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Application of a Marketing Concept to Patient-Centered Care: Co-Producing Health With Heart Failure Patients

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Robert P. Leone, PhD
Charles A. Walker, PhD, RN
Linda Cox Curry, PhD, RN
Elizabeth J. Agee MSN, RN, ACNS-BC


Increasing numbers of patients are being treated for heart failure each year. One out of four of the heart failure patients who receives care in a hospital is readmitted to the hospital within 30 days of discharge. Effective discharge instruction is critical to prevent these patient readmissions. Co-production is a marketing concept whereby the customer is a partner in the delivery of a good or service. For example, a patient and nurse may partner to co-produce a patient-centered health regimen to improve patient outcomes. In this article we review the cost of treating heart failure patients and current strategies to decrease hospital readmissions for these patients along with the role of the nurse and the concept of co-producing health as related to heart failure patients. Next we describe our study assessing the degree to which discharge processes were co-produced on two hospital units having a preponderance of heart failure patients, and present our findings indicating minimal evidence of co-production. A discussion of our findings, along with clinical implications of these findings, recommendations for change, and suggestions for future research are offered. We conclude that standardized discharge plans lead to a mindset of ‘one size fits all,’ a mindset inconsistent with the recent call for patient-centered care. We offer co-production as a patient-centered strategy for customizing discharge teaching and improving health outcomes for heart failure patients.

Citation: Leone, R., Walker, C., Curry, L., Agee, E., (April 3, 2012) "Application of a Marketing Concept to Patient-Centered Care: Co-Producing Health With Heart Failure Patients" OJIN: The Online Journal of Issues in Nursing Vol. 17 No. 2.

DOI: 10.3912/OJIN.Vol17No02PPT03

Keywords: patient-centered care, heart failure, discharge teaching, hospital readmission, adherence, cost reduction, improved health outcomes, patient satisfaction, co-production

Heart failure (HF), a chronic disorder in which the heart loses its ability to pump blood efficiently, is a serious threat to the health of almost six million Americans.  Heart failure (HF), a chronic disorder in which the heart loses its ability to pump blood efficiently, is a serious threat to the health of almost six million Americans. Over 600,000 patients are newly diagnosed with HF each year (Centers for Disease Control and Prevention [CDC], 2010) and a million patients are hospitalized each year for HF (Hines, Yu, & Randall, 2010). Although HF is not curable, management of symptoms is possible with medication, lifestyle changes, and correction of underlying disorders or co-morbidities (Medline Plus, 2010). The purpose of this article is to introduce the concept of co-production and to assess the degree to which discharge processes were co-produced on two hospital units with a preponderance of heart failure patients. Table 1 presents a discussion of the concept of co-production.

Table 1. What is Co-Production?

What is Co-Production?

Co-production is defined as a situation in which both the customer and the firm’s contact employee interact and participate jointly in the production and delivery of a good or service (Bendapudi & Leone, 2003). Increasingly, customers are encouraged to take on more active roles in producing goods and services. They crop, enlarge, correct, or enhance their photographs in photography stores; they scan and bag their own groceries at supermarkets; and they plan family vacations by booking airline and hotel reservations online. Hence customer participation is not a new concept in the fields of marketing and consumer psychology (Dabholkar, 1990). Companies that sell goods and services have found that encouraging customers to be ‘co-producers’ can create win-win situations.

Experts in marketing and health care have witnessed an emergence of consumers who examine market offerings and create a customized consumption experience for themselves (Etgars, 2008; Payne & Frow, 2005). This shift in perspective views consumers as active co-producers, rather than passive audience members. Co-production both offers economic benefits to consumers and influences their psychological processes and evaluations. Bendapudi and Leone (2003) have shown that consumer co-production also affects their satisfaction.

The Cost of Heart Failure

In 2010 the estimated cost of HF in the United States (US) was $39.2 billion in direct costs (e.g. health care services) and indirect costs (e.g. lost work productivity) (CDC, 2010; Lloyd-Jones et al., 2010). According to the CDC (2010) one in four patients treated for HF within a hospital is readmitted within 30 days. Medicare readmissions alone increased costs $17.4 billion during 2009 (Hines, Yu, & Randall, 2010). Given the aging of the American population, the incidence of HF is projected to increase markedly during the next decade, yielding higher hospital admission rates and increased cost for Medicare and other third party payers. Interventions are needed to reduce patient readmissions and contain costs.

Strategies to Reduce Readmission

Research has demonstrated that patient-centered education yields better outcomes than scripted discharge instructions... Patient and family participation in health care can enhance self-management strategies so as to improve patients’ health status and quality of life (The Joint Commission [TJC], 2006). Hughes (2011) has noted that “patient- and family-centered care is generally understood to be an approach in which patients and their families are considered integral components of the healthcare decision making and delivery process” (p.1). Research has demonstrated that patient-centered education yields better outcomes than scripted discharge instructions, resulting in fewer readmissions, improved quality of life, increased life expectancy, and reduced treatment costs (Discher & Levine, 2003; Paul, 2008; Velez, Westerfeldt, & Rahko, 2008; Washburn & Hornberger, 2008).

