Direct Clinical Application With Nurse-Led Research: Impact of "Boot Camp" Intervention for Caregiver Discharge Readiness

Purpose: The purpose of this clinical nurse-led interventional research study was to determine the effectiveness of a “boot camp” training-for-discharge program on 34 caregivers of 34 medically-dependent children (compared to retrospective data prior to January 2015 start of boot camp training) as measured by lengths of stay on a transitional care unit (TCU) and overall days in the hospital, total days of documented discharge teaching, and levels of caregiver stress and satisfaction with training. Unprepared or poorly trained caregivers for medically-dependent children could result in poor patient outcomes, added caregiver stressors such as psychological distress or “burn out”, and increased financial strain on families and hospitals (DiZazzo-Miller, Samuel, Barnas, & Welker, 2014; Hendrix, Landerman, & Abernethy, 2013). Teaching parents, families, and caregivers to care for their complex medically-dependent children can be a challenge. These infants and children are often discharged home with tracheostomies, ventilators, feeding tubes, and other conditions that require specific learned skills or competencies to manage. A lack of individualized training can lead to inconsistent practice and poor patient outcomes once the patient is transferred home (Hendrix et al., 2013). When a patient lacks a well-trained caregiver, the discharge environment can be considered unsafe. The patient is directly affected by the training of their caregiver. If a caregiver is trained well and thoroughly, there is a higher likelihood that the patient will receive adequate care from their caregiver (Forster et al., 2013). The caregiver is affected by their training because an unprepared caregiver can be anxious, depressed, and unprepared for the complex care sometimes needed by patients (Hendrix et al., 2013). The medical team is affected because lack of a training program or inconsistent teaching for each caregiver can lead to confusion on how to properly prepare caregivers. Often, patients are limited in the amount of days allowed by insurance to be inpatient on a teaching floor or TCU. If the parents or caregivers are not trained within the allotted days, much of the inpatient stay is not reimbursed to the hospital or the caregivers are left with a substantial medical bill (O'Brien, & Dumas, 2013). It is more cost-effective to provide home health care than institutional medical care (Bookman, & Harrington, 2007). The economic value of the care provided by caregivers at home in the United States was estimated to be $350 billion in 2006 (DiZazzo-Miller et al., 2014). The term “boot camp” typically refers to military basic training. This standardized training prepares military recruits for service by providing the basic tools to perform their duties in a structured format with time constraints (Kubin & Fogg, 2010). The term “boot camp” was chosen for this caregiver training program because the basic skills needed to care for their dependents will be taught in a structured format within a predetermined time frame.

Methods: Developed and implemented by two night-shift frontline nurses, the study utilized a quasi-experimental comparative intervention design. The study was conducted on the transitional care unit within a large metropolitan pediatric medical center in the southwestern United States; Institutional Review Board approval was obtained. Study sample included: (1) experimental group composed of prospectively-recruited caregivers (n =34; average age 34 years; 88% female) and (2) a medical-condition-matched control group (n = 34; average age 5 months; 59% male; 74% respiratory failure diagnosis) where retrospective chart review data from pre-intervention TCU patients, prior to January 2015, were obtained for the length of stay and days of documented discharge teaching variables. In addition, this study also used a within-group repeated-measure study design for parental stress levels of experimental group caregivers at two time points: prior to start of boot camp training program and upon completion of program. The “boot camp” training program included: (1) admission care conference, (2) training contract, (3) structured daily training schedule, and (4) completion with nine structured training sessions (three hours of content per session). Outcome measurements included: (1) demographic data from 34 caregivers and their children, (2) pre- and post-intervention scores on parental stress levels from the 36-item Parenting Stress Index-4-Short Form with three subscales (PSI-4-SF; Abidin, 2012), (3) caregiver satisfaction related to the training, and (4) comparisons of average or median lengths of stay of patients (on unit and in hospital) whose caregivers were enrolled in the experimental group and matched-control group of medically-dependent patients whose caregivers completed pre-boot camp training. Data analyses performed were descriptive data (means, standard deviations, medians, percentages, frequencies for all study measures, independent-sample Mann-Whitney U tests for non-normal data (total length of stay in hospital, length of stay on TCU), paired-sample ttests for total number of days of documented discharge training, and repeated measures analysis of variance (RMANOVA) for within-group PSI-4-SF scores.

Results: Results pre-and post- boot camp implementation included: (1) median unit length of stay (LOS; 77 versus 43 days [p=0.004]), decreased by 44%; (2) median hospital LOS (146.5 versus 82 days [p=0.017]), decreased by 44%; (3) average documented discharge training days (41.5 versus 15.7 days [p<0.0001]), decreased by 62%; (4) Parental Stress scores related to: (a) Perceived Parental Distress (26.7 versus 23.1 [p<0.0001]), (b) Dysfunctional Interaction (22.3 versus 20.5[p=0.012]), (c) Perceived Difficult Child (23.4 versus 21.8 [p=0.021]), and (c) Total Parental Stress scores (72.8 versus 65.4 [p<0.0001]); and (4) Caregiver Satisfaction with Boot Camp Training (>90% were very satisfied). With DRG-related 42-50 day LOS limits, pre-boot camp 77-day LOS, and average daily unit cost of $1974, savings were estimated between $53,300 and $69,900 per patient on the transitional care unit.

Conclusion: The boot camp training program significantly decreased days of documented discharge training, parental stress, and length of stay with positive financial impact. One lesson learned was the need for frequent communication between disciplines regarding research process and outcomes, to sustain support and buy-in. The structured training format and engagement of research team with unit frontline nurses have contributed to caregiver satisfaction and accountability as well as nursing staff engagement with the boot camp initiative. Based on study findings, senior nursing administration has agreed to develop a Family Educator position to track and evaluate boot camp discharge education and its outcomes on the transitional care unit. Next step will be the evaluation of correlations between caregiver boot camp training and patient early hospital readmissions. The implementation of a structured “boot camp” training program for caregivers led to increased staff comprehension on what is expected for the discharge training needed by caregivers of complex medically-dependent children. This model could be customized to other areas (adult and pediatric) where there are medically complex patients.