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The nursing shortage has clearly impacted the amount of time nurses have to teach patients, says Mary Szczepanik, MS, BSN, RN, manager of cancer education, support, and outreach at Grant/Riverside Methodist Hospital in Columbus, OH.
"The best way for us to measure how much patient education is going on is to look at the medical record to see what is getting documented, and we have seen a decline in the documentation of patient education," she says. There could be two reasons for the decline. Nurses don’t have enough time to complete the education or they don’t have enough time to document it, explains Szczepanik.
To address the problem, in June 2001, a clinical nurse specialist was placed on the oncology unit on the Riverside Methodist Hospital campus to provide education to patients. For example, if a cancer patient is starting chemotherapy, it is the clinical nurse specialist who shows him or her the video and does the teaching. One of the answers to the nursing shortage is to assign responsibility for patient education to someone who doesn’t have a staff or patient assignment for the day, says Szczepanik.
To make the position of an educator designated to patient teaching more appealing to administrators, the clinical nurse specialist at Riverside has a dual role and is responsible for professional education as well. She makes sure that nurses complete their mandatory educational programs every year, says Szczepanik. Because hospitals have their patients categorized according to disease, it wouldn’t be too difficult for health care facilities to hire clinical nurse specialists to teach, she says. For example, there could be someone on the cardiovascular unit, someone assigned to neurology, and another specialist for maternal child health.
Staff shortages make efficiency extremely important, says Patricia A. Mathews, MA, FHCE, president of Mathews Associates in Chambersburg, PA, a health care consulting firm. "What I am seeing is more efficiency in the consistency of the delivery of patient education and the ease of staff to get hold of what they need," she says. For example, patient education managers are ferreting out the nice-to-know information more efficiently than ever before and making connections for further teaching through home visits, workshops, or at the primary care physician’s office. Also, educational materials often are available via the computer or by some other quick method.
Hamot Medical Center in Erie, PA, implemented a computerized documentation system to improve efficiency. "When people have little time, we have to make the most efficient use of it," says Barbara Magee, BSN, RN, patient education coordinator.
In another effort to help staff make better use of time, the institution implemented an intranet system and is in the process of putting all patient education resources on the computer for ease of access. To supplement existing materials, the hospital purchased commercial patient teaching sheets on medications and patient care. "We are finding that staff have very little time to search out and find resources," explains Magee.
Also on the intranet are cultural resources with information on how to get an interpreter, tips on working with an interpreter, and how to get devices for patients with special needs.
The installation of a video on-demand system has proven to be a great teaching aid at Centra Health in Lynchburg, VA. Tent cards in every room provide instructions on how to use the system so nurses can prescribe videos when the patient is ready to learn the topic without having to bring a VCR cart to the room, says Regina Phelps, RN, MN, director of education services.
While technology and designated educators can improve education in light of staff shortages, there are less costly methods. "We have been encouraging staff to focus on involving the patients so that they can make the most effective use of the time they have. For instance, really focusing on the patient’s questions," says Magee. To aid staff in this endeavor, a notepad and pencil is left at each patient’s bedside, and patients are encouraged to write down their questions. In that way, staff can quickly determine the patient’s concerns and address them.
The notepad idea was piloted on one unit with a sheet of paper. It was popular with patients who had a new diagnosis such as cancer, and while older patients did not use it often, their family members did. When families could not be present to see the physician, they would leave written questions on the sheet.
"I have seen Dry Erase boards used effectively to reinforce patient education," adds Mathews. A nurse writes the question of the day on the board, something the patient needs to learn before discharge, and staff during daily interaction ask the patient the question each time he or she comes into the room. For example, they may write: "What do you do when your colostomy bag needs changing?"
Scripts and protocols make patient education more efficient as well, says Mathews. For example, the protocol may be to give patients information about their procedure, then briefly review it and ask if they have any questions. If the patient has no questions, the nurse may go over a few that are frequently asked. "There are prompts to elicit the kinds of questions that nurses and other staff know are really common, therefore reinforcing what is in the written material," says Mathews.
Standardizing patient education also makes it more efficient and simplifies the documentation process, says Szczepanik. Standardize learning outcomes and teaching materials, and it becomes much easier for the nurses to document the education that they do because they can document that they taught according to the standards, she says. (For an example of a standardized teaching plan, see "Toolbox contains teaching aids for diabetes education," in this issue.)
To save time, two directories were created at Centra Health, one for written materials and another that listed educational programs. The directories are good communication tools for this large health care system that has two hospitals, a long-term care facility, and several clinics. "We found that people were often reinventing a patient handout or somebody would want to know who to call for smoking cessation classes for example, so we put together directories," says Phelps. The directories also help staff locate educational materials that are not stocked on their unit because the health issue is not a common occurrence in their patient population.
Although teaching aids improve the efficiency of patient education, staff must be aware that they exist and know how to use them. It’s also important that staff have basic teaching skills. Yet with a high rate of turnover at many institutions it’s difficult to keep everyone up to speed.
To address this problem, Grant/Riverside Methodist Hospitals created a four-part staff education program on patient education with each session 30-minutes long so that staff are able to attend during their lunch break. "We want everyone to have the same basic information about the education of patients and families and to know where the resources are so they can do this quickly," says Szczepanik. The program will be offered several times a year.
In response to the increase in the number of new hires at Hamot Medical Center, the institution expanded the amount of information covered about patient education in its nursing orientation. "We use an interactive approach to discuss learning styles and preferences and we review case studies so we can showcase teaching techniques and resources we have available," says Magee.
Steps to make staff education on teaching patients ongoing also have been put into place. The institution conducts quarterly updates on competencies that are required of staff, and patient education now is included in that program. Updates might cover how to access an interpreter or introduce a new teaching kit for a particular diagnosis. A quarterly newsletter alerts staff to changes in patient education.
A section on teaching skills is available on the intranet, and there’s also a hard-copy self-learning packet available. In this section staff can go on-line and review differences between child and adult learners and find many teaching tips. "Each day, we seem to be adding more teaching tips," says Magee.
At Centra Health, there is a channel on the video on-demand system that is dedicated to staff education. "We did one of our mandatory educational sessions about pain on the video on-demand system," says Phelps. For new employees, a system that provides one-on-one teaching has proven to be effective. While all new employees attend a general hospital orientation, they work with a preceptor on their unit to learn about patient education because each unit is so specialty-based, says Phelps.
In her consulting, Mathews observes that institutions are using more self-learning packets, computerized education, and incorporating more patient education into the orientation of new employees to ensure that staff know how to educate patients in spite of the high staff turnover rate and staff shortage. "I think the biggest trend is that managers are better equipped to educate staff or be the liaison so that staff can find whatever they need to help educate patients," says Mathews.
For more information on how to ensure that patients receive good teaching in spite of staff shortages and high turnover, contact: