Implementation of Discharge Planning in Hospital Inpatient Room by Nurses

Introduction: Discharge planning is still become a problem for health services in hospital in-patient rooms. Discharge planning commonly is only done when the patients leave hospital by giving them an explanation about the content of the controlling card. Discharge planning is a routine activity that must be done by nurses in order to give information to the patients about their condition and any actions can or should be undertaken by them. In fact, the importance of discharge planning is not yet balanced, nor effectively applied in field. This research was conducted to find out about the implementation of discharge planning by nurses in one of the hospital in-patient rooms at the hospital of study. Methods: This research was a qualitative research study conducted with the phenomenological approach. The informants were 6 patients and 6 nurses in first, second and third class nursing wards. The instruments used in this research were the researchers themselves with interview guidance, field notes and a tape recorder. The data was collected through an in-depth interview. Results: There were three themes found through the analysis, which were 1) the information dimension involving room orientation, rights and obligations, and patient health problems as the sub-themes; 2) the understanding dimension with knowing and understanding the discharge planning as the sub-themes; 3) the implementation dimension with the time of implementation and content of discharge planning as the sub-themes. Discussion: Complete information given to the patients will bring about a positive impact, so then they can help themselves in relation to their curing time at home. A lack of and unclear information will bring about negative impacts such as mistakes when taking drugs, poor diet, neglecting activity while staying at home ARTICLE HISTORY Received: September 18, 2017 Accepted: July 05, 2018


INTRODUCTION
The important elements involved when providing health-care services to patients does not only focus on the adequacy of the infrastructure facilities that can be used as a mirror of quality services, but it is about the fulfilment of the rights of the patient from the beginning of entry until their discharge from the hospital.One of the inherent rights of the patients and their families when admitted to hospital for treatment is to get comprehensive information about their health when it comes to discharge planning.Delgado-Passler et al (2006) explained that discharge planning should be done comprehensively.
Discharge planning services are the responsibility of all health-care professionals in hospital, such as nutritionists, pharmacists, doctors and nurses, as the perpetrators of the 24-hour service that accompany patients during hospitalization.The discharge planning program is focused on providing health education to patients covering nutrition, activities or training, medicine and special instructions on the signs and symptoms of the disease that the patient has (Perry et al, 2006).Before discharge, patients and their families need to know how to manage their condition and/or recovery.Teaching the patients and their families is the duty of the nurses as part of an innovative strategy that is at the forefront of patient care (Bastable et al., 2002).Both patients and their families need a health-care system that enables them to meet their needs, facilitated by self-care services (Mullen et al, 2006).http://e-journal.unair.ac.id/JNERS | 107 The process of discharge planning is used to prepare the patient to leave the hospital (Goodman et al, 2013).Nurses have an importance role in discharge planning (Holliman et al, 2003;Sturdy et al, 2010;Kerr, 2012), so as it can reduce re-visits for patients (Jha et al, 2009;Bailey, 2012;Holland et al, 2012;Mathews et al, 2014;Goodman, 2016).
Patient discharge programs, also known as discharge planning, in hospitals must have standard operational procedures.This is so then each patient gets a discharge program of equal standard regardless of who gives it.Discharge planning that is not good can be one factor that prolongs the duration of healing at home.Patients are declared ready for discharge if the patient is aware of their treatment, signs of harm, activities that need to be performed, and can conduct follow-up care at home (The Royal Marsden Hospital, 2004).
An effective discharge plan should include an ongoing assessment to obtain comprehensive information about any changing patient needs, nursing diagnostic statements and extensive planning to ensure that the patient needs are met according to what healthcare provider they can access (Kozier, 2004).It can be said that discharge planning is a broad and complex process (Durstenfeld et al, 2014).
Field studies have found that a discharge plan can still become a problem for health services in hospital in-patient rooms (Kraft, 2013), where discharge planning is commonly only done when the patients leave the hospital by giving them an explanation about the content of the control card.Popejoy (2008) stated that bad discharge planning could cause serious consequences for the patient.The research done by Lindo et al (2016) at three hospitals in Jamaica showed that discharge planning was done 72 hours after hospitalization.Joanne (2006) stated that the nurses did not have the education and experience needed to provide complex health care to the patients.

