Ahrens, Susan L.; Wirges, Ashley M.
Many interactions occur between the patients and nurses during a hospital stay; given that, providing education and effective communication to patients on their medications is a responsibility that most often rests with the nurses. Effective communication is an essential skill for the nursing profession because it has been linked to improved patient satisfaction and health outcomes. One of the ways nursing can affect healthcare outcomes is to promote healthcare literacy by improving the way that medical information and self-care instructions are provided (Potter & Martin, 2005).This can be challenging with patients with cognitive deficits resulting from neurological conditions.
In an effort to improve outcomes and curtail healthcare costs, third-party providers are beginning to link payments to quality care measures (American Nurses Association, 2007). Organizations are now collecting data on a variety of performance measures and are using these data to draw attention to quality issues that need improvement. Paying for performance incentive programs are being used as a strategy to promote improvements in the delivery of quality healthcare, and patient satisfaction is becoming of ever-increasing importance. Furthermore, patient satisfaction data are publicly analyzed and can be used by patients in making decisions about where to seek their healthcare.
A hospital in the midwest sought to improve their Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) scores regarding patient satisfaction of medication side-effect education. Comparing national adjusted data from the HCAHPS survey from 2010–2011, this hospital realized that patients were dissatisfied with the education they had received regarding medication. On the HCAHPS questionnaire, two items relate to medication education; one of which asks, “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” The hospital’s composite score (58%) related to medication education was significantly lower than the national benchmark data (61%; U.S. Department of Health and Human Services, n.d.). The composite score represents the percent of patients who reported that staff “always” explained about their medicines before giving it to them.
A patient perception team (PPT) was developed to focus on and improve in areas such as medication education. A diverse team of hospital employees including managers, bedside nurses, and individuals who had been treated at the hospital was organized to address patient dissatisfaction. A subcommittee was commissioned by the PPT to implement changes focused on improving scores for medication education among post acute neurosurgical patients. This particular unit was selected because the HCAHPS scores in the hospital were the lowest on the neuro-medical surgical (NMS) unit.
The purpose of this quality improvement practice change based on evidence was to (a) develop an educational approach for post acute neurosurgical patients and (b) evaluate whether the use of the approach is successful in improving patient satisfaction scores related to medication education on side effects. An educational approach for the study was based on the literature and implemented on the NMS unit. A multimethod approach was used for improving satisfaction scores that consisted of (a) patient informational fliers inserted into admission folders, (b) nurse education with repeated communications about the importance of providing education on side effects to patient, (c) unit flyers with nurse education, and (d) various communications with bedside nurses through personal work mail and emails. Preprinted written material on side effects of commonly used first-time medications was provided and made readily available on the unit. Also, along with providing both written and verbal education to the patients, the nurses were asked to consistently use the “teach-back” method to reiterate potential medication side effects during their hourly rounds and bedside report. This article describes the project and its impact on the NMS-unit patient’s satisfaction.
Review of the Literature
Hospital readmission rates are an important measure of the quality and costs of healthcare. An estimated 17.4 billion dollars are spent on hospital readmissions per year (Boulding, 2011). Research has shown a correlation between patient satisfaction and a decrease in readmission rates. A study by the same author showed that higher overall patient satisfaction and satisfaction with discharge planning are related to a lower 30-day risk of hospital readmission rate after adjusting for clinical quality (Boulding, 2011). The study concluded that patient-centered information can have an important role in the evaluation and management of hospital performance.
According to an earlier study, although subjective, only patient satisfaction surveys accurately assess the patient’s experience (Drain & Clark, 2004). A hospital must recognize and understand patient expectations when providing care because patient satisfaction is recognized as a core operating strategy for successful organizations (Counts & Mayolo, 2007). The HCAHPS is a patient satisfaction survey developed by the Agency for Healthcare Research and Quality to evaluate a patient’s perspective of hospital care (Centers for Medicare & Medicaid Services [CMS], 2012). Since its development, the HCAHPS survey has become a national standard for collecting and comparing data on patients’ perspectives of inpatient hospital care across all hospitals (CMS, 2012).
An important domain of the HCAHPS survey is patient satisfaction regarding education on medication side effects. Research indicates that patients want to be informed about their medications and the potential side effects (Borgsteede, Karapinar-Carkit, Hoffmann, Zoer, & van den Bemt, 2011). Previous literature also shows that not understanding side effects of treatment causes an increase in dissatisfaction with the overall care (Gandhi et al., 2000).
