http://e-journal.unair.ac.id/JNERS | 25 Jurnal Ners Vol. 15, No. 2, Special Issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18905 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Systematic Review The Influence of Impedance and Enhancement Factors of Discharge Planning Implementation at Hospital: A Systematic Review Hari Soebagiyo1, Nursalam Nursalam1, Ahsan Ahsan2 1 Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia 2 Nursing Department, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia ABSTRACT Introduction: Discharge Planning is one of various nursing duty agendas, starting from when patients are admitted to hospital up to being allowed to go home. The phenomenon of implementation discharge planning for patients today is not optimal whereby nurses just do limited implementation of routine activities in the form of information on re- control. Based on those facts, the author wishes to study the analysis of impedance and enhancement factors in discharge planning implementation at hospitals. Methods: The researcher conducted investigation in February 2020 and involved exploration of some scientific papers journal from ScienceDirect, ProQuest, Scopus, and, PubMed as references with keywords nursing discharge planning, enhancement and impedance factors, implementation, and, hospital. This paper identified15 relevant research articles from 500 original full texts between 2010 and 2018 and analyzed inclusion criterion of enhancement and impedance factors in discharge planning implementation. It involves three RCTs, eight descriptive, and four qualitative research papers Results: As a result, there are found eight enhancement and five impedance factors influencing in discharge planning implementation. Meanwhile, from 3250 research respondents, 2125 persons reports enhanced factors contrary 1.125 samples imply impedance factors. Conclusion: The implementation discharge planning is influenced by some factors that should be given attention by nurses to do discharge planning properly. ARTICLE HISTORY Received: Feb 27, 2020 Accepted: April 1, 2020 KEYWORDS nursing discharge planning; enhancement and impedance factors; implementation; hospital CONTACT Nursalam Nursalam  nursalam@fkp.unair.ac.id  Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Cite this as: Soebagiyo, H., Nursalam, N., & Ahsan, A. (2020). The Influence of Impedance and Enhancement Factors of Discharge Planning Implementation at Hospital: A Systematic Review. Jurnal Ners, Special Issues, 25-33 doi: http://dx.doi.org/10.20473/jn.v15i2.18905 INTRODUCTION Discharge planning is dynamic and systematic process starting when patients were admitted up to permitted to leave hospital related with activity evaluation, preparation , and coordination to provide health observation, and , social service preparation (Nursalam, 2018). This process will give a professional healthcare team an opportunity to prepare patient to become more independent to their healthcare at home Discharge planning must be focused on the patient's problem an includes; promotive, preventive, rehabilitative and nursing care aspects. Nursing healthcare at hospital will have meaningful value when continued at home, principally by: focusing on patients’ health needs (Yilmaz & Ozsoy, 2010), identifying probably health problems at home (Backer et al., 2007), integrating and collaborating team inter-professional healthcare (R. Watts et al., 2005), adjusting implementation program with environment resources (Yilmaz & Ozsoy, 2010), applying discharge planning at every system / level of healthcare (Gray, Constance; Christensen, Martin; Bakon, 2016). Today, implementation discharge planning for patients is not optimal whereby nurses just do limited implementation of routine activities in the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id H. SOEBAGIYO ET AL. 26 | pISSN: 1858-3598  eISSN: 2502-5791 form of information on re-control (Nursalam, 2018). Other conditions related to implementation of discharge planning have been investigated by Voie, Tunby and Strømsvik (2018) who explained how discharge plan implementation by NICU of premature patients at hospital are a result of: 1) different expectation and lack of communication between NICU nurses and public health nurses, 2) responsibility and interaction between two groups of nurses not clearly defined, 3) public health nurse’s competence not recognized by NICU nurses and patients (Pauline Voie , Mona; Tunby , Jorunn; Strømsvik, 2018). Based on such facts, the author wishes to study an analysis of the influence of impedance and enhancement factors in discharge planning implementation at hospital. This analysis is aimed to give; 1) nurses’ awareness of enhancement and impedance in providing nursing discharge planning, purposely to make clients satisfied and to avoid organizations struggle to create an identity in the market and to help them contribute to the community they serve; 2) therefore, organizations must recognize the influence of impedance and enhancement factors of discharge planning implementation at hospital to improve the quality of nursing care. MATERIALS AND METHODS Search strategies We searched for articles published from 2010 to 2018 using PubMed, ScienceDirect, Scopus, and ProQuest as databases. We entered keywords by using the terms discharge planning, enhancement and impedance factors, and implementation as variables. Using