Key elements of a successful discharge plan include an interdisciplinary team approach, effective communication, patient and family involvement, and continuity of care.  It is recommended that discharged HF patients receive follow-up care within five days of discharge (Nielson et al., 2008; Riegel et al., 2009). However, the Institute for Healthcare Improvement (Nielson et al., 2008) has reported that 81% of patients requiring assistance with basic functional needs fail to receive a home care referral. In addition, 64% of patients reported that no one taught them how to manage their HF care at home (Nielson et al., 2008). Key elements of a successful discharge plan include an interdisciplinary team approach, effective communication, patient and family involvement, and continuity of care (Mosca et al., 2011; Walker, Hogstel, & Curry, 2007). HF programs that include multiple interventions with the patient during and after hospitalization have been found to reduce 30-day readmission rates by as much as 25% and increase patient satisfaction (Hines, Yu, & Randall, 2010; Sochalski et al., 2009; Welch et al., 2005).

Role of the Nurse

Nurses should involve patients as full partners in care that is customized to meet patient’s unique needs and concerns.  The Institute of Medicine’s (IOM) 2011 recommendation that delivering “the right care at the right time” (p.26) requires a transformed workplace in which “nurses practice to the full extent of their education and training” (p.4). Consistent with this recommendation, nurses are expected to assume responsibility for assisting patients to self-manage their illness with the goal of maximizing functional independence. Nurses can promote independence among HF patients by delivering patient-centered education and by teaching them to use strategies, such as tracking sheets to monitor exercise, diet, medication, and disease signs and symptoms at home. Because nurses’ knowledge of HF self-management principles may be limited (Washburn & Hornberger, 2008), standardized discharge teaching plans have been developed to ensure accuracy and consistency of information. Yet patient-centered care demands more than standardization; it demands that patients take an active role in managing their health (Small & Small, 2011). Nurses should involve patients as full partners in care that is customized to meet patient’s unique needs and concerns. Co-production of a home-setting plan of care that involves both nurses and patients supports patient-centered care.

Co-Producing Health

Nurses who co-produce health care outcomes with patients are similar to individuals engaged in co-producing outcomes in the consumer marketing arena. Although co-production has been investigated in the marketing literature, the explicit effect of patient co-production on health outcomes, satisfaction, and adherence to health care regimens has not been investigated.

Co-production has the potential to enhance patient education. When patients have difficulty executing a health care regimen developed by the nurse alone, they might assign responsibility for resulting health outcomes to the nurse, particularly if the outcome is negative (Bendapudi & Leone, 2003). In contrast when patients and nurses co-produce a health care regimen, it is predicted that they will better manage their illness and share joint responsibility for resultant outcomes.

Box A. Typical Case Scenario: Mrs. Jones

Mrs. Jones, a 74-year-old heart failure patient, was assigned to home health services after discharge from the hospital where she received the standard discharge teaching. During biweekly visits, a registered nurse monitored such physical parameters as blood pressure, weight, edema, and heart and lung sounds. In addition the nurse discussed personal habits influencing the progression of Mrs. Jones’s chronic and disabling condition. For instance, during her second visit the nurse observed that Mrs. Jones’s legs had become severely swollen. She inquired whether Mrs. Jones had also been taking her medications, specifically furosemide, lisinopril, and propranolol, and asked about her recent dietary intake. According to Mrs. Jones, she had been taking her medications every other day because she did not have money to refill her prescriptions. Mrs. Jones also had been watching her diet by not adding salt to her food. Nonetheless, the nurse saw a half-eaten bag of salted tortilla chips on the TV tray by Mrs. Jones’s recliner. When questioned about the chips, Mrs. Jones admitted to eating them at one sitting the previous evening. Although her daughter had purchased a digital scale for daily weights, Mrs. Jones had not weighed herself since the nurse last visited.

Eight days later Mrs. Jones was readmitted to the hospital for symptom exacerbation including labored breathing, oxygen saturation of 82%, lung sounds with crackles (wet), complaints of mild chest pain, and 3-4+ pitting edema of ankles and feet.

The case of Mrs. Jones (Box A) is an example of discharge teaching and follow up that failed to demonstrate a patient-centered approach. In a retrospective analysis, Mrs. Jones’s home health nurse ascertained that the teaching and materials provided prior to hospital discharge were not patient-centered and had not translated into positive behavioral changes. Mrs. Jones’ understanding of a low-sodium diet, proper use of medications, and the importance of daily weights was inadequate. Failure to report obvious symptoms (e.g., leg swelling) provided evidence that Mrs. Jones was not doing well in managing her HF at home.

A patient-centered approach to discharge teaching might have helped Mrs. Jones and her family better understand the discharge instructions and how to use them (Mosca et al., 2011). Applying principles of co-production to discharge teaching has the potential to improve health outcomes. In Mrs. Jones’ case, co-production might well have occurred if she and her family had been involved in designing a personalized discharge plan with appropriate follow up. Co-producing her discharge plan might have improved her health outcomes and her satisfaction.

The Study

This study investigated evidence of patient co-production in discharge teaching using semi-structured interviews with registered nurses (RNs) caring for HF patients. Procedures to safeguard human participants were approved by Institutional Review Boards at both the health care agency and sponsoring university. The investigator (fourth author) conducted all the interviews, asking the bedside RNs to describe their typical approach to preparing HF patients for discharge. Additionally the RN participants were asked to complete a survey describing their perceptions of their use of co-production.


