Quality of Discharge Teaching among Intergenerational Discharged Patients in a Medical-Surgical Ward of a Government Hospital

Jason D. Manolong, MAN, Resty L. Picardo, DM, JD, MAN, and Jake C. Napoles, DHCM, MAN, BSBio

College of Allied Health Sciences, University of the Visayas

DOI: https://doi.org/10.51244/IJRSI.2024.1103038

Received: 02 March 2024; Revised: 10 March 2024; Accepted: 16 March 2024; Published: 13 April 2024

ABSTRACT

Discharge instructions play a significant function in patient care. It planned at the time the patient is admitted. They assist patients in comprehending the state of their condition and the treatment provided. Additionally, they include a treatment and follow-up plan, as well as justifications for returning to the hospital. This quantitative research utilized the descriptive, comparative (non-causal) design in assessing the significant difference in the quality of discharge teaching and the significant difference in the content needed and content received of the different generations of 212 discharged patients in the Medical-Surgical Ward of a government hospital in the 3rd quarter of 2021. Findings of the study revealed that the quality of the content of the discharge teaching was high with the Baby Boomers as the highest and the Generation X as lowest. The quality of content needed and received in the discharge teaching were high with the Generation X as lowest and the Baby Boomers as highest. The quality of the delivery of the discharge teaching was high with the Generation X as lowest and the Baby Boomers as highest. Overall, the four generations suggested that in the delivery of the discharge teaching be done through a combination of face-to-face and use of printout. There was a significant difference in the quality of discharge teaching in terms of content needed, content received, and delivery between Baby Boomers and Generation X. The Baby Boomers perceived the quality higher over the Generation X. There was no significant difference between the content needed and content received. The Baby Boomers differ in their perceptions with the Generation X in terms of the content needed, content received, and the delivery of the discharge teaching. Lastly, the quality of the content is significantly correlated with the quality of delivery of discharge teaching. It is important for the nursing service to guarantee quality discharge teaching taking into the generational classification of patients and a way of doing so, a generational discharge teaching enhancement plan is proposed.

Keywords: Descriptive, Comparative Design; Medical-Surgical Patients; Quality of Discharge Teaching.

INTRODUCTION

The process of preparing for discharge from the hospital is an important component of every hospitalization. It is critical in ensuring that the transition from the hospital to the home is as seamless as possible. This is accomplished by ensuring that appropriate clinical and community-based support services are in place, if and when they are necessary. Nurses play a vital role in providing discharge teaching to patients. As early as the admission of the patient, discharge planning also commences. Nurses should be able to deliver a discharge teaching that is both complete and accurate in terms of content and not only that, the manner in which the discharge teaching is delivered is of pivotal importance also as this can also make or break the patient’s successful transition from the hospital to the community.

Poor discharge planning can be detrimental to the patients. Multiple sources of evidence suggest that care quality can be suboptimal in, or as a consequence of, hospital discharge (Laugaland et al., 2012). In a major telephone survey of 400 patients following discharge, Forster et al. (2003) found that nearly 20 percent reported some form of adverse event, of which 6 percent were preventable and 6 percent ameliorable. Research highlights a number of common discharge-related risks associated, for example, with the management of medicines, the provision of appropriate health and social care, incomplete tests and scans, the fitting and use of home adaptation, and the risks of falls, infections or sores (Forster et al., 2003; Laugaland et al., 2012).

According to Family Alliance Center (2021) studies have shown that as many as 40 percent of patients over the age of 65 experience medication mistakes after being discharged from the hospital, and 18 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days of their discharge. This is bad for the patient, bad for the hospital, and bad for the financing agency, whether it is Medicare, private insurance, or personal finances. It is also bad for the financing agency. In contrast, research has shown that effective planning and follow-up can enhance patient health, minimize read missions, and lower overall healthcare expenditures in some cases. Discharge planning and transitional care have been studied extensively, with several studies highlighting the very substantial benefits in terms of improved patient outcomes and decreased re-hospitalization rates that may be achieved via good planning and transitional care. Even if a number of pilot programs have demonstrated the benefits of such changes in care, they will remain out of reach for many people unless health-care funding structures are reformed to encourage such innovations. Caregivers, patients, and activists are continuing their efforts to change the healthcare system so that discharge planning is a top priority for all patients.

Having been worked as nurses, the researchers were able to observe that at times discharge teachings were hurriedly done as a consequence of the nurses being overloaded with patients that problems in terms of the contents and delivery are very evident. There were instances where the prescriptions during discharge were interchanged that patients or their significant other had to go back to the hospital to verify the given prescription. There were instances in the medical-surgical Ward where the patient had to be re-admitted for complications such as dehiscence for failing to give a comprehensive discharge teaching. Such incident could have been prevented if the patient and the significant other was properly given discharge instructions. Furthermore, an exhaustive search for published relevant research on discharge planning studies in the City of Cebu revealed that there appeared to be a shortage of such studies. While patients from hospital wards are facing the consequences of inadequate discharge planning, this phenomena continues to occur at the present day, much to the detriment of the patients who are experiencing it. This is one of the reasons why the researchers are doing this study, among other things. In the many years of working as nurses, the researchers were also able to observe that different generations of patients take different paths and attacks on giving prioritization to their health. The researchers are puzzled with how these different generations differ in terms of their perceptions on the quality of the discharge teaching as coming from different generations may require different or specific contents or delivery that is specific to a generation. Also, while discharge teaching is vital to all types of patients, this study is singled-out on patients discharging from the Medical-Surgical Ward as according to Kang et al. (2018), discharge education is essential for postoperative general surgery patients for their self-management of care at home post discharge. The first 30 days’ post-surgery is pivotal to the post-operative recovery process as this is when most post-operative complications occur. Insufficient discharge education can compromise patients’ recovery process causing postoperative complications and unplanned hospital read missions. The conduct of the study in the Medical-Surgical Ward can serve as a starting point where it can further branch out to the other wards as part of the recommendation later on and that the findings in the Medical-Surgical Ward will serve as baseline information.

