An ethnographic study of the process of medication discharge education (MDE)

A Culturally Competent Approach to Discharge Planning and Transfer of Care

Culturally competent discharge planning and transfer of care play a leading role in communication and the effective provision of high-quality care to patients from diverse sociocultural backgrounds. However, no standardization has been established. Here, we present the case of a Spanish-speaking patient discharged with instructions in English on two separate occasions, which resulted in readmission and deleterious outcomes. We emphasize the need to provide a safe and culturally competent transition of care.

Challenges of collecting data in the clinical setting

Undertaking a piece of research in the clinical setting is often far more difficult than it appears from descriptions in textbooks. This paper describes some of the challenges faced in the course of completing a non-participant observational study that examined how health promotion practice was carried out by hospital-based nurses in an acute setting. The challenges included deciding which observational role to adopt, whether to use structured or unstructured observations, which observational position to adopt, how long observation sessions should be and how to deal with ethical issues when the researcher is also a nurse. It is concluded that the answers to some dilemmas and challenges are not always found in the literature and that decisions taken often depend on the researcher's morality and pure common sense.

A review of the literature on heart failure and discharge education

The Centers for Medicare and Medicaid Services (CMS) have proposed changes in the health care reimbursement for patients diagnosed with heart failure (HF) if readmission to a hospital occurs within 30 days of their discharge. The Joint Commission (TJC) has identified 6 key education topics for HF patients with their families that can result in decreased readmissions. Though the patient may be too ill, critical care nurses have an opportunity to begin the discharge education process immediately with families or caregivers. This literature review discusses studies focused on discharge education in general and then those studies specific to HF discharge education. This review reports on what is known or supported by evidence within 8 major topics. Finally, the discussion section summarizes the evidence for discharge education by answering 6 questions that address the "who and when" as well as the "what" of discharge education.

Providing health information to older adults

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.

Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study

BACKGROUND

There is increasing emphasis on person-centred care within the literature and the health care context. It is suggested that a person-centred approach to medication activities has the potential to improve patient experiences and outcomes.

OBJECTIVES

This study set out to examine how nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care.

DESIGN

A qualitative approach was used comprising naturalistic observation and semi-structured interviews.

SETTING

The study setting was an acute care ward with a collaboratively developed philosophy of person-centre care, in an Australian metropolitan hospital.

PARTICIPANTS

Eleven nurses of varying levels of experience were recruited to participate in observations and interviews. Nurses were eligible to participate if they were employed on the study ward in a role that incorporated direct patient care, including medication activities. A stratified sampling technique ensured that nurses with a range of years of clinical experience were represented. Patients who were being cared for by participating nurses during the observation period were recruited to participate unless they met the following exclusion criteria: those less than 18 years of age, non-English speaking patients, and those who were unable to give informed consent. Twenty-five patients were observed and 16 of those agreed to be interviewed.

RESULTS

The results of the study generated insights into the nature of interactions between nurses and patients where person-centred care is the underlying philosophy of care. Three major themes emerged from the findings: provision of individualised care, patient participation and contextual barriers to providing person-centred care. While the participating nurses valued a person-centred approach and perceived that they were conducting medication activities in a person-centred way, some nurse-patient interactions during medication activities were centred on routines rather than individualised patient assessment and management. These interactions were based on nurses' perceptions of what was important for the patient and did not provide opportunities for patient participation. Two main contextual barriers in relation to a person-centred approach to medication activities were identified as multidisciplinary communication and time constraints.

CONCLUSIONS

While some nurse-patient interactions during medication activities were consistent with the principles of person-centred care, the study results highlighted factors that influence the nature of these interactions, and identified opportunities to improve nursing practice. To ensure person-centred care is applied to medication activities, nurses should undertake ongoing assessment of patients' needs in relation to their medications and encourage opportunities for increased patient participation.

Nurses' attitudes toward their role in patient discharge medication education and toward collaboration with hospital pharmacists: a staff development issue

This qualitative pilot study explored nurses' attitudes toward their role in patients' discharge medication education and collaboration with pharmacists. Purposive sampling was used, and data were collected by a focus group interview. The findings give a clear indication of the need for extensive staff development. It is unfortunate that nurses in this study appeared not to value their role in educating patients on medications prior to discharge. They were somewhat resistant to collaboration with pharmacists, and they tended to accept limited responsibility for improving patient discharge medication adherence or compliance. Although the findings are of concern, they do provide clear evidence of the need for intensive staff development.

