Intensive and Critical Care Nursing (2005) 21, 39—46

ORIGINAL ARTICLE

How do critical care nurses define the discharge

planning process?
Rosemary J. Wattsa,∗, Jane Piersonb, Heather Gardnerb

a Alfred/Deakin Nursing Research Centre, Deakin University, 221 Burwood Highway, Burwood, Vic. 3125,
Australia
b School of Public Health, Faculty of Health Sciences, La Trobe University, Bundoora, Vic. 3083, Australia

Accepted 13 July 2004

KEYWORDS Summary
Critical care nurses;
Discharge planning Background: Professional, political and organisational factors have focused atten-
process; tion on the discharge planning process in the Victorian health care sector. Discharge
Health care planning for patients, as part of continuity of care, is seen as a key concept in the
delivery of nursing care. However, there is no question that discharge planning has
emerged as a complex area of practice, and is, perhaps, most complex in the critical
care area.
Aim: The study reported here is part of a larger thesis exploring critical care
nurses’ perceptions and understanding of the discharge planning process in the
health care system in the state of Victoria, Australia. As part of the survey par-
ticipants were asked to define discharge planning as it related to the critical care
environment in which they worked.
Methods: Utilising an exploratory descriptive approach, 502 Victorian critical care
nurses were approached to take part in the study. The resultant net total of 218
participants completed the survey, which represented a net response rate of 43.4%.
The data were analysed using quantitative and qualitative methodologies.
Findings: Three common themes emerged. A significant number of participants
did not believe that discharge planning occurred in critical care, and therefore,
thought that they could not provide a definition. There was uncertainty as to what
the discharge planning process actually referred to in terms of discharge from critical
care to the general ward or discharge from the hospital. There was an emphasis on
movement of the patient to the general ward, which was considered in three main
ways by first, getting the patient ready for transfer; second, ensuring a smooth
transition to the ward and third, transfer of the patient to the ward often occurred
because the critical care bed was needed for another patient.

* Corresponding author. Tel.: +61 3 9244 6123; fax: +61 3 9244 6159.
E-mail address: rjwatts@deakin.edu.au (R.J. Watts).

