Nurses' knowledge, perception and practice toward discharge planning in acute care settings: A systematic review

Abstract Aim Discharge planning (DP) guides patients' transition to out‐hospital services. This systematic review investigates nurses' knowledge, perception and practices of discharge planning. Design We conducted a systematic review following PRISMA guidelines. Methods Search terms were used to identify research studies published between 1990–2020 across six databases: CINAHL, MEDLINE, PubMed, Complete Academic search, Science Direct and Google Scholar. A total of nine studies met the inclusion criteria. Results Nine articles revealed nurses' knowledge, perspectives and practices of discharge planning. Obstacles included low‐level knowledge of patients' activities and discharge; inability to define DP; debates over the timing of beginning, implementing and preparing discharge; patients and their family members' negative attitudes towards DP; and perceiving DP as excessive, time‐consuming paperwork for which the physician is responsible. Better time management during work improves DP in acute care settings.


| INTRODUC TI ON
Historically, discharge planning (DP) has been defined as the activities that guide patients to community services after being discharged from any care setting (Abdulfattah & Mushcab, 2017). It was concerned only with the physical aspects of the patients. However, over time, the word "planning" began to involve short-term goals, such as predicting changes in the patients' needs and long-term goals, such as providing continuous care. Today, the main aim of DP is to help patients progress through various levels of care. For instance, the needs may need to be met in critical care units or regular wards (Abdulfattah & Mushcab, 2017). DP is now considered a process, not a single event. The process ought to begin at admission and proceed until the patient is allocated to the next level of health care (Birjandi & Bragg, 2008). The patient should receive the understanding, motivation and skills necessary for self-management at home (Flink & Ekstedt, 2017).

| BACKG ROU N D
Discharge planning sets the foundation for effective changes in patients as they move from hospitals to their homes (Nordmark, Zingmark, & Lindberg, 2016;Pellett, 2016). It prepares individuals and their families for independent self-care by providing them with appropriate support and resources in their community. Effective hospital DP can be classified into four categories: policymakers', service providers' and recipient service behaviours; organization; payment and financing; and regulation (Gholizadeh, Janati, Delgoshaei, Gorji, & Tourani, 2018). DP is a multidisciplinary process for the continuity of care outside the hospital. The process includes identification, assessment, goal setting, planning, implementation, coordination and evaluation (Lin, Cheng, Shih, Chu, & Tjung, 2012).
A discharge planner advises, sets the process within a health institution, prepares and educates all staff and provides assistance in planning for discharge. The discharge planner plans, coordinates and communicates with patients, families and other healthcare providers while observing the DP process. A discharge planner can be a nurse, social worker, attending physician or case manager (Lin et al., 2012). DP involves (a) the early identification and assessment of patients needing DP assistance; (b) working with the patient, family and multidiscipline team to promote DP; (c) recommending alternatives for continued patient care and referring to accommodations, programs, or facilities to satisfy patient requirements and preferences; (d) collaboration with community organizations and care centres to encourage patients and address service gaps; and (e) support patients and families during hospital evaluation phases (Lin et al., 2012).
Numerous organizational, personal and socio-cultural factors influence DP (Alreshidi, Long, & Cappleman, 2016) and the discharge planner must address the aspects that may affect patients during this transition period. First, physiologic factors include the assessment of patients' physical and functional abilities and their nutritional status and medications (LPN2009, 2006Mehta, Nair, Rao, & Shukla, 2015). Second, psychological factors entail the assessment of patients' learning abilities and feelings about their diseases. Finally, discharge planners must assess social factors, such as the duration of care needed, the types of services available and the family involved in the care (LPN2009, 2006Mehta et al., 2015).
The complexity of DP depends on the patient's needs. A simple DP should be applied when the patient does not need referrals outside the hospital. However, care planning requires assessment, preparation and effective communication with multidisciplinary teams. Simple DP may include check-ups for smooth transport to home after ensuring readiness at home and a review of the patients' medication and nutritional needs (Goodman, Brompton, & Trust, 2010). The discharge planner must also verify whether patients and their families have received the specific information that they need. Complex DP should be introduced when patients' demands are more complicated and nurses are urgently needed to guarantee that patients have adequate support outside the hospital to achieve better health outcomes . If a patient needs a referral to an occupational or physiotherapist outside the hospital, or continuous nursing care at home, complex DP will need to be implemented (Goodman et al., 2010;Shimogai, Izawa, Kawada, & Kuriyama, 2019).
Due to the inconsistencies in the literature and the scarcity of consistent evidence regarding the assessment of nurses' knowledge, perception and practices of DP in acute care settings, the review questions for this study were as follows.

| S TUDY DE S I G N
We performed a systematic review using clearly formulated questions based on the background. All authors identified relevant studies, appraised their quality and summarized the evidence using an explicit methodology. We thoroughly reviewed studies that addressed nurses' knowledge, perception and practices of discharge planning in acute care settings.

