A disorderly landscape: people, practice and politics in hospital discharge and transition to the community

Abstract

The New Zealand health environment has undergone major changes in recent years in response to fiscal pressures and a push for increased efficiency and accountability (Boston, 1991). One of the many effects of these changes has been a reduction hospital in-patient length of stay (Health Funding Authority, 1998). The impact of the reformed environment had been largely unexplored in relation to the discharge planning practice of nurses' and consumer experiences of the transition home from hospital. Using a constructivist methodology (Guba & Lincoln, 1989) this study built a picture of the personal experiences of transition from hospital to home alongside the professional experiences of nurses involved with this transition. Six stakeholders were involved in the study. Three nurses took part from different settings: one nurse from the acute hospital setting, one district nurse and one practice nurse. Three consumer participants were involved who had recently experienced the transition from hospital to home. Central to the participant constructions were the sociopolitical environment in which the study took place and the international body of literature in relation to discharge planning. What evolved were multiple constructions of discharge planning and hospital transition from divergent perspectives. Methodological tensions are also discussed. Several issues emerged from the study. Firstly the transition from hospital to home was a complex and often difficult experience, which frequently remained unrecognised. Discharge planning occurred in a haphazard rather than a planned manner, with nurses dealing with complex situations and organizational constraints. Orderly discussions that occur within discharge planning literature and health care documents were not reflected in the disorderly experiences of people receiving the service and nurses working within health care. While a picture of chaos has emerged, the horizon is not all bleak as opportunities exist for nurses to position themselves in ways to deal with the complexities that exist within contemporary health care.