0964-3397/$ — see front matter © 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2004.07.006
40
Conclusion: The findings presented here suggest at a nursing level, the discharge
planning process is not well understood and some degree of mutual exclusivity still
remains. There is a need for further education of critical care nurses with regard to
the underlying principles of the discharge planning process.
© 2004 Elsevier Ltd. All rights reserved.
Introduction
Professional, political and organizational factors
have focused attention on the discharge planning
process in the Victorian health care sector. Dis-
charge planning for patients, as part of continuity
of care, is seen as a key concept in the delivery
of nursing care. However, there is no question that
discharge planning has emerged as a complex area
of practice, and is, perhaps, most complex in the
critical care area.
The Report of the Study of Professional Issues
in Nursing (Marles, 1988) highlighted the impor-
tance to the nursing profession of involvement in
the discharge planning process. A recommendation
to come from this report was that hospitals should
undertake a critical review of discharge planning
procedures. The report considered that the profes-
sional nurse has a responsibility to ensure continuity
and quality of patient care. The introduction of Di-
agnostic Related Groups (DRGs) into Victorian hos-
pitals in 1993, a decrease in the average length of
patient stay and the development of competency
standards for specialist critical care nurses, which
consider the implications for discharge, have all
re-focused attention on discharge planning proce-
dures.
While the discharge planning process is multi-
disciplinary in nature (Anthony and Hudson-Barr,
1998), it is one in which nurses play a promi-
nent role (Lowenstein and Hoff, 1994). Structurally,
nurses are in close proximity to patients through
providing care on a continuous basis, 24 hours
per day. While other members of the health care
team provide episodic interventions (Anthony and
Hudson-Barr, 1998), the 24 hours per day monitor-
ing and care of patients is a nursing responsibil-
ity (Corless, 1982). It is the nurse who requests,
sorts and clarifies care plans among members of the
health care team (Clausen, 1984); and while mem-
bership of teams varies from setting to setting, the
nurse is a constant member of the multidisciplinary
team (Anthony and Hudson-Barr, 1998).
Beck et al. (1993) illustrate the additional rea-
sons why it is important for the nurse to be involved
in the discharge planning process, citing the adop-
tion by the American Nurses Association (ANA) of
the Code of Ethics for Nurses. Beck et al. believe
R.J. Watts et al.
that the use of the Code of Ethics ensures registered
nurses (RNs) have accountability in the discharge
planning process, stating ‘‘all nurses need to antic-
ipate future long-term needs of patients and incor-
porate measures in discharge planning to address
those needs’’ (1993:6). In addition, Fiesta (1994)
also emphasises the importance of nurses providing
discharge instructions to patients and reports that,
in the US, failure to do so has resulted in liability
issues for nurses.
The discharge needs of patients admitted to crit-
ical care are unquestionably complex, diverse and
dynamic. As technology expands, more people will
survive acute, severe illness or injury, leading to
an increase in degree and complexity of discharge
planning needs. Four distinct phases of discharge
planning are described in the literature: assessment
of the patient’s discharge needs; development of
the discharge plan; provision of services or imple-
mentation of the discharge plan (included in this
phase is patient education and referrals to ser-
vices); and evaluation of the discharge plan (Hedges
et al., 1999; Mamon et al., 1992). In essence, the
discharge planning process parallels the stages of
the nursing process, which involves assessment,
planning, implementation and evaluation of patient
care. Discharge planning is a facet of the overall
care of the patient, developed through the appli-
cation of the nursing process, therefore, it can be
strongly argued that nurses should integrate dis-
charge planning into their nursing care.
A lack of literature regarding the discharge plan-
ning process in the critical care environment is ap-
parent; in particular, in the Australian literature.
In general, while most of the literature is written
from the perspective of the hospital or commu-
nity service (Hedges et al., 1999), there is a lack
of research-based literature pertaining to the role
of the critical care nurse in the discharge planning
process.
Literature review
Patients admitted to critical care rarely follow an
uncomplicated linear pattern of admission to the
unit followed by discharge to a ward and then to
the community. Therefore, planning for continu-
How do critical care nurses define the discharge planning process? 41

