=Paper= {{Paper |id=None |storemode=property |title=Interaction Climate and Use of Information Systems in Discharge Planning: Hospital Nurses' Perspectives |pdfUrl=https://ceur-ws.org/Vol-984/paper3.pdf |volume=Vol-984 }} ==Interaction Climate and Use of Information Systems in Discharge Planning: Hospital Nurses' Perspectives== https://ceur-ws.org/Vol-984/paper3.pdf

Interaction Climate and Use of Information Systems in
Discharge Planning: Hospital Nurses’ Perspectives

Ragnhild Hellesø1, Hanne Marie Rostad1
1
University of Oslo, Faculty of Medicine, Institute of Health and Society
P.O. Box 1130 Blindern
NO-0318 Oslo
ragnhild.helleso@medisin.uio.no

Abstract. We report on a study in which we explored Norwegian
hospital nurses’ assessments of their use of information systems and the
interaction climate in their cooperation with colleagues in
municipalities. Our hypotheses were that the hospital size and type of
department influenced how hospital nurses assessed the interaction
climate with nurses in the municipalities and how they used their
information systems. A cross-sectional sample survey was conducted
with 20 Norwegian hospitals, and 510 nurses responded using a
questionnaire. Applying a factor analysis, we identified three climate
factors representing interaction climate, and found that the hospital size
and type of department had implications for nurses’ agreement about
collaboration and medical information climate, though not for nursing
information climate. Furthermore, hospital size and type of department
also exerted an influence to some extent on hospital nurses’ use of their
information systems. Further studies should elaborate on the reason for
the identified differences.

Keywords. Interaction climate, collaboration, hospital, municipalities,
discharge planning.

1 Introduction

In this paper, we will address the interaction climate between the hospital and home
health-care nurses. In addition, we investigate the hospital nurses’ use of information
systems in preparing for patients’ discharge. Over the last few decades, much effort
has been made to elaborate on information practices between hospitals’ physicians
and general practitioners (GP) in primary care, while less attention has been focused
on nurses’ collaboration [1]. When it comes to patients in need of continuing nursing
care in the municipalities after being discharged from the hospital, nurses play a
pivotal role in the collaboration and exchange of patient information, thereby ensuring

In: H. Gilstad, L. Melby, M. G. Jaatun (eds.): Proceedings of the European Workshop on Practical Aspects
of Health Informatics (PAHI 2013), Edinburgh, Scotland, UK, 11-MAR-2013, published at
http://ceur-ws.org
21

that providers who are involved in patients’ post-hospital health care have the correct
and adequate information available. The quality of the interaction between nurses in
hospital- and home health-care systems must improve to help meet future challenges.
An increasing number of elderly and people with chronic illnesses imply that many
will experience one or more transitions across hospital- and home health care [2-4].
Deficits in communication, information transfer and uncoordinated care are identified
as a threat against effective patient care [5, 6] because it complicates hospital
discharges [7], threatens patient safety [4, 8], lengthens hospital stays [9-11] and has
been shown to increase the number of re-hospitalizations [12, 13].
The overall aim of health care is to ensure a seamless provision of care, i.e. a
continuity of care throughout the entire health-care system and across all levels of
care delivery [14]. As an initiative to overcome discontinuity in the Norwegian
health-care system, the government launched a Coordination Reform with several
suggestions for improvements. The Coordination Reform, which came into force
starting in January 2012, emphasize the need for the development and deployment of
electronic information systems as electronic patient records (EPR) as a prerequisite
for ensuring the transfer of information that links care providers aiming to deliver
safe, connected and consistent health care to their patients [4]. All hospitals and most
of the municipalities (where home care nurses work) in Norway have implemented
EPRs, although the use of EPR is often combined with the use of paper-based
information systems [15]. Hospitals and home health-care nurses have different and
incompatible EPR systems, but initiatives to develop the use of standardized e-
messages has been established, thus allowing hospital nurses to be able to
electronically exchange discharge information. A previous study has shown that the
use of discharge summaries from hospitals to nurses in the municipalities is most
often transferred by the patient or by ordinary mail [16]. Initiatives to exchange
information electronically have shown that home health-care nurses report that having
information available at the right time allows them to be able to prepare for a better
reception of the patient when they are discharged from the hospital [17].
Nevertheless, challenges still exist in the effort to ensure the exchange of appropriate
and timely information from the hospital to home health care because nurses in the
two different organizations represent different cultures and have different perspectives
on what and when information is relevant to exchange [1, 18].
We conducted a study to explore Norwegian hospital nurses’ assessments of their
interaction with their colleagues in municipalities when patients are discharged from
the hospital to home health care. Our hypotheses were that the hospital size and type
of department influenced: 1) how hospital nurses assessed the interaction climate with
nurses in the municipalities, and 2) how they used their information systems in
preparing for a patient’s discharge.
22

