Satoko Nagata, Department of Community Health Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-0033, Japan. Email: firstname.lastname@example.org
Aim: To evaluate the effects of an educational program on discharge planning for staff nurses that was developed to improve their knowledge, attitudes, and practice as well as the organizational climate regarding discharge planning.
Methods: Quasi-experimental design was used. Participants were 256 staff nurses on general internal medicine units in a 1210-bed national university hospital in the Tokyo area. Two groups were studied: an education group consisting of 102 nurses from 4 units and a control group consisting of 154 nurses from 6 units. The 3-month education program included study meetings, periodic conferences, and home visits following discharge. The control group received no education. Both groups answered an anonymous self-administered questionnaire before and after the intervention period. For post-intervention group comparisons, analysis of covariance was used.
Results: We analyzed the data obtained from 87 education group nurses (response rate: 85.3%) and 104 control group nurses (response rate: 67.5%). In the education group, knowledge increased post intervention regarding home visiting nursing services, the hospital discharge planning department, and two relevant Japanese laws related to discharge planning. In addition, the education group showed improvement in attitudes towards discharge planning. Likewise, co-workers' recognition of discharge planning needs and their support for discharge planning were significantly improved in education-group units compared with control-group units.
Conclusion: This education program was successful in strengthening knowledge of various systems related to discharge planning, improving the nurses' attitudes towards discharge planning, and impacting the climate of entire units; therefore, it was found to be effective.
As in other advanced countries, substantial increases in medical expenses have become a big issue in Japan and hospital stays are being shortened by revising the medical treatment fee schedule (Japan Ministry of Health, Welfare, and Labor, 2008). To achieve smooth transfer of patients after the acute phase to another facility or to home for recuperation, discharge planning is becoming increasingly important. Discharge planning for patients aged 75 and over, psychiatric patients, and patients who need long-term care has been part of the medical treatment fee schedule since 2008. One requirement for a hospital to receive this new discharge planning reimbursement fee is the creation of a Department of Discharge Planning. Establishment of these departments is expected to increase among hospitals all over Japan (Nagata et al., 2004).
The need for discharge planning has accelerated throughout the industrialized world; as the population ages, more individuals are living with chronic illnesses, and the length of hospitalization is being curtailed to contain costs. In the USA, hospital Medicare participation has required discharge planning since 1986 (Volland, 1988). The percentage of US elders hospitalized continues to increase with associated complex discharge needs (Walker, Hogstel, & Curry, 2007). Limited reimbursement from Medicare and other insurers has led to early discharge of unstable patients who are vulnerable to poor outcomes. One-fifth of US hospitalizations results in complications that include preventable visits to the emergency room or readmission (Jack et al., 2009). The US Centers for Medicare and Medicaid Services now requires public reporting on hospital performance of discharge planning (Jha, Orav, & Epstein, 2009).
Given the compelling need to determine the most effective discharge planning process, we have developed a new educational program for Japanese staff nurses. The purpose of the study herein reported was to evaluate the effects of this educational program that had been devised to improve staff nurses' practice of discharge planning. In this paper, we used the term “staff nurses” to mean nurses that were “not discharge planning nurses or visiting nurses”, including chief nurses in the hospital ward.
In the discharge planning process, staff nurses play important roles in meeting patients' needs, making referrals to discharge planning resources (discharge planning nurses or social worker), communicating and collaborating with multidisciplinary staff, and adjusting the usual care processes to devise suitable methods for home care (Bristow & Herrick, 2002; Macleod, 2006; Rhudy, Holland, & Bowles, 2010; Robinson & Street, 2004). However, research has revealed that one of the nursing care categories that staff nurses in medical-surgical units regularly missed or omitted is discharge planning (Kalisch, 2006). The reasons for inadequate discharge planning were interdisciplinary miscommunication, lack of knowledge of community resources, busy nursing work schedules, workflow disruptions, and information gaps in the nursing ward handover (Atwal, 2002; Lowenstein & Hoff, 1994; Macleod, 2006; Rhudy et al., 2010; Watts & Gardner, 2005). McKenna, Keeney, Glenn, and Gordon (2000) revealed inadequate communication between hospital nurses and district nurses in Great Britain, and indicated the need for education regarding staff roles. Thus, it is important for staff nurses to build skills in discharge planning and participate in discharge planning in a responsible way.
