Hello,

This essay is about the topic I chose for the research paper. I provided the full guidelines below as well as the article I want to use. This is due tomorrow (March 21st) at 11:59pm. 

Thank you for your help!

ChamberlainCollege of Nursing NR449 Evidence-Based Practice

NR449 RUA Topic Search Strategy x Revised 07/25/16 1

Required Uniform Assignment: Topic Search Strategy

PURPOSE
The Topic Search Strategy Paper is the first of three related assignments which are due in Unit 3. The purpose of

this initial paper is to briefly describe your search strategies when identifying two articles that pertain to an

evidence-based practice topic of interest.

COURSE OUTCOMES

This assignment enables the student to meet the following course outcomes.

CO 1: Examine the sources of knowledge that contribute to professional nursing practice. (PO #7)

CO 2: Apply research principles to the interpretation of the content of published research studies. (POs #4 and
#8)

DUE DATE
Refer to the course calendar for due date. The college’s Late Assignment policy applies to this activity.

POINTS POSSIBLE
This assignment is worth 160 points. The college’s Late Assignment policy applies to this activity.

REQUIREMENTS
You will be assigned a group in unit 2 (located in the team collaboration tab) to formulate an evidence-based
practice topic of interest that will be used to complete the unit 3 and unit 5 independent assignments, as well as
the group PowerPoint presentation in unit 7.

The paper will include the following.

a. Clinical Question
a. Describe problem
b. Significance of problem in terms of outcomes or statistics
c. Your PICOT question in support of the group topic
d. Purpose of your paper

b. Levels of Evidence
a. Type of question asked
b. Best evidence found to answer question

c. Search Strategy
a. Search terms
b. Databases used (you may use Google Scholar in addition to the library databases; start with

the Library)
c. Refinement decisions made
d. Identification of two most relevant articles

d. Format
a. Correct grammar and spelling
b. Use of headings for each section
c. Use of APA format (sixth edition)
d. Page length: three to four pages

PREPARING THE PAPER

1. Please make sure you do not duplicate articles within your group.
2. Paper should include a title page and a reference page.

Chamberlain College of Nursing NR449 Evidence-Based Practice

NR449 RUA Topic Search Strategy x Revised 07/25/16 2

DIRECTIONS AND ASSIGNMENT CRITERIA

Assignment
Criteria

Points % Description

Clinical Question 45 28 1. Problem is described. What is the focus of your group’s work?
2. Significance of the problem is described. What health

outcomes result from your problem? Or what statistics
document this is a problem? You may find support on
websites for government or professional organizations.

3. What is your PICOT question?
4. Purpose of your paper. What will your paper do or describe?

This is similar to a problem statement. “The purpose of this
paper is to . . .”

Levels of
Evidence

20 13 1. What type of question are you asking (therapy, prognosis,
meaning, etc.)?

2. What is the best type of evidence to be found to answer that
question (e.g., RCT, cohort study, qualitative study)?

Search Strategy 65 41 1. Search topic(s) provided. What did you use for search terms?
2. What database(s) did you use? Link your search with the

PICOT question described above.
3. As you did your search, what decisions did you make in

refinement to get your required articles down to a reasonable
number for review? Were any limits used? If so, what?

4. Identify the two most relevant and helpful articles that will
provide guidance for your next paper and the group’s work.
Why were these two selected?

Format 30 18 1. Correct grammar and spelling
2. Use of headings for each section: Clinical Question, Level of

Evidence, Search Strategy, Conclusion
3. APA format (sixth ed.)
4. Paper length: three to four pages

Total 160 100

Chamberlain College of Nursing NR449 Evidence-Based Practice

NR449 RUA Topic Search Strategy docx Revised 07/25/2016 3

GRADING RUBRIC

Assignment
Criteria

Outstanding or Highest
Level of Performance

A (92–100%)

Very Good or High Level of
Performance

B (84–91%)

Competent or Satisfactory
Level of Performance

C (76–83%)

Poor, Failing or
Unsatisfactory Level of

Performance
F (0–75%)

Clinical Question
45 points

ALL elements present
1. Problem is presented clearly.
2. Significance of problem

is

described completely.
3. PICOT question is presented.
4. Purpose of paper is stated.

42–45 points

All but one element present
1. Problem is presented clearly.
2. Significance of problem

is described completely.
3. PICOT question is presented.
4. Purpose of paper is stated.

38–41 points

ALL but two elements present
1. Problem is presented clearly.
2. Significance of problem

is described completely.
3. PICOT question is presented.
4. Purpose of paper is stated.

34–37 points

Three or more elements missing
1. Problem is presented clearly.
2. Significance of problem is

described completely.
3. PICOT question is presented.
4. Purpose of paper is stated.

0–33 points

Levels of Evidence
20 points

1. Accurately identifies type of
question being asked.

2. Accurately identifies best type
of evidence available to
answer question being asked.

19-20 points

1. Accurately identifies type of
question being asked.

2. Inaccurately identifies best
type of evidence available to
answer question being asked.

17-18 points

1. Incompletely or inaccurately
identifies type of question
being asked.

2. Incompletely or inaccurately
identifies best type of
evidence available to answer
question being asked.

16 points

1. Does not identify type of
question being asked.

2. Does not identify best type of
evidence available to answer
question being asked.

0–15 points

Search Strategy
65 points

ALL elements present
1. Search topic(s) and terms

provided.
2. Includes database(s) used for

search and links to PICOT
question.

