Essay Paper

September-October 2016 • Vol. 25/No. 5 297

Jessica R. Sherman, DNP, RN-BC, is Clinical Assistant Professor, Department of Nursing, College of Nursing and Health Sciences, University of Vermont, Burlington, VT.

An Initiative to Improve Patient Education by Clinical Nurses

A fter hospitalization, patients need to understand how to care for themselves at home.

One of the most important things nurses can do to improve outcomes is to educate patients about their self-care needs before discharge (London, 2016). Nurse educators must prepare clinical nurses through continuing education, in-service programs, and staff development to improve and maintain their teach- ing abilities (Bastable, 2014). Accord - ing to Lau-Walker, Landy, and Murrells (2016), as patient-centered education be comes more wide- spread, the need increases to support healthcare staff in confidence and satisfaction with delivery of patient education. Bastable (2014) suggested nurses must be equipped to provide effective education that meets the needs of individuals and groups from diverse backgrounds with dif- ferent needs. Reiter (2014) further noted the patient’s preconceived views are influenced by age, culture, learning ability, and language, which need to be considered when individ- ualizing education. Additionally, nurses who assess patient education requirements swiftly and modify educational efforts to the patient are invaluable members of the health- care team.

Literature Review A literature search for 2011-2016

was performed using CINAHL, Ovid, and PubMed databases. Key search words included patient educa- tion, nurse and patient education, self- care, teaching modalities, and learner assessment. Because the nursing lit- erature had little information on

methods for improving patient edu- cation or outcomes of patient edu- cation, an interprofessional search was conducted to determine if edu- cating healthcare personnel about a structured teaching approach would improve education delivery as well as patient outcomes.

Wilhelm and Petrovitch (2011) developed a structured anticoagula- tion teaching program to improve education services to inpatients before discharge with anticoagula- tion therapy. The setting included three facilities as part of an eight- hospital system: a large teaching hospital, a women’s hospital, and a rehabilitation center. This educa- tional program, which included a didactic presentation, focused on standardized counseling for oral and injectable anticoagulants. It was provided to pharmacy students and residents. The rationale behind developing such an educational program was a lack of patient edu- cation regarding anticoagulation therapy by pharmacists. After phar- macy students and residents were educated, they were placed on a teaching service responsible for anticoagulation patient education.

Using a retrospective review of 387 inpatient charts, authors exam- ined the impact of the anticoagula-

tion education teaching service on the rate of education being delivered and rate of readmission (Wilhelm & Petrovitch, 2011). Patients had been discharged home with a prescrip- tion for warfarin (Coumadin®) or low molecular weight heparin dur- ing a 5-month period before and after implementation of the teach- ing service. Authors found signifi- cant improvement in anticoagula- tion education rates after implemen- tation of the program (p<0.0001). Prior to implementation of the edu- cational program, 169 patients received education; 218 patients received education after the pro- gram began. No significant differ- ence was found in anticoagulant- related 30-day readmission rates of patients who received education versus those who did not. However, a significant difference was found in the 60-day readmission rate for patients who did not receive the teaching service anticoagulation education (50.5% vs. 37.9%, p=0.0141). This study concluded ini- tiatives in which healthcare person- nel are provided education on methods to deliver patient educa- tion can result in positive outcomes.

Warden, Freels, Furono, and Mackay (2014) also developed a structured educational approach

Jessica R. Sherman

Clinical nurses play a vital role in the delivery of patient education. The focus of the project described in this article was to promote a standard of practice that would improve nurses’ ability as effective, efficient patient educators.

Instructions for Continuing Nursing Education Contact Hours appear on page 300.

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with pharmacy students. Authors used a quasi-experimental design to measure the effect of a pharmacist- managed program for heart failure medication education and discharge instruction on 30-day readmission rates. They found a significant in - crease in discharge education and reduced 30-day hospital admissions in comparison to the control group (p=0.007).

Lau-Walker and co-authors (2016) evaluated the impact of integration of a Personalized Patient Education Protocol (PPEP) into an existing post-myocardial infarction care pathway. Nurses received training on use of the PPEP along with a workbook for patients. During a 2- month pilot, they practiced using the PPEP tool during patient dis- charge and were debriefed by the researcher on its use. Nurses also provided feedback to researchers on more effective use of the tool. Pat - ients with a confirmed diagnosis of myocardial infarction in a London hospital were invited to participate in a longitudinal patient survey. They were asked to complete ques- tionnaires before discharge and 3 months after discharge. Based on information about patients’ illness beliefs and expectations from the first questionnaire, nurses discussed and assisted patients to make con- nections between their individual illness perceptions and specific rec- ommended health promotion beha - vior to manage illness better. A PPEP workbook also was provided to the patients, with its purpose explained.