these terms, we also combined other keywords, such as Nurse * OR Nursing *for Nursing so as to retrieve all relevant articles. In addition, only studies written in English were used for the current study. Search results in the form of titles and abstracts are the responsibility of the author to read and select articles that are relevant to the criteria set by the author Selection criteria The inclusion criteria of the articles are: 1) including discharge planning implementation as part of nursing activity; 2) is original research; abstract and 3) the subjects of the study are nurses and patients; 4) the location of the study is a hospital. Exclusion criteria from the articles sought are those focusing on location in the non-clinical area and the research is a thesis or part of a conference process. Data extraction From the fifteen studies chosen, we extracted the types of research, research subjects, and research data sources. Research subjects in fifteen of these studies could be nurses, nurse leaders, and patients. In addition, we extracted the results of articles that discussed the relationship between enhancement and impedance factors and discharge planning implementation at hospital. Discussion of differences in research results requires consideration from the author. RESULTS Selection of Studies The initial search retrieved a total of 500 studies: 20 from PubMed, 30 from ScienceDirect, 250 from ProQuest, and 200 from Scopus. From this, 300 articles have been deleted. Based on inclusion and exclusion criteria, the author reviewed each article and reached a consensus regarding its exceptions. The review process for selected articles was developed in three stages, including title review, abstract review, and full text review. We extracted 84 studies from abstract titles and reviews and 69 studies from full text review. Finally fifteen articles in total were selected for this study. The retrieval and screening process is summarized in Figure 1. Based on the research subject, we found the number of respondents was 3250 respondents with details of nurses as many as 1551 respondents and patients as many as 1699. Based on the location of the study, we found all of 15 studies were conducted at the hospital. Based on the research design, we found eight quantitative studies with the type of descriptive 135 Articles screened at title and abstract review 51 articles excluded 69 articles excluded: - Location not in hospital - Subject not nurse, or patients 15 articles included PubMed: 20 ScienceDirect: 30 Scopus: 200 ProQuest: 250 500 articles 300 Articles removed 84 Full-text articles assessed for eligibility Figure 1. Literature search flow JURNAL NERS http://e-journal.unair.ac.id/JNERS | 27 studies and three types of cross RCTs, and, four qualitative studies. For data sources, the questionnaire is the instrument used from the fifteen articles. We identified several instruments, including R for Hospital Discharge Scale, complete the Self- Directed Learning Readiness Scale, and Delphi Survey Questionnaire methodology and a satisfaction questionnaire The enhancement and impedance questionnaire and discharge planning implementation questionnaire were tested for reliability with Cronbach’ alpha and everything was stated as reliable, but some instruments were also utilized. From the fifteen journals, we found that the analysis tests used were Pearson correlation coefficient, independent-samples t-test, SEM, ANOVA, t-test, independent t-test, Mann–Whitney, multiple logistic regression, and Chi Square. Table 1 Summary of studies’ methods. Outcomes measure From the results of a review of fifteen articles it was found that the implementation of discharge planning at hospital can be influenced by enhancement and impedance factors. The enhancement factors that have been identified include: the level of knowledge of a nurse toward discharge planning implementation (Roberts & Moore, 2018); the ability of the discharge planning format to be implemented (Durocher et al., 2016); patient readiness to do discharge planning and pro-active treatment rooms carry out discharge planning (Yilmaz & Ozsoy, 2010); effective communication (Fitzgerald et al., 2011); and, a family role in implementing discharge planning (Durocher et al., 2016). Meanwhile, it is found that the factors that impede discharge planning implementation at hospital are : lack of planning of discharge programs and lack of coordination of health workers with different disciplines (Yilmaz & Ozsoy, 2010); lack of nurse communication in hospitals with nurses in community services and there no continuity of staff (Fitzgerald et al., 2011). DISCUSSION This systematic review of enhancement and impedance factors in discharge planning implementation at hospital will try to explore some factors involved in these conditions. Firstly, a correlation of those factors with each other has identified from the enhancement factors side; Carrie et al (2012) state that the ability of the discharge planning format to be implemented is very influential for effective discharge planning implementation. In the discussion of the participants from their research it also stated that the lack of a number of human resources, skills and time also greatly affected the implementation of discharge planning effectively (Yilmaz & Ozsoy, 2010). It means there is also a relation to the level of knowledge of a nurse. Elly (2011) explained