3. Explains process of refining
search to locate evidence.

4. Identifies and defends the
choice of the two most
relevant articles to provide
guidance for your next paper
and the group’s work.

60-65 points

All but one element present
1. Search topic(s) and terms

provided.
2. Includes database(s) used for
search and links to PICOT
question.
3. Explains process of refining
search to locate evidence.
4. Identifies and defends the
choice of the two most
relevant articles to provide
guidance for your next paper
and the group’s work.

55-59 points

ALL but two elements present
1. Search topic(s) and terms

provided.
2. Includes database(s) used for
search and links to PICOT
question.
3. Explains process of refining
search to locate evidence.
4. Identifies and defends the
choice of the two most
relevant articles to provide
guidance for your next paper
and the group’s work.

49-54 points

Three or more elements missing
1. Search topic(s) and terms

provided.
2. Includes database(s) used for
search and links to PICOT
question.
3. Explains process of refining
search to locate evidence.
4. Identifies and defends the
choice of the two most
relevant articles to provide
guidance for your next paper
and the group’s work.

0–48 points

Chamberlain College of Nursing NR449 Evidence-Based Practice

NR449 RUA Topic Search Strategy x Revised 07/25/2016 4

Format
30 p

o
i
n
t
s

1. Grammar and mechanics are
free of errors.

2. Headings are free of errors
and include all of the
following.

a. Clinical Question
b. Level of

Evidence
c. Search Strategy
d. Conclusion

3. APA format is used
without errors.

4. Total length: Three to four
pages, excluding references
and title page.

28–30 points

1. Grammar and mechanics
have no more than one
type of error.

2. Headings are free of
errors and include three
of the following.

a. Clinical Question
b. Level of Evidence
c. Search Strategy

d. Conclusion
3. APA format is used
without errors.

4. Total length: Three to four
pages, excluding
references and title page.

26–27 points

1. Grammar and mechanics
have no more than two types
of errors.

2. Headings are free of
errors and include two of
the following.
a. Clinical Question
b. Level of

Evidence
c. Search Strategy
d. Conclusion
3. APA format is used
without errors.

4. Total length: less than three
or more than four pages,
excluding references and
title page.

23–25 points

1. Grammar and mechanics have
three or more types of errors.

2. Headings have errors, are
missing, or include just one of
the following.

a. Clinical Question
b. Level of Evidence
c. Search Strategy

d. Conclusion
3. APA format is used

without errors.
4. Total length: less than three

or more than four pages,
excluding references and title
page.

0–22 points

Total Points Possible = 160 points

Hesselink et al. BMC Health Services Research 2014, 14:389
http://www.biomedcentral.com/1472-6963/14/389

RESEARCH ARTICLE Open Access

Improving patient discharge and reducing
hospital readmissions by using Intervention
Mapping
Gijs Hesselink1*, Marieke Zegers1, Myrra Vernooij-Dassen1,2,3, Paul Barach4,5,6, Cor Kalkman4, Maria Flink7,8,
Gunnar Öhlén9,10, Mariann Olsson7,8, Susanne Bergenbrant11, Carola Orrego12, Rosa Suñol12, Giulio Toccafondi13,
Francesco Venneri13, Ewa Dudzik-Urbaniak14, Basia Kutryba14, Lisette Schoonhoven1, Hub Wollersheim1

and on behalf of the European HANDOVER Research Collaborative

Abstract

Background

: There is a growing impetus to reorganize the hospital discharge process to reduce avoidable
readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and
underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving
hospital discharge.

Methods

: The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and
consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26
focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and
community care providers. Second, improvements in terms of intervention outcomes, performance objectives and
change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge
interventions was carried out to select theory-based methods and practical strategies required to achieve change
and better performance.

Results

: Ineffective discharge is related to factors at the level of the individual care provider, the patient, the
relationship between providers, and the organisational and technical support for care providers. Providers can
reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-
coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers,
should participate in the discharge process and be well aware of their health status and treatment. Assessment by
hospital care providers whether discharge information is accurate and understood by patients and their community
counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates,
medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective
and promising strategies to achieve the desired behavioural and environmental change.

Conclusions

: This study provides a comprehensive guiding framework for providers and policy-makers to improve
patient handover from hospital to primary care.