Quality of discharge teaching among patients is a well-studied concept that literature and studies are widely available. However, by taking a step higher by assessing the significant differences among the four generations in a localized setting would be worth spending time to generate new knowledge if not refine what is already available. It had been established that each generation is unique. This serves as the research gap of the study which is to assess whether these different generations have different needs in terms of the provision of discharge teaching along with the intention of assessing whether there is a difference in the content needed and the content delivered in order to ascertain if what is essential in a discharge teaching is what is received by the patients. Also, the study will assess whether the delivery is being influenced by the content by assessing their correlation. This way the content and delivery of the discharge teaching can become more personalized and generational. In doing so, this work will be able to provide valuable contribution to the nursing profession and the community in general as nurses will be given the opportunity to continually improve and deliver quality care and patients will be served better resulting to better patient outcomes.

According to Majors (2018), speaking to multiple generations requires a multi-faceted approach. Each generation has its own unique motivators and make healthcare decisions differently. For instance, Baby Boomers, compared to younger consumers, they possess more expendable income and less tech-fluency. They do not appreciate convenience any less. Generation X typically shops for healthcare the same way they shop for retail goods and services-they bring an active, discerning attitude. Generation Y generally expects ease and accessibility. They value clear comparisons among health plans. They are often emotionally driven. They use personal relationships to determine brand loyalty. According to Harvard Pilgrim Health Care, Inc. (2019), Generation Z is the first generation to grow up surrounded by digital devices, and they expect their health benefits to be digital, too. From choosing a benefits package to finding a provider, Gen Z wants to take care of their health on their own terms.

With the researchers’ goal of providing contribution into the field of medical-surgical nursing through the output of the study, the researchers are confident that this scholarly work will be able to achieve its purpose. With the researchers’ interest on the topic along with the determination and competence in conducting research studies, the researchers are hopeful that this work will be a successful one.

Research Objectives

The main purpose of the study was to compare the significant difference in the quality of discharge teaching and the significant difference in the content needed and content received of the different generations of discharged patients. It further assessed the relationship between the content and delivery of discharge teaching in the Medical-Surgical Ward of Cebu South District Hospital in the 3^rd quarter of 2021.

The study further answered the following queries:

1. What is the generational classification of the discharged patients in terms of:
   • Baby Boomers;
   • Generation X;
   • Generation Y; and
   • Generation Z?
2. What is the quality of discharge teaching of the discharged patients according to generations in terms of:
   • Content in terms of:
   • needed and
   • received; and
   • delivery?
3. What are the different suggestions and recommendation on the quality of discharge teaching according to generations?
4. Is there a significant difference in the quality of discharged teaching of the discharged patients according to generations in terms of:
   • content; and
   • delivery?
5. Is there a significant difference between the content received and the content needed according to generations?
6. Is there a significant relationship between the content and the delivery of the discharge teaching?
7. What were the experiences on the quality of discharged planning among discharged patients?
8. What generational discharge teaching enhancement plan can be proposed based on the findings of the study?

REVIEW OF RELATED LITERATURE

Quality of Discharge Teaching

The content and delivery quality of surgical nurses’ discharge instruction was moderate, according to Nurhayari et al. (2019). Participants mostly earned certificates. Nearly a decade of nursing with seven discharges every day. Verbal and teach-back training lasted 30 minutes on average. Discharge planning is vital for comprehensive patient care worldwide. At admission, discharge planning is done. Patient care is never complete without planning for a patient’s departure from the hospital to the community. An (2015) defines discharge planning as moving a patient to the next level of care. Discharge plans are specific instructions given to the patient as they leave the hospital for home or a long-term care facility. Effective discharge planning aims to improve a patient’s quality of life by assuring continuity of care and reducing unplanned readmissions and problems (Gonçalves-Bradley et al., 2016; Gholizadeh et al., 2018).

Participants in Horstman et al. (2017) study understood discharge instructions. During interviews, participants cited post-discharge care as a source of support, hospital education, a living record, and empowerment. Despite good comparisons, participants said the guidelines lacked information to help with acute difficulties following discharge. After discharge, participants had problems accessing providers, requiring workarounds. Patient education is key to preventing readmissions (Jack et al., 2009; Coleman et al., 2006; Makaryus & Friedman, 2005; Olson & Windish, 2010; Albrech et al., 2014; Coleman et al., 2013). 40% of freshly discharged patients 65 and older couldn’t explain their admission condition, and 80% didn’t know what prescriptions were stopped (Horwitz et al., 2013; Ziaeian et al., 2012). Written discharge instructions supplement inpatient spoken education. The Joint Commission requires hospitals to offer patients and caregivers formal discharge counseling (Joint Healthcare Organizations Accreditation Commission, 2015).

