Liaison nurse competences at hospital discharge

Competencias de la enfermera de enlace en el alta hospitalaria

ABSTRACT

Objective:

To identify the liaison nurse competences at hospital discharge in the light of Strengths-Based Nursing Care theoretical reference.

Method:

Descriptive and qualitative study, developed at the province of Quebéc-Canada, with 23 liaison nurses. The data were collected from March to July 2016, by a semi-structured questionnaire via Survey Monkey® electronic platform and analyzed through the content analysis, supported by software Qualitativa Data Analysis Miner.

Results:

The categories that has emerged were: competences related to patient care, competences related to personal characteristics of the liaison nurse and managerial competences.

Final considerations:

Liaison nurses hold a set of competences from different dimensions, which provide the care centered in the person, in its potentialities, and assure the continuity of patient care with hospital discharge.

Keywords:
Nursing; Professional competence; Patient discharge; Transitional care; Continuity of patient care; Nursing theory

RESUMEN

Objetivo:

Identificar las competencias de la enfermera de enlace en el alta hospitalaria a luz del referencial teórico Cuidar de Enfermería Basada en las Fuezas.

Método:

Estudio descriptivo, cualitativo, desarrollado en la provincia de Québec - Canadá, con 23 enferemeras de enlace. Los datos fueron recolectados, de marzo a julio de 2016, por medio de un cuestionario semiestructurado vía plataforma electrónica Survey Monkey® y analizados mediante el análisis de contenido con apoyo del software Qualitativa Data Analysis Miner.

Resultados:

Las categorías que surgieron fueron: competencias relacionadas con la atención al paciente, competencias relacionadas a las características personales de la enfermera de enlace y competencias gerenciales.

Consideraciones finales:

Las enfermeras de enlace tienen un conjunto de competencias de diferentes dimensiones lo que proporciona el cuidado centrado en la persona, en su potencial y asegura la continuidad del cuidado para el paciente con alta hospitalaria.

Palabras clave:
Enfermería; Competencia profesional; Alta del paciente; Cuidado de transición; Continuidad de la atencion al paciente; Teoría de enfermería

RESUMO

Objetivo:

Identificar as competências da enfermeira de ligação na alta hospitalar à luz do referencial teórico Cuidar de Enfermagem Baseado nas Forças.

Método:

Estudo descritivo, qualitativo, desenvolvido na província do Québec- Canadá, com 23 enfermeiras de ligação. Os dados foram coletados de março a julho de 2016, por meio de um questionário semiestruturado via plataforma eletrônica Survey Monkey® e analisados pela análise de conteúdo com apoio do software Qualitativa Data Analysis Miner.

Resultados:

As categorias que emergiram foram: competências relacionadas ao cuidado com o paciente, competências relacionadas às características pessoais da enfermeira de ligação e competências gerenciais.

Considerações finais:

As enfermeiras de ligação detêm um conjunto de competências de diferentes dimensões, o que proporciona o cuidado centrado na pessoa, em suas potencialidades e assegura a continuidade do cuidado para o paciente com alta hospitalar.

Palavras-chave:
Enfermagem; Competência profissional; Alta do paciente; Cuidado transicional; Continuidade da assistência ao paciente; Teoria de enfermagem

INTRODUCTION

Nursing competencies involve a complex set of integrated skills. It is defined as the capacity of nurses to demonstrate a set of attributes, such as personal characteristics, professional attitudes, values, and knowledge and skills, which, applied together, reflect their professional responsibility through practice. A competent nurse must possess these attributes and have the motivation and ability to use them effectively to provide safe and effective care to patients and their family members1.

Nurses are constantly challenged regarding how they can contribute to society's health issues. Currently, faced with the challenges of demographic and epidemiological transitions that have an impact on the increase in the number of elderly people and people with chronic non-communicable diseases (NCDs), nurses need to provide care that meets the complex and diverse needs of patients1. Thus, it is critical to gain further insight into the competencies of nurses.

Patients with chronic diseases need continuous follow-up2 since they are commonly dependent on technologies and devices for continued care at their homes or other care environments, on trained health workers, and on the support resources at the hospital3. Moreover, hospital discharge can expose patients to several adverse events, such as medication errors, use of emergency services, and hospital readmissions4; therefore, it is essential to ensure adequate continued care, especially for elderly patients and/or patients with NCDs.