2 Methods

A cross- sectional sample survey was chosen for the purpose of investigating hospital
nurses’ assessments of their interaction with nursing colleagues in the municipalities.

2.1 Setting and participants

Nurses at Norwegian hospitals were invited to participate in the study, and we
selected providers in internal medicine, surgical and mixed (a combination of internal
medicine, surgical and orthopaedic) departments because we expected to find the
highest proportion of patients who needed post-hospital, community-based health care
in these departments. In total, 27 Norwegian hospitals were invited to participate.

2.2 Data collection procedure

Hospitals in Norway have a different number of beds, so for the purpose of testing our
hypothesis about hospital size, we included small-, medium- and large hospitals.
Therefore, all Norwegian hospitals were initially stratified according to bed size, and
we randomly chose 19 small (33 - 88 beds), four medium (89 - 218 beds) and four
large (219 - 2046 beds) hospitals to be included in the sample. Of the total of 27
hospitals randomly selected, 20 hospitals consented to participate in our study, and all
eligible nurses were identified by a dedicated contact person at each hospital. Each
contact person provided us with the number of nurses who fulfilled the inclusion
criteria, and the number of questionnaires sent out corresponded with that number.
The inclusion criteria were: working in an internal-, surgical- or combination of these
departments, having more than six months experience at the department and having a
permanent or temporary position. The contact persons identified a total of 1430 nurses
who met these inclusion criteria.
We applied a researcher-developed questionnaire containing eight sections, and
we also asked for demographic information. Moreover, the development of the
questionnaire was based on findings from qualitative interviews with 14 hospital
nurses and eight physicians [19], and previous research regarding interactions
between hospital and home health-care nurses [16-18]. For the purpose of the current
paper, we used a 10- item interaction scale, in which the respondents scored on a
Likert scale from 1 - 5, ranging from 1, totally agreeing, to 5, totally disagreeing.
Questions addressing information systems contained items on how the hospital nurses
approached the home health-care nurses during the discharge planning process (use of
the telephone, meetings, paper-based messages and electronic messages) and which
information sources they used in their EPR when producing the discharge
information. The nurses scored on a Likert scale from 1 - 5, ranging from 1 = never, 2
= often, 3 = half of the time, 4 = often and 5 = always, with content validity being
based on the conceptualization of a continuity of care [20, 21]. An expert panel
consisting of 11 expert nurses evaluated the questionnaire in accordance with
recommendations from Polit and Beck [22], and we also interviewed 10 hospital
23

nurses for the purpose of testing the instrument [23]. After revisions were made, the
questionnaire was pilot- tested by 39 hospital nurses. The study was approved from
the Norwegian Social Science Data Services.

2.3 Analysis

The data was analysed using SPSS, version 20, and descriptive statistics were used to
analyse nurses’ age and years of experiences. Cross tabulation and chi-square tests
were used to analyse categorical data such as gender. The interaction scale was
subjected to an exploratory factor analysis (EFA) using the extraction method
principal component analysis with Oblimin rotation. Prior to performing an EFA, the
suitability of the data for factor analysis was assessed according to Pallant’s (2010)
recommendations [24].
A Kruskal- Wallis test was used to compare the differences between: 1) different
hospital sizes (small, medium, large), and 2) different department types (medical,
surgical, mixed). Non-parametric statistics were chosen because the data was not
normally distributed, with a p-value of <.05 regarded as significant.