As home care has grown in importance, classroom and clinical experience in home care nursing was introduced into basic nursing education in Japan in 1996. However, nursing education has included only basic knowledge of discharge planning, and nursing students are not given opportunities to practice discharge planning. Thus, education in the clinical workplace that can promote the ability to practice discharge planning is necessary (Hansen, Matt-Hensrud, Holland, & Severson, 2000). In the UK, a post-registration discharge practice education module was developed and the evaluation of this module is continuing (Lees, Price, & Andrews, 2010).
Hospital educational programs on discharge planning have also been recently introduced in Japan. For staff nurses they have included lectures on relevant topics, periodic conferences about discharge planning (Araga, Kasai, Yamaguchi, & Hatsushika, 2008; Hosokawa, Ishinabe, & Mitsuya, 2008), and practical training through home visits (Sogi, 2007). However, these interventions did not involve controlled studies, so their effectiveness has not been determined in Japan. Therefore, an intervention based on a theoretical framework is needed, and evaluation of the effect of such an intervention program by a controlled study is essential.
Applying KAP to develop our educational program, we planned study meetings, periodic conferences, and home visits. Programs in which participants visit a patient's home combined with lectures are more effective than lectures only to promote the awareness of difficulties faced by discharged patients and improve the activity of discharge planning by staff nurses (Jones, Clark, Merker, & Palau, 1995). To enhance effectiveness, we planned for the program to be provided at the nursing unit level as the organizational climate of the work unit directs motivation and action of individual members (Litwin & Stringer, 1968).
The design of this study was quasi-experimental (i.e. non-equivalent control group pretest-posttest design).
Possible study participants were 256 staff nurses (including chief nurses in wards) working at 10 internal medicine units in hospital A, which is a national university hospital with a total of 1210 beds, located in a metropolitan area of Tokyo. In 2006, the mean hospital stay was 14.7 days. In hospital A, a Department for Discharge Planning was instituted in April 1997, and now includes three physicians (one part time), three nurses (two having other responsibilities as well) and three medical social workers. Staff nurses are expected to complete a high-risk assessment sheet for all adult patients upon admission to identify patients at risk for difficulty at discharge. Physicians in charge or staff nurses request discharge planning to the Department of Discharge Planning for patients who are identified through the high-risk assessment sheet or are judged during the hospitalization as likely to present difficulty at discharge. In response to a written request, the Department of Discharge Planning initiates a discharge plan for patients. Staff nurses have differing degrees of interest or activity for discharge planning, and routine discharge planning conferences are seldom held.
All 256 nurses agreed to participate in the study. Assigned to the education group were 102 nurses from four units who were introduced as candidates to receive the educational program by the respective nursing section and approved by nursing administration. One hundred fifty-four nurses from the other six internal medicine units were assigned to the control group. Randomization was not possible in our study.
Design of educational program for discharge planning
Knowledge in the KAP model was presented through study meetings and periodic conferences. At the study meeting, participants were given information about the discharge planning system, and at the periodic conference, they were encouraged to utilize their knowledge and execute the discharge planning process for actual patients. The model of the program is shown in Figure 1.
