Nursing Journal Volume x.
Issue x.
Page 158-164 e-ISSN: 2354-6050 https://ejurnal.
id/index.
php/JKep/article/view/x DOI: https://doi.
org/10.
32668/jkep.
THE EXPERIENCE OF HEALTHCARE WORKERS AND PATIENTS IN
THE IMPLEMENTATION OF DISCHARGE PLANNING FOR HEART
FAILURE PATIENTS
1st Amoy Amelia Sanusi1 Abstract 2nd Wan Nishfa Dewi1* Ineffective discharge planning results in discontinuity of patient care at home.
This condition worsens patient outcomes, leading to patients returning to health services with the same medical history or with new and more severe This study aims to explore the experience of healthcare workers and patients in implementing discharge planning for heart failure This study employed a phenomenological design with a qualitative, interpretative approach.
The participants consisted of 17 individuals: ten health workers from a private hospital in Pekanbaru, two heart specialists, three nurses, two pharmacists, three nutritionists, and seven patients with heart failure who were planning to return home.
Participant recruitment was conducted using a purposive sampling method.
Data collection was through in-depth interviews, and data analysis used the Colaizzi analysis stages.
Four themes are interrelated with the studied phenomena: the information received by patients regarding discharge planning, specific education for heart failure patients, the challenges faced by healthcare workers in completing the discharge planning form, and the important components of discharge planning for heart failure patients.
The experiences of healthcare workers and patients in implementing discharge planning in this study reveal that there are still inadequacies that concern both healthcare workers and The themes identified in this study can contribute to the development of discharge planning forms for heart failure patients.
Therefore, this study on healthcare services suggests that it may reduce the recurrence rate of heart failure in patients.
3rd Bayhakki1 4th Sri Wahyuni1 5th Nurul Huda1 6th Erika1 1Faculty of Nursing.
Universitas Riau.
Pekanbaru.
Riau.
Indonesia *email: wan.
dewi@lecturer.
Keywords:
Components Discharge planning Health Education Received: August 2025 Accepted: September 2025 Published: November 2025 A year The Authors.
Published by Published Jurusan Keperawatan.
Politeknik Kesehatan Kemenkes Jakarta i.
This is Open Access article under the CC-BY-SA License .
ttp://creativecommons.
org/licenses/by-sa/4.
0/).
DOI: https:// https://doi.
org/10.
32668/jkep.
The frequency of heart failure rehospitalisation reaches INTRODUCTION Efforts to develop effective discharge planning, particularly for patients with heart failure, are crucial to improving the quality of patient care.
A case study revealed that there is currently no specific discharge planning for heart failure patients in Indonesia, 45% per year .
Heart failure cases in Central Java from 2016 to 2018 at the Islamic Hospital of Banjarnegara.
Central Java, ranked among the top three, with a rehospitalisation rate of more than 50% for heart failure cases .
Rehospitalisation data from one of the private hospitals in Pekanbaru from January 2021 to highlighting the significance of this research .
September 2022 showed that 369 patients .
%) out of Heart failure is one of the most common causes of a total of 453 heart failure patients were readmitted or rehospitalisation within the first 60 days after hospital The occurrence of rehospitalisation in discharge due to inadequate discharge planning and non-adherence to patient .
After heart failure patients is influenced by discharge planning .
discharge, the care ability of the patient and family is undoubtedly required to manage and prevent fatal risks, as well as to prevent rehospitalisation within 30 days .
Currently, there is no specific discharge planning format for patients with heart failure.
This underscores the need for tailored discharge planning components for heart JKEP (Jurnal Keperawata.
Vol 10 Issue 2.
November 2025.
Page 158-164 e-ISSN: 2354-6050 failure patients.
By addressing the unique needs of these The interviews were conducted at locations patients, such as medication adherence and lifestyle determined by the participants.
During the interview changes, we can reduce the rate of repeated process, recordings were made using a recorder and a hospitalisations, accelerate the healing process, and mobile phone, and the recorded results were then decrease the mortality rate due to heart failure.
transcribed verbatim by the researcher.
The data analysis process in this study used Colaizzi's The development of discharge planning that aligns with The first step was to ensure the credibility of patient needs is a crucial aspect for achieving continuity the data by validating it through providing each of patient care.
The objective of this study is to participant with a verbatim interview transcript and investigate the experiences of healthcare workers and asking them to verify the accuracy of the transcript.
patients in the implementation of discharge planning for Second, the transferability process was carried out by patients with heart failure.
writing the research report with clear and detailed METHODS This study employed an interpretive qualitative dependability test the data analysis process, and then the researcher The interpretative qualitative approach in this conducted by involving the thesis supervisor throughout approach, which is highly suitable for the research study used Third, processed the data into themes.