A convenience sample of nurses was recruited by posting a notice in the staff lounge announcing the hospital-approved study, noting participation was voluntary, and indicating that the investigator would contact potential participants who indicated an interest being part of the study. The investigator contacted each participant, explained the study’s general purpose, and offered a $25 gift card as an incentive. Ten staff nurses, all of whom were responsible for comprehensive bedside care and discharge teaching, were invited to participate. All agreed to participate in the study. Participant ages ranged from 22 to 55 years of age with a mean of 38 years (SD=10.4). Most participants (90%) were female, with 40% being non-Caucasian (1 Hispanic, 1 Eastern Indian, 1 Filipino, and 1 African American). Seven participants held baccalaureate degrees in nursing, including one who held a Master in Public Health degree; the other three participants held associate degrees in nursing. Six participants were certified in Advanced Cardiac Life Support. Time in nursing practice ranged from less than one year to 18 years (M=7.5 years, SD=6.5). In terms of cardiac care practice experience, four participants had less than one year of experience and the others had 1 to 14 years (M=4.0, SD=5.25).


Interviews were conducted on two units of a large, suburban hospital in the southwestern US. Although the two units admitted a preponderance of patients with HF, other admitting diagnoses included pneumonia, hip fractures, renal failure, and uncontrolled diabetes. Interviews were conducted in a quiet, isolated room, away from patient care responsibilities, when nurses were off duty.

Qualitative Interview Procedure

Informed consent, including permission to audiotape the interview, was obtained prior to conducting each interview. Participants were assured their responses would remain confidential. Because nurses had recently completed a staff development program focusing on a newly instituted HF discharge protocol, participants were asked to describe that protocol. Nonthreatening questions provided a context for establishing rapport with participants and represented the interview’s ‘orientation phase.’ The following initial questions were asked:

  • What are your discharge protocols and who performs them?
  • How much time is spent?
  • What equipment is provided?
  • Is there any follow up?

These general questions eased the transition to the interview’s ‘working phase,’ which centered on the prompt: Describe how you perform discharge teaching. The working phase included asking open-ended questions, paraphrasing, and active listening to elicit detailed information from participants and encourage them to tell their story. The following open-ended questions related to preparing HF patients for discharge included:

  • What obstacles do you frequently encounter, and how do you resolve them?
  • How do you get the family involved?
  • How do you know the patient and family understand what’s expected of them?
  • If they don’t understand, what do you do?

To reduce interviewer bias and elicit candid descriptions, co-production was not mentioned. Participants were encouraged to respond spontaneously providing their own thoughts, recollections, and examples of their discharge teaching. They were encouraged to clarify as needed. Interviews lasted from 30 to 45 minutes.

While unit managers were aware of the research project and staff participation, the identity of the interviewees and information obtained during interviews was kept confidential. The audio-recorded interviews were transcribed, and the interviewer confirmed veracity of the transcripts.

Data Analysis and Findings of Qualitative Interviews

Data were analyzed in three stages, namely development of a continuum of co-production, a key-word count, and a narrative analysis. Each stage will be described below.

Development of a continuum of co-production. To analyze these data we used an inductive, discovery-oriented approach in which data revealed an underlying structure of meaning, as opposed to a deductive approach in which data are used to test hypothetical structures (Wells, 1993).The underlying structure was a continuum ranging from an absence of co-production (patient is told what to do) to clear evidence of co-production (patient is a partner in designing the discharge plan) (Bendapudi & Leone, 2003). The continuum was ‘discovered’ as members of the research team met together and read each of the transcripts aloud. The two end-points (absence and evidence) were clear anchors for the four-stage continuum. Intermediate stages represented other strategies participants used in their discharge teaching as described below.

When co-production is absent, communication flows in one direction from nurse to patient without reciprocation. The first stage of the continuum was found to be the ‘absence of co-production.’ When co-production is absent, communication flows in one direction from nurse to patient without reciprocation. Words or phrases commonly associated with absence of co-production include telling, informing, explaining, teaching at, teaching to, and giving printed materials. For example, the nurse ‘tells’ a patient with HF he needs to weigh himself every day at the same time using the same scale and ‘provides’ written instructions on how to do so.

The second stage of the continuum was identified as the ‘verification of learning.’ To verify patient learning the nurse may request a restatement of information or demonstration of a skill. While this process indicates bidirectional communication, the patient is simply responding as the nurse attempts to verify learning. Words or phrases commonly associated with verification include asking, encouraging, explaining, repeating, and teaching with. For example, after the patient receives written instructions, the nurse ‘asks’ him to restate how often he should weigh himself at home so as to assess his understanding of the nurse’s instructions. The nurse then reemphasizes the importance of recording his weight daily.

An invitation to co-produce includes the patient as an active participant in learning. Once the nurse provides instructions and verifies learning, the nurse attempts to determine if there are any barriers to implementing the teaching plan. The third continuum stage was labeled the ‘invitation to co-produce.’ An invitation to co-produce includes the patient as an active participant in learning. Once the nurse provides instructions and verifies learning, the nurse attempts to determine if there are any barriers to implementing the teaching plan. Examples of words or phrases commonly associated with an invitation to co-produce include involvement, interaction, participation, and proaction. For example, the nurse ‘involves’ the patient by asking if he perceives any obstacles to carrying out the discharge instructions, such as not owning a scale. If obstacles are present, the nurse ‘offers possible solutions,’ for example a referral to a case worker to obtain a scale.

We described the fourth and final continuum stage as ‘clear evidence of co-production.’ In co-production patients become partners in their own care. A discharge plan is customized to achieve desired health outcomes. The nurse engages the patient in a conversation to identify a mutually agreed upon plan to achieve these outcomes. Examples of words or phrases commonly associated with co-production include goal setting, engagement, and revision. For instance, the nurse ‘engages’ the patient in a conversation about the best way to obtain his daily weight. After identifying barriers such as being unable to read the scale because of poor eyesight, the patient is encouraged to offer possible solutions (e.g. recruiting another person to help him).