To decide the content of the lectures and method of the conference presentation, based on the theory of adult education by Knowles (1980), in March and April 2007, group interview sessions attended by staff nurses were held to determine their educational needs with regard to discharge planning. Attending the first session were three nurses who worked at hospital A for less than 5 years, and attending the second session were two nurses who worked more than 10 years at the hospital. All were members of a study group on discharge planning in the hospital, and they attended these interview sessions upon request of the researchers through use of a mailing list. The facilitator of the sessions was the first author (SS), and other researchers (NS and TH) provided additional support during the sessions. In addition, functions and roles necessary for staff nurses were deduced by examining those described by Shinoda (2005). From that information, content was determined in collaboration with researchers specializing in discharge planning. Three nurses in the Department of Discharge Planning of hospital A examined the validity of the program content. Program content is shown in Table 1.
Table 1. Content of educational program on discharge planning
To increase necessary knowledge in and promote change in attitude towards discharge planning. Conducted in each medical unit to influence the organizational climate.
To deepen the knowledge through each case and to promote change in attitude and action. Conducted in each medical unit to influence the organizational climate.
To promote change in attitude and practice by actual visit. To know the real life after discharge, and reflect their discharge planning. Aimed to change the organizational climate by sharing the result of the visit in the whole unit.
All participants in the education group.
All participants in the education group.
Participants who wished to visit a patient's home.
Time: One course consisted of two sessions 30 min each after the day shift. The head nurse arranged that each session be held twice so that all nurses could attend each session.
Time: Conferences were held once a week; sessions were 15–30 min in the afternoon.
Selection of the patient to visit: Patients who would receive home nursing care services after discharge and whose primary nurse wished to visit home. The researcher explained the research to the target patient orally and in writing, and obtained written consent. The rationale of the home visit was conveyed to the doctors and consent was obtained orally.
Place: Nurses' center in each unit.
Procedure: Dependent on unit. Head nurse or nurses in charge of discharge planning moderated. Discussion targets were usually patients judged to be at high-risk for discharge based on scores of “discharge planning sheets” or nurse's own judgement. Researchers confirmed the content of assessment and information lacking and helped staff nurses to participate in discharge planning on their own initiative.
Place: Lecture room in each unit.
Procedure: Researcher lectured on topics and encouraged Q&A and discussion among participants. Materials developed by researchers were distributed later to those who failed to attend the study meeting.
Time: Participant's day off and time when the home care nurse visited the patient's home.
1st session: “Assessment of discharge planning”.
Place: Patient's home.
Procedure: Participant observed how patients received home nursing care services and how they behaved at home. After the visit, the participant made a report of the visit to other nurses on the unit.
Explanation of assessment points from admission to discharge and how to manage the high-risk patients.
2nd session: “Various social resources and systems relevant to discharge planning”.
Explanation of long-term care insurance, Handicapped People Independence Promotion Law, home-visit nursing care services, Policy for Specified Rare and Intractable Diseases, Department of Discharge Planning.
Expected goals were set to the level of an experienced practitioner or newly qualified practitioner (Department of Health, 2004, pp. 41–43). After completion of the program, staff nurses would be expected to:
1Knowledge: Understand the systems related to discharge planning, such as long-term care insurance, as well as the procedures necessary for their utilization (See Table 2) and know the function of the hospital Department of Discharge Planning.
2Attitude: Recognize that discharge planning is their responsibility and intend to do discharge planning routinely.
3Practice: Be able to anticipate problems related to management of medical care and care-giving or daily self-care after discharge. For example, these might include poor understanding of medication or diet therapy, poor family support, or a compromised treatment regimen after discharge. They should make referrals to the Department of Discharge Planning appropriately.
Table 2. The various systems relevant to discharge planning
Long-term care insurance (LTCI)
System for elderly that provides care management and health and welfare services
Handicapped People Independence Promotion Law (HPIPL)
System based on a new law for handicapped people that aims to improve convenience for the users, increase help in obtaining jobs, clarify the process of determination of eligibility, and ensure a stable source of revenue
Policy for Specified Rare and Intractable Disease (PSRID)
System for patients with intractable diseases (such as some neurological diseases and autoimmune diseases). Provides healthcare benefit and nursing or welfare services
Home-visit Nursing Care Services
Very important and familiar system for patients in need of medical care
Difficult to understand the system because it is provided from multiple sources (general medical insurance or LTCI)
In addition, we expected that the quality of communication and collaboration within the target unit would be strengthened after the intervention.
