ABSTRACT
Aim
Effective discharge planning requires ward nurses to understand the circumstances of receiving facilities. Perspective‐taking—the active cognitive process of imagining another party's situation—may play a central role in promoting interfacility collaboration. This study examined a theoretical process model that positions perspective‐taking, nurses' boundary‐crossing experiences, and their collaborative practice in discharge planning.
Methods
A cross‐sectional online survey was conducted with acute care nurses in Japan in 2021. Perspective‐taking and collaborative practice in discharge planning were measured using validated scales. Boundary‐crossing experiences, encompassing other‐facility experience and interaction opportunities with external professionals, were assessed using newly developed measures. Structural equation modeling was employed to evaluate the fit of the proposed theoretical model.
Results
Data from 416 respondents were analyzed. Perspective‐taking was significantly associated with collaborative practice in discharge planning (p < 0.05). Both other‐facility experience and interaction opportunities were significantly associated with perspective‐taking (p < 0.05). The theoretical process model met the criteria for good fit (comparative fit index = 0.93; root mean square error of approximation = 0.07; standardized root mean square residual = 0.05).
Conclusions
The results indicate that ward nurses' boundary‐crossing experiences are positively associated with perspective‐taking, and perspective‐taking supports collaborative practice in discharge planning. Providing nurses with diverse facility experiences and external interactions could promote interfacility collaboration.
Keywords: boundary‐crossing, cooperative behavior, discharge planning, perspective‐taking
1. Introduction
Discharge planning is essential to ensure continuity of care across fragmented healthcare systems. As hospital stays shorten and the need for post‐discharge care increases, effective discharge planning requires interfacility collaboration, including home‐care services (Kato et al. 2018; Khatri et al. 2023; Waring et al. 2016). Nurses coordinate care within hospitals and with staff at receiving facilities to support continuity of care in the next care setting (Foust 2007; Goodman 2016; Jeffs et al. 2018).
Although nurses play a central role in discharge planning, they do not always perform well in discharge planning. Failure to consider the conditions in subsequent care settings can lead to insufficient coordination and delays in post‐discharge care (King et al. 2013; Petersen et al. 2019; Smith and Treschuk 2018). Therefore, nurses should anticipate the constraints and priorities of the receiving facilities (Gilmore‐Bykovskyi et al. 2017; Høyem et al. 2018). However, the cognitive processes that enable nurses to understand and respond to external contexts remain unclear. Social cognitive theory suggests that behavior is shaped by interactions between cognitive and environmental factors (Bandura 1986). Using this framework, the cognitive mechanisms supporting nurses' effective discharge planning across institutional boundaries could be identified.
As a cognitive factor, discharge planning requires careful consideration of the situation at the next facility. Perspective‐taking refers to “the active cognitive process of imagining the world from another's vantage point or imagining oneself in another's shoes to understand their visual viewpoint, thoughts, motivations, intentions, and/or emotions” (Ku et al. 2015, 94–95). Perspective‐taking has been reported to show a positive association with cooperative behavior (Ku et al. 2015; Longmire and Harrison 2018) and improve occupational performance in various occupational environments (Grant and Berry 2011; He et al. 2018; Jiang 2017; Todd et al. 2012). While empathic concern tends to be attenuated toward others, perspective‐taking is more effective in bridging intergroup differences (Longmire and Harrison 2018). In healthcare, perspective‐taking has been reported to help broaden network understanding beyond one's own department (Calvard et al. 2023). In the context of discharge planning, perspective‐taking can help ward nurses better anticipate the circumstances of staff at receiving facilities and adjust hospital discharge planning accordingly. However, the contribution of perspective‐taking in discharge planning remains unclear. The gap highlights the need to examine how nurses' perspective‐taking relates to collaborative practice in discharge planning.
As an environmental factor, understanding how to foster perspective‐taking in clinical settings is crucial. Boundary‐crossing, referring to a person's transition and interaction across different sites, has been shown to facilitate perspective‐taking (Akkerman and Bakker 2011). For example, working in different facilities promotes interfacility collaboration, accounting for the perspectives of both sides (Jenkins and Anstey 2017). Likewise, frequent meetings with community healthcare professionals facilitate the discharge planning practices of hospital nurses (Miyamoto et al. 2019). This study operationalizes boundary‐crossing as experiences that expose nurses to care delivery systems different from their current practice setting. Both experiencing work at other facilities and engaging in interactions with external professionals represent forms of boundary‐crossing that expose nurses to diverse environments and may foster perspective‐taking.
