Introduction
Proper preparation of the patient for independent functioning after discharge from the hospital is crucial for their return to everyday life and maintaining health [1, 2]. The following attributes belonging to readiness for hospital discharge (RHD) were extracted from the literature: physical stability, adequate support, psychological ability, and adequate information and knowledge [3]. A better understanding of this phenomenon, measuring and identifying patient needs will help healthcare professionals implement interventions if necessary to ensure patients are ready for hospital discharge and to help deepen the knowledge of all professionals involved in hospital discharge. The topic of readiness for discharge has been analysed in particular in patients treated in hospital for chronic diseases [4–6], however preparing the patient to leave the surgical ward seems equally important. Given the specific nature of the patient being treated in a surgical ward, there is a need to highlight the need to adequately prepare the patient for discharge, equipping/providing them with the necessary knowledge and skills to avoid complications and reduce the frequency of hospital admissions. Studies have shown that RHD in patients was closely related to the incidence of complications, the incidence of unplanned readmissions, and quality of life [7–10]. Therefore, it is important to identify the factors influencing patients’ readiness for discharge and to develop interventions to support the process of preparing to leave hospital, especially as it is possible to reduce the length of stay in surgical wards, which is in line with the enhanced recovery after surgery (ERAS) protocol, thanks to a holistic approach to surgical patient care, increasingly newer surgical technologies [11, 12]. Therefore, the aim of the study was to assess the readiness for discharge of patients treated in a surgical ward and to try to identify the factors influencing it.
Material and methods
The cross-sectional study included 100 patients who were treated at the Surgical Ward of the Wojciech Oczko Independent Health Care Facility Complex in Przasnysz, a medical unit of the first and second reference level, who were discharged from the hospital between January and March 2023. At that time, 360 patients were discharged, 28% of whom met the inclusion criteria: they gave voluntary consent to participate in the study, they were patients with verbal and logical communication preserved, and aged ≥ 18 years. A diagnostic survey method and questionnaire technique were used to conduct the study. The discharge readiness questionnaire was used (original Canadian health outcomes for better information and care), which was supplemented with socio-demographic data (gender, age, education, place of residence) and questions related to the patient’s hospital stay and general health status. A validated Polish version of the questionnaire was used, with the permission of the author. The Canadian health outcomes for better information and care contains 8 questions in the areas of: knowledge of medicines, knowledge of the reasons for taking medicines, ability to take prescribed medicines, ability to notice health-related symptoms, ability to adhere to treatment, knowledge related to people to go to for help with daily activities, knowledge related to people/institutions to call in case of an emergency, ability to undertake daily physical activity. Six response options are assigned to each of the above-mentioned questions, from which respondents could choose one: 0 – not prepared, 1 – poorly prepared, 2 – partially prepared, 3 – moderately prepared, 4 – well prepared, 5 – very well prepared. The overall readiness for discharge score could range 0–40 points.
Statistical calculations were carried out with an Excel spreadsheet, using SPSS 23 statistical software. The following statistical methods were used in the analysis: the Spearman rank correlation test, the Mann-Whitney U test and the Kruskal-Wallis ANOVA test. In the analysis, the Spearman rank correlation test was used to test the relationship between variables such as patients’ age, length of hospitalisation and readiness for discharge. The Mann-Whitney U test was used to test for differences in terms of readiness for discharge between men and women, between those who have chronic diseases and those who do not, those who are on permanent/regular/long-term medication and those who are not. It was also used to check readiness between emergency and elective hospital admissions, as well as between those who underwent surgery and conservative treatment. The Kruskal-Wallis ANOVA test was used to test the influence of education, place of residence and type of surgery. For statistically significant results, a post hoc analysis using the Dunn test was performed to see exactly which groups differed. The significance level was 0.05.
