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Studies have shown that early discharge planning, multidisciplinary care, and a focus on functional abilities for older adults do reduce acute care hospital readmissions. Of the 101 records reviewed of acute care admissions 75 years of age and older, 36 had no multidisciplinary service documented and 75 had no discharge planning documented within 48 hours of admission. Eleven functional activities were assessed and documented in one record with a range of 4 to 11 activities assessed in the remaining 100 documents. Identifying and filling gaps in care provided to this age group might provide substantial cost savings, improve care, and decrease complications. Advocacy, coordination of care, and greater knowledge may be keys to narrowing these service gaps.

Patricia A. Martin, PhD, RN; Janet Dugan, MS, RN; Margaret Freundl, MSN, RN; Susan E. Miller, MS, RN; Rita Phillips, MSN, RN, FNR C; and Loretta Sharritts, MS, RN ABSTRACT This study measured the knowledge of and attitudes toward the nursing process held by nurses who provide direct patient care. The Dayton Attitude Scale Toward Care Planning (DASC) was returned by 1,096 nurses practicing in nine hospitals. Overall, participants were knowledgeable of the nursing process and held a relatively positive attitude toward the nursing process and nursing diagnosis. Higher nursing degrees were associated with more positive attitudes. The most common barrier to the use of the nursing process was insufficient time. The study found that less than 30% of the subjects liked the way care planning was done. These findings suggest that improving care planning systems would further promote consistency in the process.