It is essential to understand the mechanisms that promote collaborative practice in discharge planning. Previous studies have examined boundary‐crossing experiences, perspective‐taking, and discharge planning practices separately; these could be conceptually connected. Drawing on Social Cognitive Theory (Bandura 1986), boundary‐crossing experiences can be conceptualized as environmental factors that expose nurses to different care contexts, perspective‐taking as a cognitive factor through which these experiences are interpreted, and collaborative practice in discharge planning as the behavioral outcome. Theoretically integrating these concepts allows us to understand the relevance of each and identify intervention points to improve practice. Therefore, this study aims to test a theoretically grounded process model that explicates how boundary‐crossing experiences are positively associated with nurses' perspective‐taking and how perspective‐taking is associated with their collaborative practice in discharge planning (Figure 1).
FIGURE 1.
Process model.
2. Methods
2.1. Design
This cross‐sectional observational study was conducted via an online questionnaire‐based survey from September to October 2021. Data collection was conducted concurrently with another study which focused on developing a scale for measuring perspective‐taking (Tanaka et al. 2024), though measures specific to perspective‐taking and boundary‐crossing were unique to this study. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology Statement recommendations.
2.2. Surveyed Facilities
Two hundred acute care hospitals without long‐term care beds were randomly selected in the Kanto Koshinetsu, Tohoku, and Tokai Hokuriku Health and Welfare Bureaus areas, based on facility reports issued by the Kanto‐Shinetsu Regional Bureau of Health and Welfare (Kanto‐Shinetsu Regional Bureau of Health and Welfare 2021), Tohoku Regional Bureau of Health and Welfare (Tohoku Regional Bureau of Health and Welfare 2021), and the Tokai‐Hokuriku Regional Bureau of Health and Welfare (Tokai‐Hokuriku Regional Bureau of Health and Welfare 2021) in Japan. Acute care hospitals were selected because they frequently discharge patients to other care settings, which means that interfacility collaboration is a central component of discharge planning—such transitions are less common in long‐term care settings. A total of 45 institutions agreed to participate in this study (acceptance rate 22.5%).
2.3. Participants
Ward nurses who provided discharge planning in general medical‐surgical and pediatric wards were included. Nurses with less than 1 year of nursing experience, nurse administrators who do not provide direct patient care, non‐ward nurses, maternity ward nurses, emergency ward staff, and intensive care unit staff were excluded. As this study focused on routine discharge planning practices in general medical and surgical wards, we excluded emergency departments, intensive care units (ICUs), and wards where discharge planning is standardized to provide education on infant growth and development (Chang et al. 2016; Jing et al. 2017). ICU patients represent a distinct population with severe and complex conditions requiring specialized discharge planning (Bilir 2023; Hassan et al. 2024). In Japan, patients admitted to ICUs are typically transferred to general wards before being discharged home; therefore, ICU nurses were excluded to standardize the context of this study and focus on routine discharge planning practices. The Director of Nursing identified eligible staff based on the inclusion criteria and arranged to receive the necessary number of questionnaires by informing the researcher. The method of distribution was at each hospital's discretion.
2.4. Survey Items
2.4.1. Perspective‐Taking
We define the perspective‐taking of ward nurses in the context of discharge planning as “an active cognitive process in which ward nurses imagine the perspective, position, and situation of the staff receiving discharged patients when they provide discharge planning (including hospital transfer) for patients requiring continued medical care.”
The Ward Nurses' Perspective‐Taking of the Staff Receiving Discharged Patients (WPSD) Scale, which was confirmed for validity and reliability in a prior study (Tanaka et al. 2024), was used. The previous study confirmed that the two‐factor structure was consistent with the theoretical framework, thereby supporting the construct validity of the scale. This scale comprises two subscales, namely, “imagine–other” and “imagine–self,” with the 10 items rated on a 5‐point Likert scale.
2.4.2. Collaborative Practice
Collaborative practices were defined as “the practice of coordinating post‐discharge care in collaboration with healthcare professionals both inside and outside the hospital in discharge planning.” “Teaching home‐care skills with community/hospital professionals,” a subscale of the Discharge Planning of Ward Nurses Scale (Sakai et al. 2016), was used. This scale demonstrated acceptable reliability and construct validity in previous research. This eight‐item subscale evaluates the extent of practices related to collaboration between the internal and external hospital staff for patients discharged from the hospital. This subscale was adopted owing to its suitability for evaluating ward nurses' degree of discharge planning practices applied to patients who are discharged or transferred to other medical institutions. Responses are evaluated on a 6‐point Likert scale ranging from 1 (Not done at all) to 6 (I've done enough).