Key word count. Content analysis of transcripts was performed using a simple search for key words that corresponded to each of the four categories described above (Polit & Beck, 2008) (See Table 2). Total key words counted across all categories equaled 211. Key words representing ‘absence of co-production’ accounted for 57.3% (n=121) of the total count. Key words representing ‘verification of learning’ accounted for 32.7% (n=69). Key words representing ‘invitation to co-produce’ accounted for 6.6% (n=14), and only 3.3% (n=7) of the total word count represented clear evidence of ‘co-production.’

Narrative analysis. Narrative analysis was performed to better understand the context in which key words were found (Denzin & Lincoln, 1994). Using a narrative analysis perspective, all four investigators independently read and reread each transcript to determine the context for key word use. Key words were reclassified. These reclassifications were compared and discussed until consensus was reached. Evidence from transcript narratives that most vividly represented each of the categories is shown in Table 2. The key word count initially indicated evidence of co-production. However, when words were read in context, co-production was not evident. For example, the key word engage was interpreted as evidence of co-production (e.g. “We engage them...”); however, contextual reading showed the interviewee’s engagement with the patient was intended to verify learning (e.g. “ see if there are any clues that they just don't understand”).

Narrative analysis revealed no evidence of co-production. One transcript met the category invitation to co-produce; 6 of the remaining 9 met the category for verification of learning, and the remaining 3 transcripts exhibited unidirectional communication with patients, signaling the absence of co-production. All 10 nurses routinely provided discharge teaching to HF patients by giving information and materials. Seven attempted to verify understanding, and only one encouraged patients to actively participate in the process.

Follow-Up Survey: Procedure, Analysis, and Findings

To assist in identifying nurses’ perceptions of their use of co-production in discharge teaching, participants previously interviewed were subsequently asked to judge the percent of time devoted to performing activities representing each of four categories (stages of the continuum) described above. The scale used to ask nurses about their perceptions regarding the degree to which they involved patients in the discharge process is shown in Table 4. To reduce the possibility that participants' responses would be biased by the qualitative interviews, this survey was conducted five months after the in-depth, qualitative interviews.

Nurses saw themselves as relying considerably more on co-production than was indicated in their descriptions of their discharge teaching.  Findings from this survey did not agree with our findings based on the analysis of the qualitative interviews. Nurses reported spending 20-35% of their time explaining to patients what they are expected to do at home (absence of co-production). They reported spending 20-30% of their time verifying that patients understood what they were expected to do (verification of learning). Encouraging patients’ involvement (invitation to co-produce) accounted for 15-30% of the reported time spent providing discharge instruction. Nurses reported spending 20-40% of their time partnering with patients to develop a personalized plan of care (co-production). Nurses saw themselves as relying considerably more on co-production than was indicated in their descriptions of their discharge teaching. Table 5 provides a comparison between results from qualitative interviews and survey findings.

Study Limitations

One study limitation was the small convenience sample consisting of 10 nurses.  Also our asking general, closed-ended questions during the interview’s orientation phase may have led participants to focus on institutional protocols, thus limiting evidence of co-production. Finally because the sample was from one hospital, generalizability of findings may be limited.


Nurses must practice versatility and clinical reasoning to expand institutional scripts in order to provide patient-centered care. Nurses are responsible for providing discharge instructions to HF patients. When nurses were asked to describe their discharge teaching, they gave clear descriptions. Some reported reading the instructions from a computer generated script provided by the hospital and saw no need to deviate from the script. Other nurses followed the script and verified what the patient heard. Some nurses used the script as a guide but involved the patient in the process of identifying and offering solutions to obstacles. No nurses went off script or engaged the patient in designing a personalized discharge plan. Failure to deviate from the script could be due to an institutional expectation to follow the script. Nurses must practice versatility and clinical reasoning to expand institutional scripts in order to provide patient-centered care. Finally, because 4 of the 10 nurses in the sample had worked less than a year in cardiac care, dependence on the script may have been a function of their limited experience. Inability to expand on the script may reflect their still-developing clinical reasoning skills.

We found it interesting that the word ‘non-compliance’ was used to describe situations in which medical recommendations were not followed. Generally nurses viewed this as a weakness or a deficiency on the patient's part. One nurse used the term ‘repeat offender’ to describe a patient who was readmitted for symptom exacerbation. A few nurses identified their own culpability, describing themselves as failures when the patient did not follow what the nurse considered as best practice. Assuming responsibility for patient failure, one nurse commented, “I haven't successfully communicated to you what you need to do if at discharge you don't do it.” Neither nurses blaming themselves or the patient for readmission is compatible with the core concepts of patient-centered care (Small & Small, 2011) and co-production (Bendapudi & Leone, 2003). This blaming substantiates that these nurses had not yet grasped the concept of co-production in which both patient and nurse assume part of the responsibility for improved health outcomes.