Authors found a significant change at 3 months (p=0.021), sug- gesting patients had a better under- standing of their illness (Lau-Walker et al., 2016). Patients also reported significant improvement in their general health (p=0.041), and 59% indicated the PPEP workbook was useful. In addition, nurses integrat- ing PPEP into the discharge process were interviewed. They identified their initial reluctance to incorporate the PPEP into their practice. How - ever, use of the PPEP allowed unique insight into patients’ perceptions of their own health

These studies suggested nurses

and other healthcare personnel may need further instruction on providing structured, effective pa - tient education. They also support- ed the premise that delivery of patient education increases and outcomes improve when providers receive this education. A need exists for the patient education curricu- lum developed for this project to improve clinical nurses’ ability as educators.

Improvement Needs The site for this quality improve-

ment project was an academic med- ical center in New England. The organization had no practice stan- dard for patient education. Central and unit-based nurse educators were responsible for educating nurs- ing staff rather than patients. The hospital also did not employ spe- cialty nurses dedicated to imple- menting patient education, which was the responsibility of clinical nurses. The purpose of this project was to provide nurses with a struc- tured approach to effective, effi- cient patient education.

Participants were clinical nurses from two inpatient medical-surgical units. The chosen inpatient nursing units were selected as the first two

units to schedule their clinical nurs- ing staff annual education days in 2013.

Quality Indicators and Data Collection

The clinical question for this project was as follows: Will clinical nurses demonstrate improvement in knowledge as well as perform- ance during a simulated patient sce- nario after completing a curriculum designed to promote effective and efficient patient education through the use of key steps to education?

The Plan Do Study Act (PDSA) cycle was used to guide this quality improvement project (Harris, Rous - sel, Walters, & Dearman, 2011). Assessment tools included a pretest- posttest (see Table 1) and pre-post simulation performance checklist (see Table 2). These tools were used to determine if an increase in base- line knowledge and performance occurred after RNs completed the patient education curriculum. They were developed by the project leader to connect directly with learner curriculum objectives. Content validity was established by experts in nursing, nursing educa- tion, and nursing simulation. Tools were edited based on expert recom-

TABLE 1. Pretest-Posttest Questions

1. The purpose of assessing a patient’s learning needs is to: 2. All are a correct example of setting mutual goals/objectives for the educa-

tional lesson with your patient except: 3. You have assessed your patient’s learning needs and determined

goals/objectives of the lesson. Your patient would like to know more about drain care and is a “hands-on” (kinesthetic) learner. What teaching method would be most appropriate to use with your patient?

4. “Teach-back” is a form of: 5. How do you know the patient has gained the necessary knowledge to

perform self-care safely at home? 6. If a patient has demonstrated or explained a detail from your educational

lesson incorrectly, you would first: 7. Health literacy means: 8. Effective patient discharge education provides the patient with: 9. You have determined your patient is an auditory learner. What would be the

best teaching tool to explain Lovenox® administration? 10. Patient education is:

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mendations and returned for review until all experts indicated the tools represented a connection to the learner curriculum objectives. The pretest-posttest consisted of 10 mul- tiple-choice questions. The simula- tion performance checklist includ- ed six performance objectives (meets to does not meet). Reliability of the tools could not be established dur- ing data analysis because partici- pants were not matched to them- selves for activities before and after education.

The patient education curriculum was reviewed, edited, and enhanced. Test questions that did not demon- strate improvement were evaluated and modified for future use. Nursing specialty simulation scenarios also were designed and added to the cur- riculum. The revised, enhanced patient education curriculum was given to the organization’s Director of Nursing Education and Research for distribution to all nurse educa- tors. The nurse educators integrated the patient education curriculum into professional development for clinical nurses throughout the organization, spreading and sustain- ing a standardized approach to patient education.

