Discharge support nurses reshape the patient experience at Colchester East Hants Health Centre

Working alongside interdisciplinary teams, discharge support nurses (DSN) guide patients and families through the discharge process, ensuring comprehensive support. They identify patient needs and connect them with essential services prior to discharge. From arranging home nursing to providing clear post-op instructions, they foster confidence in patients and families as they prepare to leave the hospital.

Reflecting on their impact, a physician recalled a critical intervention by a DSN with an elderly patient living in a rural area with no supports. “Natalie’s dedication ensured a patient’s safety post-discharge,” they explained. “She took the time to identify areas of need, connect the patient with essential services and ultimately foster their recovery and prevent readmission to the emergency department.” 

Another physician added, “They are instrumental in streamlining processes and reducing our workload.” When a patient with dementia was transitioning back to their long-term care home, the DSN called the home directly to discuss the patient’s discharge. They also worked with the family to help facilitate a smooth transition and avoid readmission. This enabled me to focus more on direct patient care,” they added.

“We also take the time to educate patients on post-operative care, empower them to navigate their recovery journey, and ensure they feel confident as they transition home,” said Justine Kelly, DSN on the medical/surgery unit. With DSNs in place, patients receive clear instructions, minimizing the risk of readmission and fostering a sense of security.

There are exciting opportunities to expand the role of DSNs, from admission avoidance strategies to reducing caregiver burnout, the impact is far-reaching. Since November when the pilot began, DSNs have not only supported patients and families but also built capacity within their teams. As we navigate the future, let’s celebrate the transformative work of DSNs.