Discharge instructions may equal confusion
Jacqueline Vance, RNC, CDONA/LTC
You've got a post-acute patient getting ready to return to the community. You feel you are prepared.
After all, you have created written discharge instructions for most common post-acute admission diagnoses: post-hip replacement, post COPD exacerbation, new diabetic, etc. Your staff gives it to the patient prior to discharge and lets her know if she has any questions, just ask before she leaves.
You make your mental check box and written note: discharge instructions given. Fourteen days post-discharge, your patient has a return to the hospital. Surely you had nothing to do with that right? Well, maybe not so right.
First, what grade level are your instructions written on? If it is over a sixth-grade reading level, it is too high for health literacy (“the degree to which individuals have the capacity to obtain, process, and understand basic health information”). The American Medical eAssociation found that most discharge instructions are written at a tenth-grade level.
It should come as no surprise then that patients grasp much less than they should when reading them. Low health literacy is not something people are usually willing to admit. I mean, who wants to talk about what they might be embarrassing?
(Like we are not going to talk about the time I accidentally shot my camp counselor with an arrow when I was 8. It was just a graze anyway! Can you believe they actually put a riffle in my hands next?! But I digress … another embarrassing habit of mine.)
According to the National Network of Libraries of Medicine, only 36% of working-age adults in the United States have adequate health literacy skills. And only 12% of adults older than 65 years have adequate health literacy skills. (Source: Canadian Council on Learning. State of learning in Canada: No time for complacency, 2007. Accessed July 11, 2016.)
So written discharge instructions shouldn't be our only source of discharge education. I am a big fan of the teach-back method. That way you can be sure if your patient really understands the instructions and responsibilities.
I also recommend not doing all the education at once. You plan for this patient to go home from day one, so maybe start preparing for it from day one.
Spend 10 to 15 minutes a day with this patient (and possibly a family member) on discharge instructions. Perhaps on day one you can go over the personal healthcare record, explaining what it is, and having them start to fill it out.
Perhaps have them start daily journaling on how they are feeling, exercise tolerance, etc.) Each day, go over something new and have the patient demonstrate or repeat back. This can go with written instructions, but education in little bits with teach-back will ensure your patient knows what to do when they get home.
Let's face it: While people may enjoy your company, they want to go home. Think of Dorothy in “The Wizard of Oz.” She's having a blast hanging out with the Tin Man and all, but there's no place like home.
Dorothy was willing to melt a witch, so your patients may be willing to tell you, “Yeah, I got this,” just to get out the door!
Besides, even the highest educated, most intelligent people can get confused when handed a bunch of instructions, especially when they have been on medications. So go slow with daily doses of education, and make your discharges more successful!
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.