ity of care is a major consideration for critically ill namic, interactive communication as planning
patients and their families. Thus, appropriate dis- progresses; places a priority on collaboration and
charge planning, beginning in the critical care en- coordination among health care professionals
vironment, is of paramount importance. involved; results in mutually agreed upon decisions
A number of definitions of discharge planning about the economic and appropriate options
are offered in the literature, resulting in a wide for continuing care; and is based on thorough,
variation in the use of the term amongst authors up-to-date knowledge of available continuing care
(Beck et al., 1993; Clausen, 1984; Farren, 1991; resources (p. 23).
Marchette and Holloman, 1986; McGinley et al.,
This multi-faceted definition describes discharge
1996; Rorden and Taff, 1990; Smeltzer and Flores,
planning as a dynamic process that involves a vari-
1986; Williams, 1991). This variation is illustrated
ety of specific skills and requires all members of the
by the following examples. Anderson and Helms
health care team to work together in a coordinated
(1994) define discharge planning as ‘‘. . . the pro-
manner to achieve mutually agreed upon goals, and
cess of coordinating the delivery of health care
ultimately, continuity of care.
services beyond the hospital services’’ (p. 69).
While it is acknowledged that there are com-
In comparison, Schlemmer (1989) refers to the
mon threads in the definitions of discharge planning
American Nurses’ Association (1985) definition of
provided in the literature, it is clear that consider-
discharge planning as ‘‘the part of the continuity
able ambiguity exists. Clarification is needed as to
of care process which is designed to prepare the
whether the discharge planning process is concep-
patient for the next phase of care and to assist in
tualised as preparing the patient for the next phase
making any necessary arrangements for that phase
of care within that period of hospitalisation, or as
of care . . .’’ (p. 88B).
anticipating, planning and/or preparing health care
McGinley et al. (1996) present a definition of
service provision beyond hospitalisation, along with
discharge planning as ‘‘. . . an ongoing process
the expected involvement of the family and signif-
that facilitates the discharge of the patient to the
icant others. This ambiguity is reinforced by Lyon’s
appropriate level of care. It involves a multidis-
(1991) study of discharge planning and case man-
ciplinary assessment of patient/family needs and
agement in hospitals, which revealed that a wide
coordination of care, services and referrals’’ (p.
variation existed in the use of relevant terms among
55). Clausen (1984) believes that ‘‘. . . discharge
hospital staff. This resulted in confusion about pro-
planning in the hospital setting is the process
grams and services offered. A clear definition of
through which the nurse coordinates the transfer
discharge planning is needed to improve communi-
of health care responsibilities to the patient, sig-
cation and eliminate confusion among health care
nificant other, or other health care professionals’’
professionals.
(p. 58). Zarle (1989) considers discharge planning
It is clear from the above summary that there is
is both a concept and a function, as well as an
variability and ambiguity in definitions of discharge
organisational management tool necessary for high-
planning. The multi-faceted definition provided by
quality patient care, sound management practices
Rorden and Taff (1990) does, however, incorporate
and the coordination, by individuals and disciplines,
most, if not all, of the elements included in the
of resources necessary to assure a timely patient
more limited definitions. Given that it is relatively
discharge.
comprehensive, it is Rorden and Taff’s definition of
Arguably, Rorden and Taff (1990) provide the
discharge planning that is utilised for the purposes
most comprehensive definition of discharge plan-
of this paper.
ning, taking into account not only the patients’
The study reported here is part of a larger the-
medical needs but also their psychological, eco-
sis exploring critical care nurses’ perceptions and
nomic and social circumstances. They define dis-
understanding of the discharge planning process in
charge planning as ‘‘. . . a process made up of sev-
the health care system in the state of Victoria, Aus-
eral steps or phases whose immediate goal is to an-
tralia. As part of the survey, participants were asked
ticipate changes in patient care needs and whose
to define discharge planning as it related to the crit-
long term goal is to insure continuity of health
ical care environment in which they worked.
care’’(p. 22).

Although the process is complex, Rorden and

Taff (1990) believe that it: begins with early Research methods
assessment of anticipated patient care needs;
includes concern for the patient’s total well-being; Utilising an exploratory descriptive approach, a sur-
involves patient, family and care-givers in dy- vey of 218 Victorian critical care nurses was un-
42
dertaken. The study was approved by the La Trobe
University Faculty of Health Sciences Ethics Com-
mittee. Approval was also sought from and granted
by the Confederation of the Australian Critical Care
Nurses (CACCN) Victorian Branch (now known as
the Australian College of Critical Care Nursing (AC-
CCN) Victorian Branch) research subcommittee to
access their membership database in order to re-
cruit participants. At the time of CACCN (Victorian
Branch) initial membership and annual membership
renewal, members are asked to consent to partic-
ipating in research deemed suitable by the CACCN
(Victorian Branch) research subcommittee.
Sample
The members of CACCN (Victorian Branch) provided
the cohort for this study. The CACCN (Victorian
Branch) database allowed identification of those
members who were working in critical care areas as
opposed to members, for example, nurses who had
specialist critical care qualifications but held aca-
demic appointments and were not working in the
critical care environment. On the basis of the pri-
mary area of work named by members of the CACCN
renewal form (1998), 502 critical care nurses were
identified as working in critical care units and were
approached to participate in the study. Participants
could work full-time or part-time and have varying
professional backgrounds.
Data collection tool
As no reliable and valid tool could be found that
was accessible to the researcher, a new 31-item
questionnaire tool was developed. The question-
naire was specifically developed and used to col-
lect data from critical care nurses working in the
critical care environment. The development of the
instrument occurred in stages. Initially, literature
searches were undertaken to determine current na-
tional and international views of the beliefs and
attitudes of nurses to discharge planning. Themes
in the literature were identified. The findings from
previous research undertaken by the researcher
(Watts, 1995) were also drawn upon, as was discus-
sion with colleagues who had expertise in the area
of discharge planning and critical care nursing. In-
formation was collated from all of these sources and
used to formulate a draft questionnaire for use in
the pilot study. Questionnaires were distributed to
eight practicing critical care nurses working in the
Victorian health care system. The researcher knew
R.J. Watts et al.
these participants, but they did not participate in
the study reported in this paper. In accordance with
the feedback from the participants about the word-
ing and ordering of the questions and the adequacy
of the alternatives, minor changes were made to
the wording of some questions.
All potential participants, identified on the
CACCN (Victorian Branch) database, were sent the
questionnaire, along with a cover letter. The cover
letter explained the purpose of the research and
how the results from the questionnaire would be
used. It was emphasised that participation in the
study was purely voluntary and that consent was im-
plied by the return of the questionnaire. Confiden-
tiality of responses was assured. A pre-addressed
postage paid envelope was supplied for return of
questionnaires by the date given in the cover let-
ter.
The initial response rate, by the date stated on
the cover letter, was 31%. A reminder letter was
then sent out to those CACCN (Victorian Branch)
members who had not returned their question-
naires. This lifted the response rate to 39%; the
questionnaire, cover letter and flyer was then re-
sent to participants who still had not returned the
original questionnaire. A final total of 250 responses
were received, a response rate of 49.5%. Thirty-
two responses from nurses, who indicated that they
were no longer involved in clinical practice in Vic-
toria at the time of completing the questionnaire,
were excluded. The resultant net total of 218 par-
ticipants completed the survey, which represented
a net response rate of 43.4%.
Data analysis
The demographic data were analysed using quanti-
tative methodology and the open-ended question
asking participants How do you define the term
‘discharge planning process’ as it relates to the
critical care environment? was analysed using ques-
tion analysis (Morse and Field, 1996).
Findings
Demographic characteristics of participants
Demographic characteristics of the participants
are presented in Table 1. The area of critical
care speciality in which participants worked var-
ied. Forty-one percent worked in a combined crit-
ical care unit (for example, a general intensive
care/cardiothoracic/paediatric unit or a general in-
How do critical care nurses define the discharge planning process? 43