MATERIALS AND METHODS
The design of this research was qualitative with a phenomenological approach, which aimed to dig into the subjective experiences presented and to gain better perspective awareness (Moleong, 2010) of the patients and nurses involved related to the implementation of discharge planning in the inpatient room of one of the hospitals.This research was conducted from March to June 2017.The population in this study were patients and nurses in class I, II, and III inpatient rooms.The informants of this research study were 6 patients/families and 6 nurses chosen via purposive sampling with the criterion being the that the patient was an adult aged 21 -60 years old or a paediatric patient represented by a parent who accompanied them during the time in the hospital.The informants in the nursing element were chosen with the criteria that they had been working for at least one year in the hospital, had a diploma-level of education and that they were Ners-qualified.The determination of the number of samples or informants was that it should be between 5 and 25 people (Creswell, 2009).There were 6 people for each sample group (Mason, 2010), since the researchers obtained saturated data by the sixth informant.The research instrument was the researchers themselves, with the help of a question guide, field notes, and a video or tape recorder.The methods of data collection was an in-depth interview with a duration of time between 45 and 60 minutes.The data analysis of this research used the stages proposed by Colaizzi in 1978: 1) describing the phenomenon; 2) collecting the description of the phenomenon on based on the information submitted by the informants; 3) reading the entire description of the phenomenon obtained from the informants; 4) re-reading the transcripts, further reciting any significant statements; 5) attempting to decipher the meaning of each significant statement; 6) organising the set of meanings formed into groups of themes; 7) writing a complete and in-depth description; 8) returning to the participants to obtain validation of the description of the results and 9) validating the results of the analysis directly to the informants (Speziale et al, 2007).As an effort to protect the respondents from any violations of ethics, the research planning study was evaluated by the ethics team in addition to its' application in the field.The researcher gave an informed consent form to each candidate about the advantages, possible risks of the research, and kept the confidentiality of the respondent's name.

Informant Characteristics
The informants in this research were patients consisting of 6 people; 4 people of the female sex, and 2 male.The informant's age was between 19 and 60 years old.The education level of the informants consisted of elementary school students (4 people), senior high school students (1 person) and a university student (1 person).The treatment period is between 2-4 days.The nurses who were on duty at the time of the data collection amounted to 6 people.Out of the total, 5 people were female, and there was 1 male aged between 25-45 years.

Patient Informants
The following questions were asked: "How was your experience while hospitalized here?"and "What kind of service do you want?" After passing the recommended stages, then came the discovery of the themes of the analysis.The analysis results obtained the main theme and subthemes as follows.

Information Dimension
The results of the interviews with the patient informants or the family of the patients found a poor level of expression that led to incomplete information being received by the patients from their first time getting to the inpatient room until leaving the hospital.This certainly can cause the patients and their families to not understand what they should do during the treatment period.The information dimension consists of the sub-themes of room orientation, rights and obligations, and health issues.

Room Orientation
The interviews related to patient orientation and family orientation were found to have no spatial orientation upon first admission.…I want, when I enter here, I get information where is my room directly (P1) … in order to enjoy when get nursing care here, is needed to know the name of the room (P2) …I never introduced before (P1, P3, P4, P5, P6) .... if the information about the room yes ... I was not introduced (P1) ... the explanation of the room, there is no such thing, sir.(P3) "Delivered here ... moved to bed, that's all" (P4) "I just know the name of this room....After my second days here (P5) "My family got the wrong room .... because they did not know" (P6).

