21
Patient Education and Counseling, 16 (1990) 21-28 Elsevier Scientific
Publishers
Ireland
Ltd.
Factors Influencing Patients’ Informational Hospital Discharge
Needs at Time of
Natalie Bubela” and Susan Gallowayb ‘Scarborough Grace Hospital and 3unnybrook Health Science Centre (Canada)
with
Elizabeth McCay’, Ann McKibbond, Judith Shamian”
Lynn Nagled, Dorothy
Pringle”, Eleanor
Rossd and
‘Mount Sinai Hospital, Toronto, Yiunnybrook Health Science Center and ‘Faculty of Nursing, University of Toronto (Canada) (Received October (Accepted Janaury
20th. 1989) 24th, 1990)
Abstract
positively correlated with informational needs at the time of discharge.
The relationship between patients’ perceived informational needs and selected illness-related sociodemographic and variables were examined in a sample of 301 adult medical and surgical patients preparing for discharge from an acute care setting. Marital status, living arrangements and chronicity of illness had no influence on the importance of informational needs as measured by the Patient Learning Need Scale (PLNS). More informational needs were identified by females than males, and those with malignant as opposed to benign disease. Length of time spent in the hospital, number of discharge medications, and patient perception of the influence of the illness on life were N. Bubela, RN, MSc(A) is Director of Nursing Practice. S. Galloway, RN, MScN is a Clinical Nurse Specialist. E. McCay, RN, MScN is a Research Assistant. A. McKibbon, RN, BScN is a Clinician. L. Nagle, RN, MScN is a PhD candidate. D. Pringle RN, PhD is Dean of Faculty of Nursing. E. Ross, RN, MScN is a PhD candidate. J. Shamian, RN, PhD is Vice-President Nursing.
0731%3991/90/$03.50 Published and Printed
0 1990 Elsevier Scientific in Ireland
Publishers
Keywords: Information; Discharge planning.
Patient
education;
Introduction Education has been shown to be effective in increasing patients’ management of their own health care [l-4]. However, with shortened hospital stays, time constraints on patient education have increased. Teaching patients in preparation for discharge from the hospital is the responsibility of health professionals, but acutely ill patients have neither the physiological stability nor the cognitive energy to learn about care at home until near the time of discharge. Once patients are ready to learn, they may find it difficult to identify what problems may arise at home [5,6]. To facilitate predischarge learning, it is necessary to understand what information patients’ perceive as important to manage their care at home and to recognize
Ireland
Ltd
22
factors which might affect the extent of the knowledge desired. Such information could help the health professional set priorities and focus’the scope and content of educational interventions. Since the literature reflected scant knowledge about factors which could influence perception of discharge informational needs, a study was conducted to describe person and illness related factors which might be associated with increased informational needs at the time of hospital discharge. It is known that patients may feel threatened during an illness experience, but they will usually strive to regain personal control of their lives as they move from the hospital to home. Averill [7] suggests that individuals will attempt to overtly manage events affecting them (behavioural control), create mental images of the sequence of events involved in their illness (cognitive control), and identify choices they have in managing their lives (decisional control). Recognition of the need for more knowledge or skills for self-management of care will be reflected by the informational needs identified by each individual. The importance of discharge teaching has been documented. Patients following hospitalization for myocardial infarction [3,8] and cancer surgery [9] reported major deficits in knowledge of self-care and treatment regimens at the time of discharge. The reports did not indicate whether information related to subjects’ concerns had been given prior to discharge. Studies which have focused on patients’ perceived needs for information during hospitalization or at the time of discharge, demonstrate agreement in some areas of informational needs across patient populaInformational needs related to tions. knowledge of condition, medications, treatments and complications, managing activities of daily living and interpersonal communication were identified [lo-121. One study noted that an increased desire for information
was found in subjects who were younger, male and had higher levels of education [13]. However, other studies have not conclusively delineated the relationship of personal or illness-related variables to informational needs as perceived by the patient [ 12,141. A factor influencing patients’ informational needs may be how the illness is perceived to be affecting their life. It would seem logical that as an individual feels an increase in the effect of the illness, more information will be sought in an attempt to control the negative impact which the illness has on life. However, at present there is limited empirical support for predictions about the nature of relationships between selected variables and perceived desire for knowledge at the time of discharge. Therefore, the study explored variables which might be associated with predischarge informational needs. Variables examined included: (a) sociodemographics of gender, age, marital status, living arrangements and educational background; and (b) illness-related factors such as type of illness, length of hospitalization, concurrent illness, number of medications and perceptions of the impact of illness on life. Method
Setting The study was conducted in a I200 bed university teaching hospital located in a large metropolitan area. The sample included 301 adult medical and surgical patients who were within 72 h of discharge from an acute care setting to their own homes. Before being approached about the study, patients were to have knowledge of their pending discharge, and based upon nursing judgement, have the ability to participate in the management of their health care. Informed consent was obtained from each subject prior to a 45 min interview which took place in the hospital setting. Each interview consisted of the administra-
23
tion of the Patient Learning Need Scale (PLNS), visual analog scales designed to measure the subjects’ perceptions of how much the illness was influencing their life at present and in the future, and structured questions related to sociodemographic data such as educational level which could not be obtained from the chart.
ness on their life at present using the Present Visual Analog Scale (PVAS). The perceived influence on life in the future was measured with the Future Visual Analog Scale (FVAS). Both scales are measured 100 mm lines with two anchor points, 0 = no influence to 100 = total influence. The test-retest reliabilities measured after 24 h were reported as 0.69 for the PVAS and 0.79 for the FVAS [lo].