Implementation of the program
The program was presented from 17 July to 28 September 2007, with a single researcher (SS) who was qualified as a care manager and specialized in discharge planning presenting all programs. The study meeting and periodic conference were given concurrently and the home visits were intended to be made thereafter. The schedule was adjusted in consultation with the chief nurse on the unit to enable staff nurses to participate in the program. In the study meeting, the researcher lectured on topics and encouraged questions and discussion among participants using materials developed by the researchers. Information on websites and textbooks were introduced to provide up-to-date information and participants were encouraged to undertake self-study. For the periodic conference, chief nurses were asked to allow the person in charge of the Department of Discharge Planning to participate if it was thought to be helpful. In fact, during the study period, a physician or social worker in the department attended the conference twice by request from nurses of the ward. The lecture content differed depending on the unit, because the target patients and concerns about discharge planning differed among the various units. A home visit was planned so that participants could learn of real life after discharge. The visit was scheduled when a patient's primary nurse wished to visit the home of a patient who received home nursing care services after discharge. The researcher provided the target patient information about the research both orally and in writing, and obtained written consent. The reason for the home visit as part of the education program was conveyed to the physician who was in charge of the target patient and consent was obtained orally. The visit was voluntary (not as duty), so the researchers explained the effect of the visit and encouraged participation to the targeted nurses. In contrast, no part of the program was provided to the control group. Everyday discharge planning activities were conducted as usual with no involvement of the researchers.
All participants were asked to complete an anonymous self-administered questionnaire before and after the intervention period. Pre-intervention questionnaires were collected between 4 and 17 July 2007 and post-intervention questionnaires were collected between 17 and 31 October 2007. To measure post-intervention changes in individual nurses, pre- and post-intervention questionnaires were numbered, with each nurse completing two questionnaires having the same number. These were distributed by chief nurses in each unit and returned in a sealed envelope. All questionnaires were opened and data were entered after the intervention and after all data had been collected. Therefore the researchers did not have access to any results during the intervention and data collection period.
Knowledge necessary for discharge planning
To measure changes in knowledge brought about by the intervention, the questionnaire elicited information on the nurses' understanding of the five study meeting topics:
1Long Term Care Insurance
2Handicapped People Independence Promotion Law
3Policy for Specific Rare and Intractable Diseases
4Home-visit Nursing Care Services
5Department of Discharge Planning
A scale of 1 to 5 was used, with 5 representing the highest level of knowledge. For example, 5 indicated a strong level of understanding that permitted the nurse to explain regulations to a patient and 1 reported no understanding at all.
Attitude toward discharge planning
To determine changes in attitude toward discharge planning, the researchers created survey questions from reviewing previous studies and authoritative Japanese textbook information on discharge planning. The following eight items were examined:
“I worry about the individual patient's life after hospital discharge.”
“I am trying to find methods of care that can be continued at home.”
“I am trying not to overlook signs indicating risk after discharge.”
“I am taking precautions to prevent disuse syndrome for smooth transfer to home.”
“Soon after admission, I try to maintain close contact with the family in order to foster trust and discuss the concern for post-discharge.”
“I am striving to get information on social resources necessary for discharge planning.”
“I am willing to cooperate with other professionals while conducting discharge planning.”
“I am willing to take part in the training on discharge planning being conducted within and outside of the hospital.”
The answers ranged from “5: exactly so” to “1: not so.” Total points were calculated under the designation of “consciousness of discharge planning” (Cronbach's α = 0.825). Content validity was checked by hospital staff and the discharge planning researcher, and the one-dimensional nature was confirmed by principal component analysis. Total scores ranged from 8 to 40 points; higher scores indicated better attitudes.
