The clinical nurse specialist's (CNS's) role includes interventions across 3 spheres of influence. These spheres include patients/families, nurses/nursing practice, and organization/systems. In the patient/family sphere, CNSs may provide the education needed for individuals to manage their own health and well-being.1 A few studies report successful CNS intervention at the patient level with prevention of infections,2 preoperative education,3 heart failure,4 and medication adherence.5 Hamric et al6 noted "CNS expert coaching and guidance are pivotal in providing or influencing patient and family education." They further indicate that CNSs are increasingly "likely to be involved in educational program planning and implementation."6 At the nurse/nursing practice sphere of influence, the CNS works to enhance clinical practice, "thereby influencing the further development of the proficient and expert nurse."6 Avery7 described an organization/systems approach to patient education, which included the development of clinical pathways and a comprehensive patient education video. There is minimal literature pertaining to CNS educational interventions within all 3 spheres of influence.
A number of core CNS competencies specify the role of the CNS in patient education. These include the following:
* facilitates the provision of clinically competent care by staff/team through education, role modeling, team building, and quality monitoring;
* determines nursing practice and system interventions that will promote patient, family, and community safety;
* establishes collaborative relationships within and across departments that promote patient safety, culturally competent care, and clinical excellence; and
* designs health information and patient education appropriate to the patient's development level, health literacy level, learning needs, readiness to learn, and cultural values and beliefs.1
The CNSs used these competencies throughout this project.
To provide timely, effective patient education requires nurses to be prepared and knowledgeable about patient education processes and resources. In a healthcare environment with shortened length of stays and increasing acuity of the hospitalized patient, essential content should be identified for patients/families while recognizing the need for ongoing education across the continuum of care. Manning8 notes that patient education requires a systematic approach. Nursing staffs in hospital settings have limited time to provide education and need the ready availability of appropriate resources to facilitate the education process. The organization/systems need to be designed to identify resources and make them readily available. Systematizing the approach to patient education can minimize the amount of time the nursing staffs spend looking for materials and can also facilitate a consistent approach by multiple caregivers. Addressing common educational situations helps ensure necessary information is imparted to the patient.8
The purpose of this article was to describe a collaborative CNS project to enhance the patient education provided by nurses across 7 general medical nursing units in a large acute care hospital.
PROBLEM
Quarterly electronic quality monitoring of nurses ordering disease-specific patient education plans and chart reviews assisted the medical CNSs with identifying a deficit in using disease-specific education plans and documentation of patient education. This institution utilizes electronic plans for ordering and documenting education. Each specific disease has its own education plan. In addition, there is a generic education plan that nurses can utilize when disease-specific education plans are unavailable or by the nurses' choice. The goal is to use disease-specific education plans as they help ensure that patients receive the appropriate education.
To determine what was causing this lack of using disease-specific education plans and documentation, an anonymous, electronic knowledge assessment of the nursing staff was administered. Key questions nurses were asked included the following:
(1) How often do you use disease-specific patient education plans?
(2) What barriers are there to using disease-specific patient education plans?
(3) How important is it to you to document the patient/family education you have provided?
The return rate for the survey was 45%. Only 6% of the nursing staff reported always using disease-specific education plans, whereas 21% of nursing staff reported never using disease-specific education plans. Several themes emerged explaining why disease-specific plans were not being used. The nurses expressed a lack of knowledge about which plans were available, a need for a resource to help them, and a need for additional education plans. The existing education plans contained all available pamphlets and videos, so there was confusion about which pamphlets would be most helpful for patients. However, many of the materials listed were not readily available on the units, and the units often had other materials available that were not identified within the electronically based education plans.
Although nurses value providing patient education, only 74% of the nurses perceived it was very important to document the education they provided. In addition to a small group of nurses who lacked knowledge related to documentation of patient education, the themes emerging from this portion of the evaluation were similar to those previously mentioned. These barriers increased the amount of time it took the nursing staff to document education. The nurses felt the amount of time it took to document the materials was not worth the result. Bastable9 summarized the factors impacting the ability of nursing staff to educate patients. The factors identified by our nursing staff are similar to those identified by Bastable9: a lack of time and a lack of confidence and competence in teaching skills, low priority status of patient education assigned by administration and supervisory staff, and documentation difficulties.
