Liaison nurse activities at hospital discharge: a strategy for continuity of care*

Objective to describe the activities developed by the liaison nurses for the continuity of care after hospital discharge. Method descriptive, qualitative study, based on the theoretical reference. Strength Based Care. The sample comprised 23 liaison nurses. The data was collected through a semi-structured questionnaire via Survey Monkey electronic platform and analyzed through the content analysis technique, with pre-defined categories. Results among the liaison nurses, nine (39.14%), between 35 and 44 years of age; 17 (73.91%) were female; 15 (65.22%) were working eleven years or more nurse and 11 (47.82%), were between six and ten years old as a liaison nurse. The professionals participate in the identification of the patients who need care after hospital discharge, coordinate the planning of the hospital discharge and transfer the patient’s information to an extra-hospital service. Conclusion the activities developed by the liaison nurses focus on the needs of the patient and the articulation with the extra-hospital services, and can be adapted to the Brazilian context as a strategy to minimize the discontinuity of care at the time of hospital discharge.


Introduction
Continuity of care is fundamental to the quality of health care, and is related to improved patient satisfaction, reduced costs, and decreased avoidable hospitalizations (1)(2)(3) . Continuity of care is a complex and multifaceted concept (2,4) . In this study, it is defined as the degree to which a series of events is experienced by the patient as coherent, connected and according to their needs (5) .
The combination of different elements results in continuity of care, such as: access to health services; good interpersonal skills; fluid information among professionals; appropriate coordination of care; integration of services (5) and, above all, professional practices centered on the person, their needs and the available resources, whether those resources of the person or the health system.
In Latin America, continuity of care has been a challenge for health systems, because there is a lack of coordination between the different levels of care, resulting in difficulties in accessing health services, duplicity of diagnostic tests (6) , fragility regarding the articulation between the hospital and Primary Health Care (PHC) at hospital discharge, inefficiency or lack of counter-referral for patients with different health problems, incipient and ineffective hospital discharge planning (7)(8)(9)(10) .
In order to find successful practices in the field of Nursing that effectively contribute to the continuity of care in the Brazilian context, a multi-centric project was developed in Canada, Spain and Portugal, focusing on the practices of nurses in the hospital discharge. These countries were chosen because they work with the liaison nurse, who has an important role in improving communication and coordination of care (11) . This study considers the results of the Canadian context.
A liaison person is a health professional designated to coordinate the discharge of the patient, to follow the care provided, and to transfer information from the hospital to the primary care professionals (12) . Liaison nurses are extremely important at hospital discharge to ensure that patients receive planned care according to their needs, regardless of where they will be assisted or the professionals who will assist them, and also, so that services of different levels of health care can operate as a network, in an articulated and coherent way.
A study on the general role of nurse liaison, regardless of the area of action, outlined six domains of practice of these professionals, being: care coordinator; educator; communicator; Advisor; lawyer of the patients; agent of change; contributor; negotiator; staff member and clinic, which pertains to the patient attending nurse based on a person-centered approach (11) .
With the person-centered approach, a relevant aspect of nursing liaison practice, this study was anchored in the theoretical framework of Strength Based Care, which argues that nurses need to learn new avenues to connect, engage, and initiate a movement that puts the patient in the center of care, with a focus on their uniqueness and their strengths (13) .
Strengths are the capacities that the person and the family have to face the challenges of life, facilitate their recovery, heal and collaborate for their well-being.
Forces encompass a person's attitudes, attributes, skills, resources, and abilities (13) . In addition, they are important social agents to unite the Nursing team in favor of care (14) .  preferably answered via Survey Monkey ® electronic platform or printed on paper, if the participant preferred.
The paper questionnaire was a requirement of the Research Ethics Committee (REC) of partner institutions to respect nurses who did not feel comfortable using Survey Monkey ® . For the liaison nurse who wished to respond to the questionnaire on paper, a copy of the questionnaire was sent via e-mail so that she could print, respond and then forward to one of the researchers by the email created specifically for this research. The methodology used to analyze the data was Content Analysis, which consists of the set of techniques of the analysis of communications and comprises three stages: pre-analysis; exploitation of the material; data processing and interpretation. In the pre-analysis, the data was gathered in a Microsoft Word ® file and the floating readings were taken to know the text and allowed to invade the impressions and orientations.
In the exploration of the material, codification and condensation of the recording units were carried out according to the pre-defined categories. Finally, the data were interpreted (15) through the theoretical reference Strength Based Care (13) .
In Brazil, the research project was approved by the   In addition to hospital health care professionals, family members may also be involved in the process of identifying patients who need the liaison service. The family can also make the request (EL4).

