A study of effectiveness of nursing referrals.

NURSES FROM ALL SERVICES at the Lexington Veterans Administration Hospital, when indicated in their judgment, refer patients to community nursing agencies. Our study of the effectiveness of these referrals was aimed primarily at determining whether followup by the community nurses was effective-that is, whether they provided the services requested. Leaders in nursing and other health professions recognize that the nursing referral is a vital link in continuity of care (1-5a). Moreover, most health authorities agree that planning for and provision of continuity of patient care is a responsibility that the nurse shares with other health professionals (6,7). Referrals are also seen as an important contribution to continuity of care between the hospital and the home (5b,8,9). Initial teaching or evaluation of information previously taught the patient and his family to assist them in adapting to the patient's health state is frequently requested in referrals. Learning is a major means by which man adapts, thereby modifying inadequate behavior (10). Today, patients are "questioning the nature of their impairments and are demanding more awareness of their treatment goals and patterns" (11). The rising tide of consumerism should enhance the provision of patient education as an element of our health delivery system. Although the nursing literature contains a number of references to continuity of care, few reports are available on systematic investigations of the effect of nursing referrals. Davis' 1972 study results support the merit of nursing intervention in the home, but the study lacked measurement tools specific to such intervention (9). In Smith's study of the referral of patients to public health nursing service, she attempted to identify factors that stimulated the referrals (12). Direct cause and effect could not be established from the data, but Smith made several suggestions for the development of referral systems based on inferences from her findings. These suggestions dealt primarily with patient selection, implementation, education, and communication. Eckelberry (13) addressed the crucial need to evaluate outcomes of referral. She cited an often neglected aspect of referral evaluation: "This is the effort to obtain from the person or persons referred an expression of what referral meant to them. " Some investigators have attempted to measure success of a referral program in terms of readmission rates (2,9,14). Rehospitalization alone, however, does not indicate the success or failure of community nursing intervention. The natural history of some disease states may necessitate intermittent rehospitalization, regardless of nursing intervention. Early detection by the community nurse may indicate rehospitalization as a positive measure for some patients, whereas it may prevent rehospitalization for others. Regardless of the reason for referral or the patient's discharge condition, an effective nursing referral should result in nursing intervention directed toward the purpose of the referral. When a patient is readmitted to the hospital, early evaluation of his or her status is essential. The time lapse between readmission and data collection may influence nursing assessment and patient response. Some