An important issue related to medication education is patient choice of how much information is desired. Many studies have found that, although patients want to be informed about their medications, their informational needs are not being met (Borgsteede et al., 2011; Costa, Poe, & Lee, 2011). In regard to possible medication side effects, a study found that informational needs varied widely (Borgsteede et al., 2011). After interviewing 31 patients from the pulmonology, cardiology, and internal medicine departments who were discharged with at least one prescribed drug from the hospital, their research showed that patients who wanted to know about side effects wanted to be prepared in case they experienced them (Borgsteede et al., 2011). The same study also found that patients wanted to be informed to be assured that their medicine was the safest choice. Conversely, the same study also found that, for some patients, information about possible side effects is fearsome and that knowledge of the side effects would lead to the actual experience of the side effects. For these reasons, some patients prefer not to be informed.
Medication education on possible side effects is often not done or told in a way that patients can understand, and this might be related to low health literacy. Health literacy is the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment (Institute of Medicine, 2004). The National Assessment of Adult Literacy is performed by the U.S. Department of Education to document the state of literacy in the American public every 10 years. The 2003 National Assessment of Adult Literacy was the first large-scale assessment of the United States to include a section aimed at measuring health literacy (Kutner, Greenberg, Jin, & Paulsen, 2006). The survey of more than 19,000 adults found that most adults (89%) surveyed had less than proficient health literacy (Kutner et al., 2006). The survey also found that adults aged 65 years and older had lower health literacy overall than adults in younger age groups (Kutner et al., 2006).
Although specific interventions that improve health outcomes for patients with low health literacy have not been definitive, strategies including strengthening patient–provider communications and improving patient comprehension of health information have been offered (Kountz, 2009; National Quality Forum, 2010; Potter & Martin, 2005). Strategies offered for improving patient comprehension include slowing down, limiting the amount of information provided in each visit, steering clear of medical jargon, providing patient educational materials in appropriate reading levels, confirming patient understanding with the teach-back method, and encouraging the patients to ask questions (Kountz, 2009; Potter & Martin, 2005).
Consideration must also be given to the patient’s literacy levels and the readability level of the written information provided (variety of resources from different populations). An earlier study found that the suitability of various neurology patient educational brochures and information found on the World Wide Web did not match to the patient population needs or the average U.S. reading levels (Murphy, Chesson, Berman, Arnold, & Galloway, 2001). The results of the study suggest that many neurological patient education materials need improved readability and overall suitability to be useful as a patient education tool. It concluded that written materials that healthcare professionals use should employ simpler words, short sentences, large print, and appropriate instructional graphics. Including these suitability factors, along with improved patient interaction, may improve the overall effectiveness of the education materials (Murphy et al., 2001).
Appropriate educational interventions and materials are also an important factor for patients with cognitive impairment (Vance et al., 2008; Vance, Larsen, Eagerton, & Wright, 2011). Comorbidities and medications used to treat them in addition to cognitive impairment may contribute to poorer cognitive functioning (Vance et al., 2011). Because nurses work with patients with comorbidities, it is important to understand their cognitive deficits and apply appropriate strategies for intervening. One such strategy is a technique called spaced retrieval (Vance et al., 2008). Using spaced retrieval in educating the cognitively impaired patient by a nurse would begin with a patient initially memorizing a piece of information and recalling it immediately (Vance et al., 2008). The patient is then asked to recall the information over progressively longer periods of time. This method has been shown to be effective in cognitively intact adults as well as in aging adults with stroke, dementia, and HIV (Vance et al., 2008).
The teach-back method has been suggested as an approach to assess and promote patient understanding (Mayer & Villaire, 2009). Patients are frequently given instructions and information by healthcare providers, but it is difficult to determine how much of the information the patient understands and can apply. By employing the teach-back method, the nurse can readily assess the educational needs of the patient. The teach-back method engages the patient and asks the patient to repeat what they have been taught in their own words. If a gap in education is identified, the healthcare provider can find another way to deliver the education. Case study evidence shows promise with this method among heart failure patients at the Leheigh Valley Hospital, and the University of California San Francisco Medical Center reduced readmission rates for patients over the age of 65 years by almost one third by employing the teach-back method (Rush-Monroe, 2011). Given the multitude of cognitive problems with the NMS population, the teach-back method may prove to be a good approach.