The knowledge and function of surgery discharge instructions, especially after patients return home, is unknown. In a recent Institute of Medicine symposium, panelists suggested more research on patients’ discharge orders and discharge documents (Roundtable on Health Literacy, 2014). Health awareness and cognitive incapacity hinder patient and caregiver understanding of discharge instructions (Coleman et al., 2013). Discharge instructions may overcome these restrictions, however providing patient-centered, low-level instructions may not be enough if the knowledge is not actionable (Health Literacy Roundtable, 2014; Chugh et al., 2009). To maximize the effectiveness of written orders, discharge instructions must encourage patient and caregiver self-care and make them active members of their post-discharge care team. Providers should be able to include patients and families in a care team. These principles should encourage team communication to reduce morbidity and readmissions (Horstman et al., 2017).

Al Rebeh’s (2018) research indicated that PDI (Patient Discharge Information) boosted experimental participants’ knowledge, attitude, and behaviors about diagnosis, medical procedure, treatment, self-care management, signs and symptoms, medicine, lifestyle, diet, and psychological health. Pre-test to post-test, control participants’ knowledge, attitudes, and behaviors about medical procedures, care, signs and symptoms sensitivity, lifestyle, diet, and mental health deteriorated. Findings affect healthcare policy and practice. Results include future study guidelines.

In another study by Humphries et al. (2020), all patients received discharge notes, mostly on sheets of paper with pre-printed headings or no structure; almost three fourths of notes provided diagnosis, pharmaceutical information, lifestyle recommendations, and follow-up instructions. Half of patients reported receiving ongoing treatment/management information and a quarter lifestyle counseling during discharge consultations. Within 18 weeks of follow-up, 5% of patients died, 13% were readmitted, and 11% said their chronic disease worsened. Low-quality written discharge communication was associated with death, and low-quality spoken discharge communication was associated with chronic noncommunicable disease deterioration within 18 weeks of follow-up.

Newnham et al. (2017) observed that various research have studied computer-generated and video-based discharge communication techniques. Healthcare practitioners and patients prefer using technology to convey discharge information because it improves patients’ awareness of their medical condition and instructions. Well-designed IT systems can increase communication, coordination, and information retention, leading to better results for patients, their families, carers, and primary healthcare professionals as well as hospital staff.

GonçalvesBradley et al (2016). Many countries routinely arrange discharges. Discharge planning aims to reduce hospital stays and unexpected readmissions and improve post-discharge care coordination. Length of stay and readmissions were reduced for hospitalized patients assigned to discharge planning. Uncertain if discharge planning prevents fall-related readmissions. Mortality was similar for elderly people with a medical condition. There was no evidence about mortality for people recovering from surgery or with medical and surgical problems. Discharge planning can boost patient and provider satisfaction. It’s unclear if discharge planning affects the cost of treatment for sick patients.

Discharge planning (an personalized plan for a patient before they leave hospital for home) paired with post-discharge support can prevent unexpected readmission for congestive heart failure patients (Phillips, 2004). Reductions in readmissions reduce inpatient expenses, but planning may enhance community service provision to counterbalance this. Unplanned hospitalizations accounted for 17% of Medicare hospital expenses in 2004, and 25% of admissions were 30-day readmissions (Jencks et al., 2009). Even a slight reduction in readmission rates could save money (Burgess, 2014).

Nurhayati et al. (2019) found low discharge teaching quality. Discharge preparedness was moderate. Overall, discharge instruction quality wasn’t correlated with patient readiness. Quality of discharge teaching scale and preparedness for hospital discharge scale subscales such as content received and delivery, knowledge, coping abilities, and expected support had favorable associations. Having a caregiver, a brief hospital stay, health insurance, and a job also increased hospital discharge readiness. Low-quality discharge instruction may reduce surgical patients’ hospital preparedness. Clinician-relevant.

Discharge planning provides continuity of care through identification, assessment, goal setting, planning, execution, coordination, and evaluation. Discharge planning is seen as a means to improve patients’ transitions from the hospital to home or chronic care units and to handle post-discharge care problems. In Taiwan, studies on discharge planning demonstrated enhanced patient satisfaction, caregiver preparation, and quality of life. Interdisciplinary discharge planning was rare. No systematic evaluation mechanism existed for interdisciplinary discharge planning, and many patients felt hospitals handled post-discharge long-term care referrals poorly. Despite positive views about discharge planning, many clinicians have inadequate understanding and conduct. To improve discharge planning, a consistent interdisciplinary discharge planning evaluation approach and more physician awareness are needed (Lin et al., 2013). Quality discharge teaching reduces readmission rates. Nursing primarily teaches patients and caregivers. Time limits, patient and caregiver overburden, and comorbidities complicate discharge instruction. Readmissions are not just a preventable expenditure, but they also signal to patients that they can’t care for themselves or that their sickness or healing is beyond their control (Luther et al., 2019).