2.4.3. Boundary‐Crossing: Other‐Facility Experience and Interaction Opportunity
To understand the experience of working at other facilities, whether owing to a job change or secondment, nurses were asked to respond to the question: “Have you ever worked as a nurse at a facility other than the one you currently work at?” The binomial answer method (yes/no) was used for the responses.
Regarding the frequency of interaction opportunities, nurses were asked to respond to the question: “In the past year, how many opportunities have you had to communicate with the staff receiving discharged patients through pre‐discharge conferences, phone calls, e‐mails, etc.?” Responses were rated on a 5‐point scale (1: None, 2: Once every 6 months, 3: Once every 3 months, 4: Once every month, and 5: Twice or more per month).
2.4.4. Demographic Data
Demographic and clinical background included gender, age, marital status, occupational position, years of clinical experience, and experience caring for family members or relatives.
Variables related to discharge planning involvement and organizational support were also assessed. These included experience serving on committees related to discharge planning at the hospital or ward level, participation in discharge planning study groups within or outside the hospital in the past year, presence of a discharge coordination nurse in the ward, and use of electronic medical records. Additionally, availability of shared critical pathways across multiple facilities in the area (Yes/No/Don't know) and frequency of involvement in discharge support activities in the past year (1: Not at all, 2: Once every 6 months, 3: Once every 3 months, 4: Once every month, and 5: Twice or more per month) were assessed.
2.5. Calculation of Sample Size
Although no clear standards exist for determining the ideal sample size while using structural equation modeling, a minimum sample size of 200 is required (Kline 2011). Therefore, the goal was to distribute the questionnaire to 1000 people with an expected response rate of 20%. To evaluate sample size adequacy, a model‐based sample size estimation was conducted as a post hoc analysis. This analysis involved the semPower package in R (Moshagen and Bader 2025). Based on the model's degrees of freedom (df = 167), the required sample size was estimated to be 123.
2.6. Data Analysis
Descriptive statistics were calculated for demographic data. The mean score was calculated for each subscale, and the frequency distribution was determined for categorical data. Cronbach's α was calculated to verify the reliability of the scale. The Spearman's correlation coefficient was used. A t‐test was used to compare the two groups. Tukey's test was used to compare three or more groups. Demographic data on perspective‐taking and collaborative practices are presented in Appendix S1. All significance levels were set at p < 0.05. Harman's single‐factor test was conducted to examine common method variance. All measurement items were entered into an unrotated exploratory factor analysis. Common method variance was considered present if the first factor accounted for more than 50% of the total variance.
Four models were constructed and tested using structural equation modeling. First, the process model (Model 1) was examined using structural equation modeling to evaluate the significance of the path coefficients and overall model fit indices. Next, a direct path model (Model 2), which included direct paths from the boundary‐crossing factors to collaborative practices, was developed to compare its fit with that of Model 1. To adjust for potential confounding factors, common clinical pathways, workshops on discharge planning, and the frequency of engagement in discharge planning were included as covariates. These three covariates were selected based on theoretical relevance and model parsimony rather than on univariate associations alone. Specifically, they represent organizational opportunities and contextual factors directly related to discharge planning practice within the proposed theoretical framework. Although multiple demographic characteristics showed univariate associations with perspective‐taking or collaborative practice, we did not include them solely on this basis because some of these characteristics, particularly age and clinical experience, are likely to be highly correlated. Including multiple correlated demographic variables could introduce multicollinearity and overadjustment. Model 3 was created by adding these covariates to Model 1, with adjustments for both perspective‐taking and collaborative practices. Similarly, Model 4 was created by adding the same covariates to Model 2. As a supplementary analysis, the indirect effects were examined for each model using bootstrapping with 2000 resamples.
Then, the goodness of fit of the process model and the direct path model was compared using the Akaike Information Criterion (AIC). Although the AIC is useful for evaluating the relative model fit, it does not provide a formal statistical test of the differences between nested models. Therefore, to assess whether the more complex model significantly improved the model fit over the simpler model, a chi‐square difference test was conducted as an additional analysis.
Supplementary analysis was conducted to verify the relationship between boundary‐crossing and collaborative practice in discharge planning between healthcare facilities. The model, in which perspective‐taking was removed from the process model and a path was drawn from boundary‐crossing factors to collaborative practice in discharge planning between healthcare facilities, was made and verified.
IBM SPSS Statistics (Ver. 28.0.0.0), IBM SPSS Amos (Ver. 31.0.0) and RStudio (Ver. 2023.06.1+524) were used for statistical analysis.