The transition of care is defined as a set of interventions aimed at ensuring continued and coordinated care for patients transferred between different services or levels of health care5. The strategies of transition of care include discharge planning, early care planning, patient education and promotion of self-management, safe use of medications, notification of all relevant information and outpatient follow-up, which is essential for patients with various health needs and multiple comorbidities, such as the elderly and those with NCDs3.

In Brazil, hospital discharge planning is rudimentary6 and the referral and back-referral process is still fragile7; moreover, few studies have been conducted on the transition of care8. A Brazilian study analyzed the activities of nurses during the transition of care for discharged patients and revealed that most of these activities consisted of patient discharge guidelines. Therefore, activities such as discharge planning by the multiprofessional team, written discharge plan, coordination between services, and patient back-referral should be further developed by health workers4. The transition of care is currently in the developing and adaptation stages and requires further research, especially in Brazil8.

However, studies have been conducted in countries such as Canada, Portugal and Spain on the transition of care strategies of nurses based on multicenter research trials9.

In the province of Quebec, Canada, the transition of care at hospital discharge is carried out by the liaison nurse, who is responsible for identifying patients who need their services, planning discharge with the other members of the multidisciplinary team, and electronically transferring patient information to a regulatory center so that treatment is continued in out-of-hospital care after discharge9.

In Portugal, the transition of care at discharge is performed by the discharge management team, which includes professional nurses. The discharge management team identifies and evaluates patients who need continued care after hospital discharge, conduct a discharge plan, and transfer patient information, thus serving as a link between hospital services and the community/family10.

In Spain, the transition of care is carried out by the liaison nurse who is responsible for identifying patients who need to continue their care after hospital discharge and for contacting the health workers of the PREALTA, or predischarge, program, to schedule a visit to patients by primary care workers within 48 hours of the patient's hospital discharge. This visit can be made by a physician or a nurse11.

Since the liaison nurse position does not exist in Brazil and this role is considered critical to ensure continued care for patients at discharge, especially elderly patients and those with NCDs, and to support implementation of this position at hospitals, the following guiding question was established: What are the required competencies of the liaison nurse at hospital discharge? The aim was to identify the competencies of liaison nurses at hospital discharge based on the strengths-based nursing approach.

Strengths-based nursing redefines the concept of care. It guides nursing toward the core of care to human beings and focuses on people and on viewing patients beyond their disease and problems by finding strength in patients and their families, that is, the competencies, attitudes, and resources that can contribute to patient recovery and healing12.

This approach challenges nurses to work with patients and family members and ensure health-related decisions are the most appropriate for the health needs and goals of these patients. It directs these professionals to act in favor of patient interests and demands that patients be placed at the core of care, which, consequently, demands new skills from nurses12.

METHOD

This is a qualitative, descriptive study with the participation of 23 liaison nurses from two hospital centers in the province of Québec, Canada - the Montreal University Hospital Center (CHUM) and Quebec University Hospital Center (CHU).

The CHUM is located in the city of Montreal and affiliated with the Université de Montréal. It is considered one of the most important hospital centers in North America. As of March 2020, it had 14,004 employees. Annually, it assists around half a million people. The CHUM is composed of the hospitals Hôtel-Dieu, Notre-Dame, and Saint-Luc. The mission of the CHUM is to treat and cure people in partnership with the health network and the Université de Montréal by providing the best specialized and subspecialized care; developing innovative solutions through research; actively participating in the development of professionals; promoting health and well-being; and evaluating and improving health interventions13.

The CHU, affiliated with Université Laval, is located in the city of Quebec. It is composed of the Université Laval Hospital Center and the hospitals L’enfant-Jésus, Saint-Sacrement, Saint-Françoisd’Assise, and L’Hôtel-Dieu de Québec. It has 11,893 employees, 1,260 beds, and annually attends two million people. The mission of the CHU is to offer general, specialized, and subspecialized care, and to serve as a field of teaching and research14.