According to Brat et al. (2016), five out of six patient satisfaction studies favored the intervention group. Exploratory subgroup study indicated that hospital-stay interventions that continue after discharge reduce readmissions more than post-discharge interventions. Multicomponent therapies weren’t more successful than single components. Patient-centered therapies were the most beneficial. Discharge preparation increases patient readiness for hospital discharge and reduces post-discharge emergency visits and readmissions. Early patient evaluation improves discharge planning (Kleinpell.2004; Reiley et al., 1996 as cited in Bobay et al., 2004). Nurse-delivered discharge instruction improves self-care adherence, clinical outcomes, and costs (Koelling et al., 2005). In a study on the association between quality of discharge teaching and hospital discharge preparedness among adult medical-surgical patients, nurses’ skills in “delivering” discharge teaching predicted readiness more than the amount of discharge preparatory information patients received (Weiss et al., 2007).

Routine “one-size-fits-all” discharge practices may cause communication gaps between health care workers and elder patients, neglecting their needs (7, Bull et al., 2000 as cited in Bobay et al., 2010; McMurray et al., 2007). Too often, patients are discharged with little information about their medications or condition and without concern for their home environment or how they will cope. They have trouble following specialist diets and don’t understand exercise constraints (Bull et al., 1996 as cited in Bobay et al., 2010; Bull et al., 2000 as cited in Bobay et al., 2010; Lough, 1996 as cited in Bobay et al., 2010). Obstacles to successful discharge preparation are more pronounced for older adults due to pain or fatigue, stress or anxiety over the imminent discharge, the complexity of medical information, and information overload (Paterson et al., 2001). In Yang et al. (2020), patients’ perception of discharge instruction quality is moderate to high. Managers should grasp the features of different departments and provide assistance, and clinical nurses should understand ward patients and provide specific guidance. Nurhayati et al. (2019) found low discharge teaching quality. Discharge preparedness was moderate. Overall, discharge instruction quality wasn’t correlated with patient readiness.

Delivery of Discharge Teaching

According to The Sullivan Group and Mackles (2022), patients must be given written instructions for home care, including prescriptions, nutrition, therapy, and follow-up appointments, before being discharged. Appointment dates and times must be listed. Providers must warn patients of upcoming lab work or testing and ensure they have transportation after discharge. Patients must be given a detailed list of all drugs. When and how to take drugs must be clear. Providers must discuss drug negative effects and warnings. Again, the teach-back strategy is excellent for confirming. Providers should check if patients can pick up and pay for prescriptions.

When coupled with spoken text, animations increased this group’s recall. Low health literate people recalled the same amount of information as high health literate people when exposed to spoken animations, but under all other scenarios, high health literate people recalled more information (Meppelink et al., 2015). Johnson and Sandford (2005) found that delivering written and vocal health information improves knowledge and satisfaction for parents of hospitalized children.

Age Differences in Quality of Discharge Teaching

According to Suwan et al. (2018), predicting hospital release preparedness is critical for efficient nursing intervention. Age, gender, family income, educational level, housing arrangements, coherence, illness uncertainty, past admissions, hospital stay length, care coordination for discharge, and discharge teaching quality were considered. High readmission rates are ascribed to inadequate release preparation, unprepared patients and caregivers, poor transition coordination, and inability to cope with everyday duties. Multiple comorbidities, illness-induced limits, decreased mobility, weariness, anxiety, cognitive impairment, hearing impairments, health literacy deficits, and living alone may affect older individuals’ discharge needs (Bobay et al., 2010). Multiple comorbidities, illness-induced limits, decreased mobility, weariness, anxiety, cognitive impairment, hearing impairments, health literacy deficits, and living alone may affect older individuals’ discharge needs (Bobay et al., 2010). In Clark et al. (23005), age, sex, self-described health status, and duration of stay did not impact discharge instructions evaluations.

Difference in Content Needed and Content Received

89 percent of patients receive more information than they need, according to Maloney and Weiss (2008). Prior hospitalizations and cardiac patients receive more content. Patients’ perceptions of receiving adequate or inadequate information before discharge do not reflect nurses’ actual teaching. Several explanations have been offered for the discrepancy: lack of attention during the information exchange (e.g., due to pain or lack of sleep; Galloway et al., 1997; Maloney & Weiss, 2008), difficulty coping (e.g., feeling anxious, stressed, or in denial of impending discharge; McNamee & Wallis, 1999; Paterson et al., 2001; Maloney & Weiss, 2008), or feelings (Burkhead et al., 2003 as cited in Maloney & Weiss, 2008; Jacobs, 2000 as cited in Maloney & Weiss, 2008).

Nurses’ characteristics may affect communication and information quality. Professionals often use complex terminology that patients don’t understand or give inconsistent and contradictory information (Henderson & Zernike, 2001). (Bull, 1994b; Paterson et al., 2001 as cited in Maloney & Weiss, 2008). Professionals may vary patient information based on previous notions and opinions (Mordiffi et al., 2003; Maloney & Weiss, 2008) or express unfavorable sentiments (Bull & Kane, 1996 as cited in Maloney & Weiss, 2008). Experienced nurses have a broader perspective on discharge preparation factors (Bull, 1994b as cited in Maloney & Weiss, 2008; Tilus, 2002 as cited in Maloney & Weiss, 2008).