Instruments Patient Learning Need Scale. Perceived informational needs at discharge were measured on the Patient Learning Need Scale (PLNS) a 50 item self-administered scale that yields a total and seven subscale scores. Subjects were asked to rate each item in terms of its importance to know for the management of their health care at home. Each item was scored on a scale of 0 (does not apply) to 5 (extremely important).
Sociodemographic and illness related variables. During the interview sociodemographic data was obtained and data related to illness and treatment were obtained from a review of subjects’ current hospital records.
The content of the subscales address knowledge related to: medication administration (Medications); guidelines for physical activity, rest, sleep and nutrition (Activities of Living); availablity of health care services in the community (Community and Followup); recognition and expression of feelings associated with the illness (Feelings Related to Condition); understanding the purpose of treatments and recognition and care of possible complications (Treatment and Complications); management of symptoms (Enhancing Quality of Life); and caring for the integument (Skin Care).
Table I. Sample characteristics learning need scale scores.
Content and construct validity of the instrument have been documented [lo]. Cronbath’s alpha reliability is reported as 0.95 for the total scale with reliabilities of six subscales ranging from 0.88 to 0.79. A reliability of 0.69 is reported for the subscale of Skin Care. Perception of influence of illness scales. Perceptions of the influence of the illness on life at present and in the future were measured by two visual analog scales. Subjects rated perceptions of the influence of their ill-
Sample The 301 subjects ranged in age from 18 to 80 (mean = 53.8, SD = 18) and had been
Variable
and patient
PLNS mean
n
%
150 151
49.8
Male
51.2
161 149
Marital status Married
176 39 60 16 10
59.5 13 19.9 5.3 3.3
159 169 148 139 148
Education in grades 6-10 11-13 College’
47 112 142
15.6 37.2 41.2
165 166 147
Diagnosis Benign Malignant
216 85
72 28
153 167
Location in hospital Medicine Surgery
128 173
42.5 57.5
164 149
Gender Female
Widow Single Divorced Other
“College = community
college and university.
24
Table II. Total and subscale scores on the patient learning need scale. Scores
No. of items
Mean SD
Range
n
Total score
50
157
50.1
27-247
254
7 9
25 28
9.7 10.8
o-35 o-45
290 292
7 5
16 13
10.1 6.9
o-35 O-25
291 293
9 8 5
33 26 12
9.9 9.7 6.7
o-45 O-40 O-25
291 288 298
Medications Activities living Community/ followup Feelings condition Complications/ treatment Quality of life Skin care
hospitalized from 2 to 84 days (mean = 13.7). Characteristics of the sample are described in Table I. Results
The overall and subscales scores of the PLNS are reported followed by correlations or comparisons of the scores by specific sociodemographic and illness related variables. Table III.
Patient learning needs Subjects demonstrated a range of learning needs at the time of discharge. The mean total score was 157 (SD = 50.1) from a possible score of 250. Subscale scores of the PLNS are outlined in Table II. Sociodemographic variables Age. Based upon the Pearson productmoment coefficient, there was no statistically significant relationship found between age and total PLNS scores. There were no significant relationships between age and six of the subscales. Age and the Community and Followup subscale showed a significant positive relationship with age (r = 0.19, P < 0.001). Thus, as age increased so did the importance of information related to knowing about community resources. Gender. The mean scores of the total PLNS were significantly higher in females than in males (t = 2.09, P < 0.05). The Activities of Living and Enhancing Quality of Life subscales contributed to the overall higher mean scores of female subjects. Level of education. One-way analysis of variance on the responses of all subjects by level of education showed that there was a significant level effect on total PLNS scores (F (2,254) = 4.4, P < 0.01). The source of significant findings was further investigated
Correlation of patient learning need scores and illness related variables.
Scale
Total score Medications Activities living Community/followup Feelings condition Complications/treatment Quality of life Skin care * = P< 0.01; ** = P< O.OOl.