2.7. Ethics Statement
This study was approved by the Research Ethics Committee of 2021137NI. The respondents were informed that their participation in the survey was voluntary, that their responses would not lead to a performance evaluation, and that participant details and survey responses would be kept confidential. Informed consent was obtained electronically at the beginning of the study. The respondents were required to indicate their agreement by selecting a consent option before proceeding with the survey, and only those who agreed participated in the survey. This survey was conducted from September 27 to October 31, 2021.
3. Results
3.1. Attributes of the Participants
The questionnaire was distributed to 1289 participants, and 416 responses were analyzed after excluding two inappropriate responses and one duplicate response (Figure 2).
FIGURE 2.
Flowchart of sampling. †In the middle of the WPSD Scale, we included an opposite item, “I do not consider the receiving staff's situation when providing discharge planning,” to determine inappropriate answers for scale development (Tanaka et al. 2024). Items that met the following two conditions were excluded: 51% of the items in the original scale that contained opposite items were answered with a score of 1 or 5. ‡As there were two responses with the same ID and basic attributes, it was considered a duplicated response. Only the latter of the two responses was used.
Demographic data are shown in Table 1. The mean total years of clinical experience was 15.62 ± 9.25 years. Of the sample, 184 participants (44.2%) had been involved in discharge planning at least twice a month in the past year.
TABLE 1.
Demographic data (n = 416).
| Mean (SD) | |
|---|---|
| Age | 38.90 (9.49) |
| Years of clinical experience | 15.62 (9.25) |
| n (%) | |
|---|---|
| Sex | |
| Woman | 390 (93.8) |
| Man | 26 (6.3) |
| Marital status | |
| Married | 224 (53.9) |
| Single | 192 (46.2) |
| Experience caring for relatives | |
| Yes | 139 (33.4) |
| No | 277 (66.6) |
| Occupational position a | |
| (1) staff | 279 (67.1) |
| (2) assistant chief nurses | 16 (3.8) |
| (3) chief nurses | 83 (20.0) |
| (4) assistant ward manager | 38 (9.1) |
| Committees related to discharge planning | |
| Yes | 151 (36.3) |
| No | 265 (63.7) |
| Workshop on discharge planning | |
| Yes | 162 (38.9) |
| No | 254 (61.1) |
| Discharge coordination nurses | |
| Yes | 299 (71.9) |
| No | 117 (28.1) |
| Electronic medical records | |
| Yes | 412 (99.0) |
| No | 4 (1.0) |
| Common clinical path | |
| (1) Yes | 175 (42.1) |
| (2) No | 153 (36.8) |
| (3) Don't know | 88 (21.2) |
| Frequencies of involvement in discharge planning | |
| Not at all | 20 (4.8) |
| Once every 6 months | 21 (5.1) |
| Once every 2 or 3 months | 90 (21.6) |
| Once a month | 101 (24.3) |
| At least twice a month | 184 (44.2) |
Note: No data is missing.
Abbreviation: SD, standard deviation.
A nurse who, despite holding a management position, provides patient care and is in charge of discharge planning.
Table 2 shows the results concerning the main variables. Two hundred and fourteen participants (51.4%) had other‐facility experience, and 109 (26.2%) had interacted with the host staff receiving discharged patients at least twice a month in the past year. The correlation coefficient between perspective‐taking and collaborative practice in discharge planning was 0.53 (p < 0.001). According to Harman's single‐factor test, the contribution of the first factor was 23.6%.
TABLE 2.
Descriptive statistics of variables included in the SEM model (n = 416).
| Mean (SD) | |
|---|---|
| Perspective‐taking (α = 0.89) | 7.21 (1.16) |
| Collaborative practice in discharge planning (α = 0.91) | 33.87 (6.39) |
| n (%) | |
|---|---|
| Other facility experience | |
| Yes | 214 (51.4) |
| No | 202 (48.6) |
| Interaction opportunity | |
| Not at all | 91 (21.9) |
| Once every 6 months | 64 (15.4) |
| Once every 3 months | 74 (17.8) |
| Once a month | 78 (18.8) |
| At least twice a month | 109 (26.2) |
Note: No data is missing.
Abbreviations: α, Cronbach's α; SD, standard deviation.
The relationship between demographic data, perspective‐taking, and “collaborative practice in discharge planning between healthcare facilities” is reported in Appendix S1.