The study participants were recruited through two Canadian researchers. The participants were informed of the research and its objectives at a meeting held in their work environment. Subsequently, an invitation to participate in the study and an informed consent form were sent to the liaison nurses via the Survey Monkey® electronic platform. After reading and agreeing to the informed consent form, the participants were directed to the survey questionnaire.

The semi-structured questionnaire was based on the research objective and consisted of a participant characterization section and the following question: What are the essential skills required to work as a liaison nurse? The questionnaire was independently translated from Portuguese to French by two individuals who met the following criteria: nurses, with knowledge of the research subject, and fluent in Portuguese and French. The pilot test of the instrument was carried out by e-mail with two Canadian liaison nurses who were not part of the research sample. After proper adjustments, the instrument was sent to a third nurse for a final pilot test.

Data were collected from March to July 2016, preferably via the Survey Monkey^® electronic platform or printed on paper, as preferred by the participant. For the participant who preferred to answer the questionnaire on paper, a copy of the questionnaire was sent by e-mail and, once answered, the participant scanned it and sent it back to the e-mail address created exclusively for this study.

All 36 liaison nurses who worked at CHUM and CHU were invited to participate in the study, of which 24 accepted and sent the questionnaire within the deadline. A questionnaire was excluded because it was incomplete. Thus, the population was 36 and the sample totaled 23. There were no inclusion and exclusion criteria. The time to complete the questionnaire was approximately 15 minutes.

Before starting the analysis, the data were translated from French into Portuguese by two individuals who are fluent in these two languages, one of whom is a nurse and researcher. The translations were carried out independently by each translator. Data were analyzed using the content analysis methodology and Qualitative Data Analysis (QDO) Miner software. Content analysis comprises a "set of communication analysis techniques" and involves the following three steps: pre-analysis, exploration of the material, and data processing and interpretation15.

In pre-analysis, the data was transferred to Microsoft Word^® and speed read. Also, the data were entered into QDO Miner software. In exploration of the material, the data were coded and the units of register were condensed to form categories. The units of register were selected based on the general meaning, namely those that more closely defined how the nurses perceived each competency. Thus, it was possible to create the subcategories and, finally, the three main categories related to competencies. Data were interpreted using the theoretical framework of strengths-based nursing12.

The ethical aspects and recommendations of Resolution 466/2012 of the National Health Council were respected. In Brazil, the research project was approved by the Research Ethics Committee of the Universidade Federal do Paraná (UFPR) under No. 1.426.575, and granted Certificate of Presentation for Ethical Consideration (CAAE), No. 36975914.5.0000.0102. It was approved by the Research Ethics Committee of the CHUM, under No. 888.681, and the CHU, under No. 2015-2016-9012. Data were collected after approval of the research ethics committees and after obtaining informed consent from the participants. To ensure anonymity, the participants were identified by the letters EL followed by a cardinal number in ascending order as the questionnaires were received.

RESULTS

Initially, the characterization of the participants is presented, followed by the skills required to work as a liaison nurse at hospital discharge.

Characterization of liaison nurses

Nine (39.14%) liaison nurses were 35 to 44 years old, seven (30.43%) were 25 to 34 years old, and seven (30.43%) were 45 to 54 years old. In all, 17 were female (73.91%). As for the time working as a nurse, 15 (65.22%) had been nurses for eleven or more years. As liaison nurses, however, eleven (47.82%) had worked from 06 to 10 years, eight (34.78%) from 01 to 05 years, two (8.70%) from 11 to 15 years, and two (8.70%) for more than 21 years.

Competencies required to work as liaison nurses

Chart 1 shows the categories and subcategories that represent the competencies of liaison nurses.

Chart 1 -
Competencies of liaison nurses, Quebec, Canada, year 2016

Category	Subcategories	Unit of registry	Number of repetitions in QDO Miner software
Competencies related to patient care	Clinical judgment	Clinical judgment. (EL1)	8
	Holistic view of the patient	Overview. (EL2)	4
	Advocate for the patient	Advocating. (EL21)	5
Competencies related to the personal characteristics of the liaison nurses	Stress management	Good management of your stress. (EL10)	4
	Creativity	Creativity. (EL21)	4
	Priority management	Ability to prioritize demands [...]. (EL7). Sense of organization. (EL13)	4
Managerial competencies	Leadership	Leadership. (EL10)	9
	Communication	Capacity to communicate and divulge information. (EL1)	13
	Flexibility	Good adaptability (EL18)	6

• Source: Authors, 2016.