Coefficients No. Medical problems
No. discharge medications
Length of stay
WAS
FVAS
0.13 0.16* 0.04 0.18* 0.12 0.04 0.09 0.13
0.22** 0.27** 0.12 0.22** 0.20** 0.07 0.17* 0.18*
0.19** 0.16* 0.20** 0.23** 0.13 0.05 0.17; 0.10
0.16; 0.11 0.07 0.11 0.15* 0.14* 0.26** 0.06
0.18** 0.11 0.09 0.19** 0.18* 0.14* 0.21” 0.09
25
by Duncan’s Multiple Range Test. Results showed that learning need scores of the middle and the low level education groups were not statistically different. However, the middle level was different than the high level group such that subjects who had not gone to university or community college reported significantly greater learning needs than subjects with education beyond high school. Marital status and living arrangements. The effects of marital status and living arrangements on total PLNS scores were examined by analysis of variance. No statistically significant difference in total PLNS scores could be attributed to either of these variables. Illness related variables Length of hospital stay. The length of time spent in the hospital was utilized as an indirect measure of illness severity as experienced by the subjects. There was a significant positive correlation between the number of days spent in hospital and total PLNS scores (r = 0.19, P < 0.001) and scores on four of the subscales (see Table III). Concurrent health problems and medications. There was no statistically significant correlation between the number of concurrent health problems and total PLNS scores. Positive correlations were found between the number of medications being taken and subjects’ total PLNS scores (r = 0.22, P < 0.001) and scores from five of the subscales (see Table III). Type of illness. No significant differences were identified between the PLNS scores of subjects with an acute illness and of those with a chronic illness. There was also no relationship between the length of time since diagnosis and PLNS total or subscale scores. Medical subjects’ total PLNS scores were higher (t = 2.63, P < 0.01) than those of surgical subjects. However, both the length of stay in the hospital (t = 6.8, P < 0.001) and the number of medications ordered for dis-
charge (t = 3.5, P < 0.01) were significantly higher for subjects on medical units. Longer stays and more medications were also associated with higher total PLNS scores and when total PLNS scores of medical and surgical subjects were compared with the control for the effects of the two variables, PLNS scores were not different. Therefore, it was not the geographical area which altered importance of informational needs but treatment regimens involving more medications and longer hospitalizations. When compared to subjects with benign diagnoses, subjects with cancer had higher total PLNS scores (t = 2.06, P < O.O$) and higher subscale scores for Activities of Living (t = 1.97, P 4 0.05), Community and Follow-up (t = 2.81, P < O.Ol), and Feeling Related to Condition (t = 4.72, P< 0.000). Perceptions of influence of illness. Perceptions of the present impact of the illness (PVAS) scores ranged from 0 to 100 (n = 299). The mean score was 67 with a standard deviation of 32. Perceptions of the future impact of illness (FVAS) scores ranged from 0 to 99 (n = 294). The mean score was 59.6 with a standard deviation of 66. It was felt that as perceptions of the amount of influence the illness would have on the life increased so would the importance for information related to discharge. The prediction was supported in the present sample (see Table III). Discussion Individuals preparing to return home expressed a variety of informational needs related to the resumption of behavioural, cognitive, and decision-making tasks of health management. Although informational needs were not related to age, marital status, or concurrent health living arrangements, problems, they were influenced by gender, level of education, number of medications, type of illness experience and individual perception of the influence that illness would have on life.
26
Influence of age, gender and educational level Although older patients placed increased importance on learning about community resources and followup, age did not correlate with other subscale or total PLNS scores. The lack of significant correlations are of particular interest since the literature indicated that increasing age decreased the number of informational needs while in the hospital [ 131. It would appear that individuals, regardless of age, acknowledge a similar number of informational requirements as they resume responsibility for health care. The latter finding is consistent with clinical accounts where the number and importance of learning needs at discharge are similar across age groups. Females reported more informational needs than males at the time of discharge. An examination of the background characteristics of the males and females indicated that there was no statistically significant difference between the two groups on the basis of age, marital status, or type of illness. Demonstrated differences may relate to role expectations and behaviours. Higher female scores in Activities of Living and Enhancing Quality of Life could be reflective of the female role as “protector of health” [13]. Nonetheless, interpretation of the gender difference should be approached with caution for the clinical significance of a difference of 0.05 is uncertain. The level of education could influence the manner in which an illness experience is perceived and did effect the degree of importance placed on learning needs at discharge. Subjects who had not attended University or more desired Community College information than with subjects who had education beyond high school. Individuals with college education may be more comfortable seeking information within a hospital setting and have more questions answered than individuals with less education. Alternatively, the same amount of information seeking may be present across patient populations, but the
clarity of communication may not be sufficient for retention of material in individuals with less education. Health care professionals should remain cognizant of the fact that individuals with less education may require more assistance in interpreting the information given. Illness related variables The finding that the longer-stay patients identified more informational needs at discharge is consistent with the problems encountered in discharge planning for patients with long hospital stays [ 151. Superfilonger cially the association of hospitalizations with increased desire for information at discharge appears to contradict the assumption that shorter hospital stays are a factor in patients requirements for more information. However, since all patients in health care systems are being discharged earlier than they might have been ten years ago, all patient education must be addressed within a shorter period of time than previously. Possible reasons for increases in informational needs after longer hospitalizations are varied. Longer stay patients may experience multiple health problems and have more queries related to self-management. Dependency on health care providers can occur during a lengthy admission. Consequently, patients faced with impending discharge may ask many questions as they try to resume independence. Experiential factors related to an illness could also impact on perceptions of informational needs. The longer an individual is hospitalized and lives with a condition, the more opportunity there is to learn about how to manage the condition. It could be argued that patients who are discharged earlier have not had much time to experience the situation and they may not have the same number of questions or concerns as they might in a later phase of their illness experience. However,
21
Table IV.