Documentation of medication management by graduate nurses in patient progress notes: a way forward for patient safety

Nursing documentation provides evidence of nurses' management, the patient response, and evaluation of care. The aim of the study was to examine how graduate nurses document their medication management in the progress notes. A prospective clinical audit of patient medication charts and the progress notes made by 12 graduate nurses was undertaken. Graduate nurses were also individually interviewed and asked clarifying questions about their medication management. Documentation was examined based on four areas: assessment, planning care, administration of medications, and evaluating outcomes of medications. Recorded information about assessment focused on cues of a biomedical rather than a psychosocial nature. Planning care involved non-specific documentation of discharge planning needs, and little information about communication with doctors, pharmacists, nurses, patients and next of kin. Administration of medications included details about the names of medications given to patients, but no information about medication education provided to patients during this time. Evaluation of outcomes of medication administration was poorly documented. Graduate nurses tended to focus on assessing medications before their administration without considering how the patient responded to treatment. Recommendations are proposed for improving the quality of graduate nurses' progress notes. These recommendations include implementing and evaluating protocols that link nurses' decision-making to documentation processes. Adopting a supportive multidisciplinary approach to quality improvement and providing education that emphasises written documentation of verbal communication are also recommended.

3D: a tool for medication discharge education

BACKGROUND

At the time of transition from hospital to home, many patients are challenged by multi-drug regimens. The authors' standard patient education tool is a personalised Medication Discharge Worksheet (MDW) that includes a list of medications and administration times. Nonetheless, patient understanding, satisfaction, and safety remain suboptimal. Therefore, the authors designed a new tool: Durable Display at Discharge (3D). Unlike MDW, 3D features (1) space in which a tablet or pill is to be affixed and displayed, (2) trade name (if apt), (3) unit strength, (4) number (and/or fraction) of units to be taken, (5) purpose (indication), (6) comment/caution, (7) larger font, (8) card stock durability and (9) a reconciliation feature.

METHODS

The authors conducted an exploratory, randomised trial (n = 138) to determine whether 3D, relative to MDW, improves patient satisfaction, improves patient understanding and reduces self-reported medication errors. Trained survey research personnel, blinded to hypotheses, interviewed patients by telephone 7-14 days after discharge.

RESULTS

Both tools were similarly associated with high satisfaction and few self-reported errors. However, 3D subjects demonstrated greater understanding of their medications.

CONCLUSIONS

Although both tools are associated with similarly high levels of patient satisfaction and low rates of self-reported medication error, 3D appears to promote patient understanding of the medications, and warrants further study.

Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists

BACKGROUND

Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting.

METHODS

The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine.

RESULTS

The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans.

CONCLUSIONS

The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes.

Patient information at discharge--a study of a combined approach

OBJECTIVE

To describe patients' perceptions of a new information procedure related to going home after urological surgery. This procedure, developed in an action research project, included a discharge talk with the nurse and an information booklet for the patients to keep.

METHODS

A convenience sample of 99 patients responded to a survey sent home 1 week after discharge (return 78.6%). The Patient Information and Nurse Interaction Scale (PINI) was used for data collection.

RESULTS

The sample were mostly male (81%), older (mean 71.9 years), and hospitalised on average less than 4 days. Patients who got the booklet had significantly more favourable perceptions on information received (p<0.05) on 11 of 21 items, and 91% said they would not have managed very well at home without it.

CONCLUSION

The patients who received the booklet knew more about what might happen to them, were less uncertain and had fewer concerns when going home.

PRACTICE IMPLICATIONS

The combination of standardised written information and a talk with the nurse where patients participated in individualising the information appears to have had a significant impact on self-management at home.

Patient self-medication – a change in hospital practice

AIMS AND OBJECTIVES

The purpose of this study was to evaluate the effectiveness of a self-medication programme (SMP) for inpatients of the Nursing Convalescent Unit, a 26-bed unit with medical and surgical patients.

BACKGROUND

Self-medication is an important part of self-management of chronic illness. Self-medication is a way of allowing patients to give themselves their medications in hospital after receiving education instead of the usual practice of medications administered by a Registered Nurse (RN).