The Bioethics Committee at the Medical University of Warsaw issued statement No. AKBE/209/2022 in which it took note of the information about the study and raised no objections. The study was conducted in accordance with the recommendations of the 1964 Helsinki Declaration and its subsequent amendments. Approval to conduct the study was obtained from the Medical Director of the facility and the approval of the Head of Department. The completion of the questionnaire by the respondents was tantamount to their consent to participate in the study.
Hundred patients, 54% being women and 46% being men aged 18–93 participated in the study. The mean age was 48.19 ±17.683 years. The respondents varied in terms of place of residence and education (Table 1).
The average length of hospitalisation in the surgical ward was 5.61 ±3.081 days. The shortest stay was 1 day and the longest was 16 days. 39% of respondents indicated that they had a chronic condition, with 47% taking medication on a regular basis. More than half of the respondents were admitted to hospital on an elective basis (58%). 66% underwent surgery; the remainder were treated conservatively. Half of the procedures to which the respondents were subjected concerned general surgery (50%), followed by urological (27%) and orthopaedic (23%) procedures. Patients undergoing surgery most commonly underwent general anaesthesia (41%), followed by subarachnoid anaesthesia (35%) and local anaesthesia (18%), while 6% of respondents did not know the type of anaesthesia. Education prior to leaving hospital on post-hospital self-care was given to 74% of respondents. They most often identified the nurse (41%) and the entire treatment team (35%, the doctor was identified by 24%) as the person providing knowledge. Recommendations in writing were received by 22% of respondents. 62% rated their knowledge of self-care after leaving the hospital as very good, 27% as good, and 11% as sufficient.
Results
The mean overall readiness for discharge score was 34.26, SD 5.695, indicating good readiness of respondents for discharge. The highest score was 40 points and the lowest score – 8 points. The best average results were obtained in terms of the ability to take prescribed medication, the ability to perform daily activities, knowledge related to people who can be contacted for help in performing daily activities. The lowest average was obtained in terms of being able to recognise health-related symptoms. Patients rated their preparation for discharge highly in all dimensions (averages of around 4.0) (Table 2).
Older people had a lower overall readiness for discharge score (rho = –0.200, p = 0.047) and a lower score regarding the ability to perform daily activities (rho = –0.318, p = 0.001). Spearman’s rank correlation analysis showed a negative association between age and ability to take prescribed medication (rho = –0.173, p < 0.1) and knowledge related to people/institutions to call in case of an emergency (rho = –0.179, p < 0.1), indicating that older respondents performed worse in these two areas. Gender did not affect readiness for discharge both overall (U = 1106.0, Z = –0.949, p > 0.05) and in its individual dimensions. The results obtained among both groups were at a similar level. The level of education of the respondents did not affect readiness for discharge. The analysis showed no statistically significant effect of education on overall readiness for discharge (F = 3.736, p > 0.05). Those with primary education had the highest average score (35.08 ±4.542), while those with vocational education had a slightly lower readiness for discharge (34.89 ±6.492). In contrast, the lowest mean score for the overall readiness for discharge score was obtained by those with a secondary education (33.00 ±5.133). Education was shown to have a significant effect on patients’ self-reported knowledge of their reasons for taking prescribed medication (F = 9.406, p = 0.024). The post hoc analysis showed that those with a secondary education (3.42 ±1.139) performed the lowest in this respect. No statistically significant differences or correlations were found between the other categories of readiness for discharge and educational level. Place of residence did not affect overall readiness for discharge (F = 0.698, p > 0.05). Those living in a small town had the highest mean score (34.84 ±5.405), while those living in a rural area had the lowest mean score for the overall readiness for discharge score (33.57 ±6.578). No statistically significant differences or correlations were observed between the different dimensions of readiness for discharge and the place of residence of the patients surveyed.