Implications for practice.
1. Greater informational needs may be seen at discharge in patients who are: 0 female ?? low and middle level of education ?? diagnosed with cancer ?? with extensive mediction regimens 2. Educational strategies while in the hospital should consider: ?? identification and early referral to material resources or personnel such as pharmacists or clinical nurse specialist . development of pamplets, videotapes and other material for discharge education 3. Continuity of patient education after discharge may be improved if ?? referrals are made to community health care agencies or support groups ?? community referrals include an outline of what information was given and suggestions for future
length of time since diagnosis did not affect learning needs so it may be that patients discharged earlier have an acuity level whereby they lack the cognitive energy to formulate questions or indeed absorb information that has been given. If either experiential awareness or cognitive energy are factors in raising concerns, patients who are discharged earlier should have access to community resources where they could obtain information about their health problem. Informational needs increased with the number of medications required at discharge. Such a finding is not unexpected given the complexity of medication regimens often prescribed, and the numerous drug interactions and contraindications that need to be considered. The medications taken may hinder mental processing of information and hinder the ability to retain information. Additionally, the number of medications required may be an indirect indicator of the severity of the problems faced by an individual. A diagnosis of cancer is often perceived as life threatening and many questions arise related to the self-management of care after discharge [9]. The results of the study support the notion that a diagnosis of cancer increases learning needs at discharge. The total PLNS scores of the malignant subgroup when
compared to a benign population were higher and not surprising the dimensions of Feeling Related to the Condition and Community and Followup were major factors contributing to the higher scores. It has been noted [8] that patients do want information related to their diagnosis, plan of care, and care for themselves out of hospital. The importance placed gaining knowledge increased as the perceived impact of the illness on life increased. Identification that perception of the impact of the illness on life is related to informational needs at discharge highlights the necessity to examine the individuals’ experiences from their perspective. Implicationsfor practice and research The findings of this study indicate that patients nearing discharge from an acute care setting have many informational needs as they resume management of their health care. Hospital health care professionals may be able to foster patients’ resumption of self management in the early postdischarge period by utilizing the suggestions outlined in Table IV. Future research concerning patients perceived informational needs could focus on a number of issues. The scale utilized in the present study did measure the importance of informational needs but did not differentiate
28
by the depth or breadth of response required. The number of questions and their importance can be helpful in targeting patient’s requirements for information, but the complexity of the query must also be addressed. The availability and the type of resources for patient education within a selected setting should be considered in assessment of informational needs at discharge. Additionally, specific populations desire for information should be explored and researchers should interview the families as an additional source of information related to preparation for discharge. Since it is likely that the type of information desired will change over time, there is a need to evaluate patients’ educational requirements at specific intervals post-discharge.
information to help their management health care is adequately met. Acknowledgment
The research was supported by the Sunnybrook Research Trust and the Department of Nursing, Sunnybrook Health Science Centre.
References 1
2
3
4
Summary 5
North American health care is moving to a model of increased home care during illness, shorter hospital stays and fewer professional restraints, nursing caregivers. Budgetary shortages and consumer awareness heighten the need to increase resources which will facilitate independence in health care. In view of the increasing age and acuity of hospital populations, informational needs at discharge should be evaluated for all types of patients. In order to facilitate patients’ return to self-care following discharge, health care professionals must identify and attend to patients’ learning needs. During an illness experience involving hospitalization, individuals may have been dependent on health care providers but will strive to regain personal control of life in the phase of the experience involving transition from hospital to home. Indicators which may help identify patients who require greater access to information at discharge include being female, a diagnosis of cancer, increased length of stay in hospital, number of medications, and perceived influence of the illness on life . Studies with specific patient populations will give further direction to effective pre- and post-discharge interventions to ensure patients’ desire for
of
6 7 8 9
10
11
12 13 14
15
Bille DA: A study of patients’ knowledge in relation to teaching format and compliance. Supervisor Nurse 1977; 8: 5-62. Given B, Given CW, Simoni LE: Relationships of processes of care to patient outcomes. Nurs Res 1972; 28: 85-93. Hentinen M: Teaching and adaptation of patients with myocardial infraction. Int J Nurs Stud 1986; 23: 125138. Redman BK: New areas of theory development and practice in patient education. J Adv Nurs 1985; 10: 425428. Baden CA: Teaching the coronary patient and his family. Nurs Clin N Am 1982; 7: 563-571. Blumberg BD, Kearns P, Lewis MJ: Adult cancer patient education: an overview. J Psycho1 Oncoll983; 1: 19-39. Averill JR: Personal control over adverse stimuli and its relationship to stress. Psycho1 Bull 1973; 80: 256-303. Edwardson SR: Outcome of coronary care in the acute care setting. Res Nurs Health 1988; 11: 215-222. Oberst MT, James RH: Going home: patient and spouse adjustment following cancer surgery. Top Clin Nurs 1985; I: 45-51. Bubela N, Galloway S, McCay E, McKibbon A, Nagle L, Pringle D, Ross E, Shamian J: Perceptions of learning needs to prepare for discharge home: development and testing of a measure. Report submitted to Department of Nursing, Sunnybrook Medical Centre, Canada, 1989. Casey E, O’Connell JK, Price JH: Perceptions of educational needs for patients after myocardial infarction. Patient Educ Couns 1984; 6: 77-82. Derdiarian AK: Informational needs of recently diagnosed cancer patients. Nurs Res 1986; 35: 276-281. Dodge JS: Factors related to patients’ perceptions of their cognitiveneeds. Nurs Res 1969; 18: 502-513. Lauer P, Murphy SP, Powers MJ: Learning needs of cancer patients: a comparison of nurse and patient perceptions. Nurs Res 1982; 31: 11-16. Morrow-Howell N, Proctor E: Evaluating discharge planning. Discharge Planning Update 1988; 8: 17-20.