Keywords: Patient handoff, Patient discharge, Patient readmission, Intervention mapping, Adverse events

* Correspondence: gijs.hesselink@radboudumc.nl
1Radboud University Medical Center, Scientific Institute for Quality of
Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB,
Nijmegen, The Netherlands
Full list of author information is available at the end of the article

© 2014 Hesselink et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

mailto:gijs.hesselink@radboudumc.nl

http://creativecommons.org/licenses/by/4.0

http://creativecommons.org/publicdomain/zero/1.0/

Hesselink et al. BMC Health Services Research 2014, 14:389 Page 2 of 11
http://www.biomedcentral.com/1472-6963/14/389

Background
Patients still experience needless harm and often struggle
to have their voices heard, processes are not as efficient
as they could be, and costs continue to rise at alarming
rates while quality issues remain. A shorter length of hos-
pital stay, the decrease in work-hours of health care pro-
viders, and the increasing number of patient transitions
between departments and institutions requires effective
patient handovers, especially those of frail patients with
comorbidities [1]. Continuity of care at patient discharge
from the hospital is a critical aspect of high quality patient
care [2,3]. Highly reliable care requires close cooperation
between care providers across organisational boundaries,
thereby establishing an interdisciplinary network [4].
Unfortunately, incomplete or incorrect information and
communication errors between hospital care providers
and the multiple receiving parties often increase the
chance of adverse events. These may ultimately lead to
life threatening situations, avoidable treatments, un-
planned re-hospitalisations [5,6], and extra costs [7-9].
Although studies have identified discharge problems

in the social, organisational, linguistic and technical
context [10-12], there is insufficient, evidence driven
insights into more effective solutions. The effectiveness
of most interventions is highly variable and limited in
daily practice. Explanations for these disappointing re-
sults include the difficulty of changing providers behav-
iour and existing practices, non-optimal intervention
strategies, inadequate resources devoted to evaluating
the impact of interventions, and inadequate methods to
design and evaluate interventions [13-15]. A systematic
approach for translating discharge problems into custo-
mised solutions is lacking. Many clinical intervention
developers select their strategies intuitively. Effective
interventions need to be theory- and evidence based,
and targeted at specific behavioural and environmental
factors [16,17].
The aim of our study was to systematically develop a

guiding framework to more effective design of interven-
tions that support care providers and policy-makers to
improve patient handovers from the hospital to primary
care.

Methods
Intervention mapping (IM) is a systematic, iterative six-
step process that helps to develop an intervention, based
on theoretical, empirical and practical information [18].
The steps are summarised in Table 1. IM was originally
used effectively in the health promotion domain to de-
velop programs for smoking cessatation [19], stroke pre-
vention [20], asthma management [21], HIV prevention
[22], and leg ulcer management [23]. We modified the
IM terminology in order to apply it to the quality im-
provement domain.

Step 1: Problem analysis
We structured the problem analysis by using the PRE-
CEDE PROCEED model [24] (see Additional file 1), to
analyse and describe the scale, causes, and conse-
quences of the health problem and to identify the target
population.

Procedure and participants
A literature search on the frequency and consequences of
ineffective hospital discharge problems was performed
[25]. We performed a large qualitative study on patient
handovers between acute care hospitals and primary care
in five countries, i.e. The Netherlands, Spain, Poland,
Sweden, and Italy, to identify the behavioural and envir-
onmental determinants influencing ineffective hospital
discharge [10-12]. The study adhered to the RATS (Rele-
vance, Appropriateness, Transparency, Soundness) guide-
lines for qualitative studies. Data collection and analysis
consisted of multi-method qualitative research including
individual and focus group interviews [26], process maps,
artefact analyses [10-12], and Ishikawa diagrams [27]
(Table 1). The discharged patients and their care pro-
viders were recruited using general and country-specific
inclusion criteria (see Additional file 2). The study was
approved by the ethics committee of the University Med-
ical Center Utrecht — Medical Ethics Committee. Pa-
tients were asked for informed consent.

Step 2: Identify intervention outcomes, performance
objectives and change objectives
In step 2, we identified the desired outcomes of the
intervention and formulated specific performance objec-
tives for the target population, such as writing a
complete, accurate and timely discharge letter by the
hospital physician. This resulted in a step-by-step check-
list of what needs to be accomplished in order to obtain
the desired outcomes [28].
It is important to identify what steps need to be

tweaked in order to affect the performance objective, and
ultimately the intervention outcome [28]. We identified
the most important determinants (e.g., lack of knowledge
and understanding between hospital and primary care
providers) that need to be changed and combined these
with performance objectives to formulate our change ob-
jectives. These change objectives specified who and what
will change as a result of the intervention.

Procedure and participants
A literature search of the desired outcomes of the inter-
vention was conducted [25]. The performance objec-
tives and matrices of change objectives were discussed
in a multidisciplinary study panel (n = 5) that included
experts in health-, social- and organisational sciences.
Members of the European HANDOVER Research

Table 1 Intervention mapping steps, objectives and methods*

Steps Objectives Methods

1. Problem analysis ▪ Gain insight into health problem, quality of care,
underlying causes and target population

▪ Problem analysis using PRECEDE-PROCEED model;

▪ Analysis based on:

– Literature research

– Individual interviews (n = 321)

– Focus group interviews (n = 26)

– Process maps (n = 5)

– Artifact analyses (n = 5)

– Ishikawa (fishbone) diagrams (n = 5)

2. Identify intervention outcomes,
performance objectives and
change objectives

▪ State intervention outcomes ▪ Use evidence from literature and empirical data
from problem analysis (step 1)

▪ Specify performance objectives

▪ Select important and changeable determinants ▪ Input from experts in the field of patient
handover (healthcare providers, and
organizational, social and health scientists)

▪ Develop matrices with change objectives based on
performance objectives and determinants of
suboptimal hospital discharge