Fourth, the principle of confirmability indicated that the research findings investigates human experiences to seek explanations of addressed the research questions and were not biased.
events based on perspectives that contain facts and are Prior to conducting the study, ethical approval was contextual .
obtained from the Research Ethics Committee for This study was conducted at one of the private hospitals Nursing and Health.
Faculty of Nursing.
Universitas in Pekanbaru City.
Riau Province.
The researcher chose Riau, this location because, based on the investigation results, 579/UN19.
8/KEPK.
FKp/2024.
Therefore, this study the hospital does not yet have a specific discharge was conducted by the institutional ethical regulations.
planning protocol for heart failure patients.
the existing discharge planning remains general.
RESULTS AND DISCUSSION
Participants in this study were selected using a Based on the data analysis using ColaizziAos purposive sampling method.
The participant recruitment thematic method, four major themes were identified: .
process was carried out through discussions with discharge planning information received by patients, .
nursing managers.
The selected participants were those provision of specific education to heart failure patients, who met the inclusion criteria, namely, heart failure .
challenges faced by healthcare workers in patients planning to be discharged and all healthcare completing the discharge planning form, and .
workers providing direct care to heart failure patients, essential components of discharge planning for heart failure patients.
The themes and sub-themes are cardiologists, three inpatient cardiac care nurses, three summarised in Table 1.
nutritionists, and two pharmacists.
The data collection process in this study used a semistructured interview method.
In this data collection, interviews were conducted directly between the and the researcher.
The researcher conducted each interview, which lasted 30 to 45 JKEP (Jurnal Keperawata.
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Results of Thematic Analysis Sub-Theme Theme hospital to home .
Information on medications and Information on physical activity and exercise Fulfilling rest needs Relapse management methods e-ISSN: 2354-6050 Medication adherence emerged as a critical area of discharge information.
This aligns with the findings of Silavanich et al.
who reported that optimal adherence Patients receive discharge planning improves physiological function, quality of life, and rehospitalization outcomes.
Supporting this evidence.
Kunz et al .
found that non-adherence to heart failure Receiving repetitive information medications significantly contributes to the progression Limited information received to acute decompensation and subsequent emergency Education related to medications and treatment department admission.
The pattern of repeatedly delivered yet insufficient Education on a healthy lifestyle Education on relapse management Provision of specific education to heart failure patients information underscores gaps in communication.
Kynoch similarly identified that inconsistent or poorly structured communication during discharge leads to Non-adherence with the treatment Obstacles in completing the current discharge planning form Fluid management component Medication administration schedule Purpose of medication Blood glucose result component Salt intake amount decreased patient confidence and limited self-care Challenges faced by healthcare workers in completing the discharge planning capabilities .
In line with this.
Oh et al .
demonstrated that implementing a structured and patient-centered discharge education approachsuch as the teach-back method significantly improves patientsAo Essential components of discharge planning for heart failure self-management abilities, and enhances their readiness for post-discharge These findings further emphasize the importance of clear, interactive, and systematic communication in Diet type component .
ow sugar, low fat, low sal.
supporting optimal outcomes for heart failure patients.
Components of diet options and nutritional needs Provision of Specific Education to Heart Failure Components of weight and BMI Patients This study found that healthcare workers provided Emergency contact number detailed education related to medications, including Discharge Planning Information Received names, dosages, quantities, frequency of administration.
Patients method of use, potential side effects, and therapeutic The findings indicate that patients received information These findings are supported by Wu and related to medications, physical activity, rest needs.
Moser, who demonstrated that patients who discontinue adherence to treatment, and relapse management.
These or modify their heart failure medications without results suggest that healthcare workers attempted to medical supervision have significantly higher risks of deliver holistic education.
however, patients perceived the information as limited and often repetitive.
This Such evidence highlights the necessity finding aligns with previous research demonstrating that of strengthening medication-related education prior to heart failure patients commonly report inadequate or JKEP (Jurnal Keperawata.
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Page 158-164 e-ISSN: 2354-6050 discharge to ensure safe and effective continuity of action, and diet components, were often incomplete.
Healthcare workers reported difficulties completing the In addition to medication-related education, patients form, leading to reliance on verbal explanations without received guidance on fluid restriction .
Ae1.
5 liters/da.
proper documentation.
These findings are consistent and low-sodium, low-fat dietary practices.
These with Nasiri et al.