3 Results

3.1 Demographics

A total of 510 (35.6% response rate) nurses returned the questionnaire, including 481
women and 28 men, with a mean age of 37.8 (range 22 - 65). The nurses had
approximately nine years (mean 9.83, SD ± 8.8) of experience as nurses, and had
worked at the current department for 6.5 years (mean 6.54, SD ± 6.7). The nurses
working at small-sized hospitals were significantly older (mean 40.3, SD ±11.1)
compared to the nurses at medium- (mean 35.7, SD ± 9.0) and large-sized hospitals
(mean 34.0, SD ±8.8), respectively (p<0.001). The nurses in small-sized hospitals
(mean 8.0, SD ± 7.7) had worked at their current department longer compared to the
nurses in medium- (mean 5.4, SD ± 5.5) and large-sized hospitals (mean 5.4, SD ±
5.1).
Table 1 shows how the proportion of nurses was distributed according to different
types of departments.

Table 1. Number of nurses per department

Frequency Percentage
Internal medicine 236 46.3
Surgical 252 49.4
Mixed 22 4.3
24

3.2 Interaction climate

Three factors were revealed from the factor analysis, whose structure explained
67.4% of the variance, with Table 2 providing an overview of the items representing
the three factors. The overall internal consistency for the three factors had a
Cronbach’s alpha of 0.77.
Factor 1 (medical information climate) reflected information transferred from the
hospital physicians to the health-care service in the municipalities when patients were
discharged for further nursing care (Cronbach’s alpha of 0.90), Factor 2 (collaboration
climate) was comprised of information about the contact between hospitals and
municipalities in the planning of discharging patients (Cronbach’s alpha of 0.66),
while Factor 3 (nurse information climate) was related to the quality of information
transferred from hospital nurses to their colleagues in the municipalities (Cronbach’s
alpha of 0.64).
Our hypotheses that hospital size and the type of department impacted how nurses
assessed the collaboration climate and medical information climate were supported.
However, no associations were found in terms of the nursing information climate.
We have collapsed the nurses’ response on the value of “agree to some extent”
and “totally agree” in the following detailed presentation of the nurses’ score on the
single variables concerning the collaboration climate and medical information
climate.

3.3 Medical information climate

The factor “medical information climate” reflected information about the patients’
medical diagnosis and medication needs after discharge, and statistically significant
differences between nurses in small-, medium- and large-sized hospitals with regard
to medical information climate were found (p=0.008).
Concerning patients’ discharge to nursing homes and to home care nursing services,
more nurses in medium-sized hospitals agreed that information about patients’
medical diagnosis were transferred compared to nurses in small- and large-sized
hospitals.
Compared to nurses in small- and large-sized hospitals, we also found that more
nurses in medium- sized hospitals agreed that information about the patients’
medications were transferred when patients were discharged to both nursing homes
and home care nursing services.
With regard to medical information climate, differences between nurses in
different department types were also found (p<0.001). Compared to nurses in
surgical- and mixed departments, more nurses in medical departments agreed that
information about the patients’ medications were transferred when patients were
discharged to both nursing homes and home care nursing services.
Lastly, compared to nurses in medical and mixed departments, a lower percentage
of nurses in the surgical departments agreed that information about patients diagnosis
were transferred when patients were discharged to both nursing homes and home care
nursing services.
25

Table 2. Three-factor solution after principal factor analysis with Oblimin rotation

