Higher learning
Reinforcing discharge education and planning By Bobbie Reddick, EdD, MPH, RN, and Cecil Holland, EdD, PhD, RN
D
ischarge education and planning are critical components of quality patient care. These elements ensure that patients’ needs after discharge from the hospital are met and they can function at an optimal level after they return home. Because inadequacies in discharge teaching or planning may also contribute to higher readmission rates, all nurses must engage in discharge instruction when the patient is initially seen in the healthcare facility. Teaching staff members and patients the importance of early discharge education is vital and must be reinforced at every level of the healthcare organization.1 Discharge planning should consist of four phases or activities: (1) patient assessment; (2) development of a discharge plan; (3) provision of services, including patient/family education and services; and (4) follow-up evaluation. An essential element of discharge planning is education. Evidence proposes that discharge education and planning improve health outcomes.1-3 As nurse leaders and patient care advocates, it’s important to assess staff members’ level of knowledge regarding discharge education. Regulatory agencies such as the Centers for Medicare and Medicaid Services and The Joint Commission mandate discharge planning as a core measure of quality, accreditation, and compliance.4 This article provides general information regarding what clinical nurses need to know about discharge education and planning. Particular focus will be directed to the nurse leader’s role in ensuring that nurses are educated to provide
10 May 2015 • Nursing Management
optimal discharge education and planning. Although the breadth of discharge education and planning has increased over the years, it’s critical that nurses understand its full scope and interdisciplinary approach. Nurse leaders must ensure that clinical nurses are knowledgeable about alternative resources available to the patient at discharge. Educating clinical nurses on in-reach and outreach services, rapid-access clinics, and other critical resources not only increases the pace of discharge, but also promotes continuity of care and embraces the concept of interprofessional collaboration.5 What we need to know Although discharge education can be challenging, it plays a vital role in ensuring quality patient outcomes. Many factors may contribute to the challenges and barriers nurses face related to discharge education, such as healthcare system issues, including, but not limited to, staff workload, patient or family members’ physical or emotional readiness to learn, low literacy levels, and social issues. The following strategies can be helpful to improve discharge planning and minimize or eliminate barriers to discharge education. Healthcare system issues One significant healthcare system issue is staffing. Research shows that adequate staffing is essential to facilitate meaningful and focused discharge education. When RN staffing is appropriate, nurses are better able to provide more effective discharge planning.5-7 By utilizing staffing data systems, nurse leaders can make sound nursing resource management decisions. Not only do data management systems provide valuable information regarding staffing mix and ratios, they also support the nurse leader’s decisions. Nurse leaders must rely on the data available to them to make the best decisions that impact quality healthcare outcomes.8 www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning Patient and family readiness A key step in discharge education is recognizing a patient and/or family member’s readiness to learn. Nurses must assess learning needs related to discharge education and planning. Individualized education and planning needs should be developed based on the patient assessment, readiness to learn, and patient and family needs.9 Nurse leaders must ensure that clinical nurses properly assess the patient’s readiness to learn. Strategies that are employed to assess patient’s readiness may also be used to evaluate the nurse’s assessment of a patient’s readiness to learn. One way to do this is by observing discharge education. The nurse leader may follow a clinical nurse during his or her rounds to ensure appropriate evaluation of the patient’s readiness to learn. Another method may be to
planning. Nurses at every level in the healthcare system must learn about the social constructs of the patient to facilitate appropriate and significant discharge education and planning. Special consideration must be given to social factors, such as transportation, support systems, finances, social programs, level of dependency on others, and so on.6 Engaging in interprofessional collaborations will ensure that social issues are addressed at multiple healthcare provider levels.11,12 Research suggests that for interprofessional collaboration to be effective, a clear understanding of roles and responsibilities is needed. This will contribute to respect and trust among healthcare providers and positive patient outcomes. Effective interprofessional collaboration improves accountability and referrals