The Four Generations of Patients

Boomers are more tech-savvy than younger doctors and employees think. Many 60-75-year-olds have smartphones and use computers at work. They’re used to patient portals. Baby Boomers explore symptoms, diagnoses, and therapy online before their visit. They want their doctors to discuss treatment pros and cons. When selecting providers, Baby Boomers frequently follow their primary care doctor’s advice, but they also consider word-of-mouth and online recommendations. Baby Boomers value finding a trustworthy doctor. They’re more “brand loyal” than younger patients and will return for exceptional care. Xers are choosy and use social media to find a doctor. They consider online reviews from Google, Healthgrades, and Yelp. Since Gen Xers are generally at the peak of their careers, they value convenient scheduling and appointment options. After-work and weekend appointments are needed. Xers value fast client service. They don’t like long appointment waits. They’d prefer not wait two or three weeks for an appointment and find another practitioner. Gen Xers look for information before appointments and compose queries based on what they’ve heard or read. They want control over their bodies and value professional opinions less. They sometimes see their healthcare provider as a confidant. Health care research includes alternative remedies (Carroll, 2021).

Millennials are the largest generation. They have hectic careers and young families. They want off-hours online appointment systems. When appropriate, they deploy mobile apps and telehealth. Financially strapped, they desire price transparency. Millennials prefer doctors who use cutting-edge technologies. They also desire strong patient-provider connections and ample appointment time. When unhappy, people submit bad reviews online and transfer providers. Millennials frequent Web MD. They aren’t always discerning about the quality or credibility of Web sources and often give their doctors with articles to validate pre-formed judgments about their symptoms or proposed therapies. Generation Z is only starting to use the healthcare system. They are truly digital natives and will expect online payments and scheduling. They want smartphone apps and appointment reminders by text (Carroll, 2021).

Characterizing the Different Generations in Relation to Healthcare Activities

To improve communication with patients, Generation X and Generation Y may be more likely to multitask when giving patient instructions, so ask for their full attention when providing critical information and provide it in multiple formats – e.g., tell them face to face, then email a link with discharge instructions. They may have self-diagnosed or researched online, so be ready to answer inquiries, etc. Develop talking points about the dangers of utilizing Google as a medical evaluation. Consider blogs, Facebook pages, and YouTube videos for tutorials for this demographic. They like social media, smartphone apps, and similar communication. Set up notifications to remind them to take medications, for example. They may not respond to dated analogies or health worries since they feel invincible. Many younger folks haven’t been to a funeral or hospital (Krischke, 2016). Baby Boomers and older generations may distrust younger nurses and doctors, so be prepared. Nurses should ask patients’ test-result preferences. Many boomers are used to acquiring their medical results via phone or mail, so internet access can be scary. Older patients may need an advocate to help them write down key information and follow instructions as needed. They may need support navigating insurance or administrative concerns if they don’t have an advocate. Across generations, and especially with older patients, information may need to be repeated or repeated back to assure understanding. Patient education uses the teach-back strategy (Krischke, 2016).

Boomers want to participate in their healthcare. They ask their doctor for advice on researched care material. Only doctors and nurses are considered medical professionals. As evidence, they use third-party comparisons to self-direct to professionals and suppliers. Many Boomers make medical decisions for their parents and children. Boomers may cause physicians the biggest communication problems due to three generations and extensive data (Integrated Healthcare Executive, 2016).

Generation X seeks engagement and education. They’re relatively healthy, curious, and information-seeking. They expect medical staff is knowledgeable. They have less provider loyalty. They switch doctors and facilities based on recent experience, not overall history. Gen Y craves connectivity. They use PCPs, urgent care centers, and OB/GYNs. They use inpatient and outpatient care rarely, usually through the ER or maternity. They use technology, have a good relationship with their doctor, and value different health sources. If people lose faith in their recent care, they may move doctors or hospitals (Integrated Healthcare Executive, 2016).

Buschi and Zani say Gen X experienced globalization (2020). Generation X, less global than later generations, faced unexpected issues. Disillusioned and practical. They’re ambivalent about digital. They simply use it, but fear hyper-benefits.

According to Scommegna (2018), baby boomers in their 50s and 60s had greater chronic disease and impairment than preceding generations at the same ages, which could affect their ability to work longer. In 2004-2010, older persons ages 51 to 61 had a greater prevalence of six out of eight chronic illnesses, including 37 percent higher diabetes prevalence, than their counterparts in 1992-1998. Choi and Schoeni (2017) compared the physical and cognitive health of retirees by generation. Adults in their late 50s now are in poorer health than their parents were at the same age, despite having to work longer to collect full Social Security payments.

Baby Boomers were educated linearly, for example. Bookworms. They read entire books. They lectured. Overhead projectors, filmstrips, and video were popular. Pods or modules taught Gen X. They learned in a lecture- and small-group-based atmosphere. Their calculators worked. Millennials were taught constructivism. They networked research. They would likely use a computer to research a topic. First digital natives. Flexible learning environments. They possessed infinite information and could switch focus instantly. Educational tools and trends necessitate digital literacy. Millennials are tech-savvy (digital natives). Digital immigrants are less computer-savvy because they learnt later in life. It doesn’t imply Baby Boomers should learn from books or face-to-face schooling while Millennials use computers. Baby Boomers learned computers later than Gen X or Millennials (Warren, 2012).