| ME THODS
The researchers conducted an extensive nursing literature search using six key databases: CINAHL, MEDLINE, PubMed, Complete Academic search, Science Direct and Google Scholar. The search was limited to articles written in English and published in scientific journals, exclusively using human samples with a publication date in 1990 or later. The following keywords were used: discharge planning, nurses' perception, nurses' attitudes, nurses' knowledge and practices towards discharge planning. At the end of the search strategy, nine studies were found to address our literature review questions.
The Preferred Reporting Items for Meta-Analysis (PRISMA; Appendix S1) was used in this review, including the PRISMA checklist and flow chart. The PRISMA flow chart displayed in Figure 1 shows our comprehensive systematic search of the six databases, and the following keywords were used: (discharge planning) AND (acute care setting) AND ((knowledge) OR (attitude) OR (practice) OR (perception) OR (behavior)). The field was limited to "title/abstract," and the publication type was limited to "journal article." We performed reference tracking to identify additional, potentially relevant references. The aforementioned keywords and selection strategies yielded 30 articles. We removed duplicate articles and excluded seven additional articles after reviewing titles, abstracts and keywords. A total of 9 full-text articles remained after excluding nine articles for reasons such as addressing DP among healthcare providers other than nurses. Figure 1 shows the nine selected articles.
Three researchers independently inspected the titles and abstracts to identify nurses' knowledge, perception and practices towards effective discharge planning (DP) in acute nursing units.
The inclusion criteria were as follows: nurses' knowledge/skill, attitude/belief or practice/behaviour/implementation of DP; barriers or facilitators of effective/successful DP; original scientific studies; and written in English. The exclusion criteria were: reports or articles on DP from patients' standpoints or opinions; studies without clearly defined DP or among other health professionals/care providers; or systematic reviews, non-research literature and conference presentations.
Three researchers independently assessed each study selected for retrieval for the quality of the methodology before inclusion in the review. The methodological quality assessment of the studies used in this study was supported with critical appraisal, using the

| ANALYS IS
Our data analysis/synthesis procedures were in line with the JBI-MAStARI tool. The extracted data included specific details about the knowledge, perception and practices of DP from nurses' standpoint, meeting the review's specific objectives. Independent reviewers of this study read the included studies, extracted the results relevant to the review questions and compared the methodologies, samples, interventions and results. When there were discrepancies in the assessment or data extraction process, the researchers discussed and resolved the issues.
Comparative thematic analysis was used to develop broader pertinent themes for the current systematic review. The researchers read and assess the papers thoroughly to familiarize themselves with the subjects. Then, the authors made initial codes using the most common results from the reviewed papers to create themes. The two main themes were as follows: (a) demographic variables' role in implementing effective DP; and (b) nurses' knowledge, attitude and practices of effective DP in acute care settings. The researchers connected the yielded themes to the research questions to answer the review questions (Table 1).

| RE SULTS
The role of demographic variables in implementing effective DP was the first theme that this review yielded. One study examined factors affecting DP based on nurses' characteristics, including age, gender, Full-text articles assessed for eligibility (N = 9), ex: nurses, provide bed side care Study revealed that hospital's culture which is not highly interested in DP, and the negative attitude of patients and their families as some nurses stated that they become frustrated when they deal with rude patients, or even if the patients not interested in DP, this theme was considered the major barrier to conduct DP.