Ensure that clinical nurses’ discharge teaching and planning occurs every day in every patient care area at the level of the patient’s literacy. conduct interviews or focus group sessions with nurses to gain an understanding of how they assess readiness to learn. This may provide valuable data in terms of possible nurse education needs related to assessing readiness to learn. Other methods to ensure nurses are appropriately assessing learning needs may include gathering information from the nurse and other multidisciplinary healthcare team members and reviewing written data in the patient’s medical record.10 Social issues A myriad of social factors may influence discharge education and 12 May 2015 • Nursing Management
between disciplines, thereby improving healthcare systems and patient outcomes.13 Interdisciplinary planning Input by multiple disciplines into discharge planning is more effective due to the expertise of each discipline in identifying and meeting the patient’s home care needs. Through professional interaction, the patient’s needs are more readily identified, and adequate and appropriate referrals and services are coordinated and provided in a timely manner. For example, a case manager with knowledge of the available community resources
and linkages to these services can efficiently implement aftercare services.12 Timing The timing and quality of instruction are also critical to the successful transition of patients from the hospital to home. Information on the patient’s present condition and continuity of care should be given to the patient and family, if possible, as soon as the patient is admitted to the facility. The nurse should identify appropriate times when the patient is alert, pain free, or has family present throughout the day when the patient and/or family can discuss home care.14 As nurse leaders, ensuring the appropriate nurse-patient ratio may facilitate the opportunity and time for clinical nurses to engage in the critical component of discharge education and planning. Learning Effective learning requires making multiple connections of new ideas to old ones; it often requires the individual to radically restructure his or her beliefs and thinking. Simply put, nurses must “provide the context of the instruction—the part the patient already knows— first.”15 The nurse must assess the patient’s beliefs, knowledge, and misconceptions before providing new information. The nurse should present new information on diagnosis, treatment, and adverse reactions slowly and use as many of the patient’s senses (visual, auditory, tactile, and kinesthetic) as possible.12 Nurse leaders must ensure that clinical nurses’ discharge teaching and planning occurs every day in every patient care area at the level of the patient’s literacy. If this isn’t happening on the nursing unit, the nurse leader must provide www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning techniques and strategies that will assist the nurse in the culture change. For example, we can provide inservice and/or continuing education that’s culturally sensitive and meets patients where they are. The barrier of low literacy levels A confounding factor to be considered during discharge education and planning is the literacy level of the patient and/or family. Many patients struggle to understand discharge instructions and healthrelated materials. Failure to understand health-related concerns, including discharge education or instructions, may lead to unwarranted healthcare outcomes. To mitigate the low literacy factor, discharge education should be presented in an easy and understandable format. Nurse leaders should design or locate educational materials based on a thorough assessment of the learning needs, style, and reading level of the patient and/or family member. Consider educational materials at the sixth grade reading level because research suggests that approximately 75% of American adults will be able to read at this level.16 Additional tips that nurses can employ when working with patients and/or family members with low literacy levels include setting realistic objectives, focusing on behaviors and skills, presenting the content before giving instructions, breaking down complex instruction, and making educational sessions interactive. These strategies are designed to improve discharge education and planning outcomes.15,16 Although all of the aforementioned issues influence an effective discharge process, nurse managers should pay special attention to the literacy skills of all patients. www.nursingmanagement.com