3.2. Model Testing
Table 3 shows parameters about path in two models. The results of the verification of Model 1 by structural equation modeling are presented in Figure 3. All paths were significant (other‐facility experience → perspective‐taking: β = 0.12, p = 0.028, interaction opportunity → perspective‐taking: β = 0.22, p < 0.001, perspective‐taking → collaborative practice: β = 0.66, p < 0.001). The model's goodness of fit values were 0.93 for CFI, 0.07 for RMSEA, 0.05 for SRMR, and 557.72 for the AIC.
TABLE 3.
Coefficient for each model (n = 416).
| Model 1 | Model 2 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| β | B | SE | Test statistic | p | β | B | SE | Test statistic | p | |
| Perspective‐taking ← Other facility experience | 0.12 | 0.10 | 0.05 | 2.20 | 0.028 | 0.14 | 0.12 | 0.05 | 2.41 | 0.016 |
| Perspective‐taking ← Interaction opportunity | 0.22 | 0.06 | 0.02 | 3.73 | < 0.001 | 0.20 | 0.05 | 0.02 | 3.28 | 0.001 |
| Collaborative practice ← perspective‐taking | 0.66 | 0.93 | 0.12 | 7.72 | < 0.001 | 0.65 | 0.92 | 0.12 | 7.50 | < 0.001 |
| Collaborative practice ← Other facility experience | −0.05 | −0.06 | 0.06 | −1.08 | 0.281 | |||||
| Collaborative practice ← Interaction opportunity | 0.06 | 0.02 | 0.02 | 1.33 | 0.183 | |||||
| Model 3 | Model 4 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| β | B | SE | Test statistic | p | β | B | SE | Test statistic | p | |
| Perspective‐taking ← Other facility experience | 0.11 | 0.10 | 0.05 | 2.05 | 0.041 | 0.13 | 0.11 | 0.05 | 2.30 | 0.022 |
| Perspective‐taking ← Interaction opportunity | 0.23 | 0.06 | 0.02 | 4.01 | < 0.000 | 0.23 | 0.06 | 0.02 | 3.85 | < 0.000 |
| Collaborative practice ← perspective‐taking | 0.66 | 0.92 | 0.12 | 7.74 | < 0.000 | 0.66 | 0.94 | 0.13 | 7.53 | < 0.000 |
| Collaborative practice ← Other facility experience | −0.06 | −0.07 | 0.05 | −1.24 | 0.216 | |||||
| Collaborative practice ← Interaction opportunity | 0.01 | 0.00 | 0.02 | 0.13 | 0.900 | |||||
| Perspective‐taking ← Common clinical path | 0.08 | 0.07 | 0.05 | 1.46 | 0.144 | 0.08 | 0.07 | 0.05 | 1.48 | 0.139 |
| Perspective‐taking ← Workshop on discharge planning | 0.12 | 0.10 | 0.05 | 2.02 | 0.034 | 0.12 | 0.10 | 0.05 | 2.09 | 0.037 |
| Perspective‐taking ←Frequencies of involvement in discharge planning | −0.10 | −0.04 | 0.02 | −1.85 | 0.065 | −0.10 | −0.04 | 0.02 | −1.83 | 0.068 |
| Collaborative practice ← Common clinical path | −0.02 | −.03 | 0.05 | −0.50 | 0.615 | −0.03 | −0.03 | 0.05 | −0.60 | 0.551 |
| Collaborative practice ← Workshop on discharge planning | 0.03 | 0.03 | 0.06 | 0.54 | 0.587 | 0.03 | 0.04 | 0.06 | 0.66 | 0.512 |
| Collaborative practice ←Frequencies of involvement in discharge planning | 0.13 | 0.07 | 0.02 | 2.85 | 0.004 | 0.13 | 0.07 | 0.02 | 2.78 | 0.005 |
Note: The standard error, test statistic, and p‐value are based on the standardized estimates.
Abbreviation: SE, standard error.
FIGURE 3.
Evaluation of the process model using structural equation modeling. Errors have been omitted. The coefficients have been standardized.
Second, when Model 2 was tested, the path coefficients from antecedent factors to the dependent variable were not significant (other‐facility experience → collaborative practice: β = −0.05, p = 0.281, interaction opportunity → collaborative practice: β = 0.06, p = 0.183, CFI: 0.93, RMSEA: 0.07, SRMR: 0.05, and AIC: 558.50) (Figure 4). In Model 3, with the covariates included, all paths in the process model were significant (CFI = 0.91, RMSEA = 0.07, SRMR = 0.06, and AIC = 724.81). In Model 4, the direct path from boundary‐crossing to collaborative practice was not significant (other‐facility experience → collaborative practice: β = −0.06, p = 0.216, interaction opportunity → collaborative practice: β = 0.01, p = 0.900, CFI = 0.91, RMSEA = 0.07, SRMR = 0.05, and AIC = 727.25). The diagrams of Models 3 and 4 are shown in Appendices S2 and S3, respectively.