3. Select theory-based methods
and strategies

▪ Identify and select theoretical methods ▪ Literature search on theory-based methods

▪ Select evidence-based interventions and design of
practical strategies

▪ Input from experts (n = 220)

▪ Ensure that interventions and strategies address
change objectives

▪ Systematic literature review on evidence based
discharge interventions

▪ Additional search for experience based practical
strategies

▪ Matching methods and practical strategies with
determinants and performance objectives (step 1
and 2)

4. Develop an intervention ▪ Provide suggestions for developing an intervention ▪ Input from literature search and experts

5. Implementation ▪ Provide suggestions for writing an implementation
plan

▪ Literature search of implementation strategies
and tools

6. Evaluation ▪ Provide suggestions for writing an evaluation plan ▪ Literature search on methods for effect and
process evaluation on complex interventions

*Adapted from Bartholomew et al. [18].

Hesselink et al. BMC Health Services Research 2014, 14:389 Page 3 of 11
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Collaborative (n = 15 experts in the field of handover
and health care providers) prioritised using a survey
the large number of determinants of importance on a
5-point Likert scale.

Step 3: Selection of theory-based methods and strategies
We selected theory-based methods that relate to the
change objectives in step 2. These methods were required
to change the behavioural and environmental determi-
nants of ineffective hospital discharge. Subsequently,
these methods were translated into practical strategies.

Procedure and participants
Theory-based methods were identified from our litera-
ture search and mainly found in overviews provided by

Bartholemew et al. [18], Achterberg et al. [29], and Grol
et al. [30]. A total of 220 international researchers,
policy-makers and regulators in the field of quality and
safety in healthcare, healthcare providers and patient
representatives were consulted about their experiences
with successful strategies or promising ideas during
three expert meetings in 2010–2011 [31]. A systematic
review of randomised controlled trials (RCTs) of the ef-
fects of discharge interventions provided an overview of
evidence-based strategies [32]. The systematic review
was performed in accordance with the PRISMA guide-
lines. An additional literature search was performed to
identify promising strategies that were not included in
the systematic review (e.g., evaluated with a weaker
study design than RCTs) or not evaluated yet (e.g., local

Hesselink et al. BMC Health Services Research 2014, 14:389 Page 4 of 11
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initiatives). The strategies were selected by the study
panel after 11 iterative discussion sessions based on the
findings from the systematic review, the experiences of
the experts and the additional literature search.

Step 4: Develop an intervention
In this step, we provide suggestions for the design of
the intervention by considering the target group and
local setting [18]. The intervention studies identified in
step 3 were classified independently by two researchers
(GH and MZ) according to the Oxford Centre for
Evidence-Based Medicine – Levels of Evidence from
2009 onward [33].

Steps 5 and 6: Implementation and Evaluation
We made suggestions for developing an implementation
plan for accomplishing program adoption, and for evalu-
ating the effects and feasibility of the intervention pro-
gram. The suggestions were based on literature regarding
effective implementation strategies [17,30,34-36], existing
implementation toolboxes [37,38], and a literature review
on methods to evaluate complex interventions in health
care [35,39,40].

Health care professional behavio

Poor information exchange betwee

care providers:

– delayed, incomplete, unclea
information (e.g., discharge

– un- or misinformed health p
specific needs)

Poor coordination of care:

– hospital and primary care pr
actor

s

– delayed or poor discharge p
follow-up

– lack of preparing patients fo

Many discharge problems remain

opportunities for improvement mis

Inadequate information exchange b

professional and patient:

– formal and swift discharge c
– lack of discharge informatio

patient (and relative) or give

discharge;

– use of medical-technical lan
providers

– overload of non-prioritized
information received by pat

Determinants for health care professional behaviour

INDIVIDUAL HEALTHCARE PROVIDER DETERMINANTS

– Lack of awareness of consequences of suboptimal hospital
discharge

– Priority on providing medical or nursing care prevails over
administrative handover tasks

– Lack of willingness, knowledge and skills to reflect, learn
and improve discharge practice

– Relying too much on discharge routines

ENVIRONMENTAL DETERMINANTS
Interpersonal

– Inward attitude
– Lack of collaborative attitude
– Distant and negative attitudes/relationship between hospital

and primary care providers

– Lack of knowledge and understanding with organization,
expectations and needs of primary care providers

– Lack of shared communication language
– Lack of structural, problem-related feedback between

hospital and primary care providers

– Lack patient-centred attitude
Organizational factors

– Hospital size and identity
– Lack of priority and awareness on a managerial level
– Lack of guidelines, standards of evidence-based practice
– Work load/ time pressure
– Work shift structures
– Poor accessibility of hospital care providers
– Pressure on available hospital beds and community

care

Technical factors
– Lack of (uniform) shared electronic information exchange

system between hospital and primary care

Determinants of patient behaviour

– Patient and relatives are unaware of option to take a
(pro)active role to contribute to effective handover

– Patients are less skilled or don’t dare to speak up
– Patients do not know what to ask
– Neither patient nor family knows the medical

history/medication

– Low health literacy/care givers use too difficult language
– Lack of family support
– Lack of social resources

