AS A NEW GRADUATE NURSE in the residency program at Beebe Healthcare in Lewes, Del., I was required to present an evidence-based project at the end of my program. The project was to focus on finding a solution to a problem encountered in the hospital.
As the nurse resident for the 40-bed medical-surgical unit, I recognized a problem with how we were educating our patients about their medications. For safe and effective therapy, patients need to understand their medications, especially at discharge. But all too often, when I asked patients to tell me something about their medication, their responses were disheartening. Most of my patients couldn't say why they were taking certain medications. Many of them explained that they took them “because the doctor told me to.”
My observations were supported by the data on communication about medications according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores on the medical-surgical unit. The score, was only 33.3% in January 2016. The HCAHPS survey publicly reports data that measure how well patients understand the purpose of their medications and potential side effects of those medications at discharge.1 (See Understanding HCAHPS.)
Rather than providing patients with multiple pages of complex and overwhelming education for each medication, I wanted to find an easier and more effective way to educate them about their medications. Before this project started, we'd begin the education process at discharge. Now education about medications begins on admission. This allows patients and families time to understand their medications and potential side effects. The objective of my project was to improve the HCAHPS scores across all areas that address medication in our hospital. This article describes my research, the medication education sheets I developed, and the project's results.
To improve our medication communication scores on the HCAHPS survey, I created easy-to-read color-coded medication education sheets. According to psychologists Dzulkifli and Mustafar, color can have a positive effect on memory.2
During my research, I found many theories about how colors can enhance memory. In 1976, Farley and Grant proposed the theory that colors have a stronger effect on a person's attention and created a study to compare memory performance with color presentations versus black-and-white presentations.3 Colored presentations proved better at attracting the individual's attention and improving memory performance.3
In another study, psychologist Yi Pan asked participants to remember colors and shapes of various objects.4 He then had the participants take a memory test on the colors and shapes presented. He found that the participants could more quickly identify the color differences than the shape differences. He concluded that colors can capture attention better than other variables and can increase memory performance.4
My research supported the idea that color-coded medication education sheets would improve the retention of medication knowledge.
The HCAHPS survey encompasses many aspects of a patient's hospitalization.1 This project focused on these questions related to medications:
- “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?”
- “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?”
Using the medication education sheets
The left side of the medication education sheet has the purpose of the medication and the most common side effects. The right side has the list of the most commonly used medications of that type at Beebe Healthcare.
When educating patients about their medications, the clinical nurse circles or highlights the medication the patient is receiving and explains the medication's purpose and the most common side effects. This form is reviewed with patients and their families on every shift.
Patient education using the medication sheets began in January 2016 on our medical-surgical unit. In February 2016, file holders were hung on the wall in each nurse's station for quick and easy access to this information.
Incorporating change into practice
To help make this practice part of our everyday routine, our medical-surgical unit selected this for a Team Daily Management (TDM) project from March to July 2016. At our facility, TDM focuses on identified areas of quality improvement that need to be addressed in each department. A visualization board in every department identifies the specific goals of the department. Twice daily, the staff and leadership conduct rounds in each department to discuss the struggles and successes of each goal, with the objective of bringing leadership and staff together to problem-solve more effectively.
During this time, the charge nurses rounded daily on patients, inquiring about their medication education and asking patients what they'd learned. Adherence to using the medication education sheets and patients' ability to acknowledge education received was measured. HCAHPS scores related to medication ranged from 84% to 95% when the project ended in July 2016.
The medication education sheets proved easy for the nurses to use, and patients and families appreciated their simplicity, according to verbal feedback during daily rounds. We reviewed HCAHPS scores from patients discharged each month for a more accurate reflection of results. We noted a significant improvement in HCAHPS scores. From February through July 2016, medication communication HCAHPS scores increased from 33.3% to 95%. We attributed this substantial change to using the medication sheets and the patients' increased ability to acknowledge the education process.
The HCAHPS scores related to teaching the patient about the purpose of new medications increased from 62.5% in February to 100% in July. Scores for staff describing possible side effects increased from 12.5% in February to 71.4% in July.
Other units have implemented this method as well, and it's become a successful hospital-wide initiative at Beebe Healthcare. After we reported our success, other departments began using the medication sheets and have also reported successful outcomes based on an increase in those departments' HCAHPS scores. We've heard positive staff feedback about the medication sheets, and we're continuing to see improvements in our medication scores on the HCAHPS surveys.
To make sure the most current and up-to-date information is being presented to our patients, the pharmacy and the diabetes teams frequently review the medication sheets and provide feedback. The medication sheets were initially reviewed by our unit pharmacist, who then approved them to be used in the unit. The medication sheets were then reviewed and approved by the main hospital pharmacy and therapeutic committee at Beebe Healthcare and are now considered a standard hospital form.
In April 2017, I gave a presentation about the medication education sheets at the Nurses Improving Care for Healthsystem Elders Conference in Austin, Tex. Since then, other hospitals have shown an interest in the medication education sheets. I hope to attend more conferences in the future, so I can continue to educate others about the success I've had by creating and using the medication education sheets. I'd like to see the medication education sheets used in all outpatient settings, including healthcare providers' offices and pharmacies, so they reach everyone in our community.
For the future, my plans include initiating follow-up phone calls about medications after hospital discharge to determine if calls help improve patients' understanding of medication use and potential side effects and in turn help decrease repeat hospitalizations due to medication nonadherence. I'm also in the process of creating an app so that the medication education sheets can continue to grow on a digital level and become available to a larger patient population.
Nurses at Beebe Healthcare continue to provide and review medication sheets with their patients every shift. We have new patient discharge folders that are given to patients upon admission so patients can keep all the information they're given in one place. These folders have a section for medication education. I hope to continue to embed the medication education sheets in not only our culture at Beebe Healthcare but also in other facilities.
To measure patients' perceptions about the care they've received in a hospital, they're asked to respond to the standardized HCAHPS survey.1 This national survey measures patients' hospital experiences by asking them about their perspectives on different areas throughout their hospitalization. The HCAHPS survey is currently a 32-item standardized survey administered to patients discharged from all U.S. Medicare-participating hospitals.1
According to the Centers for Medicare and Medicaid Services, the results are publicly reported on Hospital Compare as top-box, bottom-box, and middle-box scores.1 The top box is the most positive score, which is “always” for the five HCAHPS composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines). The middle-box response is “usually” for five HCAHPS composites. The bottom-box is the least positive response, which is “sometimes or never” for five HCAHPS composites.
HCAHPS Hospital Survey. Centers for Medicare & Medicaid Services, Baltimore, MD. 2014. http://www.hcahpsonline.org.
2. Dzulkifli MA, Mustafar MF. The influence of colour on memory performance: a review. Malays J Med Sci. 2013;20(2):3–9.
3. Farley FH, Grant AP. Arousal and cognition: memory for color versus black and white multimedia presentation. J Psychol. 1976;94(1):147–150.
4. Pan Y. Attentional capture by working memory contents. Can J Exp Psychol. 2010;64(2):124–128.
Bartlett Ellis RJ, Werskey KL, Stangland RM, Ofner S, Bakoyannis G. Using HCAHPS data to model correlates of medication understanding at hospital discharge. Nurs Res Rev. 2017;7:1–7.
Zullig LL, Peterson ED, Bosworth HB. Ingredients of successful interventions to improve medication adherence. JAMA. 2013;310(24):2611–2612.