INTERVENTIONS
Based on the survey results, the medical CNSs realized that the current system was quite cumbersome for bedside nurses, and it needed to be changed. The project complemented the nursing care model used by the institution's department of nursing. The institution's nursing care model is based on the core value of the institution: the needs of the patients come first. Elements were also taken from Jean Watson's10 Theory of Human Caring. Watson's10 theory is based on 10 carative factors that help explain the science of caring. The institution's nursing care model also uses concepts from Mary Koloroutis'11 Relationship-Based Caring Model, which focuses on the importance of the relationship between the nurse and the patient. By building relationships with patients, caring for the patient, and always putting the patients' needs first, the institution trusts that nurses will be prepared to implement several roles to their full potential. These roles include caring healer, problem solver, navigator, teacher, pivotal communicator, vigilant guardian, and transformational leader. An integral role of the nurse is teacher. In order for nurses to fulfill this vital role, the medical CNSs used the survey results to determine interventions. The interventions implemented included the creation of new patient education brochures, updating the electronic system to enhance the ease with which nurses are able to determine what patient education materials to provide and document, creating a video-on-demand (VOD) education channel, and ensuring that patient education materials were easily accessible.
The nurses are expected to educate patients about the "survival skills" needed after discharge including specific disease processes, diets, medications, when they should call the provider, and activity. Many of the patient education pamphlets would include some of this information, but not all of it. It is part of the CNS competencies to be able to design appropriate patient education; therefore, the medical CNS group revised or developed education pieces that focused on the medical diagnoses patients were most frequently admitted with.1 The diagnoses that were targeted included cellulitis, pneumonia, alcohol withdrawal, cellulitis, deep vein thrombosis or pulmonary embolism, kidney infection, low-back pain, bowel obstruction, and sepsis. Although these diagnoses may not reflect the most frequently reported national admitting diagnoses, this list reflects the most common diagnoses of patients admitted to the 7 general medical units. The institution also has specialized medical cardiology and oncology units, which were not included in this project. The education pamphlets were concise and covered all the elements expected to be taught by nursing. Any new pamphlets were given similar titles so they would be easily recognized by the nurses.
The nurses needed an easy way to electronically order the appropriate education and then to document against the order. With the previous system, nurses were presented with multiple choices for education, and it was difficult for them to pick the ones that would be best for their patients. In order to facilitate the most appropriate care by the nurses, the CNSs developed and revised electronic education plans to improve this process. The Patient Education Center reviews all patient education materials every 2 to 5 years. Clinical experts, as well as patient education specialists, ensure that the materials are current, appropriate for patients, and evidence based. Thus, the CNSs were assured that the most current materials were available within the facility. The materials were then reviewed so that the pamphlets and videos that were consistent with the specialty's current practice and appropriate for hospitalized patients who need "survival skills" can be chosen. The items the CNS group felt would benefit most of the patients were preselected in the electronic education plan. Nurses could also select any of the other education resources, if needed, based on the patient's learning needs, abilities, and readiness to learn.
For example, if a patient is admitted to the hospital with a pulmonary embolus, the nurse would go into the electronic medical record and search for the term pulmonary embolus. Then, he/she could choose the pulmonary embolism/deep vein thrombosis education plan option. Once the education plan was chosen, a list of the best pulmonary embolus education resources would be listed. The best education pamphlets and/or videos would be preselected (Figure 1).
The institution has VOD programming for patients. The list of programs that are available is extensive; including 119 videos. This means that at times choosing the appropriate video was confusing and cumbersome for patients and the nursing staff. The nursing staff reported a lack of knowledge regarding the various programs available and requested making the channel easier to navigate. The CNSs collaborated with a patient education specialist from the Patient Education Center to explore opportunities to revise the VOD channel. The content of each of the videos was reviewed for relevance and congruity with the educational plans being developed. A separate channel was proposed that would be clearly labeled for inpatient medical patients. In addition, the videos were categorized into groups that corresponded with the categories of the educational plans, such as cardiovascular and gastrointestinal. The goal is that if a nurse implements a specific educational plan for a patient, then the appropriate video will be easily identified and available for the patient.
It is also very important for the education to be readily available to the bedside nurse. Each unit restructured its patient education setup to fit its needs. One unit organized the individual pamphlets by body system. Others organized the pamphlets alphabetically. Another unit created packets of education materials for each disease process that coincided with the prechecked education items from the education plans. Units clearly labeled the education pamphlets and set up a system for timely reordering. One unit placed a list of the available education plans next to the computer work stations so the nurses could readily view what was available. The units worked to make education more readily available to patients and nursing staff by placing most commonly used pamphlets on racks in the hallways for patients and nurses to access.