Patients with and without chronic diseases had similar overall discharge readiness scores (U = 1003.0, Z = –1.330, p > 0.05). No statistically significant differences were also found for individual dimensions of readiness for discharge. Taking medication on a regular basis did not affect the overall readiness for discharge. Patients who were not on permanent/regular/long-term medications had similar results to those on permanent/regular/long-term medication (U = 1057.0, Z = –1.003, p > 0.05). Patients who were not taking any medication permanently/on a regular/long-term basis had a slightly higher mean score (35.04 ±4.832). Higher willingness in terms of knowledge regarding taking medication was characteristic of patients who declared that they were not taking any medication on a permanent/regular/long-term basis (4.17 ±1.014). For the other dimensions of readiness for discharge, there were no statistically significant differences according to whether or not medication was taken permanently/on a regular/long-term basis. The mode of hospital admission influenced patients’ overall readiness for discharge (U = 703.5, Z = –3.625, p = 0.000). A higher overall readiness for discharge was characteristic of patients admitted in the elective mode (36.17 ±3.821). Analysis of individual dimensions of readiness for discharge showed statistically significant differences between patients admitted as elective and as emergency in all dimensions. Higher average results were obtained by patients admitted in the elective mode. Duration of hospitalisation affected overall readiness for discharge (rho = –0.202, p = 0.044) and ability to perform daily activities (rho = –0.252, p = 0.011). Long hospitalisation times had a particularly negative impact on patients’ knowledge of medicines (rho = –0.190, p = 0.059). All relationships were described by weak strength and negative direction; the longer the patient’s hospitalisation time, the lower their readiness for discharge.
Patients undergoing surgery and those not undergoing surgery had similar overall readiness for discharge scores (U = 943.5, Z = –1.310, p > 0.05). For the dimensions of readiness for discharge, there were also no statistically significant differences according to whether or not there was surgery during the hospital stay. The specificity of the surgery performed did not affect the overall readiness for discharge (F = 2.525, p > 0.05), with the highest mean score achieved by those who were after urological surgery (36.06 ±4.412) and orthopaedic surgery (36.07 ±3.150). In contrast, the lowest mean score for the overall readiness for discharge score was obtained by patients who had general surgery (33.67 ±6.455). The type of surgery had a statistically significant effect on the dimension concerning the ability to perform daily activities (F = 8.528, p = 0.014). A post hoc analysis showed that those who had undergone general surgery rated their ability to perform daily activities the lowest (4.27 ±1.126). On the other hand, the highest average score in this dimension was obtained by those who had undergone orthopaedic surgery (5.00 ±0.00). For the other dimensions of readiness for discharge, there were no statistically significant differences between the groups.
The study showed a difference in overall readiness for discharge between patients educated about self-care after leaving hospital and those who were not educated (U = 680.0, Z = –2.236, p < 0.05). Higher readiness for discharge was characteristic of patients who were educated (35.00 ±5.389 vs 32.15 ±6.117). Significant differences between the groups were shown for the assessment of patients’ readiness for discharge in the dimensions: knowledge related to people to go to for help with daily activities (U = 743.5, Z = –2.044, p < 0.05) and knowledge related to people/institutions to call in case of an emergency (U = 737.0, Z = –2.004, p < 0.05). Significant results were shown for the dimensions: ability to adhere to treatment recommendations (U = 746.5, Z = –1.876, p < 0.1), ability to notice health-related symptoms (U = 729.5, Z = –1.930, p < 0.1) and knowledge of medication (U = 770, Z = –1.661, p < 0.1). Higher scores on dimensions where differences were statistically significant were obtained by patients who were educated before leaving hospital (Table 3).
Readiness to leave hospital did not depend on the person who educated the patient about self-care and self-care (F = 1.901, p > 0.05). Those who were educated in this area by a doctor had the highest mean score (36.28 ±4.456), while those educated by the whole team had the lowest mean score (33.88 ±6.936). For the individual dimensions of readiness for discharge, there were also no statistically significant differences depending on by whom the patient was educated before leaving hospital.