One nurse commented there was not time to do a dietary analysis when recommending a low salt diet. This time limitation constrained their ability to individualize teaching. Institutional expectation of a timely discharge may also have contributed to limited personalized teaching. Nurses indicated barriers to teaching included resource limitations, such as time limitations and knowledge related to material resources. They described the limited amount of time available at discharge as being 5 to 20 minutes per discharge. Some nurses were rewarded for expediting patient discharges. One nurse commented there was not time to do a dietary analysis when recommending a low salt diet. This time limitation constrained their ability to individualize teaching. Nurses also stated they lacked knowledge of resources when there were specific patient needs such as buying a scale or modifying diet.

Other reasons given for not individualizing the teaching of HF patients included their custom of using a computer-generated script specific to a diagnosis of HF to guide discharge teaching, unavailability of family caregivers, and the belief that individualized care was someone else's responsibility. Nielson et al. (2008) noted that these beliefs and practices impede the goal of providing a comprehensive, personalized discharge plan.

In the follow-up survey nurses overestimated the time they devoted to co-production compared to what they reported during the interview. The discrepancy may be related to system limitations, such as high work expectations and patient acuity, that may prevent nurses from providing patient-centered care even though they desire to do so. Recognizing these barriers emphasizes the importance of the IOM statement (2011) that “increasing the time that nurses can spend at the bedside is an essential component of achieving the goal of patient-centered care” (p. 317).

Despite describing barriers to providing individualized discharge teaching, nurses often commented how much they enjoyed patient care activities. Nurses expressed a sincere desire for patients to do well, yet they were frustrated by limited opportunities for formal patient feedback. Unless patients were readmitted, nurses had no idea what happened following discharge. Current delivery systems are not compatible with patient-centered care and fail to harness the passion nurses have for bedside care (Small & Small, 2011). Organizational support is needed to allow for co-production of patient care.

Box B. Ideal Case Scenario: Co-production

Mrs. Smith, a widow aged 72, entered the hospital’s emergency department complaining of shortness of breath. She was admitted to a nursing unit, placed on continuous oxygen, heart monitoring, weighed, and given furosemide(40mg). By the next morning her breathing was easier and she had lost 5 pounds.

The nurse assigned to her care had just completed a continuing education program entitled “Co-Producing Health with Heart Failure Patients.” Nurse B entered the room and initiated a conversation concerning Mrs. Smith’s condition and ways to avoid future readmission by asking, “Did you notice a weight gain?” Mrs. Smith stated “I have not weighed myself for over a week. My scale is old and difficult to read. It would be nice if I had a new scale and someone would remind me to weigh myself. Sometimes, I just forget to write it down.”

Nurse B worked with Mrs. Smith to co-produce a plan to closely monitor her weight and provide the assistance Mrs. Smith requested. In conversation with Mrs. Smith, Nurse B learned that her daughter visits daily. They agreed that the daughter could assist Mrs. Smith. Nurse B gave Mrs. Smith a form she and her daughter can use for recording daily weights and made plans both to purchase an easier scale for Mrs. Smith to use and for Mrs. Smith’s daughter to call her daily as a reminder. Plans for the care of Mrs. Smith in the hospital included her being assisted by hospital personnel with taking and recording her daily weight on the new form.

Nurse B reassured Mrs. Smith that her heart problem would be manageable if she followed her customized plan of care. Nurse B also contacted the home-health nurse and scheduled a follow-up appointment with Mrs. Smith’s primary care physician to maintain the care partnership.

Clinical Implications

A discharge script catalogues discrete behaviors to be followed without exception, whereas co-produced discharge teaching creates a partnership between the patient, family, and the nurse. The ideal case for Mrs. Smith (Box B) presents a different approach than the scripted discharge teaching described by most of the nurses in this study. A discharge script catalogues discrete behaviors to be followed without exception, whereas co-produced discharge teaching creates a partnership between the patient, family, and the nurse.

Co-produced discharge teaching includes four strategies recommended by Nielson et al. (2008) for an ideal transition to home. These strategies include an enhanced admission assessment, enhanced teaching/learning, patient and family-centered handoff communication between the hospital team and subsequent care providers, and post-acute care follow up. Each of these strategies is discussed below.

‘Enhanced admission assessments’ include patients and families as full partners  in the assessment process, as exemplified by Nurse B initiating a conversation with Mrs. Smith about how to avoid a readmission.This invitation to co-produce encourages the patient to identify obstacles to self care. Including Mrs. Smith and her daughter as partners in assessment (co-production) provided a framework for the discharge plan.

‘Enhanced teaching and learning’ improves the patient education process by increasing patient and family caregiver understanding of self-care. Because Mrs. Smith admitted she had not recently weighed herself at home, Nurse B made arrangements for Mrs. Smith to record her weight, utilizing the new recording form, while hospitalized (co-production).This learning activity reinforces a daily routine which Mrs. Smith will need to follow at home.

‘Patient and family-centered handoff communication’ transmits critical information to patients and their family caregivers. For instance Nurse B included Mrs. Smith’s daughter in discharge planning, which resulted in the daughter agreeing to remind her mother to weigh daily and record her weight.

‘Post-acute care follow up’ provides care coordination from inpatient stay to home. For instance, prior to discharge, Nurse B scheduled a physician office visit on a day convenient for Mrs. Smith (co-production). To ensure care continuity, Nurse B also shared particulars of Mrs. Smith’s case with the home health nurse.

Recommendations for Change

Moving toward a co-production model of discharge teaching requires a redesign of the discharge teaching process. Moving toward a co-production model of discharge teaching requires a redesign of the discharge teaching process. The first step involves improvement in information-sharing systems. For example, the nurse who admits and initially treats the patient may not be the nurse who provides summative discharge teaching. Rather the nurse who provides care on the day of discharge may be meeting a patient for the first time.This fragmentation of care creates a disconnect (IOM, 2011). An appropriate information system enables nurses to share what they have heard and learned from the patient and family members about what communication and resources will be needed for a successful discharge.

