovery period mostly behind you, these questions may have more meaning to you. They concern how we could have been of more help to you before and during your convalescence. Be as specific as you can in your answers. INTERVIEWER NOTE: Circle appropriate response or write in when 60. 61. a line is provided. Encourage client to be as Specific as possible. Did anyone discuss with you the subjects we have talked about so far? Yes No If so, who? What kinds of things were discussed? ~~~~ INTERVIEWER NOTE: Medications to take, activity restrictions 62. (note how Specific, e.g. not lifting anything heavier than 10 lbs. vs. no heavy lifting), appointments, etc. When did such a discussion take place? Before Soon after Day before Day of No discussion Surgery Surgery Discharge Discharge Other (Specify) INTERVIEWER NOTE: May circle more than one, if applicable. 63. 64. How were you given information regarding your care at home? Verbally Written Both verbal No instructions And written Given Other (Specify) Who gave you information about your care at home? Nurse Doctor Social No one Other (Specify) Worker ' 110 65. Did you have any unanswered questions during your convales- cence at home? ' Yes No If so, what questions? (Note # of questions ’77 INTERVIEWER NOTE: When can I drive, can I go up and down stairs, etc. 66. Who did you feel most comfortable asking these questions? Nurse Doctor Social Other (Specify) Not sure Worker INTERVIEWER NOTE: If the client seems to feel that more than one person could be asked, you can note that here. Try to obtain a rank order if the client can state. 67. Did you feel prepared to go home? Yes No Why or why not? INTERVIEWER NOTE: Good instructions, still hadt questions, no one at home to help, still felt weak, etc. 68. Were there any ways someone could have helped you be better prepared to care for yourself at home? Yes No If so, explain. INTERVIEWER NOTE: Spoke with me sooner, been more specific, given a name to call, etc. 69. Was there any particular time that was especially discouraging or difficult for you during the past six weeks? Yes No If yes, when INTERVIEWER NOTE: During the first week, middle weeks, now, etc. 111 Thank you again for your time and help with this project. If you wish results of the study, I will be glad to send them. (name & mailing address if desires results) Interviewer's Comments: 112 POST-DISCHARGE NEEDS INVENTORY Interviewer Instructions Establish rapport with the client before beginning questioning. Use probes as indicated by examples given and as you feel needed to obtain as much information as possible from the open-ended questions. Familiarity with the survey in advance is vital to a smooth interview. Circle appropriate answer when a choice is provided or write in, as indicated. Sex and race can be entered by observation rather than questioning client, unless there is doubt. Explain any questions the client seems unsure about. Use the interviewer comments section or the margins to note any unusual responses, e.g. client cries or refuses to answer. Also note situational or environmental observations such as home ex- ceptionally unkempt or family arguments prevalent. If the client asks further questions and you need to refer him/ her, note the nature of the question and to whom you referred in the comments section. Also include any feedback you receive from providers to whom.you referred the client and/or family members. Remember: - Conduct the interview in a private setting - Refresh the client as to the purpose of the study - Thank the client for his/her time and help with the study - Fill in the comments section, as necessary - Note the amount of time you spend with the client (in the comments section). REFERENCES 113 References . 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Discharge planning handbook, Thorofare, N. J.: Charles B. Slack, Inc., 1978. Stevenson, J. Issues and crisis during middlescence. New York: Appleton-Century-Crofts, 1977. Sullivan, J. Continuity of care between hospital and home. Nursing Administration Quarterly, 1981, 6 (1), 19-22. Tagliacozzo, D. and Ima, K. Knowledge of illness as a predictor of patient behavior. Journal of Chronic Disease, 1970, 33 (11), 765-775. Tebbitt, B. What's happening in continuity of care? SuperviSor Nurse, 1981, 33 (3), 22-26. Trowbridge, P. A randomized study of cholecystectomy with and without drainage. Surgery, Gynecology & Obstetrics, 1982, "155 (2), 171-176. 120 Tucker, S. M. et a1. Patient care standards. St. Louis: The C. V. Mosby Company, 1980. ' Ward, M. and Lindeman, C. (Eds.) Instruments for meaSuring nursing practice and other health care variables, Volume I. U} S. Dept. of Health, Education and Welfare publication #HRA 78-53, 1979. Watson, J. 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Handbook of perception: New York: Academic Press, 1974. Ketola, J. Effectiveness of a hospital dischargejprocedure with parents in increasingcompiiance to numerous medical orders fOr children. Masters Thesis, Department ofNurSing, California State University, Long Beach, 1981. Pesznecker, B., and Draye, M., Family nurse practitioners in primary care: A study of practice and patients. American Journal of Public Health, 1978, §3_(10), 977-980. Silver, H. The essentials of primary health care. Journal of Family Practice, 1977, i (1), 151-152. 122 Personal References DenHartog, J. C., M.D., 1005 W. Green Street, Hastings, Michigan. 3 1293 02493 0632