Although most adults read at an eighth grade level, one fifth of the adult population reads at or below a fifth grade level. Approximately 90 million adults have fair-to-poor literacy and one half of adults are unable to understand printed healthcare material. Research suggests that most healthcare materials are written at a 10th grade level.17 According to the literature, low reading skills and poor health are related. Patients with low health literacy have many problems or obstacles when accessing and using
Nurse leaders must assess clinical nurses’ knowledge related to educating patients with low-literacy levels and develop and implement inservice education activities to improve and enhance staff members’ ability to handle low-literacy patients. Nurse leaders must be engaged in on-going evaluation of all plans aimed at improving clinical nurses’ ability to educate low-literacy patients. Leaders must prepare Discharge planning and education of patients from the hospital to the
Inadequacies in discharge teaching or planning may contribute to higher readmission rates, so all nurses must engage in discharge instruction. the healthcare system.17 Many can’t complete health insurance forms, sign documents that they don’t understand, or follow directions provided to them at the physician’s office. In addition, many don’t understand their medical conditions because they don’t understand the words used by their healthcare providers. This problem is confounded for patients whose primary language isn’t English. Educational materials must be clear, simple, and written at an appropriate level.17 Other strategies to improve discharge education and patient outcomes include using “living room” language instead of medical language, utilizing pictures to enhance understanding, limiting the amount of discharge instruction given at any one time, repeating instructions, using the “teach back” method, and being respectful and sensitive to the needs of the patient.17
community has always been viewed as a critical part of meeting the patient’s continuing care needs. However, a smooth transition is needed to achieve this objective. Therefore, nursing and hospital leaders must develop and have a formal discharge planning process in place that includes interprofessional collaboration to effectively meet the treatment needs of patients and achieve adequate healthcare results. NM
REFERENCES 1. Mamon J, Steinwachs DM, Fahey M, Bone LR, Oktay J, Klein L. Impact of hospital discharge planning on meeting patient needs after returning home. Health Serv Res. 1992;27(2):155-175. 2. Carroll A, Dowling M. Discharge planning: communication, education and patient participation. Br J Nurs. 2007;16(14): 882-886. 3. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse. 2008;28(2):66-82. Nursing Management • May 2015 13
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning 4. Treitler QZ, Kim H, Hunter M. Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2656019/. 5. Lees L. The key principles of effective discharge planning. http://www.nursingtimes. net/Journals/2013/01/17/x/l/m/ 130122-Effective-discharge-planning.pdf. 6. Rakoczy C. 5 of the biggest discharge dilemmas: barriers to effective case planning. https://www.openplacement.com/ community/blog/5-of-the-biggestdischarge-dilemmas-barriers-to-effectivecase-planning/. 7. TruthAboutNursing.org. What happens to patients when nurses are short-staffed or work with a high nurse-to-patient ratio? http://www.truthaboutnursing.org/faq/ short-staffed.html. 8. Department of Veteran Affairs Office of Inspector General. Healthcare inspection evauluation of nurse staffing veteran health administration facilities report number 03-00079-183. http://www.va.
14 May 2015 • Nursing Management
gov/oig/54/reports/VAOIG-03-00079183.pdf. 9. UH.net. Patient/family learning education module. http://www.uhnj.org/uhnetweb/ patienteducation/Learningmodule.htm. 10. Bastable S. Essentials of Patient Education. Sudbury, MA: Jones and Bartlett Publishers;2006:73. 11. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. 12. Bethea DP, Holland CA Jr, Reddick BK. Storming the gates of interprofessional collaboration. Nurs Manage. 2014;45(9): 40-45. 13. Tarling M, Jauffur H. Improving team meeting to support discharge planning. http://www.nursingtimes.net/Journals/ 2013/04/10/d/h/v/060627Improvingteam-meetings-to-support-dischargeplanning-.pdf. 14. American Association for the Advancement of Science. Effective learning and
teaching. http://www.project2061.org/ publications/sfaa/online/Chap13.htm. 15. Euromed Info. Helping patients who have low literacy skills. http://www.euromedinfo. eu/helping-patients-who-have-low-literacyskills-introduction.html/. 16. Euromed Info. Designing low literacy materials. http://www.euromedinfo.eu/ designing-low-literacy-materials.html. 17. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. At Winston-Salem University in WinstonSalem, N.C., Bobbie Reddick is an associate professor of Nursing and Cecil Holland is the assistant dean of Nursing and an associate professor. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000463887.70222.50