The second step in a co-production model would be restructuring the rewards system. In order to meet institutional demands for efficiency, nurses in this study defined their role in patient discharge quite narrowly. A reward structures that fosters standardization and speed over personalized care restricts the ability of nurses and patients to work as partners. Reward systems favoring co-production principles should be implemented so that nurses may depart from a standardized script. For example, the computer generated script could be modified to provide the discharge nurse opportunities to customize patient information by embedding optional or alternative sections into the current script. Additionally systematic training sessions are necessary for all nurses who will utilize the discharge script. Currently, health care systems have a financial incentive to understaff. Yet nurses need the resources to do their job effectively; therefore there is no expectation that patient-centered care will reduce cost in the short term (IOM, 2011).

...isolated interventions are common but often ineffective. A third step would be to enhance post-discharge strategies using co-production principles. Because “all nursing care is treated equally in its effect on revenue” (IOM, 2011, p.115), isolated interventions are common but often ineffective. The full value of nurses’ work may be better realized through multidisciplinary, comprehensive approaches (Sochalski et al., 2009). One recent innovation in HF care and follow up is the HF clinic (Hines, Yu, & Randall, 2010). These clinics use intensive, personalized out-patient therapies and education that are reimbursed by Medicare.Patients usually come to the clinic once a week where their weights are taken, medications and labs are reviewed, and IV medications are given. In addition to these routine tasks, clinic nurses can co-produce health with their HF patients by helping the patient and family set treatment goals, troubleshoot unanticipated problems, and assess the patient and family’s ability to manage the disease.

Future Research

Co-production is one method of making nurses full partners in health care redesign and implementing the mandate for patient-centered care (IOM, 2011; TJC, 2011). Future directions for research might include investigating ways to incorporate co-production principles within the discharge teaching process so as to improve patient outcomes. Testable hypotheses include:

  • Co-production will increase patient satisfaction with their hospital experience.
  • Co-production will produce less frequent hospital readmissions for HF patients.
  • Co-production will provide long-term cost savings for all stakeholders, including patients, providers, and insurers.


Standardized discharge plans assume a mindset of ‘one size fits all,’ which is inconsistent with the recent call for patient-centered care. In this study, few nurses deviated from the standard script and none involved patients in designing personalized discharge plans. Based on what has been shown in the marketing literature, involving an individual in the design of a product or service (co-production) increases both consumer satisfaction and quality of the outcome. Co-production offers a patient-centered strategy for customizing discharge teaching and improving health outcomes for chronic conditions such as HF.


Robert P. Leone, PhD

Dr Leone has taught marketing for over 30 years and has held endowed faculty positions at The University of Texas at Austin, The Ohio State University (Columbus), and Texas Christian University (TCU). His areas of professional expertise include branding, relationship marketing, and co-production. Dr. Leone has presented at over 100 national and international conferences and has published in the top academic marketing journals, such as the Journal of Marketing, as well as the top practitioner journals, including Harvard Business Review. He served as Co-Editor of the Journal of Marketing from 2009-2011. Dr. Leone received his BA in Mathematics and MBA degrees from the University of Texas (Arlington) and a PhD in Marketing from Purdue University in West Lafayette, IN.

Charles A. Walker, PhD, RN

Dr. Walker, who has taught nursing for 26 years, is currently in his 10th year on the graduate faculty at TCU’s Harris College of Nursing & Health Sciences. His areas of professional expertise include gerontology, community mental health, ethics and moral theory, family systems, and humanities for the health sciences. Dr. Walker has presented at over 100 regional, national, and international conferences and published numerous scholarly monographs, journal articles, and book chapters on such topics as aging readiness among baby boomers, elder caregiving, relocation stress, and discharge planning for people with chronic and disabling illnesses. He is editor of the Journal of Theory Construction & Testing. Dr. Walker earned his BS and BSN from Texas Christian University in Fort Worth, his MSN from the University of Texas, and his PhD from Texas Woman’s University in Denton. He has also studied adult education, community counseling, pastoral care, and theology at the University of North Texas, Ohio University, and Southwestern Theological Seminary.

Linda Cox Curry, PhD, RN

Dr. Curry has taught nursing for over 40 years and is in her 35th year on the nursing faculty at TCU’s Harris College of Nursing and Health Sciences. Her professional expertise addresses issues related to human growth and development with a focus on the older adult and healthy aging. Dr. Curry has presented at numerous regional and national conferences and has numerous scholarly publications including journal articles, book chapters, and a book on physical assessment. Publication examples include research on recovery post-hip fracture, relocation stress, discharge planning, caregiving, and osteoporosis education. Dr. Curry’s degrees include an AA, BSN, and MN from the University of Florida (Gainesville) and a PhD from the University of North Texas in Denton

Elizabeth J. Agee MSN, RN, ACNS-BC

Ms. Agee has been a staff nurse in critical care for 28 years and has held a certification as a Critical-Care RN (CCRN). She has also worked for a home health agency caring for heart failure patients after discharge from hospitals and educating these patients regarding ways to better manage their symptoms of HF. Ms. Agee is currently in her 5th year as a clinical instructor at TCU’s Harris College of Nursing and Health Sciences.  She served as a hospital nurse educator for two years before starting at TCU. Ms. Agee received her ADN from Tarleton State University in Stephenville, TX and her MSN from Texas Christian University in Fort Worth.