The project was conducted in a 403-bed, for-profit Midwestern tertiary care facility. The hospital is located in a suburban area with a population of approximately 253,000. Specialty services provided at the hospital include a transplant center, chest pain center, cancer center, and stroke center. The NMS is a 21-bed unit with a budgeted average nurse-to-patient ratio of 1:3.5. Permission was requested to conduct the project through the hospital’s institutional review board, and the project was considered exempt from the institutional review board review.
The general patient population for this unit includes patients recovering from neurological, neuro-trauma, and neurosurgical events. As a result, many of the patients on the unit have a variety of neurological and cognitive deficits. During the time of the study, a random chart audit of 23 patients indicates that these patients have an average length of stay of 2.7 days (range, 1–9 days), average age of 62 years (range, 20–96 years), and Glasgow Coma Scale at discharge of 11–15.
The questionnaire used to evaluate this project was the CMS HCAHPS survey. The data were gathered by the facility on a regular basis, and the results were reported to the unit management. The process of data collection for the survey involved randomly selecting patients who had been discharged from the unit and then contacting trained data collectors by telephone, using preset CMS HCAHPS questions. To evaluate the project, data from 3 months before and 3 months after the implementation were used.
The HCAPS survey measures patient satisfaction by asking 27 specific questions related to 18 core questions about communication with doctor and nurses, the responsiveness of hospital staff, the cleanliness and quietness of the hospital, pain management, communication about medications, discharge information, overall rating of the hospital, and whether they would recommend the hospital. For five of the HCAHPS composites (communication with nurses, communication with doctors, responsiveness, pain management, and communication about medications), results are based on a scale of always, sometimes, usually, and never. The survey also measures patients’ overall rating of the hospital and their willingness to recommend it on a scale of 0 to 10.
After adjusting for the mode of survey administration, the characteristics of patients in participating hospitals, and differences between participating and nonparticipating patients, the government “bundles” the questions into 10 categories and calculates composite scores (CMS, 2012). Patient satisfaction with medication education was evaluated using only the preadjusted HCAHPS scores of those who answered “always” to the question “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?”
After performing a literature review and contacting facilities that were successfully managing patient education to gather strategies, the program was developed and named “Always Ask.” The program consisted of multiple interventions including (a) patient informational handouts inserted into admission folders, (b) nurse education about the importance of providing education on side effects to patient and discussion of their involvement with the program, (c) unit flyers with nurse education, and (d) various communications with bedside nurses through personal work mail and emails.
A patient informational handout was developed and inserted into all patient admission folders. The inserts encouraged the patients to simply ask their nurses, “What is this medication? Why am I taking this medication? What are the possible side effects of this medication?” The message of the inserts was to encourage patients to always ask their nurses when they have questions about their medications. The “Always Ask” handouts were introduced to the patient folders on January 16, 2012.
An important part of the program was to garner nursing support. Each nurse was provided information about the program and the intended outcome. Specific information about medication side-effect education was provided to all the nurses working in NMS using both verbal communication and written reminders. A member of the PPT met with many of the NMS staff nurses in small informal groups to provide verbal instructions before the implementation of the “Always Ask” patient handouts. The nurses were asked to begin providing patients with both verbal and written medication side-effect education on all first-time medications. The PPT member, along with various written reminders, asked the nurses to focus on deliberately using the key word “side effects” when giving the education to their patients while keeping things simple and steering clear of medical jargon.
In addition, before the administration of new medication, the nurses were asked to provide written education to all of their patients by obtaining a handout of common side effects from Micromedex CareNotes. CareNotes provides a simple list of possible side effects as well as the more serious side effects of a medication. The nurses were asked to initially review these side effects with the patient when a medication was given for the first time. Nurses were asked to employ the teach-back method to review and reinforce the medication side-effect teaching. More specifically, during hourly rounding, the nurses were asked to have the patient recall the side effects from the previous teaching and ask the patient if they are experiencing any of the side effects discussed. At bedside report, the nurses were asked to use the teach-back method to review and reinforce the possible side effects with the patient and oncoming nurse. Nurses were given time to express their concerns and offer suggestions. Once all the nursing staff had been contacted and educated, the program was implemented.