Action Plan and Evaluation This project used a one-group

pre-post design, with the designed patient education curriculum as the intervention. The curriculum focus - ed on providing nurses with key steps to standardize delivery of patient education and allow in - creased, improved patient educa- tion delivery. These key steps focused on assessing the learner, setting mutual learning goals and objectives, using appropriate teach- ing modalities, and evaluating with

teach-back. The 15-20 minute pres- entation also offered ways to imple- ment the key steps.

The project occurred during eight annual RN education days January- May 2013, with 85 nurses invited to participate. Before implementation, the project leader ex plained what could be expected in the pretest- posttest and pre-post simulation. Signed consent included agreement to maintain confidentiality of the exercises and to be video recorded. RNs who were participating in new graduate orientation were excluded from participation.

Participating RNs first completed the pre-test, after which they reviewed the simulation scenario and then entered the simulation. The scenario addressed a patient who was ready for discharge and needed education on a topic specif- ic to the participating RN’s unit (e.g., wound care, neutropenia). The simulation scenario used a standardized patient (SP) and was ended automatically if the partici- pant reached 15 minutes. After the simulation, RNs received instruc- tion in the patient education cur- riculum from one of two nurse edu- cators trained by the project leader. RNs who chose not to participate in the project also received the patient education content. Immed iately after the presentation, participants completed the posttest. RNs were allowed to review the same simula- tion scenario but complete it with a different SP. Again, simulation was ended for anyone reaching 15 min- utes in the scenario. After comple- tion of the final simulation, the SP stepped out of character to debrief the RN. The entire participant group then reconvened for a group debriefing by a certified healthcare simulation educator.

No identifying information was collected during the pretest-post - test. To maintain anonymity, simu- lations were recorded and viewed by two additional nurse educators who did not have direct contact with the participating nursing units. Nurse educators viewed each simulation using the simulation performance checklist. All tests, recordings, and simulation per- formance checklists were se cured in a locked office.

All participant answers were entered into an Excel (Microsoft, Inc.; Redmond, WA) document. Pretest and posttest averages were compared by participating unit and as a group. Individual test scores and simulation performance check- lists were compared as an overall test average. SPSS Statistics 21 soft- ware (IBM Corp.; Armonk, NY) was used to determine results of the Pearson Chi-Square test, Levene’s Test for Equality of Variance, and a t-Test for Equality of Means. The Pearson Chi-Square test also was completed on the pre-post simula- tion performance checklist data, with a Kappa statistic to determine inter-rater reliability.

Results The author collected 66 pretests

and 66 posttests. Comparison of participating units from pretest to posttest demonstrated an improve- ment in knowledge (pretest average 83%, posttest average 89%). All but three questions demonstrated improvement between tests; they focused on assessing learners with use of appropriate teaching modali- ties, clarifying incorrect teach-back, and defining health literacy. The range of improvement was 2%- 16%. Three questions demonstrated statistical significance (p=0.001, 0.026, and 0.032) with the Pearson Chi-Square test: assessment of the learner (question #1), validation of patient learning (#5), and a defini- tion of patient education (#10). Levene’s Test for Equality of Variance result (p=0.010) illustrated statistically significant variability between the two tests. A t-Test for Equality of Means result (p=0.003)

An Initiative to Improve Patient Education by Clinical Nurses

TABLE 2. Simulation Performance Checklist Objectives

Learner will: 1. Demonstrate the ability to assess the patient’s preferred learning style. 2. Validate with the patient the topic/goals/objectives of the educational session. 3. Use appropriate teaching modalities based on the learning needs assessment. 4. Use teach-back method/questioning to evaluate the patient’s understanding of

educational content.

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demonstrated a significant differ- ence between the two tests that was likely a result of the intervention (Burns & Grove, 2012).

Forty simulations were viewed. The difference in participant num- bers between the test and simula- tion is multifaceted. One group of RNs was incapable of completing the simulation portion of the proj- ect on their education day due to room scheduling conflicts. A few participants decided not to com- plete the second simulation, but did complete both tests. Finally, the project leader omitted some simula- tion data provided by the nurse educators who viewed and collected data on the simulations because they were unclear.

Each simulation performance checklist objective demonstrated improvement (pretest to posttest range 16%-31%). Three objectives dem onstrated statistical signifi- cance (p=0.010, 0.005, 0.005) on a Pearson Chi-Square test.