To facilitate implementation of these changes, the medical CNSs provided education to the nurses at Professional Development Days about how to use the new system. One-on-one education was also provided to some of the nursing staff.
OUTCOMES
To determine the successful implementation of project initiatives, multiple evaluation methods were used including a preimplementation and postimplementation knowledge assessment of nursing staff, electronic tracking for ordering disease-specific education plans, and electronic chart reviews to determine documentation rates.
The nursing staffs from the 7 medical units were asked to complete an electronic postimplementation assessment to determine their use of disease-specific patient education plans, documentation skills, and knowledge/use of resources. The return rate for the postassessment was 34%. Although this return rate is lower than the first survey, the American Association for Public Opinion Research12 states that low return "rates do not necessarily differentiate reliability between accurate and inaccurate data." In addition to the response rate, the association encourages evaluating reported results for conformity with other research findings, potential biases, and missing data.12 The literature does not speak to any similar projects with which we can compare our survey results; however, this project's results, related to the use of disease-specific education plans and documentation rates, are consistent with the survey results. Key survey questions included those asked in the preimplementation assessment plus one additional question: Medical patient care units have implemented a number of strategies in the past year to support patient education; which have you found to be most helpful?
Postimplementation assessment results showed that nurses' reported use of disease-specific education plan increased from 6% to 39% (Figure 2). The nurses' perception of the importance of documenting patient education provided also increased since 74% of the staff stated it was very important to document in the preimplementation assessment, whereas 83% confirmed the importance of documentation in the postimplementation assessment (Figure 3).
In the postimplementation assessment, nurses were asked which interventions were the most important to them. They reported reorganization of patient education material drawers/cupboards, updating the electronic patient education plans, creation of new brochures, and Professional Development Day presentations to be the 4 most useful interventions.
The nursing staff's use of disease-specific education plans was monitored before, during, and after the education plans were updated (Figure 4). The education plans chosen to be monitored were selected based on the most frequent diagnoses seen on the medical care units. As the generic education plan use decreased, an increase was seen in the use of the disease-specific education plans.
The final outcome measured was the documentation rates for learning needs assessment, disease process education, and medication education. Documentation rates increased by 5%, 15%, and 12%, respectively, and have held stable at this increase for 9 months. There continues to be a need for further improvement in documentation.
DISCUSSION
Because hospital stays are becoming shorter, and patients are frequently acutely ill with complex medical needs, it is a challenge for nurses to do quality patient education. An organized education process can help guide the nurse to provide the patient with the survival skills needed for success at home. To maintain this type of patient education process, there are ongoing CNS activities that include evaluating current and newly developed patient education resources, updating existing educational plans, and developing new educational plans as needed. This review is essential so the nurse can be confident that he/she is discussing the most current information with patients regarding their medical conditions.
Ongoing quality improvement audits are being completed to assess how often the specific disease education plans are being documented. This information is being shared with the nursing staff. This follow-up is very important so the CNS can mentor the registered nurse in the importance of patient education and that disease-specific education can potentially improve patient outcomes.
CONCLUSION
As noted throughout the article, this project exemplifies a number of core CNS competencies specific to the role of the CNS in patient education. Quality monitoring assisted the medical CNSs with identifying a need to increase use of disease-specific education plans and documentation of patient education. The CNS used an anonymous, electronic knowledge assessment survey of the nursing staff to help determine nursing practice and system interventions that would promote a consistent way for medical nurses to utilize the best disease-specific patient education resources. The CNSs collaborated with the Patient Education Department to design patient education appropriate to patients' development level, health literacy level, and learning needs.1 This collaboration also resulted in updating the electronic system to enhance the ease with which nurses are able to determine what patient education materials to provide and document and the redesigning of the VOD system. To ensure clinically competent care, education was provided to staff nurses regarding the new processes.
Disease-specific patient education plans enhance the ability of the nurse to partner with the patients/caregivers, to use appropriate educational materials, and to assist the patients in managing their care when they leave the hospital. This project demonstrates CNSs' ability to design, develop, and implement a systematic and structured process to promote a consistent way for medical nurses to utilize the best disease-specific patient education resources.
References