Patient Problems and Advanced Practice Nurse Interventions During Transitional Care

Abstract

This study is a secondary analysis of patient records written by advanced practice nurses (APNs) as they provided discharge planning and 4 weeks of home follow-up to elderly patients hospitalized with common medical and surgical conditions. The purposes of this study were to examine the problems experienced by elders who were hospitalized and discharged to home, the interventions used by APNs as they cared for these patients, and the linkages between patient problems and APN interventions. Care logs written by the APNs to document the patient problems and nursing interventions were content analyzed and coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. The results provided a description of the 10 most frequent problems experienced by the patients linked with the APN's interventions. The study provides a description of the nature and complexity of patient problems as they transition from hospital to home and increases our understanding of the contribution of APNs to the care of elders.

Describing pediatric hospital discharge planning care processes using the Omaha System

“…In this study, health care supervision was documented as a problem for every patient, which validates the rationale for engaging DP staff to coordinate care in the transition to home-based care services. In contrast, Bowles (2000b) and Naylor et al (2000) found the most frequent problems to be in the physiological domain. No physiological problems were addressed by DP staff in our study, which may be explained by the division of DP responsibilities across numerous members of the health care team at the study site.…”

“…Each clinical note was printed and placed in a binder for coding and review by the study team. Previous studies testing the Omaha System using DP notes demonstrated the feasibility of coding nearly 100% of text phrases to Omaha System problems and interventions (Bowles, 2000a andNaylor et al, 2000).…”

“…In the DP literature, three reports have used the Omaha System as a standardized tool to describe patient problems and nurse interventions related to hospital DP (Bowles, 2000b, Brooten et al, 2003and Naylor et al, 2000. All three studies included DP interventions within the greater context of providing transitional care to adults.…”

“…This is likely because discharge teaching is often a primary role of the bedside nurse in preparing patients for discharge (Bowles, 2000a, Bowles, 2000b, Kornburger et al, 2013and Maloney and Weiss, 2008 and, therefore, not a primary focus of DP staff. In contrast, case management was the least frequent category in descriptions of DP in adults (Naylor et al, 2000). This may be due to changes in practice over the past decade or differences between accessed by following the link in the citation at the bottom of the page.…”

“…In contrast, in complex care situations that involve an advanced practice nurse (eg, a transplant coordinator) in the continuum of care from inpatient to outpatient services, the DP functions may include medical treatments and procedures, as well as the discharge management responsibilities (Lerret et al, 2014). This was true in the studies of adult patients (Bowles, 2000b, Brooten et al, 2003and Naylor et al, 2000. Within a DP model of care that includes a prescribed DP role, the design and initial implementation of the discharge plan most likely involves activities such as management, oversight, and supervision, rather than hands-on care.…”