Patient behavio

ural causes

– Patient does not ask for more
– Patient does not protest again
– Lack of knowledge of patient
– Patient forgets to handover di
– Patient does not signal specif

Figure 1 Model of suboptimal hospital discharge: overview of the he

Results
Step 1: Problem analysis
The health problem and the underlying causes are pre-
sented in Figure 1. The published studies demonstrate
that one in five patients experience an adverse event
within 3 weeks after hospital discharge, of which one in
three was considered preventable [41]. Three per cent
of the adverse events led to permanent disability, in-
cluding death. The one month unplanned readmission
rates varied between 13% [42], and 20% [43]. Unneces-
sary hospital readmissions lead to considerable suffer-
ing, harm and extra costs. Friedman and Basu estimated
hospital costs for preventable readmissions during
6 months at about $730 million [7]. Jencks estimated
total hospital costs at $44 billion per year for rehospita-
lisations among Medicare patients within 30 days of
hospital discharge [44].
We found that ineffective handovers that lead to patient

readmissions are caused by poor information exchange,
poor coordination of care and poor communication be-
tween hospital and primary care providers, and between
care providers and patients. The underlying causes in-
clude attitudinal and behavioural factors (e.g., lack of un-
derstanding of the needs of the counterpart, a distant
relationship and a lack of collaborative attitude between

Health outcome

Preventable adverse

(drug) events

Preventable deaths

ural causes

n hospital and primary

r or inadequate

letters or medication lists)

rofessionals (e.g. patient-

oviders work as separate

lanning/organization of

r discharge

unspoken and possible

sed

etween healthcare

onsultations;

n and -instructions to

n just before actual

guage by healthcare

written and verbal

ients at discharge

Quality of care

Primary care providers

un- or misinformed after a

patient’s discharge

Delayed or inadequate

follow-up of care

Primary care providers

unable to provide optimal

care

Patients un- or

misinformed and

unprepared at discharge

specific information

st discharge decisions

s

scharge letter to GP

ic needs

Inefficiencies leading
to cost constraints

Unplanned

readmissions

Unplanned outpatient

visits

Over- or underuse of

diagnostics, treatments,

medications

Quality of life

Patient anxiety

Misunderstandings

Dissatisfaction

alth problem, causes and their determinants.

Hesselink et al. BMC Health Services Research 2014, 14:389 Page 5 of 11
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hospital and primary care providers), organisational fac-
tors (e.g., lack of guidelines), technical factors (lack of a
shared electronic information system) or patient factors
(e.g., patients are less skilled or don’t dare to speak up).
All the identified causes and their underlying factors are
summarised in Figure 1.

Step 2: Matrices of change objectives
Intervention outcomes and performance objectives
Measurable and feasible endpoints to evaluate the dis-
charge process are hospital readmission rates and ad-
verse events rates after the hospital discharge.
All performance objectives are listed in Table 2. It is

important for healthcare providers to transfer high-
quality discharge information to primary care providers
and patients. For example, using discharge letters that
are complete (i.e., no redundant/irrelevant or missed in-
formation), accurate and understandable (i.e., structured
presentation of information, explanation of abbreviations
jargon), and patients being informed at discharge in
plain language. Regarding coordination of care, health-
care providers are expected to have organised and accur-
ate follow-up services at patient’s discharge in a timely
manner and tailored to the patient’s preferences and

Table 2 Performance objectives for healthcare providers
and patients

Healthcare providers

Discharge information 1a. Complete discharge information

1b. Clear discharge information

1c. Accurate discharge information

Coordination of care 2a. Ensure that follow-up services are being
organized at actual discharge

2b. Tailor follow-up care to patient needs
and preferences

2c. Organize timely and accurate follow-up

Discharge
communication

3a. Seek direct/personal contact with
primary care counterpart

3b. Discharge information easily accessible
to counterpart care providers and patients
(and relatives)

3c. Exchange discharge information on time
to primary care counterparts

3d. Inform patient (and relatives) personally
and in timely manner

Patients

Participation in discharge
process

4. Contribute, if capable, to the continuity of
care in the discharge process

Awareness of health
status and treatment

5. Well aware about medical history and
medication use, diagnosis/indication and
(side) effects of the treatment, post
discharge appointments, scheduled tests
and (pending) test results

psychosocial needs (e.g., assessment of home setting, so-
cial risks and support). Examples of performance objec-
tives for discharge communication are hospital care
providers being accessible for primary care providers or
patients and exchanging discharge information in time
to support primary care providers or patients.
Patients are, if capable, expected to contribute to the

continuity of care by participating in the discharge
process (e.g., by handing over a discharge letter to their
GP after being discharged), and by being well aware of
their health status (e.g., medical and medication history)
and treatment plan.

Selected determinants and change objectives
The most important determinants (as perceived by ex-
perts in the field of patient handovers and described in
step 2 of the methods) were classified according to the
individual professional, interpersonal, organisational,
technical and patient levels. Combining the performance
objectives with the selected determinants resulted in two
matrices with change objectives for healthcare providers
and patients, which interventions need to target. The
matrices are presented in Additional file 3.