Table 1 Demographic characteristics of the sample.

pitals (country) with the same percentage of par-
ticipants also working in critical care units at pri-
Characteristic Value (%)∗ vate hospitals in the Melbourne metropolitan area.
Age (years) A small number of participants, 1%, were employed
25—35 53 by a nursing agency and therefore worked in a va-
35—44 40 riety of critical care units.
>44 7
Number of years qualified as a critical care nurse Exploration of critical care nurses
7 or less 46
understanding of the discharge planning
8—14 40
15 or more 14 process within the context of critical care
Position title
Registered nurse 25
Participants were asked to define discharge plan-
Clinical nurse specialist 35 ning as it related to the critical care environment in
Associate charge nurse 22 which they worked. Some common themes emerged
Nurse manager 7 from the responses to the open-ended question
Clinical educator 7 ‘‘How do you define the term ‘discharge planning
Area of specialization
process’ as it relates to the critical care environ-
General ICU 31 ment?’’ It must first be said that 22% of participants
Coronary care 7 stated in response to this question that they be-
Cardiothoracic 9 lieved that discharge planning did not occur in the
Trauma ICU 3 critical care environment in which they worked. It
Combined ICU 41 should be noted that these participants did not go
Model of allocation on to complete any or all of the rest of the ques-
Primary nursing 19 tionnaire. Examples of responses of this group of
Patient allocation by shift 65 participants follow:
Other 16
Discharge planning occurs in the general wards not
∗ Where percentages do not equal 100, there is missing ICU. Preparing somebody for a return home is not a
data. priority in intensive care (Participant 198).