Limitations The small sample and the unifo-

cal project setting were limitations of the project. Reliability of the tools

was not determined statistically because tools were not matched to participants; in other words, a par- ticipant’s pretest or pre-simulation was not compared to his or her posttest or post-simulation. Another limitation was completion of the pretest-posttest by one group of nurses who were unable to complete the simulations due to a scheduling conflict within the simulation department. Finally, inter-rater relia- bility between the two nurse educa- tor observers was poor. Only two objectives demonstrated inter-rater reliability when a Kappa statistic was completed: educators demonstrated inter-rater reliability focused on set- ting mutual learning goals/objec- tives, and continual reassessment of learning using teach-back until learner comprehension occurred.

Nursing Implications The patient education curriculum

will contribute to provision of effec- tive, efficient education by clinical nurses within the organization. The development of a standardized patient education ap proach for clini- cal nurses promoted improvement in patient education practices, which in

turn may promote a patient’s ability in self-care and improve patient out- comes. Outcomes of this project sup- ported research by Wilhelm and Petrovitch (2011), Warden and col- leagues (2014), and Lau-Walker and co-authors (2016) in which educat- ing healthcare professionals on a structured approach increased educa- tion encounters and improved patient outcomes.

Patient education is a required component for successful patient outcomes. The clinical nurse has a unique opportunity to impact pa - tient outcomes through patient education. Barriers to patient educa- tion included lack of motivation, skill, confidence, and competence. While educating patients has been an essential part of nursing practice for many years, most nurses be - lieved they did not have formal preparation to be successful at the role as educator (Bastable, 2014). This project was developed to pro- vide nurses a standardized approach and increased knowledge to over- come barriers related to knowledge, preparation, and confidence, in turn improving their patient educa- tion practices.

continued on page 333

Instructions For Continuing Nursing Education Contact Hours

An Initiative to Improve Patient Education by Clinical Nurses

Deadline for Submission: October 31, 2018 MSN J1613

To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the

article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library

2. Evaluations must be completed online by October 31, 2018. Upon completion of the evaluation, a certificate for 1.2 contact hour(s) may be printed.

Learning Outcome After completing this learning activity, the learner will be able to recognize how a structured approach improves patient education practices.

The author(s), editor, editorial board, content reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director.Fees — Member: FREE Regular: $20

September-October 2016 • Vol. 25/No. 5 333

Improve Patient Education continued from page 300

Conclusion To promote better patient health

outcomes, clinical nurses need to be involved increasingly with patient education. However, they require support and resources in their role as patient educators to be successful (Lau-Walker et al., 2016). Organi - zational support, such as the curricu- lum used in this project, promotes increased knowledge and confidence in clinical nurses as they contribute to improved health outcomes through patient education.

REFERENCES Bastable, S.B. (2014). Nurse as educator.

Principles of teaching and learning for nursing practice (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Burns, N., & Grove, S.K. (2012). The practice of nursing research: Appraisal, synthe- sis, and generation of evidence (7th ed.). St. Louis, MO: Saunders Elsevier.

Harris, J.L., Roussel, L., Walters, S.E., & Dearman, C. (2011). Project planning and management. A guide for CNLs, DNPs, and nurse executives. Sudbury, MA: Jones & Bartlett.

Lau-Walker, M., Landy, A., & Murrells, T. (2016). Personalised discharge care planning for postmyocardial infarction patients through the use of a Personalised Patient Education Protocol – implementing theory into practice. Journal of Clinical Nursing, 25(9-10), 1292-1300. doi:10.1111/jocn.13177

London, F. (2016). No time to teach: The essence of patient and family education for health care providers (2nd ed). Atlanta, GA: Pritchett & Hull Associates, Inc.

Reiter, K. (2014). A look at best practice for patient education in outpatient spine sur- gery. Association of Perioperative Registered Nurses Journal, 99(3), 376- 384. doi:10.1016/j.aorn.2014.01.008

Warden, B.A., Freels, J.P., Furuno, J.P., & Mackay, J. (2014). Pharmacy-managed program for providing education and dis- charge instructions for patients with heart failure. American Journal of Health- System Pharmacy, 71(2), 134-139. doi: 10.2146/ajhp130103

Wilhelm, S.M., & Petrovitch, E.A. (2011). Implementation of an inpatient anticoag- ulation teaching service: Expanding the role of pharmacy students and residents in patient education. American Journal of Health-System Pharmacy, 68(21), 2086- 2093. doi:10.2146/ajhp10065

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