Regarding the competencies related to patient care, the liaison nurses stated clinical judgment, holistic view, and advocating for patients as essential competencies for their performance. The liaison nurse is responsible for identifying patients who need care after discharge, so hospital discharge planning must include an adequate biopsychosocial patient evaluation to provide the right conditions for each patient's care needs.

In this regard, clinical judgment allows liaison nurses to identify care according to the patient's clinical status, coordinate plan discharge for people with complex health conditions, and prevent events that may harm the patient's clinical condition. A holistic vision is one of the core competencies of the liaison nurse. Moreover, this competency allows liaison nurses to assess patients beyond disease, as individuals with physical, emotional, social, and spiritual needs that must be considered in the planning of hospital discharge.

The advocacy competence allows liaison nurses to protect the rights of patients and family members, defends the care that meets the individual needs of each patient, intercede for necessary resources in a timely manner, and, thus, ensure conditions for the continued care after discharge.

In terms of competencies related to the personal characteristics of the liaison nurses, they stated the need to develop the competencies stress management, priority management, and creativity. The liaison nurses coordinate discharge planning and create the link between different professionals and services, which entails different obstacles that generate stress among the nurses. However, it is essential for nurses to recognize the need to manage this stress and develop strategies that minimize stress.

The competency of priority management is the ability to determine that the hospital discharge of one patient may be more urgent than that of another either due to patient-related or institutional reasons, among others. Moreover, some patients need resources, such as medical hospital equipment, a caregiver, and home adaptations to be discharged from hospital. Depending on the availability of these resources, the patient's hospital discharge may be impaired. Priority management at discharge affects the fluidity of hospital discharge, the management of hospital beds, and the quality of continued care.

The creativity competency leads to innovative solutions to problems related to hospital discharge and supports new approaches to the difficulties of liaison nurses with other workers of the multiprofessional team, patients, and their families. Creativity is considered an important strategy for nurses who work in the transition of care because each hospital discharge is unique.

The managerial competencies stated by the liaison nurses include leadership, communication, and flexibility. Leadership is paramount for these nurses since one of their activities is the coordination of discharge planning. In this regard, the liaison nurses must act as leaders and encourage other workers of the health care team to establish an effective discharge plan in a timely manner.

Since these nurses are the link between workers of the multiprofessional team at the hospital and because they are responsible for transferring patient information to the out-of-hospital service and for providing guidelines to patients and family members and/or caregivers about care after discharge, they must communicate assertively for efficient and safe discharge that promotes continued care.

The role of liaison nurses in the planning of hospital discharge involves different dimensions, such as the patient's clinical status, the organization of external resources, and communication between different health workers and with family members and/or caregivers, all of which require the competency of flexibility to make assertive decisions when faced with challenges encountered in practice.

DISCUSSION

Liasion nurses are expected to develop competencies in different dimensions, such as those related to patient care, the personality traits of the professional, and management. Although the practice of liaison nurses does not involve direct patient care, they must identify needs, plan discharge, and transfer patient information to the services that will provide continued care after discharge9. Thus, the set of competencies of these nurses implies the integration of clinical knowledge, management, specific personal characteristics, such as stress management, creativity, and a sense of priority.

Currently, nurses are increasingly expected to combine various sources of information and incorporate them into nursing decision-making and practice, thus demonstrating their competency as health workers. The development of competencies requires a complex integration of knowledge, which encompasses judgment, skills, values, and attitudes, and the combination of different factors and issues in each situation1.

Among the competencies related to patient care, clinical judgment and the holistic view of the patients was considered essential for the position of liaison nurse. According to a Spanish study on the competencies of nurses who perform a similar role to that of liaison nurses, experience with complex patients is essential in this position given the difficulties of managing care, which involves the competency of clinical judgment11, as adequate clinical judgment is critical for an effective discharge plan.

Clinical judgment and the holistic view of patients are consistent with the values of the strengths-based approach to nursing care. According to this framework, clinical judgment and decision-making are the final stage of the clinical reasoning process. Clinical judgment is the capacity to evaluate alternatives for solving a given problem, whereas a clinical decision is a choice between the options12.

