Other Titles

PechaKucha Presentation

Abstract

Background: Hospital discharge represents a critical transition in care, particularly for individuals without caregiving support. Patients who identify as having “no one to help” face heightened vulnerability to complications and rehospitalization. Understanding how nurses can identify and address these gaps is essential to reducing post-discharge complications and readmissions.

Purpose: To explore from the patient perspective how nurses can effectively prepare patients, who have no identified caregivers, for discharge home.

Methods: A qualitative descriptive design was used. Semi-structured interviews were conducted with 16 adults recently discharged from a large metropolitan hospital in the western United States who reported having no one to assist them after discharge. Interviews were transcribed and analyzed using deductive coding based on existing literature and interview guide, which were refined into a codebook through weekly team consensus. New codes were added as they emerged during coding. Directed content analysis was applied to identify themes related to patient experiences and the nursing role in preparing unsupported individuals for discharge.

Results: Participants identified the critical areas of managing medications, treatments, and wound care as essential for successful discharge without a caregiver. While written instructions were helpful, comprehension varied. Additionally, participants highlighted the financial limitations they experienced, which often delayed access to medications, professional assistance, or transportation. Transportation challenges were common, with some patients relying on ride-share services or community options, while others missed follow-up appointments entirely. Across interviews, participants emphasized that well-organized, easy-to-understand written discharge instructions enhanced confidence and independence.

Conclusion: Nurses are pivotal in preparing patients without caregivers for a safe transition home. These findings point to the vital role of nurses in ensuring that discharge plans for unsupported patients address practical, financial, and educational needs comprehensively. Comprehensive discharge planning must extend beyond standard instructions to include medication education, treatment reinforcement, financial assessment, and coordination of transportation and follow-up care. Providing individualized, clearly communicated discharge education helps patients manage independently, preventing complications.

Notes

This is a PechaKucha presentation, and the slide deck contains images instead of text. To compensate for this, the presenter notes are available in the attached slide deck. To see the notes in Adobe Acrobat, go to Tools > Comment or look at your Layers Panel. If the notes were saved as comments or layers, you can toggle them visible. 

References:

Bobay, K. L., Weiss, M. E., Oswald, D., & Yakusheva, O. (2018). Validation of the registered nurse assessment of readiness for hospital discharge scale. Nursing Research, 67(4), 305-313. https://doi.org/10.1097/nnr.0000000000000293

Manges, K. A., Wallace, A. S., Groves, P. S., Schapira, M. M., & Burke, R. E. (2021). Ready to go home? Assessment of shared mental models of the patient and discharging team regarding readiness for hospital discharge. Journal of Hospital Medicine 16(6), 326-332. https://doi.org/https://doi.org/10.12788/jhm.3464

van Son, I., Guicherit, O. R., & Lombarts, A. (2024). ‘Help, I may have to go home…’ Leaving the hospital not too early and not too late: Optimising the discharge process. Journal of Health Management, 26(1), 92-101. https://doi.org/10.1177/09720634231222984

Victor, C. R. (2024). The use of services by the elderly three and twelve months after discharge from hospital. In Gerontology (pp. 130-145). Routledge.

Weiss, M. E., Yakusheva, O., Bobay, K. L., Costa, L., Hughes, R. G., Nuccio, S., Hamilton, M., Bahr, S., Siclovan, D., & Bang, J. (2019). Effect of implementing discharge readiness assessment in adult medical-surgical units on 30-day return to hospital: The READI randomized clinical trial. JAMA Netw Open, 2(1), e187387. https://doi.org/10.1001/jamanetworkopen.2018.7387

Description

This qualitative descriptive study examined how patients without identified caregivers attempted to navigate post hospital discharge needs and how nurses can prepare patients without caregivers for discharge. Findings emphasize the importance of nursing identifying that patients lack a formal support system, assessment and intervention in medication management, treatment adherence, financial planning, and transportation.

Author Details

Christine Rae Platt, PhD, DNP, FNP-C; Alycia Bristol, PhD, RN; Hannah Wilkerson, NS; Susy Vega, RN; DeeDee Long, RN; Catherine Elmore, PhD, RN; Andrea Wallace, PhD, RN

Sigma Membership

Iota Iota

Type

Presentation

Format Type

Text-based Document

Study Design/Type

Descriptive/Correlational

Research Approach

Qualitative Research

Keywords:

Health Equity or Social Determinants of Health, Interprofessional, Interdisciplinary, Patient Discharge, Postoperative Complications, Readmission

Conference Name

37th International Nursing Research Congress

Conference Host

Sigma Theta Tau International

Conference Location

Toronto, Ontario, Canada

Conference Year

2026

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

Abstract Review Only: Reviewed by Event Host

Acquisition

Proxy-submission

Date of Issue

2026-07-29

Funder

Agency for Healthcare Research and Quality (AHRQ)

Click above link to access the slide deck.

Share

COinS
 

Preparing Patients Without Caregivers: Nursing Strategies for Safe Discharge to Home

Toronto, Ontario, Canada

Background: Hospital discharge represents a critical transition in care, particularly for individuals without caregiving support. Patients who identify as having “no one to help” face heightened vulnerability to complications and rehospitalization. Understanding how nurses can identify and address these gaps is essential to reducing post-discharge complications and readmissions.

Purpose: To explore from the patient perspective how nurses can effectively prepare patients, who have no identified caregivers, for discharge home.

Methods: A qualitative descriptive design was used. Semi-structured interviews were conducted with 16 adults recently discharged from a large metropolitan hospital in the western United States who reported having no one to assist them after discharge. Interviews were transcribed and analyzed using deductive coding based on existing literature and interview guide, which were refined into a codebook through weekly team consensus. New codes were added as they emerged during coding. Directed content analysis was applied to identify themes related to patient experiences and the nursing role in preparing unsupported individuals for discharge.

Results: Participants identified the critical areas of managing medications, treatments, and wound care as essential for successful discharge without a caregiver. While written instructions were helpful, comprehension varied. Additionally, participants highlighted the financial limitations they experienced, which often delayed access to medications, professional assistance, or transportation. Transportation challenges were common, with some patients relying on ride-share services or community options, while others missed follow-up appointments entirely. Across interviews, participants emphasized that well-organized, easy-to-understand written discharge instructions enhanced confidence and independence.

Conclusion: Nurses are pivotal in preparing patients without caregivers for a safe transition home. These findings point to the vital role of nurses in ensuring that discharge plans for unsupported patients address practical, financial, and educational needs comprehensively. Comprehensive discharge planning must extend beyond standard instructions to include medication education, treatment reinforcement, financial assessment, and coordination of transportation and follow-up care. Providing individualized, clearly communicated discharge education helps patients manage independently, preventing complications.