Throughout the program, various flyers were hung around the unit to remind the nurses of their responsibilities with the “Always Ask” program. Work mail communications were used to emphasize the importance of medication side-effect education and acted as reminders. To stay informed on their progress and improvements, nurses received weekly updates on HCAHPS scores via email.
CMS HCAHPS Sampling Process
The sample was obtained from all patients on the NMS unit. Sampling for the HCAHPS patient satisfaction data is done from eligible discharges on a monthly basis. Inclusion criteria that are eligible for the survey include that patients must (a) be 18 years or older at the time of admission to the hospital, (b) have a length of stay that includes at least one overnight stay, (c) have received a nonpsychiatric diagnosis at discharge, and (d) be alive at discharge. Exclusion criteria for the HCAHPS survey are (a) prisoners, (b) patients with a foreign home address, and (c) patients discharged to hospice care. Patients who met the inclusion criteria for the survey were contacted by telephone at some point between 48 hours to 42 calendar days from their discharge date. The 3 months before and after the implementation was the time period for the sample to be collected.
The sample consisted of 163 respondents discharged from NMS. Sixty respondents were seen in NMS preintervention, and 61 respondents were surveyed in postintervention. The success of the project was evaluated using a preimplementation/postimplementation design. The goal was to see improvement in satisfaction scores regarding medication side-effect education after the implementation. Patient satisfaction data consisted of scores for medication education on side effects using the standardized HCAHPS patient satisfaction survey.
The preintervention HCAHPS scores were compared with the scores after the implementation of the “Always Ask” program. Before the project, the average satisfaction score was 29.7% of the respondents who reported “always” when asked how often hospital staff described possible side effects in way they could understand. After implementation, the average score was 77.3% of the respondents who reported “always” (Table 1).
A graphic representation of the data showed a sharp climb in satisfaction scores after the project implementation (Figure 1). This sudden increase was followed by a slight decline in mid-February and then a leveling off with the scores obtained from March and April. Postimplementation scores continued to trend higher than preimplementation scores.
In this project, an evidence-based approach was implemented to attempt to improve patient satisfaction scores related to medication side effects on an NMS unit. These patients frequently experience cognitive impairment and functional difficulties that can affect the way they understand and handle medications. Adequate education and awareness of the importance of medication education on side effects was the cornerstone to the “Always Ask” project. The purpose of this project was to develop an educational approach for medication side effects for the post acute neurosurgical patient, initiate an approach on NMS unit, and evaluate whether the use of the approach was successful in improving patient satisfaction scores related to the education on medication side effects.
Informational handouts were provided to the patients that encouraged them to always ask about their medications including the possible side effects. Nurses were responsible for providing the patients with both written and verbal education on the potential side effects of all first-time medications. The written information was obtained from Micromedex CareNotes and provided a simple list of both common and serious side effects. The written and verbal information provided to the patients was to be reviewed and reinforced during hourly rounding and bedside report using the teach-back method.
Upon evaluation of the data, there was an increase in patient satisfaction after the implementation of the “Always Ask” program. Although the increase in scores could have resulted from the “Always Ask” program, it could have also been a result of the bedside reporting and hourly rounding hospital-wide competency that occurred around the same time as the “Always Ask” program. The hospital competency was a nursing skills laboratory that required nurses to show proficiency of bedside report and hourly rounds. In the competency, nurses were required to teach the patients on medication side effects. This, in combination with the “Always Ask” program, could have provided enough impact to affect the satisfaction scores on the NMS unit.
The project was successful in identifying a major barrier within this patient population. In the discussion with the nursing staff and after brief surveys, nurses on the unit reported being skeptical about the benefit and rationale of educating this specific patient population because of their cognitive deficits. In fact, when the nurses were asked to identify the barriers in educating patients on medication side effects, responses included “cognitive deficits” and “poly-pharmacy.” Other barriers stated by these nurses included short staffing, time constraints, and citing that medication education is not a part of their workflow. One nurse also stated that “all the side effects scare people.” Many of these barriers were addressed informally by providing the nurses with the education and the literature that educating those with neurological and cognitive deficits requires tailoring and reinforcing. However, it was evident that some of the attitudes and beliefs of the nurses on NMS regarding education of the cognitively impaired were barriers that may require a more formal approach to staff education to change perceptions.