Items Factor Factor Factor
1 2 3
The discharging physician always makes sure 0.920
that information about patient’s diagnosis is
sent to the municipal health-care service when
patients are discharged to nursing homes.
The discharging physician always makes sure 0.918
that information about the patient’s diagnosis
is sent to the municipal health-care service
when patients are discharged to home care
services.
The discharging physician always makes sure 0.857
that information about the patient’s medication
is sent to the municipal home care service
when patients are discharged to nursing
homes.
I always know what kind of information the 0.846
municipal home care service needs in the
nursing discharge note.
I feel it is easy to get in touch with the correct 0.795
person in the municipal home care service
when I need it.
I experience that the hospital nurses and 0.763
municipalities’ nurses have a common
understanding of the patient’s needs after
discharge.
I experience that the nurses/contact persons in 0.745
the municipality are responsive to my advice
The nursing discharge note we sent to the -0.834
home care nurses usually gives good details of
the patient’s need for continuing health care.
The municipal home care service always gets -0.738
the nursing discharge summary when the
patient is in need of further health care.
I always know what kind of information the -0.711
municipal home care service needs in the
nursing discharge note.

3.4 Collaboration climate

The factor “collaboration climate” comprised information about the contact between
hospital nurses and nurses in the municipalities in their discharge planning.
Statistically significant differences between nurses in small-, medium- and large-sized
hospitals with regard to collaboration climate were found (p<0.001). An overall
finding was that nurses in small-sized hospitals more frequently said that they agreed
on the collaboration climate variables compared to nurses in large- and medium-sized
hospitals.
26

Significant differences with regard to collaboration climate were also found
between nurses in different department types (p=0.001), as the percentage of nurses
working in surgical departments (61.3%, N=152) who agreed that their contact
persons in the municipalities were responsive to their advice was higher compared to
the nurses in internal medicine (43.3%, N=100) and nurses in mixed departments
(22.7%, N=5, p=0.001). The degree of agreement changed for the other collaboration
climate variables, with the ratio, respectively, being that nurses in the medical
departments more often agreed on the collaboration climate variables than surgical
nurses and nurses working in mixed department, who agreed less.

3.5 Information systems

In relation to home health-care nurses being contacted during the discharge planning
process, an overall finding for all hospital nurses was that 487 (96.3%) nurses
reported that they often used the telephone, while 301 (61.9%) often used paper-based
messages, 78 (15.8%) often used meetings and 37 (8.0%) often used electronic
messages.
Our second hypothesis was that hospital size and type of department influenced
hospital nurses’ use of information systems in preparing for patients’ discharge,
which was also partially supported, as hospital size had a significant influence on
nurses’ use of telephone (p=0.006), meetings (p=0.002) and paper-based messages
(p=0.027).
We have collapsed the nurses’ response on the values “never” and “seldom”, and
named it “seldom” in the following detailed presentation of findings. Likewise, we
have collapsed the values “often” and “always” to “often”.
Compared to nurses in small- and large-sized hospitals, a larger proportion of
nurses at medium-sized hospitals responded that they most often used telephone and
meetings. Moreover, the nurses in large-sized hospitals accounted for the largest
portion of the nurses who mostly used paper-based messages.
Likewise, significant differences were found regarding type of department in relation
to meetings (p<0.001) and the use of paper-based messages (p=0.014).
When producing information for the nursing discharge note, a total of 90% of the
nurses reported that they used EPR for this purpose. We found that 73 (14.3%) used
paper-based patient records, whereas 81 (15.9%) used a combination of paper-based
and EPJ (they had the option of responding on all alternatives).
As shown in Table 3, nurses’ notes (written during the hospital stay) and
physicians’ admission notes were the most used information in the EPR when they
produced a discharge summary.
Nurses working in medium-sized hospitals more frequently said that they used the
telephone (98.7%, p=0.006) and meetings (30.8%, p=0.002) than their colleagues in
small- and large-sized hospital. By contrast, nurses in small-sized hospitals more
often reported that they used paper-based messages (65.6%, p=0.027).
Nurses working in mixed departments more often used meetings (40.9%, p
=<0.001), while nurses in surgical departments more often used paper-based message
than their colleagues in other departments (67.1%, p=0.014).
27