Step 3: Selecting theory-based methods and strategies
Our literature review identified a raft of change methods,
such as knowledge transfer, active listening and guided
practice from the Social Cognitive Theory (SCT) [45],
consciousness raising from the Transtheoretical Model
[46,47], shifting perspectives and interpersonal contact
from the Intergroup Contact Theory [48] and standar-
dised working processes from the SCT and Rational
Decision-making theories [30] as influencers of the be-
havioural and environmental determinants of ineffective
hospital discharge. Goal-setting and implementation in-
tentions were derived from theories of Goal Directed
Behaviour [49,50], and multi-disciplinary collaboration
and case management from theories of Integrated Care
[51]. These theory-based methods were subsequently
operationalised into practical strategies and correspond-
ing activities and materials for the targeted population
[52-76] as shown in Table 3.

Step 4: Develop an intervention
We formulated a wide variety of change objectives at the
individual clinician and patient levels, the interpersonal
level, organisational and technical levels that need to be
considered in order to tackle ineffective handovers at dis-
charge more reliably (Additional file 3). Given these
change objectives the intervention likely needs to be
multi-faceted and needs to be tailored to the needs en-
countered in the local setting. Table 3 shows a framework
with examples of strategies and related materials and ac-
tivities guiding healthcare providers and policy makers in

Table 3 Overview of change determinants, theory-based methods, strategies and practical applications, and evidence

Determinants and
change objectives

Theory-based
methods

Examples of strategies/
practical applications

Examples of activities
and materials

References

* Evidence†

Individual healthcare provider

Aware of the
consequences of
suboptimal hospital
discharge

Knowledge
transfer/Active
learning

Education in the medical and
nursing curriculum

Lectures on patient handover
and exercises with workbook
and online materials (e.g.,
communication skills and
discharge letter requirements)

52 3a

Perceive handover
administrative tasks as
important part of patient
discharge care and act
accordingly

Stimulus
control/
Reinforcement

Punishment by financial
penalties; visual electronic
reminders

Red, orange and green flags
indicating status of discharge
letter and planning; visualization
of deadline for sending discharge
letter

NF NA

Interpersonal

Outward focus by
hospital-based care pro-
viders to ensure continu-
ity of care after discharge

Integrated care Post-discharge monitoring of
follow-up

Standard post-discharge telephone
call or home visit to the patient to
evaluate follow-up, provide
additional instructions and answer
questions

53 1a

Hospital and primary care
provider collaborative
during the discharge
process

Integrated care/
Intergroup
contact/ Case
management

Case conference Hospital or community-based
face-to-face or telephone meetings
between hospital and primary care
providers

54-57

1b

Liaison person Designated care provider
coordinating hospital discharge,
follow-up care and the
communication between
hospital and primary care providers

58-60 1b

Knowledge and
understanding of the
primary care organization,
expectations and needs

Team building/
Intergroup
contact/ Shifting
perspective

Meetings between hospital and
primary care providers to
increase mutual understanding
and respect between both
parties

Focus group sessions, regular
meetings and site visits to get
to know each other, to learn
each other’s organization and
needs and to identify improvement
opportunities

61 1b

Structural, problem-related
feedback between hos-
pital and primary care
providers

Stimulus control Means to facilitate and
stimulate structural feedback

Standard feedback form and return
envelop along with discharge letter
send to primary care providers

NF NA

Patient-centered attitude Modeling/
Individualization

Use of plain, patient-friendly,
nonmedical language

Discharge summary in language
that is understandable for patients
and relatives

62 1b

Active listening Teach back Care provider checks if patients
received all discharge information
needed and if they understood the
received information

63 2b

Organizational

Guidelines and standards
of evidence-based
practice

Standardized
working
processes

Standardized discharge letter (e.
g. templates, formats)

Templates, formats, required (web-based)
fields, clinical decision-support, pick lists

64-66 1b

Standardized discharge
planning

Guidelines, protocols, checklists for
discharge planning, organizing
follow-up

67-68 1b

Medication reconciliation Standardised medication reconciliation
checklist/medication discrepancy
tool/ reconciliation by (liaison)
pharmacist

54,57,65-67,
69-71

1b

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Table 3 Overview of change determinants, theory-based methods, strategies and practical applications, and evidence
(Continued)

Technical

Shared electronic
information exchange
system

Multi-disciplinary
collaboration

Shared electronic patient
information system

Electronic notifications to primary care
providers to inform them about patient
hospital visits and to provide them
(web-based) access to available discharge
information

65,66,71-73 1b

Patient and relative

Participation in the
discharge process

Self-
management/
Guided practice

Encouraging and facilitating
patients in self-management
skills

Provide patient with discharge record (e.
g., active problem list, medication,
allergies, patient concerns) owned and
maintained by the patient to facilitate
cross-site information transfer

62,74,75 1b

Skills and dare to speak
up

Coaching/
Guided practice

Encouragement to assert a
more active role during
discharge

Question form for patients 74 1b

Understanding of medical
history and/or medication

Guided practice/
Knowledge
transfer

Medication counseling at the
hospital at discharge or at the
patient’s home

Visits by a pharmacist counselor 76 1b

NF = not found; NA = not available.
*The majority of the references relate to interventions or a component of a studied intervention program with an aim to improve hospital discharge. Other types
of interventions (e.g., improving clinical handovers within the hospital) were also used as references in case they were considered to be relevant and appropriate
for improving hospital discharge.
†Grading of evidence, adapted and adjusted from the Oxford Centre for Evidence-based Medicine Levels of Evidence33: 1b = systematic review or meta-analysis of
randomized controlled trials (RCTs); 1a = RCT of good-moderate quality or sufficient size and consistency; 3-4 = comparative trials (non-randomized, cohort studies,
patient-control studies); 4 = non-comparative studies; 5 = Expert committee reports, opinions and/or clinical experience of respected authorities.