FIGURE 4.
Evaluation of the direct path model using structural equation modeling. Errors have been omitted. The coefficients have been standardized. The dashed arrow indicates non‐significant results.
Table 4 presents the goodness‐of‐fit measures for each model. A chi‐square difference test revealed no significant difference between model 1 and model 2 (χ 2 = 3.21, df = 2, p = 0.201).
TABLE 4.
Goodness of fit for each model (n = 416).
| χ 2 | df | p | CFI | RMSEA | SRMR | AIC | χ 2 difference test | ||
|---|---|---|---|---|---|---|---|---|---|
| With model 1 | With model 3 | ||||||||
| Model 1 | 471.716 | 167 | 0.000 | 0.93 | 0.07 | 0.05 | 557.72 | ||
| Model 2 | 468.502 | 165 | 0.000 | 0.93 | 0.07 | 0.05 | 558.50 | p = 0.200 | |
| Model 3 | 620.811 | 224 | 0.000 | 0.91 | 0.07 | 0.06 | 724.81 | ||
| Model 4 | 619.248 | 222 | 0.000 | 0.91 | 0.07 | 0.05 | 727.25 | p = 0.458 | |
Note: Goodness of fit: CFI ≧ 0.90, RMSEA < 0.10, SRMR < 0.08.
Table 5 presents the results of the indirect effects of each model. In all models, “other‐facility experience → perspective‐taking → collaborative practice” and “interaction opportunity → perspective‐taking→ collaborative practice” had a significant indirect effect.
TABLE 5.
Indirect effects of each model (n = 416).
| Bootstrapping bias‐corrected 95% CI | |||||||
|---|---|---|---|---|---|---|---|
| B | SE | Z | p | Lower | Upper | ||
| Model 1 | Other facility experience → Perspective‐taking →Collaborative practice | 0.10 | 0.04 | 2.18 | 0.032 | 0.008 | 0.183 |
| Interaction opportunity → Perspective‐taking→Collaborative practice | 0.06 | 0.02 | 3.73 | 0.001 | 0.025 | 0.085 | |
| Model 2 | Other facility experience → Perspective‐taking →Collaborative practice | 0.11 | 0.05 | 2.30 | 0.025 | 0.017 | 0.200 |
| Interaction opportunity → Perspective‐taking→Collaborative practice | 0.05 | 0.02 | 3.33 | 0.001 | 0.020 | 0.078 | |
| Model 3 | Other facility experience → Perspective‐taking →Collaborative practice | 0.09 | 0.04 | 2.00 | 0.040 | 0.003 | 0.177 |
| Interaction opportunity → Perspective‐taking →Collaborative practice | 0.06 | 0.02 | 3.70 | 0.001 | 0.028 | 0.090 | |
| Model 4 | Other facility experience → Perspective‐taking →Collaborative practice | 0.10 | 0.05 | 2.15 | 0.024 | 0.013 | 0.201 |
| Interaction opportunity → Perspective‐taking →Collaborative practice | 0.06 | 0.02 | 3.48 | 0.001 | 0.026 | 0.092 | |
Note: Bootstrap sample size = 2000.
Abbreviations: CI, confidence interval; SE, standard error.
As a supplementary analysis, we estimated Model 2 without perspective‐taking to examine the direct associations between the two boundary‐crossing variables and collaborative practice. The paths from other‐facility experience to collaborative practice were not significant (β = 0.04, p = 0.413), whereas the paths from the interaction opportunity to collaborative practice were significant (β = 0.19, p < 0.01).
4. Discussion
This study found that boundary‐crossing experiences were associated with perspective‐taking, and perspective‐taking was associated with collaborative practice in discharge planning between healthcare facilities. These results suggest that boundary‐crossing experiences alone may not be sufficient to be positively associated with collaborative practice in discharge planning; they may need to operate through cognitive factors such as perspective‐taking. Although causal mechanisms cannot be inferred from this cross‐sectional study, the findings support associations consistent with the proposed theoretical model based on social cognitive theory, which posits that environmental, cognitive, and behavioral factors influence each other (Bandura 1986).