Relationship between Content and Delivery

Mackles (2022) says that delivering discharge instructions effectively is a clinician’s most effective tool for promoting patient healing. A well-planned hospital discharge is crucial to a patient’s rehabilitation and post-discharge care. The attending clinician and discharging nurse must have a thorough discharge dialogue to ensure a safe discharge and good follow-up. Family, friend, carer, or home health assistant should also be involved.

According to Zeng-Treitler et al. (2008), memorizing hospital discharge instructions is difficult. Patients or family members may be physically or emotionally uncomfortable at discharge. They may be impatient to depart and uninterested in directions. Many patients lack literacy and/or health literacy. The hectic hospital environment may also distract the patient. To mitigate these problems, discharge instructions must be delivered in an easily comprehended way.

Synthesis. While literature and previous studies are in one in affirming that discharge teaching should be of quality in order to lessen patient length of stay and readmissions, it appears that there is a scarcity of the related literature and studies on the differences among different generations on the variable of quality of discharge teaching. This further affirms the need of this study. Different generations have different unique characteristics based on their historical background from the time that they were born and the environment that they grew up with.      While contents of the discharge teaching have to be complete and accurate, it might also be that the delivery matters to each or every generation of patients or even the other way around.

METHODOLOGY

Design. This quantitative research made use of the descriptive, comparative (non-causal) design.

Environment. The study was conducted in a government specifically in the Medical-Surgical Ward. It is a 200-bed capacity and a level I government hospital with a pending application for Level III classification. The Medical-Surgical Ward has a bed capacity of 53 beds.

Respondents. Respondents of the study were the discharge patients of the Medical-Surgical Ward of the hospital. 53 respondents were taken from each generation making the total sample size to 214 discharged patients.

Sampling Design. The study made use of the quota sampling.

Inclusion Criteria and Exclusion Criteria. The criteria included the following: (a) the respondent should be a resident Cebuano who had been residing in Talisay City for at least 1 year; (b) the respondents should be admitted for at least 24 hours in the Medical-Surgical Ward are for discharged and are only waiting for their discharge while their bill is being settled; (c) respondents must belong to any of the following generational classifications, namely: Baby Boomers; Generation X, Generation y, or Generation Z; (d) respondents must be willing to provide voluntary consent, regardless of sex, marital status, educational status, religion and economic status but must be at least 18 years old; and (e) must be mentally sound and able to provide voluntary consent. Excluded from the study were: (a) those who discharge by reason of ‘home against medical advice’; and (b) significant others cannot serve as a respondent in behalf of the discharged patient.

Instrument. This study made use of a four-part questionnaire. Part one of the instrument determined the age group of the discharged patients. Part two of the instrument determined the patients’ needs of discharge teaching in terms of content (needed and received) and delivery. It is a standardized tool. The Quality of Discharge Teaching Scale (QDTS) (19-items) Part three of the instrument measured the suggestions and recommendations on the discharge teaching. The fourth part asked about the experiences of the respondents on the quality of discharged planning

Data Gathering Procedures. The study sought permissions to conduct the study. The study was then submitted to the Institutional Research Ethics Committee of the university and the ethics committee of the hospital for ethical approval. A notice to proceed was needed by the researchers prior to the recruitment of the first respondent. With the prevalence of the COVID-19 pandemic, periodic data gathering was done wherein Inter-Agency Task Force protocols were strictly observed as a face-to-face intercept was used. Data were then treated statistically and were presented in tables together with the interpretations, analyses, and supporting literatures and studies. All answered questionnaires were shredded at the completion of the study as well as the electronic copies of the data were also deleted permanently.

Statistical Treatment of Data. The following statistical treatments were used in the study Relative Frequency, Mean score, Paired samples t-test, Analysis of Variance (ANOVA), and Pearson r.

Ethical Considerations. This study followed ethical standards. To do so, the researchers made sure that ethical standards were strictly followed to protect study participants.

RESULTS AND DISCUSSION

Table 1 Generational Classification of the Discharged Patients

Note: n=212.

The table shows an equal distribution of respondents coming from the different four generations. An equal number of respondents were chosen from the different generations as the researchers wanted to get an equal representation from all the four generations considering that the intent of the study is to get the significant difference among the four generations on the variables studied. In doing so, there an equal distribution of respondents from all the generation which will avoid bias where concentration of respondents from one generation or two will be avoided. From the set sample size of 212, each generation is represented with 53 respondents. These four generations are the last and most recent generations. As defined in the study, the Baby Boomers are born between 1955 and 1964. They are currently between 57-75 years old. Generation X are born between 1965 and 1980 and are currently between 41-56 years old. Generation Y or Millennials, are born between 1981 to 1996. They are currently between 25 and 40 years old. Generation Z is the newest generation, born between 1997 and 2012. They are currently between 9 and 24 years old.

Table 2 Quality of Discharge Teaching in terms of Content according to Generations

Legend: A score of 9-10 is (a great deal [GD]) very high (VH), 8-8.9 is (almost a great deal [AGD]) high (H), 7-7.9 is (moderate [M]) moderate (M), and <7 is (none [N]) low (L).