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Reinforcing discharge education and planning By Bobbie Reddick, EdD, MPH, RN, and Cecil Holland, EdD, PhD, RN
D
ischarge education and planning are critical components of quality patient care. These elements ensure that patients’ needs after discharge from the hospital are met and they can function at an optimal level after they return home. Because inadequacies in discharge teaching or planning may also contribute to higher readmission rates, all nurses must engage in discharge instruction when the patient is initially seen in the healthcare facility. Teaching staff members and patients the importance of early discharge education is vital and must be reinforced at every level of the healthcare organization.1 Discharge planning should consist of four phases or activities: (1) patient assessment; (2) development of a discharge plan; (3) provision of services, including patient/family education and services; and (4) follow-up evaluation. An essential element of discharge planning is education. Evidence proposes that discharge education and planning improve health outcomes.1-3 As nurse leaders and patient care advocates, it’s important to assess staff members’ level of knowledge regarding discharge education. Regulatory agencies such as the Centers for Medicare and Medicaid Services and The Joint Commission mandate discharge planning as a core measure of quality, accreditation, and compliance.4 This article provides general information regarding what clinical nurses need to know about discharge education and planning. Particular focus will be directed to the nurse leader’s role in ensuring that nurses are educated to provide
10 May 2015 • Nursing Management
optimal discharge education and planning. Although the breadth of discharge education and planning has increased over the years, it’s critical that nurses understand its full scope and interdisciplinary approach. Nurse leaders must ensure that clinical nurses are knowledgeable about alternative resources available to the patient at discharge. Educating clinical nurses on in-reach and outreach services, rapid-access clinics, and other critical resources not only increases the pace of discharge, but also promotes continuity of care and embraces the concept of interprofessional collaboration.5 What we need to know Although discharge education can be challenging, it plays a vital role in ensuring quality patient outcomes. Many factors may contribute to the challenges and barriers nurses face related to discharge education, such as healthcare system issues, including, but not limited to, staff workload, patient or family members’ physical or emotional readiness to learn, low literacy levels, and social issues. The following strategies can be helpful to improve discharge planning and minimize or eliminate barriers to discharge education. Healthcare system issues One significant healthcare system issue is staffing. Research shows that adequate staffing is essential to facilitate meaningful and focused discharge education. When RN staffing is appropriate, nurses are better able to provide more effective discharge planning.5-7 By utilizing staffing data systems, nurse leaders can make sound nursing resource management decisions. Not only do data management systems provide valuable information regarding staffing mix and ratios, they also support the nurse leader’s decisions. Nurse leaders must rely on the data available to them to make the best decisions that impact quality healthcare outcomes.8 www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning Patient and family readiness A key step in discharge education is recognizing a patient and/or family member’s readiness to learn. Nurses must assess learning needs related to discharge education and planning. Individualized education and planning needs should be developed based on the patient assessment, readiness to learn, and patient and family needs.9 Nurse leaders must ensure that clinical nurses properly assess the patient’s readiness to learn. Strategies that are employed to assess patient’s readiness may also be used to evaluate the nurse’s assessment of a patient’s readiness to learn. One way to do this is by observing discharge education. The nurse leader may follow a clinical nurse during his or her rounds to ensure appropriate evaluation of the patient’s readiness to learn. Another method may be to
planning. Nurses at every level in the healthcare system must learn about the social constructs of the patient to facilitate appropriate and significant discharge education and planning. Special consideration must be given to social factors, such as transportation, support systems, finances, social programs, level of dependency on others, and so on.6 Engaging in interprofessional collaborations will ensure that social issues are addressed at multiple healthcare provider levels.11,12 Research suggests that for interprofessional collaboration to be effective, a clear understanding of roles and responsibilities is needed. This will contribute to respect and trust among healthcare providers and positive patient outcomes. Effective interprofessional collaboration improves accountability and referrals