Discharge planning is not a planned process in my

tensive care/cardiothoracic unit). No respondent
selected the response category ‘neurosurgical in-
tensive care’.
Fifty percent of participants had undertaken
a hospital certificate to obtain their general
nursing qualification. Twenty-three percent had
undertaken either a diploma or degree in nursing
to obtain their general nursing qualification. Thirty
participants or 14% had been qualified as registered
nurses for 21 years or more. Seventy-one percent
of the participants had been qualified as RNs for 15
years or less with 40% being qualified for 10 years
or less.
Seventy-one percent of participants had
obtained a hospital certificate critical care quali-
fication, and 13% had obtained a university critical
care qualification. A further 15% of participants had
obtained their critical care nursing qualification
through a combination of hospital certification and
further university studies and this was referred to
in the questionnaire as a combination.
Fifty-one percent of participants worked in criti-
cal care units at level 3 public hospitals (metropoli-
tan, and associated with a health care network).
Seventeen percent worked at level 1 public hos-
work environment. Our patients transfer to a gen-
eral ward area and discharge planning occurs from
there (Participant 461).
I can’t define it as I don’t think our unit does it
(Participant 292).
No participant offered a concise operational
definition of discharge planning in response to this
question. No participant used the words assess-
ment, planning, implementation and evaluation
sequentially to describe the discharge planning
process. Of those participants who believed that
discharge planning has a place in the critical care
environment, a number were clearly uncertain if
discharge planning in critical care referred to dis-
charge home or discharge to the ward. Participants
wanted clarification of what they were being asked
to define as illustrated by the following responses:
I take it that discharge planning means discharge
home not discharge from the unit (Participant
91). Are you talking about discharge from the
unit or discharge from the hospital??? (Participant
191).
44
Overall there was an emphasis on moving the pa-
tient out of the critical care environment. A num-
ber of participants used the word ‘transition’ to the
ward in order to define discharge planning. The fol-
lowing responses are indicative:
All members of the health team work together to
ensure that when the patient leaves critical care it
is a smooth transition (Participant 195). Discharge
planning for patients in the intensive care unit in-
volves ensuring a smooth transition to the ward area
with emphases on ensuring that the patient doesn’t
bounce back to ICU . . . (Participant 498).
Other participants defined discharge planning as
the process of getting the patient ready to go to the
ward as illustrated by the following comments:
. . . getting the patient ready and prepared for the
ward (Participant 182).
Discharge planning in the critical care environment
is usually the discharge to the ward . . . (Participant
278).
. . . being given 1—2 h notice to get the patient ready
for the ward (Participant 412).
For other participants, discharge planning was
concerned with ensuring availability of beds as the
high demand for critical care beds governed many
aspects of the discharge planning process as illus-
trated by the following:
. . . Patients are discharged to the ward usually when
their bed is needed for a more critically ill patient
(Participant 14).
. . . Co-ordinating demand for ICU beds. Optimising
resource use . . . (Participant 122).
In summary, the ‘‘strain on beds’’ forced the par-
ticipants, when assessing readiness for discharge,
to focus primarily on the patient’s physical indi-
cators rather than assessing the patient from a
broader perspective in order to prepare a more
complete plan of care for the patient on discharge.
Discussion
In summary, the participants’ definitions of dis-
charge planning varied. However, three common
themes did emerge from the participants’ re-
sponses. First, a significant number of participants
did not believe that discharge planning occurred
in critical care, and therefore, believed they could
not provide a definition. The second theme to
R.J. Watts et al.
emerge was that there was uncertainty as to what
the discharge planning process actually referred to
in terms of discharge from critical care to the gen-
eral ward or discharge from the hospital. The third
theme to emerge was an emphasis on movement
of the patient to the next level of care, as opposed
to discharge from hospital, which was considered
in three main ways. While some of the participants
considered that discharge planning referred to
the smooth transition of the patient from critical
care to the ward, for other participants’ discharge
planning was concerned purely with getting the
patient ready for the ward in a physical sense such
as removing monitoring lines. Finally, to other
participants, discharge planning was concerned
with ensuring the availability of critical care beds,
through the process of transferring patients to
the wards as the need arose. Daffurn et al. (1994)
believe that discharge of the patient from the
critical care unit often occurs suddenly because
of bed demands. As a consequence, the discharge
planning process is poorly co-ordinated.
