Nurses are concerned with the whole person who becomes a patient. They have recognized the psychological and social implications of medical care. They are alert to family interaction and cultural values as they influence the patient. In spite of the demands that technology has placed on the health care worker and the limits the shorter hospital stays have placed on their ability to communicate fully with patients and their families, nurses continue to be concerned about the people who are their patients. Discharge planning is a process that is part of nursing care, not an activity separate from it.

　Educating nurses in efficient and effective discharge planning is essential to ensuring the continuum of care is provided for the patient in their transition from hospital to community. The skills needed for effective discharge planning are the assessment, communication and teaching skills that the nurse uses throughout the nursing process.

　Rapid changes in the health care delivery system have placed increasing emphasis on discharge planning as a process that expedites the progress of patients through acute care to community. Discharge planning is a process that really begins upon admission to acute care and continues following discharge. Discharge planning is only one part of the care planning that extends throughout the wellness-illness continuum of an individual. Discharge planning involves the coordination of services and resources, patient education, provision of care, and consultation with other disciplines and with the patient, family, and friends. Expertise in all of these areas is a prerequisite for effective patient discharge.

　

　Educating health care workers to acquire assessment skills is essential in order to develop resourceful, efficient and compassionate discharge plans for patients. Implementing evidence-based curriculum is important to ensure the graduating nurse will have the skills that are necessary for efficient and effective patient care including discharge planning.

　At McMaster, the expected outcome for learning for the professional practice is incorporated throughout the four years of learning within the institution. Learning for the professional practice of nursing is both a process of inquiry and a skill which is developed as a life-long activity. The process is learner-centered and focused on solving clinical problems or addressing potential health care issues through the use of inductive and deductive reasoning. It requires the acquisition of appropriate knowledge, skills and personal qualities.

　Self-directed learning skills such as defining personal objectives, understanding the dynamics of behaviourial change, information acquisition/assimilation, and self-evaluation are acquired within the context of a respectful and facilitative teacher-learner relationship where learners take responsibility for their own learning.

　

　The learner's perception of the demand situation changes, in which the situation is seen less and less as a compilation of equally relevant bits, and more and more as a complete whole in which many of the parts are relevant to each other, just as the relevant bits of information that are required for discharge planning.

　The student needs to be aware of the roles of the interdisciplinary team members when considering discharge planning. Each member of the team has pertinent information about the best care for the patient and will have access to information regarding community resources upon discharge. The collaboration between the interdisciplinary team, the patient and the family will assist in making informed decisions for the best care.

　Decision making is a fundamental element of discharge planning, one that is essential to understand as organizations explore cost effective ways to deliver quality health care. These decisions address the complex network of interactions involved with enactment of the discharge planner's role, the repertoire of leadership skills such as collaboration, negotiation, and delegation required to elicit the involvement of other individuals; discretionary decisions made in the allocation of resources; priority setting; and strategizing. These findings have implications for discharge planner competency and quality of care, cost-effectiveness delivery of health care, and education of the discharge planner.

　Students have to incorporate and develop critical thinking skills, as mentioned before. Examples of such considerations include:

　The student as a discharge planner has to take into consideration and use their discretion about decisions about resources. Considerations include:

　Practicing nurses will have an understanding of many of the concepts previously mentioned regarding effective discharge planning, different elements of the learning process has to be considered. There are a variety of methods to educate the discharge planner for more effective discharge planning.

　

　Representatives from various community type settings, multidisciplinary team members and a discharge planner can collaboratively present to the audience the considerations and process for discharging a patient. Self-learning packages can then be given out and will be incorporated into a focus group or workshop. Case scenarios can then be incorporated as well as the participants can contribute their personal experiences. Information sessions can be used periodically to inform the health care worker of the resources / services available within the community.

　The health care worker for the new millennium needs to be educated in broad areas such as policy frameworks. For example, in Japan, knowledge of the services covered under the national long term care insurance program is critical in order to access relevant services. The clinician needs to know how to assist the patient in accessing the services in an efficient and effective manner. A systems approach has to be used in order to evaluate the quality of services coming into the home. Often there are different providers from different agencies. Homemaking services can be provided by one agency and nursing services provided by another. Quality control becomes a critical issue as it is often the patient's family that is the major advocate for continuity of care in the home. This puts an additional burden on the family. Communication between the interdisciplinary team (doctors, nurses, physiotherapists) is essential in order to assure a smooth care plan is implemented.