Discussion
Properly preparing the patient to function independently after leaving hospital is key to their return to daily life and coping with maintaining their health. Lack of RHD is associated with difficulties in coping after discharge and a higher likelihood of returning to hospital within 30 days [13–20]. Analysis of the topic indicates the need to monitor readiness for discharge in terms of, among other things, taking medication as prescribed, recognising and managing distressing symptoms, performing activities of daily living and managing change in health status after discharge from hospital [21]. Readiness for hospital discharge is the feeling that the patient is well cared for during their hospital stay and that they can be safely discharged with the assumption that they will cope once they leave hospital [6], which is an important indicator for assessing a patient’s safe discharge [7, 22]. In the readiness evaluation and discharge interventions cluster randomised clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, – March 31, 2017, included all adult patients discharged to homecare, it was shown that the implementation of readiness evaluation reduced the number of hospital readmissions when the patient themselves assessed their readiness for discharge [13].
In the self-reported survey, the overall readiness for discharge score indicates a good readiness of respondents to leave the hospital. Patients were best prepared in terms of their ability to take prescribed medication, to perform daily activities, and having knowledge related to who to go to for help with daily activities. They were weakest in the categories of being able to recognise health-related symptoms and knowledge of the reasons for taking prescribed medication. In a study by Andruszkiewicz et al. [1], discharged patients with chronic diseases had the most knowledge about the people/institutions to call in case of an emergency (4.63 ±0.85), while they had the least knowledge about the medicines they should take (3.28 ±1.72). In the analysis of studies of patients discharged from the surgical ward, RHD was visible at different levels. Patients discharged with a drain [23, 24] or a stoma of the urinary tract/ureteral stoma [25] performed less well than others [26–29]. This difference may indicate the need for an individual approach to the patient and the elements to consider when educating and preparing a patient with different clinical features for discharge.
Factors negatively influencing RHD were age, which is in line with results obtained by other researchers [23, 25, 30, 31]. Older people achieved lower readiness for discharge. A study by Wallace et al. [27] showed that patients in the age range of 30–45 years had worse outcomes than other patient groups. Older patients show a poorer quality of assimilation and understanding of new information and skills. Therefore, it is important that the family is involved in the education of the patient with impaired cognitive abilities, and the time allocated to education should be selected according to the actual needs. All information provided should be adapted to the patient’s age, mental and physical condition [32, 33]. In our study, a significant factor influencing RHD was the length of hospitalisation, the longer it was the worse the readiness for discharge. Qian et al. [23] studying patients discharged from the hepatobiliary surgery ward who left the hospital with biliary drainage observed that patients who had stayed < 7 days in hospital were worse prepared for discharge. The presence of a drain and the associated specificity of self-care posed a challenge for patients and they needed more time to be ready for discharge. An important factor influencing RHD was the mode of hospital admission. Patients admitted on an elective basis showed significantly higher readiness overall and in all its dimensions. The same results were obtained by Forster et al. [34]. Patients admitted on an emergency basis often have less time and resources to prepare to leave hospital. This may suggest that this group of patients requires additional support and education during the treatment and discharge process. Given these findings, it is clear that although the vast majority of patients are educated, there are many aspects of the discharge process that can be improved. For example, improving the formal process of communicating recommendations in writing can help to increase patients’ readiness for discharge. However, it is also important to remember that the elective patient has time before coming to hospital to familiarise themselves with aspects of self-care after surgery. Therefore, a greater effort should be made in the education of emergency patients.
In our own study, variables such as education, type of surgery and education provided during the stay only influenced some dimensions of readiness for discharge. Patients with a secondary/high school education fared the worst. Patients who were educated performed better in almost all dimensions, but not in overall preparedness. Patients following orthopaedic surgery were better prepared for discharge, particularly in terms of performing daily activities. Several studies [23, 31] have shown that educational level matters in RHD and those with primary education performed significantly worse. This may be related to poorer assimilation of knowledge and information, lower health awareness and lower engagement.
