Queensland University of Technology Faculty of Health School of Nursing Emergency Department Nurses’ Experience of Implementing Discharge Planning for Emergency Department Patients in Taiwan: A Phenomenographic Study Chin-Yen Han RN, BN, MN (Emergency Nursing) Submitted for the award of Doctor of Philosophy July 2008 TABLE OF CONTENTS ABSTRACT ................................................................................................... 6 CHAPTER ONE BACKGROUND AND SIGNIFICANCE OF STUDY ................................. 8 1.0 Introduction .......................................................................................... 8 1.1 Discharge Planning in Contemporary Emergency Nursing Practice ... 9 1.1.1 Emergency nurses ― the key to discharge planning .................... 9 1.1.2 Dilemmas for emergency nurses ................................................. 12 1.2 Development of Discharge Planning in Taiwan ................................ 16 1.2.1 Importance of discharge planning in the emergency department in Taiwan .............................................................................................. 16 1.2.2 Historical development of discharge planning in Taiwan .......... 17 1.3 Summary ............................................................................................ 19 1.4 Aim and Objective of the Research ................................................... 20 1.5 Overview of Chapters ........................................................................ 20 CHAPTER TWO LITERATURE REVIEW ............................................................................ 22 2.0 Introduction ........................................................................................ 22 2.1 Definitions of Discharge Planning ..................................................... 22 2.2 Significance of Discharge Planning ................................................... 25 2.2.1 Health care system reform .......................................................... 26 2.2.2 Demographic changes ................................................................. 29 2.2.3 Hospital and community nurses .................................................. 32 2.2.4 Patients and their families .......................................................... 35 2.3 Nurses’ Experiences of Implementing Discharge Planning ............... 41 2.3.1 Nurses understanding of discharge planning ............................. 41 2.3.2 Assessment of patient needs ........................................................ 47 2.3.3 Communication and coordination .............................................. 53 2.4 Summary ............................................................................................ 58 CHAPTER THREE RESEARCH METHODOLOGY: PHENOMENOGRAPHY ..................... 60 3.0 Introduction ........................................................................................ 60 3.1 Phenomenography: An Overview ...................................................... 60 1 3.1.1 Origins of phenomenography ...................................................... 60 3.1.2 Qualitative research .................................................................... 64 3.1.3 A second-order perspective ......................................................... 65 3.1.4 Non-dualist ontology ................................................................... 67 3.1.5 Conceptions ................................................................................. 68 3.1.6 Epistemological assumptions ...................................................... 74 3.1.7 Phenomenographic results .......................................................... 75 3.1.8 Implications for nursing research and this study ........................ 79 3.2 Research Method ................................................................................ 81 3.2.1 Participant selection criteria and participant hospitals ............. 81 3.2.2 Participant recruitment ............................................................... 82 3.2.3 Data collection ............................................................................ 84 3.2.4 Interview/interview questions ..................................................... 84 3.2.5 Interview setting .......................................................................... 89 3.2.6 Drawing ...................................................................................... 89 3.2.7 Data analysis ............................................................................... 90 3.2.8 Quality of the study ..................................................................... 96 3.3 Ethics Statement ............................................................................... 101 3.3.1 Ethics approvals ........................................................................ 101 3.3.2 Consent ...................................................................................... 102 3.3.3 Confidentiality ........................................................................... 102 3.3.4 Risks .......................................................................................... 103 3.4 Summary .......................................................................................... 103 CHAPTER FOUR THE EXPERIENCE OF IMPLEMENTING DISCHARGE PLANNING 105 4.0 Introduction ...................................................................................... 105 4.1 Categories of Description ................................................................. 107 4.1.1 Categories of description one: ED nurses experience implementing discharge planning as ‘getting rid of my patients’ ..... 107 4.1.2 Categories of description two: ED nurses experience implementing discharge planning as completing routines ................ 117 4.1.3 Categories of description three: ED nurses experience implementing discharge planning as being involved in patient education ............................................................................................ 124 2 4.1.4 Category of description four: ED nurses experience implementing discharge planning as professional accountability ..... 146 4.1.5 Categories of description five: ED nurses experience implementing discharge planning as autonomous practice ............... 160 4.1.6 Category of description six: ED nurses experience implementing discharge planning as demonstrating professional nursing care in the ED ...................................................................................................... 170 4.2 The Outcome Space ......................................................................... 180 4.2.1 The referential aspects .............................................................. 182 4.2.2 The structural aspects ............................................................... 187 4.3 Summary .......................................................................................... 189 CHAPTER FIVE DISCUSSION, RECOMMENDATIONS AND CONCLUSIONS ........... 191 5.0 Introduction ...................................................................................... 191 5.1 Review of the Research Findings ..................................................... 191 5.2 Implications of the Research for Contemporary Emergency Nursing ................................................................................................................ 192 5.2.0 Introduction ............................................................................... 192 5.2.1 Level One: no engagement with discharge planning ................ 192 5.2.2 Level Two: engaging with discharge planning ......................... 195 5.2.3 Level Three: engaging with effective discharge planning ........ 200 5.2.4 ED nurses’ commitment to providing discharge services in the ED ...................................................................................................... 209 5.3 Strengths and Limitations of the Study ............................................ 211 5.3.1 Strengths of the research ........................................................... 211 5.3.2 Limitations of the study ............................................................. 212 5.4 Recommendations ............................................................................ 213 5.4.1 Clinical emergency nursing practice ........................................ 214 5.4.2 Nursing administration ............................................................. 215 5.4.3 Nursing education ..................................................................... 216 5.4.4 Healthcare policy ...................................................................... 216 5.4.5 Further nursing research .......................................................... 217 5.5 Conclusion ....................................................................................... 218 REFERENCES ........................................................................................... 220 3 APPENDIX ................................................................................................ 249 Appendix A Ethical approval (Tau-Yuan General Hospital Department of Health) . 250 Appendix B Ethical approval (St. Paul’s Hospital) .................................................... 251 Appendix C Ethical approval (Queensland University of Technology)..................... 252 Appendix D Participation Information Sheet ............................................................. 255 Appendix E Participant Consent Form ......................................................................