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the development of their intervention. The list of all
identified strategies and related materials, level of evi-
dence and references are available upon request.
Many interventions were evaluated in well-designed

studies. For example, the use of standardised discharge
practices such as the use of discharge letter templates, dis-
charge planning guidelines and medication reconciliation
checklists are effective strategies [65-67,70]. The use of a
shared electronic patient information platform facilitates
discharge communication between hospital and primary
care providers [66,71-73]. There is evidence demonstrat-
ing that the patient’s role in the discharge process is en-
hanced by the provision of written and verbal discharge
information and by assistance and guidance in self-
management (e.g., discharge counselling, follow-up calls
or home-based visits and a patient discharge record or
question form) [74,76]. However, many promising inter-
ventions have not been evaluated properly or were tested
using weak study designs. For example, the effects of lec-
tures and exercises on discharge practice in the medical
curriculum, and regular group discussions involving hos-
pital and primary care providers are largely unknown [52].
Moreover, there is limited evidence on the effects of

reinforcement by using discharge planning reminders,
mandatory administrative tasks or financial incentives
and penalties [77].
Insight also lacks into the effects of strategies to in-

crease care provider reflections on discharge practices
(e.g., use of a standardised feedback form, video

reflection, role play or simulation of discharge consulta-
tions) [52] and regarding the use of teach-back to check
the patient’s understanding of their medical and medica-
tion history [63,78].

Steps 5 and 6: Implementation and evaluation
Commitment from and ownership by the target group is
essential to successful implementation [79,80]. The aware-
ness among end users is enhanced when they are directly
involved in the development or modification of the
innovation, in mounting the implementation plan, and in
selecting the implementation strategies to be used [35].
Moreover, uptake of policies and protocols, reimburse-

ment and the consideration of patients’ preferences are
necessary for a sustainable implementation [81].
Strategies that address the barriers to change are re-

quired to implement interventions in daily practice [36].
Most theories on implementing interventions in health
care emphasise that an analysis of the barriers to change
practice is a prerequisite to selecting or developing an
effective implementation strategy [17]. An implementa-
tion plan should be developed specifically after selecting
the implementation strategies to tackle the barriers. This
plan should be compatible with the target group and set-
tings in which the implementation will take place. Good
management and planning of implementation activities
(i.e., what, when, where, how and by whom) also appears
to be a requisite for successful implementation of inno-
vations in patient care [35].

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Formative and summative effect evaluation should be
carried out using hospital readmission and adverse events
as defined patient outcome effects to evaluate whether
the intervention led to the desired degree of change. The
formulated performance objectives in step 2 can be oper-
ationalised in measurable process indicators, for example
by assessing the proportion of patients discharged with a
complete discharge letter and assessing the proportion of
patients discharged after medication reconciliation.
A process evaluation should be performed to under-

stand the effect, success or failure of the intervention
and to get an impression of its feasibility, generalizability
and its acceptability in the target population. The
process evaluation gives insight into the black box of the
implementation process and can explain the variation in
results in evaluating interventions. The activities carried
out as part of the intervention, the actual exposure of
participants to these activities, and their experience of
these activities should be studied [40].

Discussion

Effective hospital discharge and reducing patient re-
admission rates are influenced by the behaviours of care
providers and patients and their environmental context.
Our findings demonstrate the existence of a large num-
ber of determinants for (in)effective discharge that
underscore the complexity of the discharge process.
Therefore, improving hospital discharge requires a multi-
component, multi-level intervention (“bundle”) instead of
trying to find a “magic bullet” single intervention.
An extensive overview of theory-based methods and

practical strategies suitable for improving patient hand-
over skills and healthcare provider and patient behaviour
in the discharge process was systematically created based
on the scale, causes, and consequences of ineffective hos-
pital discharge presented in our study. Most interven-
tions were aimed at improving the organisational and
technical aspects of the discharge process. There is a lack
of evidence-based interventions on improving healthcare
provider skills by means of handover training and
evidence-based guidance. Moreover, effective interven-
tions for changing the individual healthcare provider’s
and patient’s competencies, awareness and attitudes (e.g.,
via education, reminders or teach-back), and the relation-
ship between providers (e.g., via frequent informal meet-
ing between hospital and primary care providers and
reflexive feedback) are lacking. All this despite our over-
whelming data demonstrating that awareness, attitudes
and skills are key factors for improving hospital dis-
charge. We found a gap between the discharge improve-
ment needs and the evidence-based interventions that
are suitable to address these needs. The lack of evidence
about the effectiveness of interventions may be attributed

to the difficulty of measuring attitudes and their effects
on healthcare performance [82-84].
This study is supported by earlier research and discharge