Patient Rights and Obligations while an Inpatient
Keywords found in this sub-theme were:

Health Issues Faced by the Patients
Keywords on the health issues faced by the patients were: ……I want to know about my condition?(P2, P3, P4, P5) "Nurses do not tell ... if they did not asked.they just told me"(P2)... ....they explain only when asked (P3, P4, P5)

Nurse Informants
The following questions were asked of the nurse informants: "How about your experience in discharge planning?"and "What kind of service that you want?"

Knowledge Dimension
The results of the interviews with the nursing informants obtained findings about the inappropriate discharge planning in place.Some of the nurses said that they did not know the term 'discharge planning'.If nurses do not know the term 'discharge planning', then they will automatically not be able to do it properly.

Knowing Discharge Planning
Keywords in this sub-theme were: …What….dischargeplanning is? (P1) …What Sir, because I've been one year here (Nurse1) …Not yet, sir because I've been only one year here (Nurse 1) …I know a little, if not mistaken when I was in college, but now I forget it, sir (Nurse 5)

About Discharge Planning
Keywords in this sub-theme were: ......I don't really understand.What I know is that it is the plan for the patient going home (Nurse 2, Nurse 3) "I did not know about discharge planning ... Is it a kind of resume nursing?(Nurse 5)

Implementation Dimension
The results of the interviews with the nurse informants about the implementation of discharge planning led to the discovery of discharge planning not being as suitable as it should be.The implementation dimension obtained two subthemes, namely implementation time and discharge planning content.

Discharge Planning Time
Keywords in this sub-theme were: …yes…when the patients get permission to leave the hospital (Nurse 2) ......When the patient has been discharged from the hospital (Nurse 2) ...... Patients who will go home, right sir? (Nurse 1) "I do it when the patient wants to go home, not at other times" (Nurse 4) …... give it only when the patient will go home (Nurse 3) "If that's usually done when taking-over, sir" (Nurse 5)" I once gave discharge planning when the patient was going home..." (Nurse 6)

The Contents of Discharge Planning
Keywords in this sub-theme were: ... The contents of discharge planning are just about drugs and control dates only ... (Nurse 1) ... Which must be done are call the patient, give the drug schedule, home care, schedule control, risk prevention and diet (Nurse 2) "Control schedule, take-home medicine, time for control, how to go home" (Nurse 3) The activities are….related with explanation about giving medicines, control date, day and control time…like that (Nurse4) "Its activities are related to drug administration, control dates, days and hours of control" (Nurse 4)