Correspondence to: S. Galloway 256 Airdrie Road Toronto, Ontario Canada M4G 1Nl
Patient Education and Counseling, 16 (1990) 21-28 Elsevier Scientific
Publishers
Ireland
Ltd.
Factors Influencing Patients’ Informational Hospital Discharge
Needs at Time of
Natalie Bubela” and Susan Gallowayb ‘Scarborough Grace Hospital and 3unnybrook Health Science Centre (Canada)
with
Elizabeth McCay’, Ann McKibbond, Judith Shamian”
Lynn Nagled, Dorothy
Pringle”, Eleanor
Rossd and
‘Mount Sinai Hospital, Toronto, Yiunnybrook Health Science Center and ‘Faculty of Nursing, University of Toronto (Canada) (Received October (Accepted Janaury
20th. 1989) 24th, 1990)
Abstract
positively correlated with informational needs at the time of discharge.
The relationship between patients’ perceived informational needs and selected illness-related sociodemographic and variables were examined in a sample of 301 adult medical and surgical patients preparing for discharge from an acute care setting. Marital status, living arrangements and chronicity of illness had no influence on the importance of informational needs as measured by the Patient Learning Need Scale (PLNS). More informational needs were identified by females than males, and those with malignant as opposed to benign disease. Length of time spent in the hospital, number of discharge medications, and patient perception of the influence of the illness on life were N. Bubela, RN, MSc(A) is Director of Nursing Practice. S. Galloway, RN, MScN is a Clinical Nurse Specialist. E. McCay, RN, MScN is a Research Assistant. A. McKibbon, RN, BScN is a Clinician. L. Nagle, RN, MScN is a PhD candidate. D. Pringle RN, PhD is Dean of Faculty of Nursing. E. Ross, RN, MScN is a PhD candidate. J. Shamian, RN, PhD is Vice-President Nursing.
0731%3991/90/$03.50 Published and Printed
0 1990 Elsevier Scientific in Ireland
Publishers
Keywords: Information; Discharge planning.
Patient
education;
Introduction Education has been shown to be effective in increasing patients’ management of their own health care [l-4]. However, with shortened hospital stays, time constraints on patient education have increased. Teaching patients in preparation for discharge from the hospital is the responsibility of health professionals, but acutely ill patients have neither the physiological stability nor the cognitive energy to learn about care at home until near the time of discharge. Once patients are ready to learn, they may find it difficult to identify what problems may arise at home [5,6]. To facilitate predischarge learning, it is necessary to understand what information patients’ perceive as important to manage their care at home and to recognize
Ireland
Ltd
22
factors which might affect the extent of the knowledge desired. Such information could help the health professional set priorities and focus’the scope and content of educational interventions. Since the literature reflected scant knowledge about factors which could influence perception of discharge informational needs, a study was conducted to describe person and illness related factors which might be associated with increased informational needs at the time of hospital discharge. It is known that patients may feel threatened during an illness experience, but they will usually strive to regain personal control of their lives as they move from the hospital to home. Averill [7] suggests that individuals will attempt to overtly manage events affecting them (behavioural control), create mental images of the sequence of events involved in their illness (cognitive control), and identify choices they have in managing their lives (decisional control). Recognition of the need for more knowledge or skills for self-management of care will be reflected by the informational needs identified by each individual. The importance of discharge teaching has been documented. Patients following hospitalization for myocardial infarction [3,8] and cancer surgery [9] reported major deficits in knowledge of self-care and treatment regimens at the time of discharge. The reports did not indicate whether information related to subjects’ concerns had been given prior to discharge. Studies which have focused on patients’ perceived needs for information during hospitalization or at the time of discharge, demonstrate agreement in some areas of informational needs across patient populaInformational needs related to tions. knowledge of condition, medications, treatments and complications, managing activities of daily living and interpersonal communication were identified [lo-121. One study noted that an increased desire for information
was found in subjects who were younger, male and had higher levels of education [13]. However, other studies have not conclusively delineated the relationship of personal or illness-related variables to informational needs as perceived by the patient [ 12,141. A factor influencing patients’ informational needs may be how the illness is perceived to be affecting their life. It would seem logical that as an individual feels an increase in the effect of the illness, more information will be sought in an attempt to control the negative impact which the illness has on life. However, at present there is limited empirical support for predictions about the nature of relationships between selected variables and perceived desire for knowledge at the time of discharge. Therefore, the study explored variables which might be associated with predischarge informational needs. Variables examined included: (a) sociodemographics of gender, age, marital status, living arrangements and educational background; and (b) illness-related factors such as type of illness, length of hospitalization, concurrent illness, number of medications and perceptions of the impact of illness on life. Method
Setting The study was conducted in a I200 bed university teaching hospital located in a large metropolitan area. The sample included 301 adult medical and surgical patients who were within 72 h of discharge from an acute care setting to their own homes. Before being approached about the study, patients were to have knowledge of their pending discharge, and based upon nursing judgement, have the ability to participate in the management of their health care. Informed consent was obtained from each subject prior to a 45 min interview which took place in the hospital setting. Each interview consisted of the administra-
23
tion of the Patient Learning Need Scale (PLNS), visual analog scales designed to measure the subjects’ perceptions of how much the illness was influencing their life at present and in the future, and structured questions related to sociodemographic data such as educational level which could not be obtained from the chart.