Practice of discharge planning
For comprehensive evaluation of behavior in discharge planning, the Discharge Planning Process Evaluation Measurement (DCP-PEM), for which reliability and validity were already examined, was used (Chiba, 2005). The DCP-PEM has 26 subjective questions in five areas for individual reporting: screening, assessment, care planning, implementation, and monitoring. Answers ranged from “5: done well enough” to “1: completely in error," with the total score ranging from 26 to 130. Higher scores indicate superior discharge planning behavior.
The researchers created six questions to determine participants' perception of other unit nurses' interest in discharge planning, how much communication about it was welcomed, and the degree to which they could get support for discharge planning from other nurses in their unit. The questionnaire was based on the interviews with staff nurses about the barriers to or facilitators of discharge planning. Factorial analysis (least squares method without weighting, varimax rotation) was performed and factors were divided into two subscales using a screen plot. The co-workers' recognition of discharge planning subscale (Cronbach's α = 0.859) included three items:
“Discharge planning is a usual topic among co-workers.”
“Co-workers understand everyday tasks for discharge planning.”
“Co-workers try to tackle discharge planning positively throughout the whole unit.”
The support for discharge planning from co-workers subscale (Cronbach's α = 0.853) included another three items:
“I can get advice on discharge planning from my co-workers.”
“I can get instructions about discharge planning from my co-workers.”
“Co-workers are willing to collaborate on discharge planning together.”
Content validity was confirmed by staff nurses and the discharge-planning researcher. The answers were from “5: exactly so” to “1: completely different.” Scores of each subscale ranged from 3 to 15 points.
Individual participation during intervention period
After the intervention, subjects from both the education and control groups were asked about whether they had participated in training on discharge planning within and outside of the hospital and whether they had attempted to learn about discharge planning on their own initiative during the 3-month period. The education group was asked about attendance at study meetings and periodic conferences.
Characteristics of participants
Prior to the intervention periods, information was obtained from participants in both groups regarding age, sex, job title (chief nurse, senior vice-chief nurse, vice-chief nurse and no title), years of nursing experience, institution attended for nursing education, presence or absence of practical training in home nursing care as a student and number of home visits as a trainee, and presence or absence of experience in home care services.
In this study it was necessary to compare data on the same participants before and after the intervention while maintaining anonymity. Chief nurses in each unit were asked to distribute questionnaires with the same numbers to the same nurses. These nurses were asked to seal each questionnaire in an envelope without a signature and put it in the collection bag placed in each unit. Data were not analyzed during the intervention period to assure that the research procedure would not be changed based on information elicited in the pre-intervention questionnaire. The above procedures were approved by the Ethical Committee of the University of Tokyo.
Based on means, standard deviations, and level of DCP-PEM score in previous trials (Chiba, 2005), we calculated that a sample size of 63–98 participants for each group was needed to detect a 10% difference between groups (alpha = 0.05, 80% power) (Polit & Beck, 2004). To compare the basic characteristics of the participants in both groups, t-test, Fisher's exact test and Mann-Whitney U-test were used. For comparison of participation and learning activities among the units in the education group, Fisher's exact test and Kruskal-Wallis test were used.
To evaluate the effect of the intervention, analysis of covariance (ANCOVA) was conducted. Post-program values were the dependent variables and the presence or absence of the intervention was the independent variable. The model was controlled for corresponding pre-program value, age, job title, educational institution, years of experience and presence or absence of practical training in home nursing care as students. Similarly, analysis of covariance was conducted to determine differences in the effects of the intervention that might be caused by participation rate in education program within the educational group. Level of significance was set at 5% (two-sided) in all analyses. Statistical package SPSS version 12.0 J for Windows was used for analysis.