TA B L E 1 (Continued)
marital status, work hours and education level (bachelor's degree or higher). It revealed a strong relationship between the level of education and the implementation of DP (p-value .023). A higher level of education made nurses more systematic and logical in planning for discharge (Zakiyah & Basuki, 2017).
All the studies identified nurses as the cornerstone of DP in their settings. Only one study reported that DP was the responsibility of physicians and healthcare providers rather than nurses. All the studies focused on female nurses as the main part of their study populations. This focus underestimated the representation of male nurses.
The participants' ages in the nine articles ranged from 18-53 years.
A review of the literature regarding demographic variables was conducted to determine their influence on nurses' knowledge, perception and practices of DP. In most studies, there were more females than males, making a comparison of gender-based respondents difficult. Eleven men and 36 women were included in a study to examine the assessment of nurses' knowledge of DP (Mohammad, Fadil, & Ahmed, 2016) and 13 females and two male nurses in another (Lalani & Gulzar, 2001). Chaboyer and colleagues did not include gender-based information because female respondents were predominant and male nurses were uncommon (Chaboyer et al., 2004;Chaboyer et al., 2002). A total of 124 females and 12 males were investigated by Morris et al. (2012), whereas 22 females and three males participated in another study (Chang et al., 2015).
One study reported strong evidence that the number of years of nursing experience affected patients' recovery and health outcomes positively (Atwal, 2002). In contrast, another study conducted in Iraq reported that new graduates and young nurses were more excited and interested in performing DP; this study was the only one to discover a relationship between age and DP (Mohammad et al., 2016).
The second theme that this review revealed was nurses' knowledge, attitude and practices towards effective DP in acute care settings. In terms of knowledge, one article showed that staff nurses perceived themselves as more qualified than other healthcare providers to perform DP (Spataro, 1994). Another article reported that nurses lacked knowledge in patients' follow-up (Mohammad et al., 2016). One article showed that most nurses were unable to define DP and that lack of time was the source of the deficit in knowledge and application of DP (Lalani & Gulzar, 2001).
In terms of nurses' perception, three articles reported that nurses felt DP was a time-consuming process, potentially affecting their engagement with it (Atwal, 2002;Chaboyer et al., 2004;Chaboyer et al., 2002). Chang et al. (2015) discovered the primary factor influencing nurses' DP implementation was an adverse attitude from patients and their relatives. One study showed that nurses believed that their role in DP was to communicate with other healthcare providers.
Another showed that communication was considered the main reason for successful DP (Watts & Gardner, 2005). Hofmeyer and Clare (1999) acknowledged that hospital liaison nurses played a crucial role in the continuity of care of the elderly because they linked the communication between hospital and community nurses and general practitioners.
Likewise, Morris et al. (2012) found that nurses believed that the DP process should be implemented only by qualified liaison nurses; in turn, using a discharge liaison nurse affected nurses' perceptions of DP. Chaboyer et al. (2002) also found that doing so made nurses' attitudes more positive towards DP. They grew more motivated to establish and engage in DP themselves.
In this systematic review, numerous demographic and daily working experience factored into DP implementation among nurses in acute care settings. Although few studies have been conducted on nurses' knowledge, perceptions and practices of successful, effective discharge planning in acute care settings, this systematic review was able to highlight obstacles pertinent to these settings.
First, more attention needs to be paid to clarifying the study methodology to more precisely assess nurses' DP knowledge, attitudes and practices. Spataro (1994)  A study conducted by Lalani and Gulzar (2001) in Pakistan to assess nurses' knowledge, perceptions and actual practice of DP used a cross-sectional design and two semi-structured questionnaires for patients and nurses. Another study (Atwal, 2002) was conducted in a British teaching hospital regarding nurses' perception of DP in an acute care setting.
Atwal interviewed and observed 19 nurses while working in the unit.
The nurses communicated with other healthcare providers in preparation for DP. A lack of time was considered the major barrier for conducting and coordinating the DP process. One of the limitations of this study was the use of only one healthcare setting.
In a qualitative study conducted in a public hospital to explore how nurses perceived DP in an acute care setting, Watts and Gardner (2005) interviewed 12 registered nurses. Only one registered nurse believed that nurses should not be the coordinator of the DP process. Most nurses believed that their role was to communicate with other healthcare providers. The study also reported that nurses should coordinate DP among multidisciplinary personnel.
This role was recognized as the main factor for strengthening or disturbing the DP process because of the necessity of collaboration and communication between nurses and medical staff. The inability to generalize the results of the study was one of the limitations (Watts & Gardner, 2005 believed that one of their roles was to prepare patients for discharge and that DP was a significant process. However, they also believed that the DP liaison team must implement the process. Their results showed that about 21% of nurses lacked understanding of DP. One of the limitations was that the study was conducted in one hospital. In a recent qualitative study, Chang et al. (2015) investigated nurses' perceptions of factors affecting DP implementation in the emergency department. The researchers surveyed 25 nurses and found three categories of factors. The first was the neglected role of nurses in the emergency department. The second was the heavy workload. The third was the negative attitudes of patients and their families towards DP. This study revealed that hospital culture did not reflect a strong interest in DP and the negative attitude of patients and their families presented an obstacle in conducting DP. Some nurses stated that they became frustrated while dealing with rude patients and that patients were not interested in DP. The results are not generalizable to the broader population of emergency nurses.
Published studies in nurses' practices of DP are limited. Although nurses showed an awareness level of DP, the literature showed that only 2% of an 8-hr shift was spent preparing patients for discharge.
Staff nurses can perform DP and assess patients' learning abilities effectively (Spataro, 1994). However, patients' records revealed that nursing assessments were incomplete and the application of DP was fragmented (Lalani & Gulzar, 2001). About 80% of nurses believed that DP should be started when patients were admitted to the hospital (Morris et al., 2012). Numerous factors are involved in the implementation of successful and effective DP. Issues that should be addressed include nurses' low knowledge levels of patients' activities and discharge, inability to define DP, debates over DP timing and preparation, facing negative attitudes from patients and family members negative and considering DP as time-consuming paperwork that the physician should do. There is an urgent need to combat these obstacles to implementing successful discharge planning. Better time management skills during work and relying on liaison nurses may improve DP in acute care settings.