Findings showed that inconsistencies exist in re-
gard to critical care nurses’ understanding of what
constitutes the discharge planning process. As such,
it is apparent that there is a variable applica-
tion of discharge planning practices among criti-
cal care nurses. Critical care nurses are uncertain
as to whether the discharge planning process of
the critical care patient should consider this dis-
crete period of hospitalisation (discharge of the pa-
tient from critical care to the ward), or consider
the whole period of hospitalisation (discharge back
to the community). The findings of this study sug-
gest, as did Arenth and Mamon (1985), that this
phenomenon exists, as nurses relate to the one
period of the patient’s hospitalisation with which
they are actively involved, rather than to the envi-
ronment to which they will be returned. If uncer-
tainty exists, then nurses new to the critical care
environment, who rely on mentoring from more se-
nior members of staff, only have this ambiguity
reinforced.
These findings indicate that critical care nurses
placed an emphasis on the transition of the patient
from the critical care ward to the next level of
care as opposed to discharge from hospital. This
focus on a discrete part of the patient’s hospital-
isation is consistent with findings from studies by
Lundh and Williams (1997) and Watts (1995) who
found that many hospital nurses viewed discharge
planning as a discrete event rather than an ongoing
process.
If we return to Rorden and Taff’s (1990) multi-
faceted definition of discharge planning, the cur-
rent confusion that exists among critical care nurses
How do critical care nurses define the discharge planning process?
as to how to define the discharge planning pro-
cess suggests that stipulated criteria is not be-
ing met. While nurses are the ideal members of
the health care team to assess, plan, implement
and evaluate the discharge planning process in the
critical care environment, there was no evidence
given that participants considered the discharge
planning process comprised these four distinct
phases.
It is important to consider reasons why this
confusion exists as to how to define the discharge
planning process and what it means. Participants’
uncertainty as to how to define discharge planning
indicate that the discharge planning process does
not appear to have been presented, or if it was,
then not effectively, in nurses’ pre-registration or
post-registration training programs. As part of the
planning phase of Chayboyer et al.’s (2002) study,
conducted in Queensland, Australia, informal
discussions among nurses revealed that approxi-
mately 40% thought that they lacked appropriate
knowledge in the area of discharge planning.
However, the number of nurses who participated in
these informal discussions is not clear. Nurses who
receive inadequate education are often unaware
of their lack of knowledge. While it is recognised
that education is only one mode that can be used
to influence nurses’ beliefs and attitudes, it is
vital the nurses have the chance to integrate
new knowledge into practice. Variations in the
definitions of discharge planning can result in
confusion among nurses as to what the discharge
planning process actually means when applied to
the practice setting, that is, the application of
theory to practice. In turn, these variations have
implications for the conduct of discharge planning,
discharge planning practice becomes variable, that
is, the degree of thoroughness of a discharge plans
is dependent upon the beliefs and understanding
that the critical care nurse caring for the patient
has regarding discharge planning.
Limitations
Because this study is a descriptive study, future re-
search is needed to direct the practice of discharge
planning in critical care. It is acknowledged that
a descriptive study cannot answer the question of
cause and effect. It is also acknowledged that, as
a whole, the nurses surveyed may not be represen-
tative of critical care nurses practicing in Victoria.
Only nurses who were members of ACCCN (Victo-
ria) were surveyed which limits the ability to make
generalisations from the results.
45
Conclusion
There was no agreement as to how to define dis-
charge planning in the critical care environment.
There was an emphasis on getting the patient to
the next level of care: that is to say an emphasis on
transition as opposed to discharge planning.
Almost 20 years ago, Alspach (1985) wrote ‘‘at
one time, not so long ago, the concepts of criti-
cal care and discharge planning were almost mutu-
ally exclusive—–not in theory but in practice’’ (p.
l). The findings presented here suggest at a nurs-
ing level, that although professional, political and
organisational factors have placed attention on the
discharge planning process, the discharge planning
process is not well understood. As a professional
body, critical care nurses need to start debating the
applicability of existing definitions of the discharge
planning process to the critical care environment
and their role in the discharge planning process.
There is a need for further education with regard
to the underlying principles of the discharge plan-
ning process and its applicability to the critical care
environment.
Acknowledgement
This study was supported by the Dean’s Ph.D. Schol-
arship, Faculty of Health Sciences, La Trobe Univer-
sity.
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