Along with formalizing the nursing staff’s education, additional benefits may be seen by taking a more collaborative and multidisciplinary approach to education. Given that the survey question is phrased, “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?,” perhaps, physician and pharmacy involvement could augment the efforts made by nursing. Further study and improvement may also be seen if the literacy level of the provided written information to patients and the literacy screening of the NMS population were tested.
The “Always Ask” project supported the literature that shows the importance of both verbal and written education that needs to be done in a simple way that patients can understand (Borgsteede et al., 2011; Kountz, 2009; Potter & Martin, 2005). This project adds to the literature by specifically addressing the potential impact that these educational strategies have on patient satisfaction for patients who may experience neurological and cognitive deficits.
Further research is needed to evaluate the “Always Ask” program implementation and its effectiveness on improving patient satisfaction related to medication side-effect education. Because implementation was done in only one NMS unit in a single hospital, further research on the effectiveness of using the teach-back method in other populations with neurological and cognitive impairments is warranted. In addition, it is difficult to determine whether the findings were a direct effect of the “Always Ask” project. Adherence to the educational approach by nursing staff is not known, and further research and interventions are needed to determine nursing’s compliance with patient education. The project helped to identify a few potential barriers, but further research is also needed to identify other barriers to patient education on medication side effects as well as the strategies that could be used to overcome these barriers.
The multimethod approach used in the “Always Ask” program has the potential to improve patient-perceived quality of care and satisfaction. Low health literacy, in combination with cognitive and neurological deficits, places an increasing responsibility on nurses to effectively communicate to promote and improve health outcomes. Regardless of cognitive and neurological deficits, nurses must recognize the importance of improving outcomes by performing medication education for all patients. The teach-back method may prove to be a viable approach for nursing to assess gaps in patient knowledge and improve patient satisfaction by communicating about possible medication side effects.
Borgsteede S. D., Karapinar-Carkit F., Hoffmann E., Zoer J., van den Bemt P. (2011). Informational needs about medication according to patients discharged from a general hospital. Patient Education and Counseling, 83 (1), 22–28.
Boulding W. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. American Journal of Managed Care, 17 (1), 41–48.
Costa L. L., Poe S. S., Lee M. C. (2011). Challenges in posthospital care: Nurses as coaches for medication management. Journal of Nursing Care Quality, 26 (3), 51.
Counts M. M., Mayolo R. (2007). Growing revenues with APNs. Nursing Management, 38 (6), 49–50.
Drain M., Clark P. A. (2004). Measuring experience from the patient’s perspective: Implications for national initiatives. Journal for Healthcare Quality Online, 26, W4–W16. Retrieved from www.nahq.org/journal
Gandhi T. K., Burstin H. R., Cook E. F., Puopolo A. L., Haas J. S., Brennan T. A., Bates D. W. (2000). Drug complications in outpatients. Journal of General Internal Medicine, 15 (3), 149–154.
Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press.
Kountz D. S. (2009). Strategies for improving low health literacy. Postgraduate Medicine, 121 (5), 171–177.
Kutner M., Greenberg E., Jin Y., Paulsen C. (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. U.S. Department of Education. Washington, DC: National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubs2006/2006483.pdf
Mayer G., Villaire M. (2009). Enhancing written communications to address health literacy. Online Journal of Issues in Nursing, 14 (3), 4. doi:10.3912/OJIN.Vol14No03Man03
Murphy P. W., Chesson A. L., Berman S. A., Arnold C. L., Galloway G. (2001). Neurology patient education materials: Do our educational aids fit our patients’ needs? Journal of Neuroscience Nursing, 33 (2), 99–104.
National Quality Forum. (2010). Safe practices for better healthcare—2010 update: A consensus report. Washington, DC: Author.
Vance D., Larsen K. I., Eagerton G., Wright M. A. (2011). Comorbidities and cognitive functioning: Implications for nursing research and practice. Journal of Neuroscience Nursing, 43 (4), 215–224.
Vance D. E., Webb N. M., Marceaux J. C., Viamonte S. M., Foote A. W., Ball K.K. (2008). Mental stimulation, neural plasticity, and aging: Directions for nursing research and practice. Journal of Neuroscience Nursing, 40 (4), 241–249.