For adequate clinical judgment, nurses must have a holistic view of patients. Holism is based on the premise that the person is a unified and indivisible whole. It refers to the understanding of individuals, their families, their community, and their strengths by defining the uniqueness of individuals and respecting unique characteristics and qualities. This means knowing each individual, their history, desires, goals, hopes, clinical situation, and treatment, as well as the physical and emotional responses12.

Caring holistically means observing the biological, psychological, social, spiritual, and cultural aspects of individuals, and their relationship with the environment. Moreover, it involves understanding that the health problem of each individual must be confronted through promotion, prevention, and treatment, and by considering individuals as main actors in this health care process. It implies multidimensional knowledge that entails not only biological aspects but also cognitions, ideas, beliefs and views of life16.

Through follow-up and holistic care, nursing professionals can observe the senses and feelings of individuals, without prejudice, and accept the existence of faith and hope while establishing a relationship of help and trust that allows individuals to confront their health and disease process, follow treatment, and make changes in their daily lives16.

Being a competent nurse implies being holistic, integrated and experienced in complex activities. Therefore, it is necessary to develop some essential components, such as the ability to understand people, the ability to provide people-centered care, and the ability to improve the quality of nursing by extending professional capacity and guaranteeing the provision of high-quality nursing care1.

Advocating for patients was another competency related to patient care and listed by the liaison nurses as essential for their practice. This competency is attributed to the theoretical framework of strengths-centered nursing as an essential quality and defense force developed by these professionals. Patients and their families need nurses to protect them and help them navigate the health system. Advocating for patients and their families requires nurses to argue for, support, and defend them and, thus, ensure adequate and timely care12.

When nurses protect, defend, and assist patients and their families, they are acting as advocates. Nurses tend to advocate for patients when they believe the patient's right to decide has been disrespected or when patient suggestions have been disregarded12. At hospital discharge, nurses can advocate for patients by guaranteeing medical and nursing appointments, home visits, or necessary inputs to maintain the patient's health.

Care-related advocacy is still defined as a complementary function of nurses to promote and defend the interests and well-being of users, while ensuring they are aware of their rights and have access to information for decision-making, thus improving their health and adherence to treatment17^-19.

The competencies related to personal characteristics listed by the liaison nurses were stress management, priority management, and creativity, which are related to the theoretical framework of strengths-based nursing since nurses must be aware of their own strengths, vulnerabilities, and weaknesses in their practice. This awareness helps them understand how their behavior affects patients and their families and how their behavior affects responses12.

Nurses must develop some essential qualities, such as the strength of mindset and the strength of experience and knowledge. The strength of mindset involves the qualities required to establish a list of attitudes, perspectives, philosophies, or values that affect behavior, as observed in the management of stress and priorities, while the strengths of experience and knowledge are necessary to acquire and use information from formal sources and experience, and use creativity in the use of resources for patient care12.

The stress response depends on the mediation of two cognitive processes, namely cognitive evaluation, which is the way available resources are identified to meet the demands of a situation, and coping, which refers to the way individuals deal with the stressful situation. Coping can be directed to the problem by seeking to change the circumstances of the relationship or directed to emotions that involve changing the way the situation is evaluated20. This mediation enables management of the stress situation and conditions for the identification of priorities.

Creativity is perceived as a constant requirement in the nursing practice. The creative strength in the practice implies collective cooperation since work is not individual but organized in relation to others. To be creative is to interfere and act in the conception of work, to be aware of its purpose and of the means and instruments necessary for its construction and realization21. Liaison nurses stated that the competencies related to the personal characteristics of nurses were empathy, self-control, initiative, responsibility, and motivation, which goes against the results obtained in this study11. However, these characteristics can contribute significantly to nurses who work in the transition of care and improve the quality of the care they provide.

The managerial skills of liaison nurses involve leadership, communication, and flexibility, which differs from the findings of a study in which teamwork was considered the essential competency for nurses who work in the transition of care. According to the same study, these nurses must be familiar with the resources available for patient discharge and the sociodemographic characteristics of the area in which they operate11 to organize hospital discharge appropriately and better manage discharge based on the population of their area of coverage.