Information Dimension
The results of this research are based on in-depth interviews with the informants, which indicate some problems in the discharge planning performed by nurses.The informant stated that at first admission, they were not given an explanation of the room where they were to be hospitalised and an explanation of their rights and obligations as the patient.The explanation about the patient's health problem was done by the nurse when asked by the patient or family.The discharge time, according to Berry et al (2014), was the transitional time usually experienced by the patients regarding some of the problems in understanding the instructions.
Whereas, before discharge, the patients and families must know how to manage their condition at home.Teaching the patients and their families is the duty of the nurses as an innovative strategy that is at the forefront of patient care (Bastable et al., 2002).The patient and their family needs a care system for health that allows them to meet their own care needs (Mullen et al, 2006).Thus, the method of re-teaching (Sawin et al, 2017) should always be done by the nurse.Brooten et al (2002) demonstrated that the teaching should begin as soon as possible during hospitalisation and frequently repeated to ensure the success of patient learning.
Information is the data that has been processed into a form that has meaning for the recipient and is useful for current or future decision-making (McLeod et al, 2001).In the activity of providing nursing care, information for the patients is needed from the beginning of them becoming an inpatient up to the time of discharge.Thus, the discharge planning should begin as soon as possible after the patient is admitted to the inpatient unit (Haber, 1992).This process can help the patients achieve stable health at home, a smooth recovery, and to see improvement in their quality of life (Backer et al, 2007).
The information needed at the beginning of hospitalisation is not only about the patient's health condition, but also information about the room and hospital where the hospitalisation takes place.The provision of early information about anything related to hospitalization can be useful to building the trust between nurses and patients.Simple, clear, and informative information will give the patients and their families an understanding of the hospital and hospitalisation, their health condition and their rights and responsibilities.The provision of information will also improve patient compliance and reduce errors during inpatient care, and later, their time of recovery.
The adherence of patients to the medical advice provided is also strongly influenced by the important role of health communication.There are two things that affect the patient's compliance with accepted medical advice, namely that the patient must first understand the health issues or health problems faced.For that, he must be able to interpret and understand all of the health information communicated by the medical personnel on him.The patient should be able to remember (and memorise) the medical advice provided.When communicating information about the health of the patient, the medical experts should not use medical terms that are difficult to understand and ensure that the information provided is not too complicated.That way, the patient can easily recall all of the health information (medical advice) that has been submitted for him.For example, how many doses for each drug and so on (Rahmadiana, 2012).
The provision of incomplete and unclear information will affect the patient's understanding of their condition.The impact is the mistakes involved from acting, behaving and making decisions based on misunderstanding.This is certainly very dangerous for the life and health of the patients.McBride (2002) said that the failure to communicate health information to patients and their families could result in the patient's lack of understanding of the outcomes of the tests (Rahmadiana, 2012).
Providing incomplete and unclear information could have an influence on the patients' understanding about their condition.Discontinuity in providing information could cause health results that are worse (Wang et al, 2008).This condition is very dangerous for the patient's health and their life.Rahmadiana (2012) stated that failure to communicate the health information to the patient and their families can cause the patients to misunderstand their test results.
Providing suitable health information is an important part of disease prevention and health promotion.Health communication is also considered to be relevant to several contexts in the field of health, including 1) the relationship between medical experts and patients; 2) the reach of individuals in accessing and utilising health information; 3) individual compliance with the treatment process that is to be followed and compliance with advice on the medicines received; 4) conveying health advice and health campaigns; 5) the dissemination of information about health risks to individuals and the population and 6) an overview of health profiles in the mass media (Rahmadiana, 2012).
The value of information that is closely related to the decision to be made, whereas if there is no choice or decision, then information will not be required.Decisions can range from simple recurring decisions to long-term decisions (Alandari, 2013).Incomplete health information may cause patients and their families to be incorrect in making decisions, whether they are taking medication, working on a set diet and other allowable or prohibited actions.
Communication between the patient and nursing staff is a key component of effective health care and lays the foundation for a safe and comfortable nursing environment (Williams et al, 2001). McCormack, (2003) also underscored the importance of patient-centered communication functions.With this in mind, it is important for the nursing staff to take part in planning the discharge of patients to communicate useful information.This is as well as fostering the attitude of sharing knowledge, experiences, hopes and concerns to resolve and describe the work routine for discharge planning.
Health information is not only addressed to the patients.Their families are a part of the inseparable environment of the individual, and have a very important role in realising the individual's health and them being someone who needs emotional support, education, and follow up (Purdy et al, 2015).The family as a support system should always be involved in efforts to solve health problems in individuals.The Medical Mutual of Ohio ( 2008) stated that patients and all of their family members should be informed of all discharge plans.Smith et al (2013) said that the provision of information to the patients and their families enables them to focus on discharge planning.

Dimension of the Nurse's Knowledge on Discharge Planning
The results of the interviews with the nurse informants found surprising data, as there were informants who said that they were not familiar with the term discharge planning.As a nurse, the term discharge planning should not be a strange thing.How can a nurse perform the activities related to discharge planning correctly, if they do not know the term?Knowing something is the first step to action.
A deeper introduction enables a person to understand, and if it is already understood, then they can act or apply it.Sparbel et al (2000) stated that the problem of understanding related to a better health care continuity could help to ensure the delivery of high quality of health care services for all patients.The problem about the lack of nurses' knowledge related to discharge planning is not only happening in Indonesia, but also occurs in other countries.Chaboyer et al (2002), in a survey of 58 nurses working in an intensive care unit, obtained that 43% lacked an understanding of return planning processes, and only 14% stated that the doctors trusted them enough for the nurses to plan the discharge.14% stated that the doctors had given enough referrals for the nurses to design the discharge planning.