that the effectiveness of discharge planning implementation for nurses who have been trained in the method and concept of discharge planning will be more effective in implementing discharge planning than nurses who have not trained (Mohamed et al., 2014). Also Rudd and Smith (2013) in found that treatment rooms that proactively carry out discharge planning will be able to reduce length of stay and decrease costs (Rudd, Caroline; Smith, 2013). Furthermore, there are also enhancement factors from the patients’ side. Patient readiness to do discharge planning is also an important factor in achieving discharge planning implementation effectiveness at hospital, with its predictors being sex, age, education status, marital status, all of which will be very helpful in achieving Table 1. General Characteristics of Subject Study (n=15) Category n % Year of publishing 2010 1 6.67 2011 1 6.67 2012 1 6.67 2013 1 6.67 2014 2 13.3 2015 3 20 2016 1 6.67 2017 1 6.67 2018 3 20 Participants Nurses 11 73.3 Patients 4 26.6 Participants’ ages Children 1 6.67 Adults 14 93.3 Type of study Descriptive research 8 53.3 RCT 3 20 Qualitative research 4 26.7 RCT: Randomized control trial H. SOEBAGIYO ET AL. 28 | pISSN: 1858-3598  eISSN: 2502-5791 Table 2. Summary of studies on enhancement and impedance factors in discharge planning implementation at hospital. Study and Author Population / sample Intervention Comparison Outcome Time Effectiveness of an instructional program on nurses knowledge and practice concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals in Baghdad city (Abdulrdha & Mansour, 2018) The study samples are composed of (58) nurses who have been working in the surgical wards of Ibn Al-Bitar specialized center for cardiac surgery; Iraqi Center for Heart Disease and Ibn al Nafees hospital; those nurses are divided equally into the study group (29) and control group (29} Those nurses are divided equally into the study group experiment (29) and control group (29). Nurses as treatment group who participated in education program. level of knowledge at general information, follow-up, wounds care, exercise program and daily activity, common health problems, medication, nutrition and risk factor modification are tested by t-test. Effectiveness of educational program regarding nurses’ practice toward planning patients’ discharge had a positive effect on nurses’ practice as compared with control group in relation to all discharge planning domains January , 2nd, 2017, to June 1st, 2018 Patients’ readiness for discharge: Predictors and effects on unplanned readmissions, emergency department visits and death (Kaya & SainGuven, 2018). This 1-year prospective cohort study included 1,601 respondents 1. The Patient Readiness for Hospital Discharge Scale/Short Form is used. 2. Data were analyzed using a Chi-square test, Mann–Whitney U test, univariate logistic regression analysis and multiple logistic regression analysis. The determination of patients self- assessment The results of multiple logistic regression analysis revealed that age, sex, marital status, educational status, presence of someone to help at home after discharge and length of stay were predictors of patients’ readiness for hospital discharge Septemb er 2018 Improving discharge planning using the re- engineered discharge program (Roberts & Moore, 2018) Sixty-nine participants Complete the Self- Directed Learning Readiness Scale prior to the RED education intervention. 1.Provide thirty- minute education interventions addressing various learning preferences 1. Nurses’ readiness to learn (RTL) before receiving education on the re- engineered discharge (RED) program 2. Measured utilization of the RED discharge process from patient chart reviews following an educational intervention. Participants scored high M = 219.8 (SD 23.7) on the SDLR, indicating nurses’ high RTL prior to educational intervention chart. Reviews found usage of the RED 12 actionable item pre-intervention, (n = 60) M = 6.55 (SD 1.478) compared to post-intervention (n = 60) M = 10.08 (SD 1.544) indicated statistically significant improvement in pre-discharge patient education and planning (t = 17.730, p=0.000 [CI 3.13– 3.93]) 2018 Framework and components. For A total of 24 nurses participated.in the Delphi methodology was Delphi approach 1. A total of 24 participants 24 Augus JURNAL NERS http://e-journal.unair.ac.id/JNERS | 29 Study and Author Population / sample Intervention Comparison Outcome Time effective discharge planning system (Yam et al., 2012) an instructional program on nurse knowledge and practice concerning patients’ discharge planning post cardiac surgery at cardiac centers and hospitals in Baghdad consensus-building process adopted to engage a group of experienced healthcare professionals to rate and discuss the framework and components of an effective discharge planning. The framework consisted of 36 statements under five major themes: initial screening, discharge planning process, coordination of discharge, Implementation of discharge, and post- discharge follow-up. Each statement was rated independently based on three aspects including clarity, validity and applicability on a 5- point Likert-scale and findings of the second stage on pre- testing the framework developed so as to validate and at test to its applicability and practicabilit y in which consensus was sought on the key components of discharge planning. participated in the consensus-building process. In round one rating, consensus was achieved in 25 out of 36 statements. Among those 11 statements not reaching consensus, the major concern was related to the “applicability” of the statements. 