Bendapudi, N. & Leone, R.P. (2003). Psychological implications of customer participation in co-production. Journal of Marketing, 67, 14-28.

Centers for Disease Control and Prevention (2010). Heart failure factsheet. Retrieved from

Dabholkar, P. (1990). How to improve perceived service quality by improving customer participation. In B.J. Dunlap (ed.), Developments in Marketing Science. (483-87). Cullowhee, NC: Academy of Marketing Science.

Denzin, N.K., & Lincoln, Y.S. (1994). Handbook of qualitative research. Thousand Oaks, CA: Sage.

Discher, C., Klein, D., Pierce, L., Levine, A., & Levine, B., (2003). Heart failure disease management: impact on hospital care, length of stay, and reimbursement. Congestive Heart Failure. 9(2), 77-83. doi: 10.1111/j.1527-5299.2003.01461.x.

Etgar, M. (2008). A descriptive model of the consumer co-production process. Journal of the Academy of Marketing Science, 36(1), 97-108.

Hines, P., Yu, K. & Randall, M. (2010). Preventing heart failure readmissions: Is your organization prepared? Nursing Economics, 28(2), 74-86.

Hughes, R. (2011). Overview and Summary: Patient-Centered Care: Challenges and Rewards. OJIN: The Online Journal of Issues in Nursing, 16(2). doi 10.3912/OJIN.Vol16No02ManOS.

Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.

Joint Commission, The. Specifications manual for national hospital quality measures: HF-1. Retrieved from

Lloyd-Jones, D., Adams, R.J., Brown, T. M., Carnethon, M., Dai, S., De Simone, G., Ferguson, TB, Ford, E., Furie, K., Gillespie, C., Go, A., Greenlund, K., Haase, N., Hailpern, S., Ho, M., Howard, V., Kissela, B., Kittner, S., Lackland, D., Lizabeth, L., Marelli, A., McDermott, M. M., Meigs, J., Mozaffarian, D., Mussolino, M., Nichol, Graham., Roger, V. L., Roamond, W., Sacco, R., Sorlie, P., Stafford, R., Thom, T., Wasserthiel-Smoller, S., Wong, N., Wylie-Rosett, J., (2010). Heart disease and stroke statistics-2010 update: A report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation, 121, e46-215.

Medline Plus (2010). Heart failure. Retrieved from

Mosca, L., Benjamin, E., Berra, K., Bezanson, J., Dolor, R., Lloyd-Jones, D. Newby, K., & Wenger, N. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 update: A guideline from the American Heart Association, Circulation.123. 1243-1262.

Nielson, G.A., Bartely, A., Coleman, E., Resar, R., Rutherford, P., Souw, D., & Taylor, J. (2008). Transforming healthcare at the bedside how-to guide: Creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement. Available:

Payne, A., & Frow, P. (2005). A strategic framework for customer relationship management. Journal of Marketing, 69(4), 167-176.

Paul, S. (2008). Hospital discharge education for patients with heart failure: What really works and what is the evidence? Critical Care Nurse, 28(2), 66-82.

Polit, D., & Beck, C. (2008). Nursing research: Generating and assessing evidence for nursing practice. Lippincott, Williams & Wilkins: Philadelphia, PA.

Riegel, B., Moser, D., Anker, S., Appel, L., Dunbar, S., Grady, K.,...Whellan, D. (2009). State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120. 1141-1163.

Small, D. & Small, R. (2011). Patients first: Engaging the hearts and minds of nurses with a patient-centered practice model. OJIN: The Online Journal of Issues in Nursing, 16(2). doi 10.3912/OJIN.Vol16No02Man02.

Sochalski, J., Jaarama, T., Krumholz, H., Laramee, A., McMurray, J., Naylor, M.,... Stewart, S. (2009). What works in chronic care management: The case of heart failure. Health Affairs, 28(1), 179-188.

Velez, M., Westerfeldt, B., & Rahko, P. (2008). Why it pays for hospitals to initiate a heart failure disease management program. Disease Management & Health Outcomes 16(3), 155-173.

Walker, C., Hogstel, M., & Curry, L. (2007). Hospital discharge of older adults. American Journal of Nursing, 107(6), 60-70.

Washburn, S., & Hornberger, C. (2008). Nurse educator guidelines for the management of heart failure. The Journal of Continuing Education in Nursing, 39(6), 263-268.

Wells, W.D. (1993). Discovery-oriented consumer research. Journal of Consumer Research, 19(4), 489-504.

Welsh, C., Sliver, M., Alikhan, N., Amiry, A., Archie, S., Bahr, M., Brody, C., Brookfield, L., Dumas, A., Haag, B.J., Funk, C., Hrejsa, L., Jone, P., Kent, N., Kolosh, K., Leskovac, T., Levinsky, R., Lynch, A., Maki, G., Mau, J., Patel, P., Pisano, C., Pouliot, J., Saltzberg, M., Shih, T., & Weatherhead, J., (n.d) Improving heart failure care through education.