DESIGN

The pilot study was undertaken over a six-month period to examine the relationship between a programme of self-medication and patient knowledge and adherence to medication regimens, number of medication errors, efficiency in relation to the number of nursing hours associated with the SMP, patient and nursing satisfaction.

METHODS

A total of 220 patients participated in the study. The SMP included three levels of patient self-administration of medications: level one, medications administered by a RN; level two, self-medication directly supervised by a RN and level three, self-medication indirectly supervised by a RN. Outcome measures included staff and patient satisfaction, number of medication errors, time taken by nurses to undertake activities related to the SMP and the number of patients who achieved levels two and three.

RESULTS

Study findings showed that 45% of patients remained on level one, 26% achieved level two and 29% achieved level three. There were no patient initiated medication errors during the study period. Efficiencies were identified in staff workload associated with patient discharge procedures. Overall, nurses perceived that the SMP increased their knowledge of medications and contributed to effective patient education.

CONCLUSIONS

In selected patients, the SMP was an effective aid for improving adherence to medication regimens. Collaboration between nurses, medical staff, pharmacists, patients and carers is integral to the success of in hospital SMP.

Designing Written Medication Instructions: Effective Ways to Help Older Adults Self-Medicate

One of the goals of Healthy People 2010 is for 95% of patients who are ordered medication to receive written medication instructions. The declining physical condition often associated with advanced age, lower literacy levels, and education among members of the current elderly cohorts, and increasingly complex medication regimes for chronic illness affect the ability of many older adults to learn. This article addresses Geragogy, the art and science of helping older adults learn, complimentary theories of learning, and examples of how they can be used to guide the construction of appropriate written medication instructions for older adults.

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.

Medication management by graduate nurses: Before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i). monitoring medications and (ii). interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.

Enhancing older people's concordance with taking their medication

It has been shown that older people are more likely than younger people to be prescribed a variety and number of medications (Lindley and Tulley, 1992). Older people are especially vulnerable to the effects of medication, particularly because of the possibility of medication mismanagement and non-concordance with prescribed medication regiment. People become increasingly sensitive to the actions of drugs with increasing age and, added to the problems of memory deterioration and physiological changes, medication-taking behaviour can alter quite dramatically (National Prescribing Centre, 2000). Reductions in the quantity of prescribed medication and the use of prescribing indicators aim to improve concordance with medication in older people. Patient education should be an inclusive component of patient care, not a concern before patient discharge. Education can take numerous forms, both written and verbal, and it needs to be patient-centred and specific to the medication being discussed. As healthcare professionals, nurses, pharmacists and medical colleagues should work collaboratively to reduce the frequency of medication mismanagement in older people.

A patient empowerment model to prevent medication errors

Each year, untold deaths occur because of medical and medication errors in the United States. In generally, most people have the naïve perception that the health-care enterprise is a fail-safe system and as such do not take proactive measures to prevent potential medication errors. This paper is timely in light of the proliferation of medication use in outpatient settings and thus warrants the education of patients to take the responsibility in proper drug use. Patients and the health-care professionals must understand the need to see patients as part of the health-care team to ensure quality of care and decrease medication errors. A patient empowerment model to prevent medication error is therefore proposed.

Preparing patients for urological surgery

There is consensus among health care professionals that patients need and use written and oral patient education to prepare for hospitalisation. The purpose of this study was to re-design information for patients preparing for transurethral surgery (TUR P-B) and describe the effect of this change. A quasi-experimental design was used to answer the research questions. The findings showed that patients did benefit in some areas. The patients found a correspondence between what they were told to expect and what actually happened in the hospital. Nurses need to evaluate written materials to see that they are current and reflect best practice.

The educational preparation of undergraduate nursing students in pharmacology: clinical nurses' perceptions and experiences of graduate nurses' medication knowledge