2.The participants expressed a lack of manpower, skills and time in particular during weekends and long holidays in carrying out assessment and care plans within 24h after admission t 2011 and re- searc h text accept ed 2012 Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals (Wong et al., 2011) A total of 41 healthcare professionals (9 Physicians, 13 Nurses, 6 Occupational Therapists, 5 Physiotherapists, and 8 Medical Social Workers) participated in the FGD. Majority of the participants were female, and the age range was 30-59 years old. Focus groups interviews were conducted with different healthcare professionals who were currently responsible for coordinating the discharge planning process in the public hospitals 1.Current practice on hospita l discharge 2.Barriers to effective hospital discharge 1. Participants highlighted that there was no standardized hospital-wide discharge planning and policy-driven approach in the public health sector in Hong Kong. 2.Potential barriers included lack of a standardized policy- driven discharge planning program, and lack of communication and coordination among different health service providers and patients as the main issues July- August 2010. Resea rch text is accepted in 2011 Mediators of marginalization in discharge planning with older adults .Qualitative study (Durocher et al., 2016). 22 participant interviews including five older adults, seven family members and eight healthcare professionals Critic bioethical approaches seeking to examine ethical issues in the provision of healthcare in relation to social and political structures, practices The themes of analysis included underlying beliefs, valued approaches and conventional practices 1. Findings included the identification of co- constituting influences on participants’ perspectives and behaviors in the process of discharge planning, which intersected to affect older adults’ 2016 year H. SOEBAGIYO ET AL. 30 | pISSN: 1858-3598  eISSN: 2502-5791 Study and Author Population / sample Intervention Comparison Outcome Time and processes agency and participation in discharge planning. 2. Resulting that discourses of ‘ageing-as-decline’ beliefs privileging healthcare professionals’ expertise; approaches that prioritized safety over all other values; and established conventions that guided the discharge- planning family conference served to marginalize Effectiveness of a discharge- planning program and home visits for meeting the physical care needs of children with cancer (Yilmaz & Ozsoy, 2010). The research population was all children, and their caregivers, who were admitted to the pediatric oncology unit at the hospital in Izmir, which.is located in western Turkey. For the experimental group, 24 child discharge planning ,discharge teaching, home visits, and telephone consultation were provided and planned investigating effectivenes s o f a discharge- planning program o n helping caregivers meeting the physical care needs of children with cancer between 0–18 years of age. A discharge- planning program and a hospital-based home care model had a very significant effect on the care needs of children with cancer and their caregiver 2010 Factors that enhance or impede critical care nurses’ discharge planning practices (R. Watts et al., 2005). 502 critical care nurses, identified from the Australian College of Critical Care Nursing (ACCCN) A total of 218 eligible participants completed the survey. One-to-one semi- structured interviews with 13 Victorian critical care nurses were also conducted Australian College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A 31-item questionnaire was developed and distributed 1.Participants reported that a lack of time was a barrier to discharge planning 2.Communication, however, could enhance or impede the discharge planning process in critical care. 2015 Discharge planning (Rudd, Caroline; Smith, 2013) They were well- attended, with more than 50%, 42 of the 69 trained staff from the unit, attending. : Two audits were conducted by a small team of nurses to measure the effectiveness of discharge management and planning in a four- ward orthopedic and trauma unit lost bed days and reduce costs 1.The findings showed that some wards were proactive: planning started on admission and patients were given realistic planned discharge dates and a list of probable capabilities. 2013 JURNAL NERS http://e-journal.unair.ac.id/JNERS | 31 Study and Author Population / sample Intervention Comparison Outcome Time 2.Discharge planning varied from ward to ward, and there was no shared common practice A Survey of Malaysian Critical Intensive Care unit nurses' awareness of patients' transition experiences (PE) and transitional care practice (TCP) (Mohamed et al., 2014). The survey had a response rate of 65.2% (178 of 273 eligible nurses). The respondents' mean age was 29.6 years. Most of the respondents were from public hospitals and the majority had one to five years' experience working as registered nurses, and in CICU 1.A descriptive questionnaire was used to survey Registered Nurses in seven CICUs in four hospitals in Malaysia. 