programs in the United States: i.e., the RED (“ReEngineerd
Discharge”) project [69,85], the Care Transitions Program
[86] and BOOST (Better Outcomes for Older adults
through Safe Transitions) [87]. An important strength of
our study is the deliberate assessment of determinants and
interventions that affect the discharge process. Qualitative
input provides comprehensive insights into a variety of de-
terminants. Our empirical data, results of a systematic litera-
ture review, theories of social behaviour and multiple
consultation rounds of a broad group of 324 experts (re-
searchers, policy-makers, inspectors) in the field of quality
and safety in healthcare, healthcare providers and patient
representatives [31], provided useful input for the selection
of change methods, practical strategies and related evidence.
A limitation of the study is our focus on the micro-

level excluding other key factors for change. The possible
barriers and facilitators at a macro- and meso-levels, i.e.,
financial and legal obligations or constrains were not in-
cluded. Moreover, the relationships between the identi-
fied determinants and theoretical-based methods and
strategies were hypothetical.
However, the determinants were systematically and

theory-driven and linked to practical strategies using the
IM method and were not intuitively chosen.

Conclusions
This study provides a comprehensive overview of patient
discharge problems and underlying causes. It provides a
guiding framework including theory-based strategies and
practical tools to support care providers and policy-
makers in their efforts to select and implement interven-
tions on a more rational basis. Intervention mapping is a
powerful method for care providers and policy makers
to assess and prioritise intervention strategies and tailor
them to the needs of individual facilities and healthcare
systems. The next step for care providers and policy-
makers is to look carefully into the discharge problems
in their own local settings and to select appropriate solu-
tions for improving hospital discharge effectively.

Additional files

Additional file 1: Modified model based on PRECEDE-PROCEED
concept and the theory of planned behavior

Additional file 2: Study Population Inclusion and Exclusion Criteria.

Additional file 3: Matrix of change objectives.

Competing interests

The authors declare that they have no competing interests.

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Authors’ contributions

GH and MZ designed and managed the study. GH, MF, ED-U, CO and GT col-
lected the data. All authors (GH, MZ, MVD, PB, CK, MF, GÖ, MO, SB, CO, RS,
GT, FV, EDU, LS, HW) were involved in the analysis and interpretation of the
data. GH and MZ drafted the manuscript. All authors read the manuscript for
important intellectual content and approved the final version.

Acknowledgements
We thank the patients, relatives, physicians and nurses who participated in
this study. We also thank the 220 expert meeting participants for their
contributions to this study.

Financial support

This work was supported by a grant from the European Union, the
Framework Programme of the European Commission (FP7-HEALTH-F2-2008-
223409).

Author details

1Radboud University Medical Center, Scientific Institute for Quality of
Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB,
Nijmegen, The Netherlands. 2Radboud University Medical Center, Kalorama
Foundation, Nijmegen, The Netherlands. 3Radboud University Medical
Center, Department of Primary Care, Nijmegen, The Netherlands. 4Patient
Safety Center, University Medical Center Utrecht, Utrecht, The Netherlands.
5Department of Health Studies, University of Stavanger, Stavanger, Norway.
6University College Cork, Cork, Ireland. 7Department of Neurobiology, Care
Sciences and Society, Karolinska Institutet, Stockholm, Sweden. 8Department
of Social Work, Karolinska University Hospital, Stockholm, Sweden.
9Department of Clinical Science, Intervention and Technology, Karolinska
Institutet, Stockholm, Sweden. 10Quality and Patient Safety, Karolinska
University Hospital, Stockholm, Sweden. 11Department of Emergency
Medicine, Karolinska University Hospital, Stockholm, Sweden. 12Avedis
Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain.
13Clinical Risk Management and Patient Safety Centre, Tuscany region, Italy.
14National Center for Quality Assessment in Health Care, Krakow, Poland.

Received: 19 March 2014 Accepted: 10 September 2014
Published: 13 September 2014

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doi:10.1186/1472-6963-14-389
Cite this article as: Hesselink et al.: Improving patient discharge and
reducing hospital readmissions by using Intervention Mapping. BMC
Health Services Research 2014 14:389.

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http://www.kaiserhealthnews.org/stories/2012/august/13/medicare-hospitals-readmissions-penalties.aspx

http://www.kaiserhealthnews.org/stories/2012/august/13/medicare-hospitals-readmissions-penalties.aspx

http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

The Care Transitions Program

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

Abstract
Background
Methods
Results
Conclusions
Background
Methods
Step 1: Problem analysis
Procedure and participants
Step 2: Identify intervention outcomes, performance objectives and change objectives
Procedure and participants
Step 3: Selection of theory-based methods and strategies
Procedure and participants
Step 4: Develop an intervention
Steps 5 and 6: Implementation and Evaluation
Results
Step 1: Problem analysis
Step 2: Matrices of change objectives
Intervention outcomes and performance objectives
Selected determinants and change objectives
Step 3: Selecting theory-based methods and strategies
Step 4: Develop an intervention
Steps 5 and 6: Implementation and evaluation
Discussion
Conclusions
Additional files
Competing interests
Authors’ contributions
Financial support
Author details
References