Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review

Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review View ORCID Profile Ida Ayu Agung Laksmi , View ORCID Profile Moses Glorino Rumambo Pandin , View ORCID Profile Tintin Sukartini doi: https://doi.org/10.1101/2025.09.17.25335454 Ida Ayu Agung Laksmi 1 Doctoral of Nursing Student, The Faculty of Nursing, Airlangga University Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ida Ayu Agung Laksmi For correspondence: agunglaksmi41{at}gmail.com Moses Glorino Rumambo Pandin 2 Faculty of Humanities, Airlangga University Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Moses Glorino Rumambo Pandin Tintin Sukartini 3 Faculty of Nursing, Airlangga University Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Tintin Sukartini Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Background Heart 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. Objective This 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. Method Guided 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 Results Across 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. Conclusion Evidence 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. INTRODUCTION Heart failure (HF) is one of the most prevalent cardiovascular diseases worldwide, associated with high mortality and morbidity rates and considerable financial burden, particularly among older adults ( Zdanowicz 2002 ; Prihatiningsih & Sudyasih 2018 ; Saelan, Dzurriyatun Toyyibah 2021 ). he growing number of patients, frequent hospital readmissions, and rising disability and mortality rates have made HF a major concern in cardiology ( Saelan, Dzurriyatun Toyyibah 2021 ). According to the American Heart Association (AHA, 2019), approximately 15 million people worldwide experience HF symptoms, and this number is projected to increase to 23.6 million by 2030 ( Zdanowicz 2002 ). Despite advances in pharmacological and device-based therapies, hospital readmission remains a major challenge in HF management, with nearly one in four patients rehospitalized within 30 days of discharge ( Kinugasa et al. 2024 ; Averbuch et al. 2025 ) . The one-year mortality rate among HF patients in the United States has been reported at 37.5%, with a hospitalization rate of 30.9% (Koikai & Khan 203). These recurrent admissions not only escalate healthcare costs but also compromise patients’ quality of life and psychological well-being ( Puspitawati & Widani 2024 ). The transition from hospital to home represents a critical period of vulnerability, as patients must adapt to complex treatment regimens, monitor symptoms, and adhere to lifestyle modifications. However, many patients lack the necessary knowledge, skills, or confidence to effectively manage their condition post-discharge. Inadequate discharge planning and poor continuity of care therefore contribute substantially to preventable readmissions and poorer health outcomes ( Dhaliwal & Dang 2025 ). Structured discharge planning has emerged as a cornerstone of transitional care. When delivered in a comprehensive, individualized, and nurse-led manner, discharge planning has been shown to improve self-care behaviors, strengthen treatment adherence, and enhance psychosocial outcomes, including reductions in anxiety and depression ( Gonçalves-Bradley et al. 2022 ; Faessler et al. 2023 ). Interventions such as patient education, self-management support, and follow-up care have demonstrated potential in addressing not only clinical but also psychosocial aspects of HF management ( Chew et al. 2021 ; Hany & Vatmasari 2023 ; Suharsono et al. 2024 ). Nevertheless, the effectiveness of these strategies varies across settings and populations, highlighting the need to synthesize recent evidence. Therefore, the problem emergence is that hospital readmissions and psychological distress continue to be major challenges in heart failure care, largely due to inadequate discharge planning and insufficient transitional care, despite advances in available therapies. This literature review aims to examine the effectiveness of discharge planning on psychological outcomes and hospital readmissions among patients with heart failure, focusing on studies published between 2020 and 2025. METHOD This study employed a literature review approach to examine the components that support discharge planning in facilitating the transition of care among patients with heart failure. Guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, a systematic search was conducted across Scopus, ProQuest, EBSCOHost, and Web of