, who demonstrated that insufficient recommendations correspond with the American Heart organizational support, lack of standardized discharge Association, which underscores sodium and fluid planning tools, and heavy workload contribute regulation as essential aspects of heart failure treatment significantly to documentation gaps and inconsistent .
Consistent with these findings.
Billingsley et al.
implementation of discharge planning.
Their qualitative reported that targeted dietary interventions, particularly study further highlighted that inadequate attention to sodium reduction and avoidance of processed foods, discharge processes and deficits in institutional sub- significantly improve symptom control, reduce edema, structure often force nurses to rely on verbal guidance and enhance adherence to heart failure self-care rather than comprehensive written documentation .
These insights reinforce the need for standardized, well- Furthermore, patients were taught to monitor daily supported discharge systems to facilitate accurate weight, assess lower-extremity edema, and measure documentation and improve continuity of care.
blood pressure correctly to detect worsening symptoms The consequences of inadequate discharge planning are at an early stage.
These findings are supported by Umeh.
The results of this study demonstrate that who demonstrated that structured self-monitoring incomplete discharge documentation may prolong behaviors, including daily weight tracking and symptom recovery, increase the likelihood of symptom relapse, and contribute to rehospitalization.
This is supported by department visits and prevent acute decompensation a Cochrane systematic review by Bradley et al, which among heart failure patients .
found that poorly structured or incomplete discharge Patients were also encouraged to perform light-intensity planning is associated with higher rates of unplanned physical activity, such as slow walking for 5Ae10 minutes readmissions, while comprehensive and standardized This is consistent with the American Heart discharge processes significantly reduce 30-day hospital AssociationAos scientific statement on exercise training for heart failure, which highlights that individualized improving discharge planning requires not only low to moderate-intensity exercise programs are safe, standardized documentation tools but also adequate training, organizational support, and streamlined rehospitalization .
Overall, these results emphasize workflows to ensure that all required information is that structured and evidence-based education is essential consistently recorded and effectively communicated.
These findings to strengthen patient self-management and minimize adverse outcomes following discharge.
Essential Components of Discharge Planning for Heart Failure Patients Challenges Faced by Healthcare Workers in Effective discharge planning requires a comprehensive Completing the Discharge Planning Form set of elements that address the patientAos medical.
The study identified several challenges experienced by functional, and psychosocial needs.
According to the healthcare workers when completing the discharge Agency for Healthcare Research and QualityAos IDEAL planning form.
Key sections, including the knowledge.
Discharge Planning Implementation Handbook.
JKEP (Jurnal Keperawata.
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Page 158-164 e-ISSN: 2354-6050 essential components include a reconciled and clearly contact information, significantly improve patientsAo explained medication list covering drug names, dosages, readiness for discharge, strengthen self-care behaviors, timing, purposes, and potential side effects as well as and reduce unplanned readmissions .
individualized instructions regarding diet, activity, and CONCLUSION symptom monitoring.
The handbook also emphasizes The discussing test results, highlighting warning signs, implementation of discharge planning for heart failure involving family members in discharge meetings, and patients remains suboptimal, particularly in terms of ensuring that follow-up appointments and emergency information delivery, specific patient education, and contact information are provided before discharge.
This study emphasises the importance These structured components are designed to support of refining the discharge planning process to make it continuity of care, enhance patient understanding, and more structured, consistent, and tailored to the reduce preventable readmissions .
individual needs of heart failure patients.
The The findings of this study indicate that, beyond the interpretation of these findings underscores the standard components, several additional elements are importance of developing a more comprehensive essential for heart failure patients due to the complexity discharge planning form, along with repeated and of their condition.
These include detailed fluid Thus, discharge planning serves not only administration schedules, explanations of the purpose of as an administrative procedure, but also as an each medication, documentation of blood glucose educational tool to enhance patient and family results, guidance on allowable salt intake, and preparedness for home care and contribute to reducing specification of dietary requirements such as low-sugar, the rate of rehospitalisation.
of this study indicate that low-fat, and low-sodium diets.
Additionally, guidance on dietary options and nutritional needs, as well as ACKNOWLEDGMENT structured monitoring of weight and body mass index The authors express their gratitude to Universitas Riau (BMI), were identified as important components of a for academic support and to the management and heart failureAespecific discharge plan .
These healthcare professionals of the private hospital in elements facilitate early identification of fluid retention.
Pekanbaru for facilitating this research.
Appreciation is support medication adherence, and help patients also extended to all participants for their valuable maintain stable clinical status at home.
The study also highlights the importance of providing an emergency contact number to support
REFERENCES