4.1. Model Evaluation
Model 1 was deemed to be generally good based on indicators (Bentler and Bonett 1980; Browne and Cudeck 1992; Hair et al. 2009; Hu and Bentler 1998). The direct path from boundary‐crossing experiences to collaborative practice in discharge planning between healthcare facilities was not significant, and the AIC value was worse than that of the process model, although the chi‐square difference test revealed no significant differences between the two models. Even after adjusting for the covariates, the AIC and chi‐square difference test results for the process and direct path models did not change. Therefore, although Model 1 was not statistically superior to Model 2, the findings were consistent with the proposed process model.
4.2. Importance of Perspective‐Taking in Discharge Planning
This study demonstrated that perspective‐taking plays a central role in supporting collaborative practice in discharge planning between healthcare facilities. Previous research has shown that perspective‐taking improves group performance and promotes supportive behaviors for those targeted, although these studies did not focus on nurses (Beersma et al. 2018; Grant and Berry 2011; He et al. 2018; Hoever et al. 2012; Longmire and Harrison 2018). In addition, a previous study examined perspective‐taking within process‐oriented frameworks, suggesting its role as a cognitive mechanism that triggers behavioral outcomes (Li and Liao 2017). Our findings extend this literature by showing that, when nurses take the perspective of the receiving staff, they are able to envision the discharge planning practices required to enable optimal care at the next facility. This suggests that perspective‐taking may contribute to collaborative practice across institutional boundaries, highlighting the importance of considering the situation of not only the patients but also the receiving staff when implementing discharge planning. In Models 1–4, perspective‐taking showed the standardized path coefficients of 0.65 ~0.66 for collaborative practice. This suggests that perspective‐taking may help ward nurses anticipate the information and preparations required by receiving facility staff and incorporate these into discharge planning. Although patient outcomes were not measured in this study, such practices may facilitate continuity of care across healthcare facilities by improving the quality of information transfer and supporting the preparedness of receiving facilities, which could ultimately contribute to better patient and family outcomes after discharge.
Both other‐facility experience and interaction opportunities were significantly associated with perspective‐taking, although the standardized path coefficients were small across all models. Furthermore, the effect of perspective‐taking on the relationship between boundary‐crossing experiences and collaborative practice across all models was relatively modest. This suggests that perspective‐taking may represent only one of several mechanisms linking boundary‐crossing experiences to collaborative practice. Prior research has reported that working in different organizations is positively associated with knowledge sharing and mutual understanding (Blayden et al. 2017; Gerrish and Piercy 2014), and that frequent contact was positively associated with the likelihood of taking another's perspective (Parker and Axtell 2001). A review suggested that boundary‐crossing interactions stimulate perspective‐taking (Akkerman and Bakker 2011). Exposure to diverse care environments through work at other healthcare facilities or interaction with external professionals may increase nurses' awareness of practices in other institutions and thereby foster perspective‐taking. The relatively small standardized path coefficients indicate that boundary‐crossing experiences alone may explain only a limited proportion of the variance in perspective‐taking. Other factors, including individual cognitive characteristics, organizational climate, opportunities for reflection, and relationships with colleagues, may also contribute to nurses' perspective‐taking. Furthermore, at the time of the survey, no established scale was available for measuring nurses' boundary‐crossing experiences in this context. Therefore, boundary‐crossing experiences were measured in a simplified manner based on previous studies (Jenkins and Anstey 2017; Miyamoto et al. 2019). Consequently, boundary‐crossing experiences were measured in a simplified manner, and variables such as duration, destination attributes, and the quality of exchanges were not assessed. This suggests that the measurement items may only partially capture the constructs of boundary‐crossing experiences. Therefore, their association with the other variables may have only been partially captured. Future research should develop a scale that can comprehensively measure boundary‐crossing experiences in order to clarify the mechanisms between these concepts.
Importantly, neither boundary‐crossing experiences were directly associated with collaborative practice in discharge planning between healthcare facilities (β = 0.06, p = 0.183) (Model 2). However, in the supplementary analysis, the interaction opportunity showed a significant direct association with collaborative practice (β = 0.19, p < 0.01), whereas other‐facility experience did not. The attenuation of the coefficient suggests that the association between interaction opportunity and collaborative practice was largely accounted for by perspective‐taking. A possible explanation is that ongoing interactions facilitate relationship‐building and mutual understanding, which have been identified as important components of interfacility collaboration (Karam et al. 2018). Frequent interactions may also help nurses update their knowledge of other facilities and actively engage with the community and networks. In contrast, other‐facility experience represents an individual's past experience and may not directly translate into current collaborative practices. Previous studies suggest that boundary‐crossing facilitates perspective‐taking through critical reflection (Akkerman and Bakker 2011), and self‐reflection has been identified as a prerequisite for taking alternative perspectives (Gerace et al. 2017). Therefore, our results emphasize that mere exposure to different environments is not sufficient; how nurses interpret and reflect on these experiences is critical. Future research should examine the cognitive changes triggered by boundary‐crossing experiences and determine how these changes influence collaborative practice.