Science to identify relevant studies published between 2020 and 2025. The search strategy applied a combination of keywords and Medical Subject Headings (MeSH), including “heart failure,” “discharge planning,” “nurse-led intervention,” “self-care,” “patient education,” and “readmission,” with Boolean operators (AND, OR) used to refine the results. Reference lists of selected articles were also manually screened to capture additional eligible studies. Studies were included if they focused on adult patients diagnosed with heart failure, examined the impact of discharge planning or nurse-led interventions on clinical, psychosocial, or behavioral outcomes, and reported at least one measurable outcome such as readmission rates, quality of life, psychological status, self-care, or healthcare utilization. Only studies published in English within the specified period were considered. Exclusion criteria included editorials, reviews, conference abstracts, case reports, studies lacking primary data, and interventions not directly related to discharge planning or transitional care. All search results were imported into Mendeley for reference management, and duplicates were removed. Titles and abstracts were independently screened by two reviewers, with full-texts of potentially relevant articles retrieved and assessed for eligibility. Disagreements during the selection process were resolved by consensus. Data extraction was carried out using a standardized form that captured key information including author(s), year of publication, study design and setting, sample size and characteristics, type of intervention, outcome measures, and major findings. RESULT A total of 1,341 records were identified from Scopus (n=241), ProQuest (n=624), EBSCOHost (n=92), and Web of Science (n=384). After duplicate removal, 577 articles remained. Following title and abstract screening, 121 were assessed, of which 32 underwent full-text evaluation. Finally, 10 studies met the inclusion criteria and were included in this review. The PRISMA flow diagram summarizing the screening process is presented in Figure 1 . Download figure Open in new tab Fig 1. PRISMA Flow-chart The 10 studies comprised a mix of randomized controlled trials (RCTs), quasi-experimental designs, cross-sectional analyses, pilot studies, and quality improvement projects, conducted in diverse settings across the United States, Pakistan, Iran, Poland, Taiwan, Hong Kong, Bosnia and Herzegovina, and other regions. Sample sizes ranged from 20 to 1,584 patients. Interventions varied from structured discharge education, nurse-led self-care programs, and teach-back methods, to transitional care models involving follow-up via telephone or digital platforms. View this table: View inline View popup Download powerpoint Table 1. Result of Article Analysis DISCUSSION This literature consists of 10 articles exploring the effect of nurse led education or discharge -planning in heart failure patients. Based on the analysis of 10 journals, the study used a quantitative method with a quasy experimental, cross-sectional stud, A pilot study methods which examines the use of discharge planning in preparing patient care in hospitals. Data collection was done through observation and medical records. The sample in this study were heart failure patients, who returned to hospital care. To assess compliance in the treatment of discharge planning that has been given by nurses, the distribution of samples came from several countries including the United States, Pakistan, Iran, Poland, Taiwan, Hong Kong, Bosnia and Herzegovina, and other regions. Effective discharge planning has consistently been shown to play a pivotal role in optimizing outcomes for patients with heart failure (HF). Across diverse settings and methodologies, the reviewed studies emphasize the importance of structured, nurse-led, and patient-centered interventions in reducing readmissions, improving self-care, and enhancing quality of life. Several studies underscore the central role of discharge education in fostering effective self-management. For example, Iqbal et al. (2020) demonstrated that nurse-delivered discharge instructions significantly improved patients’ awareness, medication adherence, and disease management competencies. Similarly, Oh et al. (2023) confirmed the effectiveness of the teach-back method, showing significant improvements in self-care maintenance, symptom perception, self-care management, and self-care efficacy. These findings are consistent with Kolasa et al. (2021) , who reported that a nurse-led educational program improved disease knowledge and self-care behaviors over a three-month period, and with Vijaya Kumari et al. (2025) , who observed notable reductions in 30-day readmissions and improvements in self-care adherence following standardized nurse-led education. Taken together, these results highlight patient education as a cornerstone of successful discharge interventions. Beyond educational strategies, several studies examined the psychological and behavioral impacts of discharge planning. Hosseini et al. (2023) found that self-management-based discharge planning significantly reduced anxiety and depression, while a newly developed transition care program improved self-efficacy and self-care behaviors after one month. These results suggest that discharge interventions have benefits that extend beyond physical outcomes, enhancing psychological well-being and patients’ confidence in managing their illness. The integration of psychosocial support into discharge planning may therefore be essential for long-term success. The influence of discharge interventions on readmissions and healthcare utilization has been another focal point of research. Abouzid and Siddiqi (2024) highlighted that effective discharge planning reduced readmissions for acute exacerbation of chronic heart failure regardless of age or gender, while Weeks, Kile, and Garber (2020) reported a reduction in heart failure readmissions during the implementation of a nurse discharge navigator, accompanied by substantial cost savings. Similarly, Dizdarevic-Hudic et al. (2025) demonstrated that none of the patients receiving structured nurse-led education were rehospitalized, in contrast to a 34% rehospitalization rate in the control group. However, not all findings were consistent; Hosseini et al. (2023) did not observe significant differences in readmission frequency or duration, suggesting that while educational and psychosocial interventions improve patient-reported outcomes, broader systemic factors may influence rehospitalization rates. Overall, these studies converge on the conclusion that structured, nurse-led discharge planning is an effective strategy to improve patient outcomes in heart failure. Interventions focusing on education, psychosocial support, and transitional care enhance self-care behaviors, reduce psychological distress, and lower hospital utilization. Nonetheless, gaps remain. Many studies relied on quasi-experimental or small-scale designs, limiting generalizability. The heterogeneity of interventions and follow-up periods also complicates comparisons. Future research should prioritize large-scale randomized controlled trials, explore the integration of digital health and telemonitoring, and investigate strategies to sustain improvements over longer periods. Implication The findings carry important implications for both clinical practice and future research. From a clinical perspective, the consistent improvements in self-care, knowledge, and psychological outcomes indicate that discharge planning should be integrated as a core nursing responsibility in the management of heart failure patients. Structured education, particularly using evidence-based methods such as teach-back, should be standardized as part of discharge protocols. Moreover, interventions that extend support beyond hospitalization—such as telephone follow-up or transition care programs, appear to enhance sustainability and may reduce readmissions more effectively than single-session approaches. From a health systems perspective, the demonstrated reductions in readmission rates and cost savings ( Weeks et al., 2020 ; Vijaya Kumari et al., 2025 ) highlight the economic value of investing in nurse-led discharge programs. Policy makers and hospital administrators should consider scaling these interventions to reduce healthcare utilization and financial burden. For future research, large-scale, multi-center randomized controlled trials with standardized outcome measures are needed to validate the effectiveness of specific components of discharge interventions. Longer follow-up periods would also help determine whether improvements in self-care and psychological well-being translate into sustained reductions in rehospitalization. Additionally, integrating digital health tools, such as telemonitoring and mobile applications, may further strengthen patient engagement and continuity of care, especially for older populations who face challenges with traditional self-management. Limitation First, heterogeneity in interventions including educational content, delivery methods, and follow-up duration—complicates direct comparisons and synthesis across studies. For instance, while some interventions incorporated ongoing telephonic follow-up ( Hosseini et al., 2023 ; Iqbal et al., 2020 ), others were limited to a single structured educational session ( Oh et al., 2023 ; Vijaya Kumari et al., 2025 ). Second, outcome measures were not standardized, ranging from self-care behaviors and psychosocial indicators to readmission rates and cost savings. This variability makes it difficult to establish consensus on the most effective intervention components. Third, most studies were conducted within single institutions or community hospitals, raising questions about scalability and applicability across different health care systems, especially in low-resource settings. Finally, this review did not include a meta-analysis, which limits the ability to quantify pooled effect sizes and establish stronger causal inferences. CONCLUSION This review provides robust evidence that structured and nurse-led discharge planning significantly improves outcomes for patients with heart failure. Interventions consistently enhanced self-care behaviors, disease knowledge, treatment adherence, and psychological well-being, including reductions in anxiety and depression. Several studies also demonstrated reductions in 30-day readmission rates and healthcare costs, although findings were not uniformly consistent due to heterogeneity in study design and healthcare settings. Overall, nurse-led, patient-centered discharge planning represents an effective and cost-efficient strategy to optimize transitional care for HF patients. By addressing both clinical and psychosocial needs, these interventions offer a comprehensive approach that extends beyond hospitalization and into sustained self-management. Data Availability All data produced in the present study are available upon reasonable request to the authors Funding Source This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest Declaration The authors declare no conflict of interest related to this study. REFERENCE ↵ Abouzid , M.R. & Siddiqi , M. , 2024 , ‘Discharge planning and resource utilization for minimizing readmissions in acute exacerbation of chronic heart failure: Insights from an observational study in a community hospital’ , Current Problems in Cardiology , 49 ( 2 ). ↵ Averbuch , T. , Zafari , A. , Islam , S. , Lee , S.F. , Sankaranarayanan , R. , Greene , S.J. , Mamas , M.A. , Pandey , A. & Spall, H.G.C. Van , 2025 , ‘Comparative performance of risk prediction indices for mortality or readmission following heart failure hospitalization’ , ESC Heart Failure , 12 ( 2 ), 1227 – 1236 . OpenUrl PubMed ↵ Chew , H.S.J. , Sim , K.L.D. , Choi , K.C. & Chair , S.Y. , 2021 , ‘Effectiveness of a nurse-led temporal self-regulation theory-based program on heart failure self-care: A randomized controlled trial’ , International Journal of Nursing Studies , 115 . ↵ Dhaliwal , J.S. & Dang , A.K. , 2025 , ‘Reducing Hospital Readmissions’ , NCBI Bookshelf. A service of the National Library of Medicine., National Institutes of Health . ↵ Dizdarevic-Hudic , L. , Halilovic , E. , Brkic , S. , Loncar , D. , Jahic , N.A. , Hudic , I. , Ibralic , A.M. & Suljic , Z. , 2025 , ‘The Impact of Patient Education on Rehospitalization Rate and Quality of Life in Heart Failure Patients’ , International Journal of the Cardiovascular Academy , 11 ( 1 ), 6 – 14 . OpenUrl ↵ Faessler , L. , Kofler , S. , Wenke-Zobler , J. , Brunner , C. , Schäfer-Keller , P. , De Geest , S. , Schubert , M. , Regez , K. , Schuetz , P. , Mueller , B. & Conca , A. , 2023 , ‘The use of nurse-led care intervention to improve self-care abilities subsequently decreasing readmission in multimorbid hospitalized patients: A quasi-experimental study in a real-world setting’ , Nursing Open , 10 ( 6 ), 3787 – 3798 . OpenUrl PubMed ↵ Gonçalves-Bradley , D.C. , Lannin , N.A. , Clemson , L. , Cameron , I.D. & Shepperd , S. , 2022 , ‘Discharge planning from hospital’ , Cochrane Database of Systematic Reviews , 2022 ( 2 ). ↵ Hany , A. & Vatmasari , R.A. , 2023 , The effectiveness of self-care management in treating heart failure: A scoping review , Healthcare in Low-Resource Settings , 11 ( S1 ). ↵ Hosseini , R. , Mofrad , Z.P. , Ayubi , E. & Najafi , F. , 2023 , ‘The Effect of Self-management-based Discharge Planning on Anxiety, Depression, and Re-admission in Patients with Chronic Heart Failure’ , Evidence Based Care Journal , 13 ( 2 ), 46 – 54 . OpenUrl Huang , Z. & Chair , S.Y. , 2025 , ‘Development and pilot testing of a