Table 3. Use of information sources when writing nurses’ discharge note

Physicians’ Nurses’ Nursing Nurses’ Flow sheet
admission admission plans notes
note note
Seldom 35 (6.9) 67 (13.3) 91 (18.1) 13 (2.6) 116 (23.4)
Half of 57 (11.3) 62 (12.3) 88 (17.5) 35 (7.0) 71 (14.3)
the time
Often 413 (81.8) 374 (74.3) 323 (64.3) 455 (90.5) 309 (62.3)

4 Discussion and conclusion

There are several limitations in this study that should be accounted for when
interpreting the findings. Using a questionnaire has the advantage of collecting a large
amount of data and reaching a wide range of nurses at different hospitals, though a
well-known disadvantage is often a low response rate [22], which our study is an
example of. However, we have an indication that the response rate might be higher
than presented here due to our method of distributing the questionnaires at each
hospital, as 15 questionnaires were returned from one hospital because the nurses did
not meet the inclusion criteria for several reasons, or because they were on leave. It is
therefore reasonable to believe that the number of eligible nurses was lower than the
number of our contact persons at each hospital, although we have no information
about the non-respondents. Nonetheless, the respondents who answered our
questionnaire did not differ with regard to age and tenure at their current department
compared to another large study conducted at 32 hospitals, in which 5,455 nurses
participated [25].
Another limitation is the lack of perspectives other than those of hospital nurses.
Taking both physicians’ and home health-care nurses’ point of view into
consideration may help to deepen and broaden our understanding of the current
study’s result, which should be elaborated on in future studies.
Our study shows that hospital size and the type of department impacted nurses’
assessment of the medical information- and collaboration climate, although such
findings did not reveal any data on the nursing information climate. Our study shows
that information about the patients’ medical diagnosis and medication were not
always transferred to home health-care nurses when patients are discharged, which is
in accordance with a previous study that showed that less than 50% of home health-
care nurses reported that they received the physicians discharge summary when
patients were in need of post-hospital home health care [16]. The findings that
differences exist between different department types in the information climate is
supported from another study, in which nurses in geriatric care more often exchanged
nursing discharge notes compared to their colleagues in non-geriatric care [26].
We found that nurses in small-sized hospitals more often agreed on the
collaboration climate than their colleagues in large- and medium-sized hospitals. We
have no explanation for these differences; however, small-sized hospitals are often
28

situated in local and urban districts in Norway, which makes it easier for the nurses to
have an overview of the entire health-care system within their area.
Nurses working in mixed departments more seldom agreed on the collaboration
climate, as these departments usually had a mixed case of patients with both internal
medical diseases and surgical conditions. To what extent the plurality of the patient
group influenced their assessment should be further elaborated on in later studies.
The findings that hospital size and type of department also exerted an influence
on how hospital nurses reported on their use of information system demonstrates that
local practices seems to be embedded in their information practices. It is worth noting
that nurses used information from the physicians’ admission note to a great extent
when they themselves prepared a discharge note. The role of admission information
seems to have a strong position in both nurses’ and physicians’ information
production through a patient trajectory [19, 27]. Olsen et al. [26] emphasize that a
lack of available and appropriate guidelines and standards for ensuring an accurate
exchange of information across organizations exists, which may be a reason why in
our study we identified a plurality in nurses’ assessment of their interaction climate
and how they used their information systems according to their hospital’s size and
department. Paulsen et al. [1] express a concern that the introduction of e-mail-like
communication does not solve the communication and information needs that home
health-care nurses have during the discharge planning process. However, our study
shows that the hospital nurses have s strong tradition for using the telephone during
the discharge planning process.
Lately, much effort has been made to increase and improve the interaction
between hospitals and health care services in the municipalities [4]. Our study shows
that the characteristics of hospital size and department exert an influence on the
interaction climate and information system in use. The current study does not elicit
why such differences exist, which is something that future studies should explore.

Acknowledgements. The authors would like to thank the nurses who participated in
this study and research assistant Linda Aasvangen for preparing the data for analysis.
The research has been supported by the Norwegian Research Council, Grant no.
181859/V50.

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