2.Data were analyzed using descriptive statistics and correlation analysis Public teaching hospital nurses (TCP) transitional care practice There was a positive correlation between nurses' awareness of patients' transition experience and its impact, and their awareness of transitional care practice performance (rs=0.42; p<0.05). . 2014 Collaboration challenges faced by nurses when premature infants are discharged (6). 1. Qualitative individual interviews were undertaken with two NICU nurses and two public health nurses. 2. A qualitative content analysis was used to analyze the data. Three main themes were identified: different expectations and lack of communication between NICU nurses and public health nurses; Responsibilities and interactions between the two professional groups were not clearly defined; and the public health nurses’ competence was not recognized by the NICU nurses and .parents. 2018 year . The role of relatives in discharge planning from psychiatric hospital the perspective of patients and their relatives (Backer et al., 2007). 98 psychiatric inpatients and 40 of their relatives with family involvement in discharge planning Satisfaction questionnaires were completed Most participants were satisfied if relatives were involved in discharge planning. However, up to 89% of patients, and 84% of relatives, reported no communication between clinical staff and relatives regarding discharge 2015 Nurses’ discharge planning and risk assessment: behaviors, understanding and barriers (Jane Graham1, Robyn Gallagher2 31 Nurse Quantitative Descriptive research - nurse comprehension toward discharge plan - Nurse adherence to implement discharge planning - Nurse adherence toward implementation discharge planning is low 20 % - Impedance factors are is lack of time to implementation discharge planning 2015 H. SOEBAGIYO ET AL. 32 | pISSN: 1858-3598  eISSN: 2502-5791 Study and Author Population / sample Intervention Comparison Outcome Time and Janine Bothe3, 2015) How do critical care nurses define the discharge planning process (R. J. Watts et al., 2005). 502 Victorian critical care nurses were approached to take part in the study Utilizing an exploratory descriptive approach, 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 2014 Assessing the effectiveness of advanced nurse practitioners undertaking home visits in and out of hours urgent primary care service in England (Collins, 2017). concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals in Baghdad city 34 advanced nurse practitioners at London Observation and survey To measure the effectiveness of advanced nurse practitioner s (ANPs) against national quality requirement s for out- of-hours Advanced nurse practitioners are as effective as GPs in undertaking urgent home visits. Their documentation is more consistent and their refer-on rate to secondary care is less than that of GP colleagues., 2017 discharge planning, especially when at home (R. J. Watts et al., 2005). In further discussion, it will affect also the readiness of their support system to provide back up to fulfill patient necessity at home. The role of the family cannot be denied as a very helpful support system, especially when the patient is at home. The patient will feel motivated to obey the treatment in order to speed up recovery. Fitzgerald (2011) has revealed he role of the family as care giver, observer, and a reminder to always remember the importance of being obedient in the treatment corridor (Durocher et al., 2016). From the other side, there are some impedance factors in discharge planning implementation, namely, lack of coordination between health workers with different disciplines also plays a role in discharge planning. Wong et al. (2011) explains that the potential barriers include lack of standardized policy-driven discharge planning programs, and lack of communication and coordination among different health service providers and patients in both acute and sub-acute care settings, which were identified as mainly system issues. Improving the quality of hospital discharge was suggested, including a multidisciplinary approach with clear identified roles among healthcare professionals and a communication of health professionals' enhancement of knowledge and patient psychology (R. Watts et al., 2005). Secondly, lack of nurse communication in hospital with nurses in community service (Rudd, Caroline; Smith, 2013). Based on those impedance factors, communication is the most crucial problem to properly afford JURNAL NERS http://e-journal.unair.ac.id/JNERS | 33 implementation discharge planning at hospital. Finally, Watts et al. (2015) implied that several factors influence the effectiveness of the implementation of the discharge, including inadequate effective communication (Fitzgerald et al., 2011). CONCLUSION The study results show discharge planning is a very important activity in nurse health care. Unfortunately, it has still lack of implementation at hospital up to now. Based on those conditions, this systematic review seeks to know what kind of factors influence discharge planning implementation at hospital. The results refer to two crucial factors, namely, enhancement and impedance factors. By knowing those factors the nurses, hopefully not only improve enhancement, but also impedance factors in their healthcare to provide high quality nursing care and patient safety optimally. 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