nurse-led common-sense model of self-regulation-based heart failure self-care program’ , BMC Nursing , 24 ( 1 ). ↵ Iqbal , Z. , Parveen , M. , Azhar , M. , Parveen , M. , Afzal , M. , Awan , M.F. & Ali , A. , 2020 , ‘Effect of nursing led discharge instructions on improvement of post discharge care management in heart failure patients at tertiary care hospital of Karachi, Pakistan’ , Journal of the Pakistan Medical Association , 70 ( 8 ), 1324 – 1328 . OpenUrl PubMed ↵ Kinugasa , Y. , Nakamura , K. , Hirai , M. , Manba , M. , Ishiga , N. , Sota , T. , Nakayama , N. , Ohta , T. , Kato , M. , Adachi , T. , Fukuki , M. , Hirota , Y. , Mizuta , E. , Mura , E. , Nozaka , Y. , Omodani , H. , Tanaka , H. , Tanaka , Y. , Watanabe , I. , Mikami , M. & Yamamoto , K. , 2024 , ‘Association of a Transitional Heart Failure Management Program With Readmission and End-of-Life Care in Rural Japan’ , Circulation Reports , 6 ( 5 ), 168 – 177 . OpenUrl PubMed Koikai , J. & Khan , Z. , 2023 , ‘The Effectiveness of Self-Management Strategies in Patients With Heart Failure: A Narrative Review’ , Cureus , 15 ( 7 ). ↵ Kolasa , J. , Fraczek-Jucha , M. , Grabowski , M. , Jankowska , E.A. , Lelonek , M. , Pawlak , A. , Uchmanowicz , I. & Nessler , J. , 2021 , ‘A quasi-experimental study examining a nurse-led educational program to improve disease knowledge and self-care for patients with acute decompensated heart failure with reduced ejection fraction’ , ADVANCES IN CLINICAL AND EXPERIMENTAL MEDICINE . ↵ Oh , E.G. , Lee , J.Y. , Lee , H.J. & Oh , S. , 2023 , ‘Effects of discharge education using teach-back methods in patients with heart failure: A randomized controlled trial’ , INTERNATIONAL JOURNAL OF NURSING STUDIES , 140 . ↵ Prihatiningsih , D. & Sudyasih , T. , 2018 , ‘Perawatan Diri Pada Pasien Gagal Jantung’ , Jurnal Pendidikan Keperawatan Indonesia , 4 ( 2 ). ↵ Puspitawati , T.L. & Widani , N.L. , 2024 , ‘An Effectiveness of Self-Management Education Through Self-Care and Quality of Life Resulting in Decreasing Readmission in Patients with Heart Failure: Based on Nursing Intervension: Systematic Review’ , Media Publikasi Promosi Kesehatan Indonesia , 7 ( 10 ), 2430 – 2449 . OpenUrl ↵ Saelan Dzurriyatun Toyyibah , G.S.A. , 2021 , ‘Gambaran perilaku perawatan diri pada pasien gagal jantung’ , Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta , 43 – 49 . ↵ Suharsono , T. , Ulya , I. , Yona , S. & Siswanto , B.B. , 2024 , ‘Initiation of self-care practices in heart failure patients: a phenomenological study’ , Jurnal Ners , 19 ( 2 ), 222 – 230 . OpenUrl ↵ Vijaya Kumari , Sreeramula , Nagaraju , Guntha C. & Darotiya , S. , 2025 , ‘Reducing Hospital Readmissions for Heart Failure Patients: A Quality Improvement Project Using Nurse-Led Education’ , International Journal of Research and Review , 12 ( 8 ), 476 – 481 . OpenUrl ↵ Weeks , K. , Kile , D. & Garber , J. , 2020 , ‘Implementing a nurse discharge navigator reducing 30-day readmissions for heart failure and sepsis populations’ , Professional Case Management , 25 ( 6 ), 343 – 349 . OpenUrl PubMed Yeh , H.S. & Tsai , Y.F. , 2024 , ‘Effects of a transition care program on depression, self-efficacy, and self-care behaviors in heart failure patients’ , European Psychiatry , 67 ( S1 ), S269 – S269 . OpenUrl ↵ Zdanowicz , M.M. , 2002 , ‘Congestive heart failure’ , American Journal of Pharmaceutical Education , 66 ( 2 ), 180 – 185 . OpenUrl View the discussion thread. Back to top Previous Next Posted September 18, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review Ida Ayu Agung Laksmi , Moses Glorino Rumambo Pandin , Tintin Sukartini medRxiv 2025.09.17.25335454; doi: https://doi.org/10.1101/2025.09.17.25335454 Share This Article: Copy Citation Tools Nurse-Led Discharge Planning and Its Impact on Psychological Outcomes and Readmissions in Heart Failure: A Literature Review Ida Ayu Agung Laksmi , Moses Glorino Rumambo Pandin , Tintin Sukartini medRxiv 2025.09.17.25335454; doi: https://doi.org/10.1101/2025.09.17.25335454 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Nursing Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4435) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6600) Geriatric Medicine (668) Health Economics (997) Health Informatics (4536) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (541) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3332) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9232) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a00bc8e2f881e2c5',t:'MTc3OTYyMDMwMQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();