ness on their life at present using the Present Visual Analog Scale (PVAS). The perceived influence on life in the future was measured with the Future Visual Analog Scale (FVAS). Both scales are measured 100 mm lines with two anchor points, 0 = no influence to 100 = total influence. The test-retest reliabilities measured after 24 h were reported as 0.69 for the PVAS and 0.79 for the FVAS [lo].
Instruments Patient Learning Need Scale. Perceived informational needs at discharge were measured on the Patient Learning Need Scale (PLNS) a 50 item self-administered scale that yields a total and seven subscale scores. Subjects were asked to rate each item in terms of its importance to know for the management of their health care at home. Each item was scored on a scale of 0 (does not apply) to 5 (extremely important).
Sociodemographic and illness related variables. During the interview sociodemographic data was obtained and data related to illness and treatment were obtained from a review of subjects’ current hospital records.
The content of the subscales address knowledge related to: medication administration (Medications); guidelines for physical activity, rest, sleep and nutrition (Activities of Living); availablity of health care services in the community (Community and Followup); recognition and expression of feelings associated with the illness (Feelings Related to Condition); understanding the purpose of treatments and recognition and care of possible complications (Treatment and Complications); management of symptoms (Enhancing Quality of Life); and caring for the integument (Skin Care).
Table I. Sample characteristics learning need scale scores.
Content and construct validity of the instrument have been documented [lo]. Cronbath’s alpha reliability is reported as 0.95 for the total scale with reliabilities of six subscales ranging from 0.88 to 0.79. A reliability of 0.69 is reported for the subscale of Skin Care. Perception of influence of illness scales. Perceptions of the influence of the illness on life at present and in the future were measured by two visual analog scales. Subjects rated perceptions of the influence of their ill-
Sample The 301 subjects ranged in age from 18 to 80 (mean = 53.8, SD = 18) and had been
Variable
and patient
PLNS mean
n
%
150 151
49.8
Male
51.2
161 149
Marital status Married
176 39 60 16 10
59.5 13 19.9 5.3 3.3
159 169 148 139 148
Education in grades 6-10 11-13 College’
47 112 142
15.6 37.2 41.2
165 166 147
Diagnosis Benign Malignant
216 85
72 28
153 167
Location in hospital Medicine Surgery
128 173
42.5 57.5
164 149
Gender Female
Widow Single Divorced Other
“College = community
college and university.
24
Table II. Total and subscale scores on the patient learning need scale. Scores
No. of items
Mean SD
Range
n
Total score
50
157
50.1
27-247
254
7 9
25 28
9.7 10.8
o-35 o-45
290 292
7 5
16 13
10.1 6.9
o-35 O-25
291 293
9 8 5
33 26 12
9.9 9.7 6.7
o-45 O-40 O-25
291 288 298
Medications Activities living Community/ followup Feelings condition Complications/ treatment Quality of life Skin care
hospitalized from 2 to 84 days (mean = 13.7). Characteristics of the sample are described in Table I. Results
The overall and subscales scores of the PLNS are reported followed by correlations or comparisons of the scores by specific sociodemographic and illness related variables. Table III.
Patient learning needs Subjects demonstrated a range of learning needs at the time of discharge. The mean total score was 157 (SD = 50.1) from a possible score of 250. Subscale scores of the PLNS are outlined in Table II. Sociodemographic variables Age. Based upon the Pearson productmoment coefficient, there was no statistically significant relationship found between age and total PLNS scores. There were no significant relationships between age and six of the subscales. Age and the Community and Followup subscale showed a significant positive relationship with age (r = 0.19, P < 0.001). Thus, as age increased so did the importance of information related to knowing about community resources. Gender. The mean scores of the total PLNS were significantly higher in females than in males (t = 2.09, P < 0.05). The Activities of Living and Enhancing Quality of Life subscales contributed to the overall higher mean scores of female subjects. Level of education. One-way analysis of variance on the responses of all subjects by level of education showed that there was a significant level effect on total PLNS scores (F (2,254) = 4.4, P < 0.01). The source of significant findings was further investigated
Correlation of patient learning need scores and illness related variables.