Table 2. Content analysis of interview transcripts


Key words and word count

Absence of co-production (default category)


  • Give materials – 34
  • Teach (at, to) – 30
  • Tell – 25
  • Inform – 18
  • Explain – 14

Verification of learning


  • Teach (with) – 30
  • Ask (nurse) – 18
  • Explain (patient) – 14
  • Repeat – 5
  • Encourage (nurse) – 2
  • Apply (patient) – 0
  • Restate (patient) – 0
  • Recite – 0
  • Demonstrate – 0

Invitation to co-produce


  • Involvement – 11
  • Proactive (patient) – 1
  • Participation – 1
  • Interaction – 1
  • Negotiation – 0
  • Dialogue – 0

Clear evidence of co-production*

  • Goal setting – 2
  • Change – 2
  • Engage – 1
  • Outcome –  1
  • Revision – 1
  • Joint design – 0
  • Modification – 0
  • Customization – 0
  • Partnership – 0
  • Personalize – 0
  • Individualize –   0    
  • Consumer/customer – 0 
  • Adapt – 0

* In order to increase the chance that evidence of co-production was not overlooked, more than twice the number of key words was used to search for co-production than for other categories.


Table 3. Evidence from transcript narratives

Category – degree of co-production

Evidence from transcript narratives

Absence of co-production

  • We review the major points of weight gain, what to look for, increased shortness of breath and swelling, and when to call the doctor to notify the doctor that you have more weight than usual.
  • I remind them that sodium doesn’t just come in the form of table salt, but that it’s actually in frozen and processed foods.
  • When they first walk in the door we start instructing them as part of the admissions process.
  • The first thing we do is we give them an information sheet about what CHF is and how it happens and all that. And that goes on until discharge. We emphasize how they need to do the daily weight, and make sure that they put in on a log sheet, so they can determine whether they are retaining fluid, or not.
  • The one thing I say is, when you do your weight, it has to be like the first thing you do. Okay, when you get up in the morning, you know you go to the bathroom, and then you weigh yourself, and you weigh yourself on the same scale, at the same time every day, and you always do it before breakfast.
  • And we make sure that we talk to them and explain to them like Lasix, they need to weigh themselves daily, and if they see an increase in their weight that they make sure to notify the physician. Any shortness of breath, any increased weakness, or just tiredness, they need to inform the physician on that. They need to have a cardio diet, low salt diet. Make sure that they take their medications like they are supposed to, and notify the physician if they have any problems with them.
  • So what we do on computer is we pull that program in, and then it has like a two page teaching for the patient for us to go over with the patient during discharge.
  • We tell them to keep a log of their daily weight. If they see a big increase in their daily weight, you know five pounds or more, we have them contact their physician. We talk to them about smoking cessation; we talk to them about basic fluid retention. You know, like if you see fluid retention in the bottom of your legs, that’s different, that’s not normal. We teach them about fluid intake.
  • Every day when we give them the meds, we explain what the meds are and they need to check their blood pressure. We reinforce that every single day before they go home.
  • I know you’re supposed to use the CHF discharge template. I usually give them information on Lasix, and weight gain, and if they’re on blood pressure medicine, diet, what else, like a low sodium diet.

Verification of learning

  • You give them printed information, you review it. Talk about diet. Talk about signs and symptoms to monitor for, what to look at. Every time you go in, ask about medications. Why are you on medication?  What is the medication supposed to do?  It is continual education… I’ve never put a time slot on it because it’s simply a continual thing.
  • When I give medication, it doesn’t matter if they’re twenty, I go with them one by one. Okay, this is an antacid, have you heard of this. Now this is your blood pressure medicine that you take at home, plus the doctor prescribed another one, and this is going to compliment you.
  • I asked (the patient) if she understood, or if she had any questions.
  • I go back to the patient maybe a few minutes later, and ask them “okay, so this medication is for...”, and kind of letting them fill in the blanks so I know they understand.
  • We make sure to go over the instructions with them, and we ask them if they have any questions. We engage them, and see if there are any clues that they just don’t understand, and we direct them, give them examples, and try to reinforce as much as we can, and make the instructions as simple as possible.
  • Usually they verbalize understanding back to us. We ask them how would you weigh yourself, and they explain how to do that. Or we’ll ask them do you have more questions, or is there something I can explain better?  Something like that. Usually its questions and answers that help us understand if they’ve gotten it.

Invitation to co-produce

  • You want to encourage them to learn more and be active, and be proactive with their illnesses.


  • None


Table 4. Follow-Up Survey*

I explain to patients what they are expected to do and show them how to do it. For example, I tell my HF patients to weigh themselves on the same scale every day at the same time of day.

____ %

I verify that patients understand what they are expected to do by asking them to repeat information or demonstrate a skill. For example, I may ask my patients to explain what they need to do to record their weights accurately in order to validate their understanding.


I encourage patients’ proactive participation in the discharge process, including their direct involvement. For example, I ask my patients if what has been suggested regarding dietary modifications will work for them. If not, I will ask what obstacles they face.


I engage patients as partners in developing a personalized plan of action to achieve mutually set goals. For example, if my patients report anticipated problems with the plan of care, I will ask what we can do or change to make it feasible for them to follow the plan.




*These categories were presented in random order.


Table 5. Comparison of Results from Qualitative Narrative Analysis and Follow-Up Survey


Qualitative interviews*

Follow-up survey**

Absence of Co-production (default category)



Verification of Learning



Invitation to co-produce



Clear evidence of co-production



*Percent of transcripts (N=10) classified into each category
**Percent of time devoted to each category during discharge teaching as judged by participants

© 2012 OJIN: The Online Journal of Issues in Nursing
Article published April 3, 2011

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