Dimension of Discharge Planning Implementation by the Nurses
Discharge planning for patients should be made from the beginning of their admission to the hospital (Rudd et al, 2002).Some research results abroad also showed the same information.Goodman's (2010) study obtained data from nurse respondents stating that the patient's discharge planning should begin at the pre-admission clinic or when they are admitted to the hospital.Morris (2012) also obtained data stating that nearly 80% of respondents agreed that the planning for at-home patients should be started upon their entry to the health care unit.Watts et al, (2005) found from most of the notations in their study that discharge planning was initiated from admission when the patients hospitalized up until they were discharged.
Based on the data above, the planning of patient discharge is not only done when the patient is in the process of being discharged, but Haber (1992) said that it must be done from the beginning when the patient goes the treatment room.It can be said that discharge planning starts from the orientation of the room, an explanation of the rights and obligations of the patient, when conducting a comprehensive assessment, formulating the nursing diagnosis correctly, creating an appropriate nursing plan, performing the planned nursing actions, and evaluating both short and long term treatment plans.
However, looking at the above interview results leading to the timing and content of the discharge planning, it was found that the nurse's understanding of discharge planning was lacking.The nurse informant said that the implementation of discharge planning is the time before discharging the patient, while the content is to provide an explanation of the contents of the control card.Chaboyer et al. (2004), in his research, found that 54% of nurses stated that the implementation of discharge planning was conducted just before the patient leave the service unit.There is concern, as many nurses do not know how to do discharge planning properly.
The implementation of discharge planning information that is important to be delivered to the patient is the possibility of the date of discharge (Lees et al, 2006;Rudd et al, 2002).The provision of this information at the treatment time will be able to provide them with motivation and the spirit to heal.Morris (2012) stated that it is important to remember that most patients want to know how long they are likely to remain in the hospital.But the reality is different, according to Lees (2003), who said that where the patient is not always given information about the possible date of discharge, their motivation was lower.
The implementation of discharge planning in health services in this research area could not be released from the control card.This can be seen from the results of the interviews that say when talking about discharge planning, then in the mind of the nurse, the purpose is to give and explain the control card to the patient.There was even a nurse informant who said that they gave the control card without any explanation of its contents.Kozier (2004) stated that discharge planning is a starting process of the patient to getting health care, followed by a continuity of care, both in the process of healing and in maintaining their health status until the patient feels ready to return to his environment.
The discharge planning in health services that is still not understood by most of the nurses has become homework that must be completed soon.This fact is not only the responsibility of the nurses, but it should be the joint responsibility of various parties, including the management of the health services and hospitals.Hospital policy related to discharge planning must be enforced, by making standard operating procedures (SOPs).The Department of Health (2010) said that hospitals should make and distribute guidance about the patient discharge planning process.The policy, coupled with a SOP for discharge planning, will strengthen the position of its implementation.Rudd et al (2002) also noted that the nurses should be pushed into being more active in performing patient discharge planning based on the given standard.

CONCLUSION
The implementation of discharge planning in one of the hospital's inpatient rooms in Jember found that the results led to incomplete information being received by the patients from the first time entering the inpatient room up to leaving the hospital.Another finding is that there are nurses who are not familiar with the term discharge planning, and who do not understand about the implementation of discharge planning both in terms of time and the content.Based on the conclusions above, the researchers have suggested that the management develop the human resources side of nursing by conducting socialization and discharge planning training.In addition, management should issue a policy in the form of a decree on the implementation of discharge planning and standard operational procedures (SOPs).

Table 1 .
Results of the interview analysis with the patient informants or the patient's family

Table 2 .
The results of the interview analysis from the nurse informants obtained two themes