The flow of participants through the study is shown in Figure 2. Collection rates of questionnaires for the two groups combined were 90.6% for the pre-intervention period and 87.9% for the post-intervention period. These high respondent rates reflect the positive culture of cooperation and respect for the researcher. Sixty-five participants were excluded because their post-intervention data could not be matched to their pre-intervention data or major data were not reported. Finally, 87 participants in the education group (85.3%) and 104 from the control group (67.5%) were included in the analysis.
Characteristics of participants
Table 3 shows the characteristics of the participants. Most were under 40 years of age; 57.5% and 65.4% in the education group and control group, respectively, were aged in their 20s. In both groups, approximately 70% had less than 7 years of nursing experience, and more than 97% of participants had no experience in the practice of home nursing care services. Higher percentages in both groups graduated from 4-year universities or colleges than from junior college or nursing vocational schools. More than 80% of participants had practical training in home nursing care as a student. These characteristics did not differ between the education and control groups.
Table 3. Characteristics of the participants (n = 191)
Education group (n = 87)
Control group (n = 104)
Fisher's exact test;
Mann-Whitney U-test. Does not include missing values.
Participation was examined for each educational unit (Table 4). The degree of participation in the interventions did not differ significantly among the four educational units. More than 60% of the education group participated in the first and second study meetings, though the percentage of participants within units varied from 40.0 to 92.3%. Most participants attended the periodic conference one to four times. We confirmed that about 80% of nurses on duty in each unit joined the periodic conference whenever it was offered.
Table 4. Participation in the program (Education group [n = 87])
A unit (n = 23)
B unit (n = 25)
C unit (n = 13)
D unit (n = 26)
Fisher's exact test;
‡ Kruskal-Wallis test. Does not include missing values.
Unfortunately, a home visit was made by only one and two participants from units A and B, respectively. In units C and D, a home visit could not be made because the patients with whom the visit was planned either died or were readmitted before the expected visit. Nurses who did make the visits realized that how patients were cared for during hospitalization made a difference in their post-discharge life and that they had not understood the patients' feelings sufficiently during hospitalization.
Table 5 illustrates the extent of nurse involvement in discharge planning education during the intervention period. Compared with the control group, a significantly greater percentage of the education group participated in training within the hospital (48.3% vs 9.7%) and conducted learning on their own initiative (31.0 % vs 12.6%).
Table 5. Learning activities related to discharge planning during intervention period (n = 191)
Education group (n = 87)
Control group (n = 104)
Fisher's exact test. Does not include missing values.
Participated in training in the hospital
Participated in a seminar outside of the hospital
Study about discharge planning voluntarily
Effects of intervention
Table 6 shows differences between baseline assessments and post-intervention period assessments between the education group and control group. At baseline, only co-worker's recognition of discharge planning differed significantly between the two groups; the mean (SD) was 10.7 (2.3) in the education group and 9.5 (2.3) in the control group (P = 0.001). Four knowledge categories improved significantly in the education group after the intervention period compared with the control group; knowledge of the Handicapped People Independence Promotion Law (HPIPL) (P = 0.004), knowledge of Home-Visit Nursing Care Services (P = 0.009), knowledge of the Policy for Specific Rare and Intractable Diseases (PSRID) (P < 0.001), and knowledge of the Department of Discharge Planning (P = 0.007). Likewise, significant improvements in attitude were observed in the education group (P = 0.045).
Mean score of “Co-worker's recognition of discharge planning” was significantly higher in the education group than in the control group at baseline;
‡ Independent variable: intervention status. Controlling variables: age, job title (administrative/no title), graduated institution, years of nursing experience, home-visit experience as a nursing student, value at baseline;
§ DCP-PEM: Discharge Planning Process Evaluated Measurement. Listed are five subscales. Does not include missing values.
In contrast, the Discharge Planning Process Evaluation Measurement (DCP-PEM) revealed a tendency toward improvement in the subscale screening (P = 0.052), but no significant improvement was shown in the other 4 subscales or the sum total of the DCP-PEM. Finally, measurement of organizational climate revealed significant improvements in the education group for both co-worker's recognition of discharge planning (P = 0.001) and support for discharge planning from co-workers (P = 0.007) in comparison with the control group.