Ensure that clinical nurses’ discharge teaching and planning occurs every day in every patient care area at the level of the patient’s literacy. conduct interviews or focus group sessions with nurses to gain an understanding of how they assess readiness to learn. This may provide valuable data in terms of possible nurse education needs related to assessing readiness to learn. Other methods to ensure nurses are appropriately assessing learning needs may include gathering information from the nurse and other multidisciplinary healthcare team members and reviewing written data in the patient’s medical record.10 Social issues A myriad of social factors may influence discharge education and 12 May 2015 • Nursing Management
between disciplines, thereby improving healthcare systems and patient outcomes.13 Interdisciplinary planning Input by multiple disciplines into discharge planning is more effective due to the expertise of each discipline in identifying and meeting the patient’s home care needs. Through professional interaction, the patient’s needs are more readily identified, and adequate and appropriate referrals and services are coordinated and provided in a timely manner. For example, a case manager with knowledge of the available community resources
and linkages to these services can efficiently implement aftercare services.12 Timing The timing and quality of instruction are also critical to the successful transition of patients from the hospital to home. Information on the patient’s present condition and continuity of care should be given to the patient and family, if possible, as soon as the patient is admitted to the facility. The nurse should identify appropriate times when the patient is alert, pain free, or has family present throughout the day when the patient and/or family can discuss home care.14 As nurse leaders, ensuring the appropriate nurse-patient ratio may facilitate the opportunity and time for clinical nurses to engage in the critical component of discharge education and planning. Learning Effective learning requires making multiple connections of new ideas to old ones; it often requires the individual to radically restructure his or her beliefs and thinking. Simply put, nurses must “provide the context of the instruction—the part the patient already knows— first.”15 The nurse must assess the patient’s beliefs, knowledge, and misconceptions before providing new information. The nurse should present new information on diagnosis, treatment, and adverse reactions slowly and use as many of the patient’s senses (visual, auditory, tactile, and kinesthetic) as possible.12 Nurse leaders must ensure that clinical nurses’ discharge teaching and planning occurs every day in every patient care area at the level of the patient’s literacy. If this isn’t happening on the nursing unit, the nurse leader must provide www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning techniques and strategies that will assist the nurse in the culture change. For example, we can provide inservice and/or continuing education that’s culturally sensitive and meets patients where they are. The barrier of low literacy levels A confounding factor to be considered during discharge education and planning is the literacy level of the patient and/or family. Many patients struggle to understand discharge instructions and healthrelated materials. Failure to understand health-related concerns, including discharge education or instructions, may lead to unwarranted healthcare outcomes. To mitigate the low literacy factor, discharge education should be presented in an easy and understandable format. Nurse leaders should design or locate educational materials based on a thorough assessment of the learning needs, style, and reading level of the patient and/or family member. Consider educational materials at the sixth grade reading level because research suggests that approximately 75% of American adults will be able to read at this level.16 Additional tips that nurses can employ when working with patients and/or family members with low literacy levels include setting realistic objectives, focusing on behaviors and skills, presenting the content before giving instructions, breaking down complex instruction, and making educational sessions interactive. These strategies are designed to improve discharge education and planning outcomes.15,16 Although all of the aforementioned issues influence an effective discharge process, nurse managers should pay special attention to the literacy skills of all patients. www.nursingmanagement.com