　After discharge, there has to be an evaluation process that examines services at time intervals during the client's care at home. A recent anecdote from a local hospital that followed up their clients discovered that the homemakers had not been going to the home and that service provision was non-existent.

　Case management is essential when the patients require acute illness support and frequent visits are required. It is important to allow independent decision making on the part of all health professionals so they do not have to continually access permission to make decisions. For example, with pain control, graduated doses may be necessary in order to assist the patient gain the level of control in order to carry out activities of daily living. New structures have to be instituted, such as community advisory panels, in order to oversee the issues in delivery of care. Once there are computers in the home, communication will be easier because clients can access personnel in the hospital settings to communicate their satisfaction or dissatisfaction with services.

　Health practitioners need to be made aware of population health factors, assessment of family dynamics and adequacy of community services. Boblin-Cummings (1998) emphasizes the need for health care practitioner to learn the skills of advocacy such as negotiation, facilitation, and manipulation. In conclusion the skill set necessary for community are very complex as there is not the bureaucratic structure to back up the necessary elements of care. Health care workers have to understand that there needs to be a very close association with the hospital and the community services.

Requirements for a seamless system between hospital and community

　

　We are likely agreeing in Japan and Canada about the educational requirements and skills for health care workers in the new millennium. But the most skilled workers cannot do their jobs well unless the system they work in supports the practice and patients in the health care system need a system that supports their needs. Together hospitals and community staff nurses:

　

　One trial that we undertook in our community was designed for people living with serious mental illness. When it was determined that a patient could potentially be discharged, nurses from the community mental health team began to visit the hospital ward and interact with the patient and the nurses on the floor. They build a relationship amongst the nurses from the two sites and with the patient. Over time the patients began to plan with the nurses for their discharge from hospital. Then when the patients were discharged from the hospital they scheduled meetings in the community with their hospital nurses and the community nurses. Although this sounds like very expensive staffing, our study showed $496,862.55 savings in 12 months for 9 patients. The savings occurred because the patients in the study were not readmitted to hospital at the same rate as would be expected. (Forchuk, 1998).

　The community nurse provides care beyond the presenting medical issue. They often act as the care coordinator, ensuring all of the patient's needs are met . The nurse provides holistic care and looks to promote optimal health for the patient.

　The community nurse does this by implementing health promotion and illness/injury prevention into his/her practice. A focus on health promotion includes: physical, family, community and population health assessment; health screening; research, data analysis, and biostatistics; epidemiology; education skills; program development, implementation and evaluation; surveillance; presentation skills and knowledge of computer technologies; environmental health; advocacy; and recognition of population diversity.

　In recognition of personal and community agency and the diversity of world views which impact upon the experience of health, community nurses provide a supportive and collaborative role at all stages of the nursing process. Hence, participatory assessment, planning, implementation and evaluation modalities are required competencies of community health nurses which increase empowerment.

　Overall skills of advocacy, needs assessment, community development, public health theory, coalition building, negotiation, outreach, facilitation, consultation, and mobilization are required to support the public's involvement directed at healthier environments in particular and communities in general.

　Knowledge and skills of the multiple determinants to health are fundamental in assessing, planning and implementing programs with communities and key stake holders across the sectors eg. education, economics. Effective participation in organizational structures requires awareness of skills to move both vertically and laterally within the power structures of the health care delivery system. From grassroots community agencies to national and international governing bodies such as the WHO, and across the wide network of health service providers, community nurses require the skills to communicate and facilitate change.

　In order to ensure the accessibility of health to all, community nurses must incorporate knowledge about the diversity of populations - physically, geographically, socially, culturally, economically, and politically, representing gender and age differences. Assessment of the barriers faced by diverse population and planning appropriate services to reduce these are again core competencies of community health nurse. Computer technologies may assist some clients to access health services; they may also detract from the accessibility of other clients and therefore assessment of the appropriateness of these and other technologies to the client's and/or community situation are important to the role of community health nurse.