Differences attributed to the extent of participation in educational activities were examined. No significant differences in any of the items were found by analysis of covariance conducted between participants who attended both sessions of the study meeting and those who missed study meeting sessions. Analysis of covariance conducted between participants who attended the periodic conference three times or more and those who did not revealed that frequent attendance was related to improvement in the co-worker's recognition of discharge planning (P < 0.001) and the screening subscale of DCP-PEM (P = 0.022).
We evaluated the effectiveness of this new program from various viewpoints. After the 3-month intervention period, knowledge of discharge planning and attitude toward discharge planning were superior in the education group compared with the control group. Improved organizational attitude was also documented in participating units.
To improve general knowledge, information on selected relevant topics was presented at study meetings. In addition, at the periodic conference, nurses discussed matters related to introduction or implementation of home-visit nursing care services for selected patients or care plans for patients with intractable diseases. Sometimes persons from the Department of Discharge Planning attended the periodic conference to explain their role in an actual case. These program components deepened the knowledge of the participants in the education group. Furthermore, more participants in the education group studied discharge planning on their own initiative than those in the control group. This is partly because materials about discharge planning were distributed and information on websites and related literature were introduced at study meetings. Such a comprehensive approach led to demonstrated effectiveness in improving nurses' knowledge level.
In contrast to the improvement shown in four of the knowledge items, knowledge of the long-term care insurance system did not improve. Study participants worked in internal medicine units in which many patients were eligible for long-term care insurance, so their knowledge of the system may already have been extensive. Thus, it is possible that content on this subject in study meetings may have been insufficient to produce further improvement in knowledge. Hereafter it may be necessary to avoid presenting information on topics for which staff nurses may already have extensive knowledge and instead focus on presenting the newest information, which may be less familiar to them.
Significant improvement in attitude was similar to that shown in previous studies (Araga et al., 2008; Hosokawa et al., 2008). In study meetings, the researcher emphasized the necessity of conducting discharge planning soon after admission and the importance of being aware of the patient's daily life at home from the time of admission. Furthermore, in the periodic conference, participants discussed how to change the care at the hospital in order to help the patient adjust to the home environment after discharge so that the patient/family could continue care at home. Through the program the participants became aware of the necessity of discharge planning and their professional role so that their attitude toward discharge planning was changed.
Results of evaluation using the Discharge Planning Process Evaluation Measurement were disappointing overall. The only subscale that improved was screening. This can be understood because assessment points necessary for discharge planning were explained in study meetings and repeatedly emphasized in the periodic conferences. In contrast, no effect of the intervention was observed with the other subscales. The DCP-PEM is a self-administered questionnaire, and therefore the results reveal respondents' subjective understanding of their own ability rather than actual performance. It is possible that they under-reported their own practice. However, it is known that changes in knowledge and attitude do not always cause changes in practice (Witte, Girma & Girgre, 2001/2002). Reform of the system or process of discharge planning may be necessary to improve practice. Or participants may not have been confident of their ability in discharge planning because the study period was too short, even though their ability and performance might actually have been improved by the program. A previous study in which the intervention was shown to have resulted in improvement in care management behavior had a 1-year intervention period (Hosokawa et al., 2008). We need to examine the program's effectiveness in altering or influencing behavior related to discharge planning over a longer period, both in relation to the length of the education program and the period of observation after the educational intervention.
Positive effects were noted in both recognizing discharge needs and supporting discharge planning. The unit-by-unit method of implementation would be expected to result in such changes. Organizational climate can be understood as an expression of the cumulative situational motivational influences for a group of individuals (Litwin & Stringer, 1968). When the intention of many people within an organizational unit becomes similar, this intention characterizes the organizational unit and makes up the framework for group judgment and behavior. A program that intends to change the unit as a whole would easily attain common cognition throughout the unit. The research of Petersson, Springett, and Blomqvist (2009) reveals that organizational support is an important factor to attain high quality discharge planning. Tsukamoto et al. (2000) noted that the support of unit staff is essential to discharge planning performance. Therefore the organizational climate determines the progression of discharge planning activities.