The quality of discharge teaching in terms of the content needed and received were high. The four generations were able to describe the quality as high with the Generation X scoring the lowest and the Baby Boomers scoring the highest of the four generations. Overall, the quality of discharge teaching in terms of the content was high with all generations rating it as high where the Baby Boomers scored the highest while the Generation X scoring the lowest. Supporting the findings of the study Yang et al. (2020), the level of the patients’ perception of quality of discharge instruction is middle to high. Managers should understand the characteristics of various departments, give corresponding guidance and help, and clinical nurses should understand the characteristics of ward patients and pay more attention to individual guidance. Overall, the quality of the discharge teaching in terms of content was high as all generations perceived it as high. This is clear indication that the nurses were able to deliver what is expected of them. While this is a positive indication, the real challenge is to make sure that this is being sustained despite the challenges in nurse turnover and other challenges. It is thus, important for nursing service managers to constantly evaluate the quality of discharge teaching so as to take appropriate measures and not to allow patients suffer.

Table 3 Quality of Discharge Teaching in terms of Delivery according to Generations

Legend: A score of 9-10 is (a great deal [GD]) very high (VH), 8-8.9 is (almost a great deal [AGD]) high (H), 7-7.9 is (moderate [M]) moderate (M), and <7 is (none [N]) low (L).

Overall, the discharge teaching in terms of delivery was of high quality as perceived by the four generations. The four generations were able to describe the quality as high with the Generation X scoring the lowest and the Baby Boomers scoring the highest. As also be noted that the Baby Boomers are consistently scoring high in all of the items measured in the quality of discharge teaching in terms of its delivery except for the delivery on the information being received from the nurses providing at times when their family member(s) or others could attend, where the Generation Z scored the highest. The Generation X on the hand are also scoring as the lowest in all aspects of the quality of delivery of the discharge teaching. Similar to the previous table, the reason behind this finding could be attributed to Baby Boomers being the most experienced of all patients considering that they have lived longer compared to the other three generations. As emphasized in the previous table, the oldest generation in the study are mostly suffering from illness as they are the most vulnerable of the four generations by reason of age that they may have frequently visited the hospital and as a consequence of frequent hospital visits, they had been discharge teaching a couple of times and therefore they know what should be contained and how it should be delivered. In other words, the oldest generation in the study already know the drill.

Table 4 The Different Suggestions and Recommendation on the Quality of Discharge Teaching according to Generations

Overall, the four generations suggested that in the delivery of the discharge teaching, they suggested that it will be done through a combination of face-to-face and use of printout. This was followed by a visual presentation using diagrams or pictures or animations. And lastly, a combination of face-to-face and sending an email. Contrary to the findings according to Warren (2012) different generations were taught differently, Baby Boomers for example were taught in a linear fashion. They read books. Not only that, they read books from cover-to-cover. They were taught by lecture. Prevalent learning technologies included overhead projectors, filmstrips, and some video. Generation X were taught in pods or modules. They learned in a structured environment that included some lecture and small group activities. These students had calculators. Millennials were taught in a more constructivist environment. They did research in a networked structure. When asked to investigate a topic they would most likely turn to a computer. They were the first entire generation of digital natives. Their learning environment accommodated flexibility. They had unlimited information available at their fingertips and were comfortable changing focus quickly. Changes in educational tools and trends require us to consider digital literacy. Millennials (digital natives) are comfortable with computer technology. In comparison, digital immigrants—those who learned to use computers later in life—are less facile with computers.

Table 5 Significant Difference in the Quality of Discharged Teaching in terms of Content according to Generations

Legend: Significant if p value is < .05.

There was a significant difference in the perceptions on the quality of discharge teaching in terms of content needed and content received between Baby Boomers and Generation X. The Baby Boomers perceived the quality higher over the perceptions of the Generation X. According to Buschi and Zani (2020), the Generation X found themselves in the middle of an epochal passage: globalisation. Not yet as cosmopolitan as the generations that follow, the Generation Xs faced challenges they were not fully prepared for. It is a disillusioned generation but also practical and pragmatic. Also, they are halfway in digital – their relationship with digital is conflicting. They use it with ease, but often give up the advantages of hyper-connection from which they feel a little threatened.

Table 6 Significant Difference in the Quality of Discharged Teaching in terms of Delivery according to Generations

Legend: Significant if p value is < .05.

There was a significant difference in the perceptions on the quality of discharge teaching in terms of the delivery between Baby Boomers and Generation X. The Baby Boomers perceived the quality higher over the perceptions of the Generation X. And as a preliminary, according to the study of Suwan et al. (2018), identification of factors predicting readiness for hospital discharge is essential to the provision of effective nursing intervention. These selected factors included age, gender, family income, educational level, living arrangements, a sense of coherence, uncertainty in illness, previous admissions, the length of the hospital stay, care coordination for discharge, and quality of discharge teaching.

Table 7 Significant Difference between the Content Received and the Content Needed according to Generations

Legend: Significant if p value is < .05.

There was no significant difference between the content needed and content received in all of the generations of discharged patients. Contrary to the findings of the study, the study of Maloney and Weiss (2008) found out that eighty-nine percent of patients receive more informational content than they perceived they needed. Patients with prior hospitalizations and cardiac patients report greater amounts of content received.