This paper explores clinical nurses' perceptions and experiences of graduate nurses' pharmacology knowledge. Six focus group interviews were conducted with clinical nurses of various appointment levels at two metropolitan public and two regional public hospitals in Victoria, Australia. Four major themes emerged from the study. First, participants indicated that graduate nurses had an overall lack of depth of pharmacology knowledge. While clinical nurses indicated that graduate nurses had enormous deficits in their pharmacology education, these deficits were not confined to graduate nurses--all nurses experienced difficulties in understanding and demonstrating pharmacological concepts in the clinical practice setting. Second, there was an unstructured approach to addressing the continuing education needs of graduate nurses. Third, theoretical and clinical principles of pharmacology knowledge were perceived to be important for practice. Fourth, improvements for nursing education involved the need for undergraduate students to take greater responsibility in monitoring and administering medications and the need for more structured learning experiences. The ultimate goal of consolidating pharmacology knowledge for graduate nurses is to optimise medication use, thereby improving the health outcomes of patients. Current teaching and learning opportunities appear to be inadequate in their efforts to enhance and improve graduate nurses' pharmacology knowledge. These inadequacies need to be addressed if the ultimate goal is to become a reality.

A qualitative study of chronic heart failure patients' understanding of their symptoms and drug therapy

OBJECTIVES

To explore patients' understanding of their symptoms and the treatment of their heart failure.

DESIGN

Qualitative analysis of in-depth interviews, using a constant comparative approach.

SUBJECTS

27 patients identified by Cardiology and Care of the Elderly physicians as having (a) symptomatic heart failure (New York Heart Association functional classes II, III and IV) and (b) a hospital admission for heart failure in the previous 20 months.

RESULTS

Patients were aged between 38-94 years (mean 69), 20 were in NYHA functional class III or IV. All had at least one concurrent illness. Analysis of the data identified four key areas: patients had little understanding of the purpose of their medications, were concerned about both the quantity and combination of drugs they were prescribed, had difficulties in differentiating between the side effects of drugs and symptoms of heart failure, and had little knowledge to help them interpret and/or treat changing symptoms.

CONCLUSION

Providing patients with relevant information about their medications may help to reduce anxiety about the drugs they are taking. Acknowledging the symptoms associated with heart failure and the likely side effects of treatments might improve patients' ability to interpret, treat or relieve symptoms.

Nursing, medication education and the new policy agenda: the evidence base

Current social and demographic trends, combined with 'the new policy agenda', highlight the importance of nurses' role in educating patients about medication. In the absence of previous research investigation, this study set out to explore nurses' current contribution to medication education and the clinical contextual factors that influence current practice. The evidence base for effective medication education was established from reviews of literature and focus groups with key informants. Nurses' practice was investigated using a case study approach in seven clinical areas representing adult, care of the older person, mental health and community nursing contexts. Methods used to collect data were: audio-recordings (n=37) and observation (n=48) of nurse-patient interactions about medication, post-interaction interviews with nurses (n=29), post-interaction interviews with patients (n=39), analysis of relevant written documentation and researcher observation and field notes. Data sources within each case were subjected to systematic content analysis in order to identify current practice and contextual influences within each case. Cross-case analysis was also employed in order to identify explanations for any differentiation in practice. Findings indicate that nurses' contribution to medication education is commonly limited to simple information giving about medicines, involving the name, purpose, colour, number of tablets and the time and frequency that medications should be administered. Nurses' practice in two of the seven clinical areas was characterised by interactions that more closely demonstrated features of what is known to constitute more comprehensive and effective medication education. Analysis of contextual influences within and between cases allowed explanations to be derived for the types of medication education interactions observed. These concerned: patient characteristics, perceived and expressed preferences of patients for information, characteristics of the nurse-patient relationship, lack of time and high workload, and the philosophy of care within the clinical area. In all clinical areas, nurses were not explicitly and judiciously using available evidence to inform their medication-related interactions. The paper concludes with discussion and implications of the findings.

Variables impacting on patients' perceptions of discharge from short-stay hospitalisation or same-day surgery

The paper presents components of a study (n = 929) that was designed to examine, at one specific point in time, the hospital experience of the patient and the patient's corresponding recovery at home. Variables that captured the hospitalization and recovery experience relate to the degree of patient involvement in decisions about their treatment and discharge plans. Levels of health and recovery-related information reported by patients and their level of confidence in ability to resume regular activities once home were also measured. In general, individuals reported what many would consider having received less than optimal levels of information about their illness and recovery at home. Many patients also reported that they neither participated, nor were consulted on their needs or perceptions during their hospitalization. Expectations were that problems that patients might experience once home would have their origins in problems from within the community. However, the community resources were found to be less implicated and hospital resources more so. This suggests the importance of examining institutional issues even when one is focusing on the delivery of community services.