Problems in implementing the program
With the aim of attracting many staff nurses, the first and second study meetings were held with attention paid to the circumstances of each unit. Nevertheless, some participants could not attend one or both of the meetings. Further examination is necessary to determine when and how frequently these meetings should be held and discern the most effective procedures for announcement of the program. As Japanese systems related to medical or long-term care are revised every few years (Tsutsui & Muramatsu, 2007), nurses must continue to acquire up-to-date information on this subject. Thus, it is necessary to prepare programs that periodically offer the newest information.
We noted that the effect on co-worker's recognition of discharge planning and screening behavior differed significantly depending on the degree of participation in periodic conferences. It is necessary to find a way for the content of such conferences to be shared within the unit.
Implementation of the home visit involved only three nurses from two medical units. Nurses who did conduct a home visit indicated that it was a meaningful experience. Generally, the need for practical training in home nursing care is high among staff nurses and the effectiveness of home visiting experiences as a component of continuing education has been demonstrated (Jones et al., 1995; Sogi, 2007). We conclude that home-visit training should be incorporated into the general education program for staff nurses together with other components of the program.
In the future, study meetings for all nursing staff will be planned to regularly address the complex issues related to discharge planning. The nursing staff of the Department of Discharge Planning will have a continuous educational connection with each unit. It is also necessary to introduce periodic conferences to all units so that all units can become involved in discharge planning on their own initiative.
Limitations of the study
Several limitations can be identified. In the present study, random allocation of the education and control groups was not possible. Because units differed according to interest in, degree of participation in and understanding of discharge planning, the results of this study are at risk of some bias. Also, the frequency of the study meetings and content of the periodic conferences were not completely standardized because the schedule and content differed depending on suitability to the units. In addition, the outcomes of the intervention were evaluated by nurses' self-reports, so they could under or over report their knowledge, attitudes, and practice.
We could not prevent the spread of the intervention effect to other units' nurses including the control group. Some nurses in the intervention group could not attend a meeting or conference, so the dose of intervention was not assured. Intervention spread or insufficient intervention dosage might have weakened the power of the intervention effect. Certainly inadequate home visiting experience was a deficiency of this study.
This study was conducted in internal medicine units of a national university hospital in a metropolitan area in Japan, so that the generalizability of the program must be examined in other situations. Furthermore, the study did not examine practice outcomes and actual changes in discharge planning behavior. To do this in the future, we would need to monitor the rate and timing of patient referrals to the Department of Discharge Planning, examine the average length of hospital stay and rate of readmission, and evaluate patient and family self reports of readiness for discharge to home.
This is the first quasi-experimental Japanese study that investigated the effect of a multi-method educational program on discharge planning for staff nurses presented unit by unit in order to improve their knowledge, attitudes, and practice and the organizational climate about discharge planning. The present program was successful in strengthening knowledge of various systems related to discharge planning, improving the individual nurse's attitude towards discharge planning, and impacting the climate of entire units. We anticipate that our multi-method educational approach may be adapted in hospitals throughout the world that are seeking to improve their discharge planning activity. The need for discharge planning is compelling, as is demonstrated by the recent campaign launched by the U.S. Centers for Medicare and Medicaid Services to improve quality while reducing readmissions; the government plan to reduce payment for hospital readmission is likely to provide a significant incentive (Jha et al., 2009). Throughout the industrialized world, skilled discharge planning to maximize patient stability at home is becoming more and more crucial to assure quality and cost effective care.
We wish to acknowledge the participants in this study. This study was funded by the Health and Labour Sciences Research Grants of Japan in 2007.