Table 8 Relationship between the Content and the Delivery of the Discharge Teaching

Note: Significant if p value is < .05. Strength of Association: Small is .1 to .3 or -0.1 to -0.3; Medium is.3 to .5 or -0.3 to -0.5; and Large is .5 to 1.0 or -0.5 to -1.0.

There was a high or large positive correlation between content needed and the delivery of discharge teaching as well as on the content received and the delivery of the discharge teaching. In support to the findings, according to Mackles (2022), the most effective tool in a clinician’s toolbox to promote patient healing is the effective delivery of communicating discharge instructions for patients. A successfully planned and executed hospital discharge is critically important to a patient’s continued recovery and fulfillment of post-discharge care. The discharge conversation initiated by both the attending clinician and discharging nurse must contain all pertinent information necessary to ensure a safe departure from the hospital and successful follow-up. It is also important to have a family member, friend, caretaker or home health aide engaged in the conversation.

CONCLUSION AND RECOMMENDATION

Conclusion. In conclusion, the different generations differ in their perceptions with the in terms of the content needed, content received, and the delivery of the discharge teaching. They vary in their perceptions in such a way that older generations perceived the quality in the content needed, content received, and the delivery higher over the younger generation. This means that the quality is more appreciated by the older generation than the generation which implies that different generations require different discharge teachings. Further, the delivery of the discharge teaching is influenced the content needed and content received. The quality of the delivery of the discharge teaching becomes better when the content needed and received are also good. The findings of the study were an affirmation of the Individual and Family Self-management Theory by Ryan and Sawin (2009). The study was able to prove that the context, process, and outcomes as evidenced by the high levels of perception on the quality of the discharge teaching as perceived by all the generations. It is important for the nursing service to guarantee quality discharge teaching taking into the generational classification of patients and a way of doing so, a generational discharge teaching enhancement plan is proposed.

Recommendations. Based on the findings of the study, the following are recommended:

Nursing Profession. As part of research utilization, the output plan is recommended for use in the hospital where the study was conducted in order to bring improvements in the quality of the discharge teaching in both contents and delivery taking into considerations generational classification of patients.

Nursing Education. The findings can be a great tool in the field of Medical-Surgical Nursing both in the undergraduate and graduate programs where the concept of discharge teaching is very well emphasized. The findings can be used as a reference in making discharge teachings more personalized based on the patient’s generational classification. The concept of identifying generational characteristics can be given emphasis as a consideration in the making and delivery of the discharge teaching.

Nursing Policy. The findings may warrant the need for a conduct of meeting by the nursing service and hospital administrators in the establishment of new standard operating procedures and policies relating to discharge teaching taking into consideration the generational classification of patients. The study may also serve as an eye opener for the accredited professional organization for nurses (Philippine Nurses Association-PNA) and the regulating agency of the government (Department of Health-DOH) to draft new policies and regulations that further strengthen patient safety through the delivery of a quality discharge teaching.

Nursing Research. As part of research dissemination, a copy of this study will be provided to the hospital where it was conducted to allow all members of the nursing service and other department to gain access on the findings of the study.

Recommendations also include the following research topics that future researchers can endeavor on:

1. Conducting a replication of the study covering the entire wards of the hospital or further extending to both public and private hospitals and covering a wider coverage of respondents;
2. A cross case analysis on the experiences on discharge teaching among intergenerational patients; and
3. A comparative analysis on the quality of discharge teaching between nurses and patients in a government hospital.

Generational Discharge Teaching Enhancement Plan

Rationale

The process of planning for hospital release is a critical component of any hospitalization. It is crucial in facilitating a smooth transition from the hospital to the home. This is accomplished by ensuring that relevant clinical and community-based support services are in place. Nurses are critical in delivering discharge instruction to patients. Discharge planning begins concurrently with the patient’s admission. Nurses should be able to offer thorough and correct discharge teaching; but, the way in which the discharge teaching is presented is equally critical, as it can make or break the patient’s successful transition from the hospital to the community. Findings of the study revealed high levels of perceptions on the content and delivery of the discharge teaching where the difference was only seen between the Baby Boomers and the Generation X with Baby Boomers having high levels of perceptions over Generation X.

General Objectives

The main purpose of this generational discharge teaching enhancement plan is to sustain the high level of perceptions on the quality of the content and delivery of the discharge teaching across all generations; addressing the differences in the perceptions of the quality of discharge teaching across generations; and addressing the different suggestions on the manner the discharge teaching be done.

Specific Objectives

1. To sustaining the high level of perception on the quality of the discharge teaching in terms of content needed and received;
2. To sustain the high level of perception on the quality of the discharge teaching in terms of delivery;
3. To improve the perceptions of the Generation X on the quality of discharge teaching in both content and delivery, specifically:

c.1. To improve the content on the information the family member(s) or others need about patient care after going home from the hospital;

c.2. To improve the contents on the information of the discharge teaching received from the nurses about who and when to call if problems arise after patients go home; and

c.3. To improve the delivery of the discharge teaching by nurses being sensitive to the personal beliefs and values of the patients.; and

1. To improve the quality of the delivery of the discharge teaching as suggested by the different generations of discharged patients

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