Scale
Total score Medications Activities living Community/followup Feelings condition Complications/treatment Quality of life Skin care * = P< 0.01; ** = P< O.OOl.
Coefficients No. Medical problems
No. discharge medications
Length of stay
WAS
FVAS
0.13 0.16* 0.04 0.18* 0.12 0.04 0.09 0.13
0.22** 0.27** 0.12 0.22** 0.20** 0.07 0.17* 0.18*
0.19** 0.16* 0.20** 0.23** 0.13 0.05 0.17; 0.10
0.16; 0.11 0.07 0.11 0.15* 0.14* 0.26** 0.06
0.18** 0.11 0.09 0.19** 0.18* 0.14* 0.21” 0.09
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by Duncan’s Multiple Range Test. Results showed that learning need scores of the middle and the low level education groups were not statistically different. However, the middle level was different than the high level group such that subjects who had not gone to university or community college reported significantly greater learning needs than subjects with education beyond high school. Marital status and living arrangements. The effects of marital status and living arrangements on total PLNS scores were examined by analysis of variance. No statistically significant difference in total PLNS scores could be attributed to either of these variables. Illness related variables Length of hospital stay. The length of time spent in the hospital was utilized as an indirect measure of illness severity as experienced by the subjects. There was a significant positive correlation between the number of days spent in hospital and total PLNS scores (r = 0.19, P < 0.001) and scores on four of the subscales (see Table III). Concurrent health problems and medications. There was no statistically significant correlation between the number of concurrent health problems and total PLNS scores. Positive correlations were found between the number of medications being taken and subjects’ total PLNS scores (r = 0.22, P < 0.001) and scores from five of the subscales (see Table III). Type of illness. No significant differences were identified between the PLNS scores of subjects with an acute illness and of those with a chronic illness. There was also no relationship between the length of time since diagnosis and PLNS total or subscale scores. Medical subjects’ total PLNS scores were higher (t = 2.63, P < 0.01) than those of surgical subjects. However, both the length of stay in the hospital (t = 6.8, P < 0.001) and the number of medications ordered for dis-
charge (t = 3.5, P < 0.01) were significantly higher for subjects on medical units. Longer stays and more medications were also associated with higher total PLNS scores and when total PLNS scores of medical and surgical subjects were compared with the control for the effects of the two variables, PLNS scores were not different. Therefore, it was not the geographical area which altered importance of informational needs but treatment regimens involving more medications and longer hospitalizations. When compared to subjects with benign diagnoses, subjects with cancer had higher total PLNS scores (t = 2.06, P < O.O$) and higher subscale scores for Activities of Living (t = 1.97, P 4 0.05), Community and Follow-up (t = 2.81, P < O.Ol), and Feeling Related to Condition (t = 4.72, P< 0.000). Perceptions of influence of illness. Perceptions of the present impact of the illness (PVAS) scores ranged from 0 to 100 (n = 299). The mean score was 67 with a standard deviation of 32. Perceptions of the future impact of illness (FVAS) scores ranged from 0 to 99 (n = 294). The mean score was 59.6 with a standard deviation of 66. It was felt that as perceptions of the amount of influence the illness would have on the life increased so would the importance for information related to discharge. The prediction was supported in the present sample (see Table III). Discussion Individuals preparing to return home expressed a variety of informational needs related to the resumption of behavioural, cognitive, and decision-making tasks of health management. Although informational needs were not related to age, marital status, or concurrent health living arrangements, problems, they were influenced by gender, level of education, number of medications, type of illness experience and individual perception of the influence that illness would have on life.
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Influence of age, gender and educational level Although older patients placed increased importance on learning about community resources and followup, age did not correlate with other subscale or total PLNS scores. The lack of significant correlations are of particular interest since the literature indicated that increasing age decreased the number of informational needs while in the hospital [ 131. It would appear that individuals, regardless of age, acknowledge a similar number of informational requirements as they resume responsibility for health care. The latter finding is consistent with clinical accounts where the number and importance of learning needs at discharge are similar across age groups. Females reported more informational needs than males at the time of discharge. An examination of the background characteristics of the males and females indicated that there was no statistically significant difference between the two groups on the basis of age, marital status, or type of illness. Demonstrated differences may relate to role expectations and behaviours. Higher female scores in Activities of Living and Enhancing Quality of Life could be reflective of the female role as “protector of health” [13]. Nonetheless, interpretation of the gender difference should be approached with caution for the clinical significance of a difference of 0.05 is uncertain. The level of education could influence the manner in which an illness experience is perceived and did effect the degree of importance placed on learning needs at discharge. Subjects who had not attended University or more desired Community College information than with subjects who had education beyond high school. Individuals with college education may be more comfortable seeking information within a hospital setting and have more questions answered than individuals with less education. Alternatively, the same amount of information seeking may be present across patient populations, but the
clarity of communication may not be sufficient for retention of material in individuals with less education. Health care professionals should remain cognizant of the fact that individuals with less education may require more assistance in interpreting the information given. Illness related variables The finding that the longer-stay patients identified more informational needs at discharge is consistent with the problems encountered in discharge planning for patients with long hospital stays [ 151. Superfilonger cially the association of hospitalizations with increased desire for information at discharge appears to contradict the assumption that shorter hospital stays are a factor in patients requirements for more information. However, since all patients in health care systems are being discharged earlier than they might have been ten years ago, all patient education must be addressed within a shorter period of time than previously. Possible reasons for increases in informational needs after longer hospitalizations are varied. Longer stay patients may experience multiple health problems and have more queries related to self-management. Dependency on health care providers can occur during a lengthy admission. Consequently, patients faced with impending discharge may ask many questions as they try to resume independence. Experiential factors related to an illness could also impact on perceptions of informational needs. The longer an individual is hospitalized and lives with a condition, the more opportunity there is to learn about how to manage the condition. It could be argued that patients who are discharged earlier have not had much time to experience the situation and they may not have the same number of questions or concerns as they might in a later phase of their illness experience. However,
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Table IV.