Readiness for discharge was not influenced by variables such as gender, place of residence, presence of chronic diseases, taking permanent/regular/long-term medication, specifics of the operation and the educator. Other studies have also found that place of residence has no significant effect on readiness for discharge [31, 35–37]. Qian et al. [23] pointed out, however, that in the case of discharge of patients with biliary tract drainage, patients living in the rural area performed worse. No analysis of the other variables presented in the/our own study was found in the literature reviewed.
The results of our study indicate several important areas for improvement. For example, although most patients were educated prior to hospital discharge, written instructions were rarely given and it appears that certain issues were omitted, which performed less well. Taking into account the study by Coleman et al. [2], which showed the importance of written post-discharge care plans, we should aim to increase their use in Polish hospitals. In addition to the medical discharge card, it is necessary to introduce a nursing card where the necessary information will be presented, which is not routine in all hospitals in Poland. It should be remembered that verbal education should be supplemented with printed or online information and it is best if they occur together. In such a situation, the patient can look at them at any time and ask the medical staff in case anything is unclear.
In our study, we found that patients taking medication on a regular basis showed some differences, especially with regard to knowledge about taking medication. These findings are in line with the study by Faessler et al. [38], where patients on permanent/regular/long-term medication often need additional education and support for their management. Further research should pay more attention to this group of patients, identifying strategies that can help them better manage their medication after leaving hospital.
In the post-operative period, it is important to recognise the patient’s independence, encouraging activities that teach self-care. The time after treatment also allows for the implementation of individual educational programmes, which should include specific goals in the cognitive, psychomotor and affective domains. The educational programme should be tailored to the patient’s physical and psychological condition and culminates in an assessment of self-care capacity, which should be carried out before discharge from the ward [39]. According to the results, it is important to implement interventions targeting older and long-term hospitalised patients as the length of hospitalisation and older age negatively affect the patient’s readiness for discharge.
The results of our study highlight the importance of conducting further research into the subject of preparing patients to leave hospital, through which the needs of patients can be better understood and effective strategies can be developed to assist in the transition from hospital to home care. Based on the results presented, it can be suggested that improved educational procedures as well as the introduction of systems to assess readiness for discharge, could contribute to better outcomes after leaving hospital. Education related to hospital discharge in a study by You et al. [28] was found to be positively correlated with readiness for discharge. Attention should be paid to the individual needs of the patient, while continuing to search for better methods of health education. This is necessary to improve both discharge readiness and health outcomes for surgical patients.
During the study, some limitations were encountered, firstly, a smaller group of patients than expected was included in the study, which, unfortunately, may affect the inability to refer the results to the general population of patients treated in the surgical ward. The study group was divided almost equally in terms of place of residence and gender. It was diverse in terms of education, form of treatment, specific surgical procedure and type of anaesthesia, which probably gives more insight into the results analysed. However, it is still a small group. The study involved patients hospitalized in a smaller, urban hospital with level 1 and level 2 beds; it is possible that a study in a clinical center would have yielded different results.
Conclusions
Overall discharge readiness for surgical patients is good, but some categories require improvement. Certain socio-demographic and medical variables influence readiness.
In light of the results of the study, the following actions are recommended to improve the process of preparing patients to leave hospital:
individualization of the patient education process: the results indicate the need to adapt the education process to the individual needs of the patient depending on his/her socio-demographic and clinical situation. For example, elderly patients and patients hospitalized for longer periods of time may require additional support and education,
improving the availability of information during hospitalisation: although most patients received information on self-care and self-observation, few received this information in written form. Providing patients with easy-to-understand written instructions can help them to better understand and comply with recommendations after leaving hospital,
interdisciplinary approach: planning, implementation and monitoring of the educational process carried out by all members of the interdisciplinary team according to their competencies, implementation of these recommendations may contribute to improving the process of preparing patients to leave the hospital, which in turn may bring benefits to both patients and the health care system as a whole.
Disclosures
1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.
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