Although most adults read at an eighth grade level, one fifth of the adult population reads at or below a fifth grade level. Approximately 90 million adults have fair-to-poor literacy and one half of adults are unable to understand printed healthcare material. Research suggests that most healthcare materials are written at a 10th grade level.17 According to the literature, low reading skills and poor health are related. Patients with low health literacy have many problems or obstacles when accessing and using
Nurse leaders must assess clinical nurses’ knowledge related to educating patients with low-literacy levels and develop and implement inservice education activities to improve and enhance staff members’ ability to handle low-literacy patients. Nurse leaders must be engaged in on-going evaluation of all plans aimed at improving clinical nurses’ ability to educate low-literacy patients. Leaders must prepare Discharge planning and education of patients from the hospital to the
Inadequacies in discharge teaching or planning may contribute to higher readmission rates, so all nurses must engage in discharge instruction. the healthcare system.17 Many can’t complete health insurance forms, sign documents that they don’t understand, or follow directions provided to them at the physician’s office. In addition, many don’t understand their medical conditions because they don’t understand the words used by their healthcare providers. This problem is confounded for patients whose primary language isn’t English. Educational materials must be clear, simple, and written at an appropriate level.17 Other strategies to improve discharge education and patient outcomes include using “living room” language instead of medical language, utilizing pictures to enhance understanding, limiting the amount of discharge instruction given at any one time, repeating instructions, using the “teach back” method, and being respectful and sensitive to the needs of the patient.17
community has always been viewed as a critical part of meeting the patient’s continuing care needs. However, a smooth transition is needed to achieve this objective. Therefore, nursing and hospital leaders must develop and have a formal discharge planning process in place that includes interprofessional collaboration to effectively meet the treatment needs of patients and achieve adequate healthcare results. NM
REFERENCES 1. Mamon J, Steinwachs DM, Fahey M, Bone LR, Oktay J, Klein L. Impact of hospital discharge planning on meeting patient needs after returning home. Health Serv Res. 1992;27(2):155-175. 2. Carroll A, Dowling M. Discharge planning: communication, education and patient participation. Br J Nurs. 2007;16(14): 882-886. 3. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse. 2008;28(2):66-82. Nursing Management • May 2015 13
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Higher learning 4. Treitler QZ, Kim H, Hunter M. Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2656019/. 5. Lees L. The key principles of effective discharge planning. http://www.nursingtimes. net/Journals/2013/01/17/x/l/m/ 130122-Effective-discharge-planning.pdf. 6. Rakoczy C. 5 of the biggest discharge dilemmas: barriers to effective case planning. https://www.openplacement.com/ community/blog/5-of-the-biggestdischarge-dilemmas-barriers-to-effectivecase-planning/. 7. TruthAboutNursing.org. What happens to patients when nurses are short-staffed or work with a high nurse-to-patient ratio? http://www.truthaboutnursing.org/faq/ short-staffed.html. 8. Department of Veteran Affairs Office of Inspector General. Healthcare inspection evauluation of nurse staffing veteran health administration facilities report number 03-00079-183. http://www.va.
14 May 2015 • Nursing Management
gov/oig/54/reports/VAOIG-03-00079183.pdf. 9. UH.net. Patient/family learning education module. http://www.uhnj.org/uhnetweb/ patienteducation/Learningmodule.htm. 10. Bastable S. Essentials of Patient Education. Sudbury, MA: Jones and Bartlett Publishers;2006:73. 11. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. 12. Bethea DP, Holland CA Jr, Reddick BK. Storming the gates of interprofessional collaboration. Nurs Manage. 2014;45(9): 40-45. 13. Tarling M, Jauffur H. Improving team meeting to support discharge planning. http://www.nursingtimes.net/Journals/ 2013/04/10/d/h/v/060627Improvingteam-meetings-to-support-dischargeplanning-.pdf. 14. American Association for the Advancement of Science. Effective learning and
teaching. http://www.project2061.org/ publications/sfaa/online/Chap13.htm. 15. Euromed Info. Helping patients who have low literacy skills. http://www.euromedinfo. eu/helping-patients-who-have-low-literacyskills-introduction.html/. 16. Euromed Info. Designing low literacy materials. http://www.euromedinfo.eu/ designing-low-literacy-materials.html. 17. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468. At Winston-Salem University in WinstonSalem, N.C., Bobbie Reddick is an associate professor of Nursing and Cecil Holland is the assistant dean of Nursing and an associate professor. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000463887.70222.50
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