Category 2: Discharge Planning
Liaison nurses begin planning hospital discharge after identifying the patient who needs their services or after receiving the referral request, which can happen at  When planning hospital discharge, the nurses assess whether the patient and / or caregiver understood the guidelines provided to continue treatment. They also reinforce the care to be taken and the services available.  The way of life. The main helpers (EL11).

Category 3: Transfer of information between the hospital and other services
The liaison services of the hospital complexes have

Discussion
Liaison nurses actively participate in the process of identifying patients who need care after hospital discharge.
In this process, it is fundamental that the nurses are open to dialogue with the patient, without judgments, because the patients and the family are predisposed to collaborate when they feel valued, understood, respected and safe (13) . The other professionals of the health team also identify the patients and refer them to the nurses, which demonstrates that all members of the health team have roles and responsibilities in the patient's hospital discharge process (16) and, consequently, with the continuity of care.
Among the forms of identification of the patients by the liaison nurses, these are highlighted by their role as coordinators of the hospital discharge process, since the liaison nurses are the points of convergence between the different members of the team and between the different health teams. In this context, communication is paramount for the liaison nurse to play her role as collaborative staff, which is key to maintaining patientcentered care (11) .
It is important to point out that the active search carried out by the nurses of liaison with the nurses who work in the care is an important strategy, since the nurse assistants are in direct contact with the patients, which allows them to make important observations about how the patients are responding to the patients. their health challenges (13) and to identify the patients who really need care after hospital discharge.
Planning for hospital discharge is a process that needs to be started shortly after the patient is hospitalized, specifically within the first 24 hours.
In this way, it is possible to identify the obstacles to discharge and to implement corrective actions (17) . The discharge planning, being a process, is characterized by different moments: in the admission, data can be collected related to the cognitive state, support systems and domestic environment; risk factors, such as the need for learning, can be evaluated near the discharge of the patient (16) .
The discharge planning does not only help the different health professionals to coordinate their services in a complementary way, but also to delineate a path of care expected for each patient, which promotes a sense of security to them and a basis for the taking shared decision (18) . In general, all inpatients require a discharge plan, which may be more or less specific (17) . For identification of strengths, the liaison nurse needs to look for them in the patient, in the family, and in the community; decide which are available and can be mobilized to deal with a specific problem or concern. What's more, the bonding nurse can identify the potential forces that can be developed and the deficits that can turn into strengths, depending on the context of each patient (13) . Different tools can be used during the discharge planning to better understand each patient. The genogram, a visual representation of family members, can be used to know about the family structure, its members and the relationship between them. The ecomapa, a graphic representation of the social network of the person that includes friends, health system, religious groups, among others, assists in the identification of available social support (13) .
Nurses, whose practice is based on Forces-Based Care, seek, in their patients and family, the skills that may be useful for recovery, development and survival.
The attention of the nurse must be directed towards health, healing, alleviation of suffering, through actions that are inspired by external forces and resources, generating conditions that allow patients to achieve maximum functioning (13) .
In addition, nurses have the role of creating means to help the patient to become active in their learning process, because in each situation the patient needs to unravel their strengths and create new ones, such as developing certain dealing with the challenges that appear with an illness. Nurses should be aware of signs of readiness for learning, both of the patient and of the family members involved. When the patient is not ready for a particular experience, it is critical that the nurse provide support (13) .
The transfer of patient information between the hospital and other health services is established through the definition of an integrated computer system, which is in keeping with other studies that point to the need for a communication channel for the transfer of information between health services and professionals, such as: e-mail; telephone; systems and programs (11,(19)(20) .
Comprehensive care depends on an articulated health network so that patients' problems can be treated at all levels of attention required for their solution and that access to these levels is appropriate and timely (21) .
The use of a computer system that stores information about the patient and can be accessed independently of the level of attention the patient is being assisted in is fundamental, as there is no continuity of care without the sharing of quality information.
When there is no flow and mechanism defined for the transfer of information, many of these can be lost along the care network, which can lead to duplication in the actions of professionals and, consequently, increase in health costs, delay in solving problems and deficiency in the referral and counter-referral system. Therefore, it is fundamental that the transfer of the patient discharge planning information is coordinated and focused on a professional.
The counter-referencing is characterized as part of the competence of specialized attention and is presented as the mode of organization of the services configured in networks, supported by criteria, flows and mechanisms of agreement of operation, to guarantee the integral attention to the people through the facilitation access and continuity of care (22) .