Implications for practice.
1. Greater informational needs may be seen at discharge in patients who are: 0 female ?? low and middle level of education ?? diagnosed with cancer ?? with extensive mediction regimens 2. Educational strategies while in the hospital should consider: ?? identification and early referral to material resources or personnel such as pharmacists or clinical nurse specialist . development of pamplets, videotapes and other material for discharge education 3. Continuity of patient education after discharge may be improved if ?? referrals are made to community health care agencies or support groups ?? community referrals include an outline of what information was given and suggestions for future
length of time since diagnosis did not affect learning needs so it may be that patients discharged earlier have an acuity level whereby they lack the cognitive energy to formulate questions or indeed absorb information that has been given. If either experiential awareness or cognitive energy are factors in raising concerns, patients who are discharged earlier should have access to community resources where they could obtain information about their health problem. Informational needs increased with the number of medications required at discharge. Such a finding is not unexpected given the complexity of medication regimens often prescribed, and the numerous drug interactions and contraindications that need to be considered. The medications taken may hinder mental processing of information and hinder the ability to retain information. Additionally, the number of medications required may be an indirect indicator of the severity of the problems faced by an individual. A diagnosis of cancer is often perceived as life threatening and many questions arise related to the self-management of care after discharge [9]. The results of the study support the notion that a diagnosis of cancer increases learning needs at discharge. The total PLNS scores of the malignant subgroup when
compared to a benign population were higher and not surprising the dimensions of Feeling Related to the Condition and Community and Followup were major factors contributing to the higher scores. It has been noted [8] that patients do want information related to their diagnosis, plan of care, and care for themselves out of hospital. The importance placed gaining knowledge increased as the perceived impact of the illness on life increased. Identification that perception of the impact of the illness on life is related to informational needs at discharge highlights the necessity to examine the individuals’ experiences from their perspective. Implicationsfor practice and research The findings of this study indicate that patients nearing discharge from an acute care setting have many informational needs as they resume management of their health care. Hospital health care professionals may be able to foster patients’ resumption of self management in the early postdischarge period by utilizing the suggestions outlined in Table IV. Future research concerning patients perceived informational needs could focus on a number of issues. The scale utilized in the present study did measure the importance of informational needs but did not differentiate
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by the depth or breadth of response required. The number of questions and their importance can be helpful in targeting patient’s requirements for information, but the complexity of the query must also be addressed. The availability and the type of resources for patient education within a selected setting should be considered in assessment of informational needs at discharge. Additionally, specific populations desire for information should be explored and researchers should interview the families as an additional source of information related to preparation for discharge. Since it is likely that the type of information desired will change over time, there is a need to evaluate patients’ educational requirements at specific intervals post-discharge.
information to help their management health care is adequately met. Acknowledgment
The research was supported by the Sunnybrook Research Trust and the Department of Nursing, Sunnybrook Health Science Centre.
References 1
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Summary 5
North American health care is moving to a model of increased home care during illness, shorter hospital stays and fewer professional restraints, nursing caregivers. Budgetary shortages and consumer awareness heighten the need to increase resources which will facilitate independence in health care. In view of the increasing age and acuity of hospital populations, informational needs at discharge should be evaluated for all types of patients. In order to facilitate patients’ return to self-care following discharge, health care professionals must identify and attend to patients’ learning needs. During an illness experience involving hospitalization, individuals may have been dependent on health care providers but will strive to regain personal control of life in the phase of the experience involving transition from hospital to home. Indicators which may help identify patients who require greater access to information at discharge include being female, a diagnosis of cancer, increased length of stay in hospital, number of medications, and perceived influence of the illness on life . Studies with specific patient populations will give further direction to effective pre- and post-discharge interventions to ensure patients’ desire for
of
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Correspondence to: S. Galloway 256 Airdrie Road Toronto, Ontario Canada M4G 1Nl