4.3. Limitations
This study had several limitations. First, it was conducted among acute care nurses in Japan. Of 200 randomly selected facilities, 45 agreed to participate. Hospitals with a strong focus on discharge planning may have been more likely to participate in the survey. However, differences in the characteristics of participating and non‐participating facilities, particularly regarding discharge planning efforts, were not examined. Furthermore, because nurses were nested within hospitals, potential clustering effects cannot be completely excluded. Future research will need to examine group‐level effects by implementing multilevel structural equation modeling. In addition, this study was conducted concurrently with the development of the WPSD Scale; participants may have a relatively high interest in discharge planning and may have already engaged in discharge planning with perspective‐taking, introducing potential selection bias. Also, all variables were collected via self‐report at a single time point, which increases the possibility of common method bias.
Second, the relationships between the study variables and patient outcomes have not yet been verified. Although the ultimate goal of discharge planning is to improve patient outcomes, we did not assess patient‐related outcomes. Future research should examine whether perspective‐taking is associated with patient outcomes.
Third, although this study supports an association consistent with the theoretical perspectives of the social cognitive theory (Bandura 1986), the cross‐sectional design does not allow causal mechanisms to be verified, and the possibility of reverse causality cannot be ruled out. For example, nurses with higher perspective‐taking may actively seek more external interaction opportunities. Furthermore, unmeasured confounding factors may have influenced the observed associations.
4.4. Implications for Future Study
This study highlights the significance of perspective‐taking in discharge planning. Moreover, boundary‐crossing experiences were positively associated with perspective‐taking. However, this study is based on a theoretical framework, and its causal relationship has not been identified. Future research should refine the conceptual model by incorporating additional dimensions of boundary‐crossing, such as the duration, destination attributes, and quality of exchanges, and examine the causal relationship among boundary‐crossing experiences, perspective‐taking, and collaborative practice using longitudinal observational study designs.
5. Conclusions
We examined whether the associations among ward nurses' work experiences in other facilities, opportunities to interact with staff in receiving facilities, perspective‐taking, and discharge planning practices were consistent with a theoretically derived process model. The findings indicated that perspective‐taking toward staff receiving discharged patients was positively associated with discharge planning practices. Creating opportunities for ward nurses to gain exposure to other healthcare facilities and interact with receiving facilities staff may represent potential approaches for fostering perspective‐taking. Future longitudinal or intervention evaluations are needed to determine whether such approaches improve discharge planning practice.
Author Contributions
Shingo Tanaka performed the conceptualization, formal analysis, investigation, data curation, writing – original draft, and project administration. All authors contributed to the methodology. Masatoshi Saiki and Yukie Takemura critically reviewed and edited the manuscript. Yukie Takemura supervised the whole study process. All authors read and approved the final manuscript.
Funding
This work was supported by the Graduate Program for Social ICT Global Creative Leaders (GCL) of The University of Tokyo.
Ethics Statement
The study protocol was examined and approved by The University of Tokyo, Clinical Research Review Board (No. 2021137NI).
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Appendix S1: Demographic data about perspective‐taking and Collaborative practice.
Appendix S2: Model 3 (Evaluation of the Process Model with covariates). Errors have been omitted. The coefficients have been standardized. The dashed arrow indicates non‐significant.
Appendix S3: Model 4 (Evaluation of the Direct Path Model with covariates). Errors have been omitted. The coefficients have been standardized. The dashed arrow indicates non‐significant.
Appendix S4: STROBE Statement—checklist of items that should be included in reports of observational studies.
Acknowledgments
This research was supported by the Graduate Program for Social ICT Global Creative Leaders (GCL) of The University of Tokyo by the Ministry of Education, Culture, Sports, Science and Technology (MEXT), Japan. We would like to thank all those who cooperated with us in our survey, even in the midst of the terrible COVID‐19 disaster.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1: Demographic data about perspective‐taking and Collaborative practice.
Appendix S2: Model 3 (Evaluation of the Process Model with covariates). Errors have been omitted. The coefficients have been standardized. The dashed arrow indicates non‐significant.
Appendix S3: Model 4 (Evaluation of the Direct Path Model with covariates). Errors have been omitted. The coefficients have been standardized. The dashed arrow indicates non‐significant.
Appendix S4: STROBE Statement—checklist of items that should be included in reports of observational studies.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.