Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review
Laksmi, I. A. A.; Pandin, M. G. R.; Sukartini, T.
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BackgroundHeart failure (HF) is a leading cause of morbidity, mortality, and hospital readmissions worldwide, creating significant clinical, psychological, and financial burdens. Despite advances in treatment, frequent rehospitalizations and poor psychosocial outcomes remain pressing challenges, partly due to inadequate discharge planning and transitional care. ObjectiveThis literature review aimed to examine the effectiveness of discharge planning--particularly nurse-led interventions--on psychological outcomes and hospital readmissions among patients with HF, drawing on studies published between 2020 and 2025. MethodGuided by the PRISMA framework, a systematic search was conducted in Scopus, ProQuest, EBSCOHost, and Web of Science. Eligible studies included adult HF patients, assessed discharge planning or nurse-led interventions, and reported outcomes related to readmissions, psychological status, self-care, or quality of life. Ten studies met the inclusion criteria, encompassing quasi-experimental, cross-sectional, pilot study, and randomized controlled trial designs ResultsAcross the reviewed studies, structured and individualized discharge planning was consistently associated with improved self-care behaviors, disease knowledge, treatment adherence, and psychological well-being. Nurse-led education, particularly when delivered through methods such as teach-back, demonstrated significant reductions in anxiety, depression, and caregiver dependency. Several interventions also reported reduced 30-day readmission rates and cost savings, though findings on rehospitalization were mixed due to variations in intervention design, follow-up duration, and health system. ConclusionEvidence supports discharge planning, especially nurse-led and patient-cantered approaches as an effective strategy to improve self-care, enhance psychological outcomes, and reduce rehospitalizations in HF patients. Future research should prioritize multi-center randomized controlled studies, longer follow-up periods, and integration of digital health tools to strengthen transitional care and sustain improvements over time.
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