In general, leadership is classically defined as an attitude that requires multiple skills to be exercised effectively. It is knowledge and not merely the exercise of authority. Leadership is the power to exert a positive influence and inspire different people toward a single goal. Therefore, it is necessary to apply practical and objective actions, especially effective communication and flexibility22^-23.

Communication, as the act of communicating, from the Latin communicare, which means to make common, involves the exchange of information between two or more interlocutors and consists of two codes - the psychosocial and the psychobiological. The first code involves linguistics and the second code involves nonverbal behavior and expressions. It is characterized by a social process that allows the creation and interpretation of messages to provoke responses and the consequent sharing of a message or information. In this regard, communicating is the process of transmitting information and understanding from one person to another24.

The transition of care is a complex process that requires coordination and communication between people of different backgrounds, experiences, and skills. Notably, one nursing activity in the transition from hospital to home is communication between the hospital and the other services of the health care network8. Thus, the competency of communication is essential for an effective transition.

Flexibility, in turn, is the ability of individuals to adapt to changes and it is fundamental for nurses to remain competent. Flexibility is one of the main competencies of care because it allows health workers to find seemingly non-evident paths within the systems, effectively involve patients and their family members, and listen to them so, together, they can find alternatives to situations previously considered insurmountable or immutable, including prejudices rooted in the nurse's work process.

Nurses should develop these managerial skills since they are entrusted with the responsibility of helping individuals and their families to find their own strength to cope with the daily challenges and adversities arising from their health-disease process12, especially when patients are being prepared for discharge and family members must assume their care at home.

Patients and their families are expected to be responsible for and assume greater responsibility for their health and participate in decision-making. They are more likely to take responsibility when they are treated as partners in care, which increases their self-confidence, and when they are made to believe they can succeed because they have strengths and support to develop these strengths. They benefit from the support, teaching, and guidance of nurses when they have a broader understanding of their own internal strengths and external resources12.

When liaison nurses are aware of their competencies and use them to guide their professional practice, they put themselves in a privileged position to exercise their profession, coordinate members of their own team and other care services, defend the rights of patients, rationalize their choices, and cope with the pressures that may harm or hinder their practice.

FINAL CONSIDERATIONS

The liaison nurses who work with patient discharge have a set of competencies of different dimensions that relate to patient care, the personal characteristics of these nurses and management. This shows that these nurses evaluate the unique needs of each patient, identify their potential, defend them when necessary, and exhibit good communication and leadership skills.

The competencies of the liaison nurses are consistent with the adopted theoretical framework, especially those related to care, clinical judgment, and holistic view of the patient since, according to the strengths-based nursing framework, these competencies are essential attributes for nursing centered on patients, their families, their life context, and their potentialities.

The adopted theoretical framework of strengths-based nursing contributes to nursing care by restoring the essence of nursing and person-centered care, which allows us to analyze factors beyond the conventional roles of nurses, reflect on which competencies are a priority for today's health care challenges, and promote continued care after hospital discharge.

With knowledge of the competencies of the liaison nurses, it is possible to extend the scope of Brazilian nursing and discuss the skills that should be included in nursing education for future nurses to work in the transition of care. For health services, knowledge of these competencies can guide the selection of nurses for hospital discharge teams or management programs from the perspective of transition of care.

Furthermore, it is possible to extend the traditional discussion of competencies related to knowledge, skills, and attitudes and enable nurses to observe values and develop essential qualities in care, thus bringing the theoretical framework closer to the care practice, enhancing assistance, and allowing patients and their family members to actively participate in the transition of care. Moreover, this knowledge reveals a new line of research involving nursing competencies.

This study presented some limitations. First, it did not include the job description of the liaison nurses because it is believed that this document could contribute to a broader discussion on the competencies of the liaison nurse. However, it was not included in the initial project of this study. Second, there was a shortage of scientific articles on the subject, which stresses the need for scientific research in hospitals with nurses involved in the transition of care.

Acknowledgements:

The authors would like to thank the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil, case No. 406058/2016-4 for the financial support and the Affaires Mondiales Canada 2016/2017 program, supported by the Canadian government.

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Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  13 Sept 2021
• Date of issue
  2021

History

• Received
  02 June 2020
• Accepted
  26 Feb 2021