The Phenomenon of Comprehension in Nursing - Research Paper Example

Concept Analysis-Comprehension The phenomenon of my interest is the comprehension of discharge instructions. For two years, I havebeen deployed in the emergency department and I have learned that after a patient is ready to go home, he/she is given discharge instructions by the nurse. The purpose of the discharge instructions is to inform patients what they are diagnosed with, how to manage their diagnosis at home, including making alterations in diet and what is to be expected, etc. The nurse is also required to let patients know and understand what symptoms should make them come back to the hospital for more profound medical assistance. Last but not least, the nurse should inform patients about their discharge medications, how to take the medications, when to take them, and common side effects of such medications. Though this is what should be discussed, many times, the nurses in the emergency department that I work in simply hand the patients’ their discharge paperwork without going over it. This leads to patients calling the hospital from confusion of discharge instructions. This also causes patients to come back to the emergency department due to limited understanding of discharge instructions. For example, some patients may stop taking their antibiotics because they feel better, causing them to get worse. This study looks into the concept of comprehension, focusing on how a patient’s comprehension of discharge instructions can be improved and thus improving patient care and saving on cost. According to the Oxford dictionary, comprehension denotes ability to understand something. Thus, in the context of a hospital discharge instructions the requirement for the nurse is to ensure that the patient understands these instructions. Unfortunately, it has been observed that this is not always the case studies on this subject indicate that ninety million Americans have a problem comprehending their own medical care. One reason for this is that most health-related documentation is above the typical users reading capacity (McCarthy et al 2012). Additionally, published discharge directions are not written at apposite reading levels meaning that most of the emergency department patients fail to understand their instructions. The resolution to discharge a patient from the emergency department (ED) is not an easy one; however, it is fundamental that once the decision is made proper measures be taken to ascertain that the patient is well versed on how to continue with the care program. The ability to continue with the care program has many ramifications that exceed direct benefits to the individual in regard to health. Other benefits can also be linked to the healthcare system as poor comprehension means that patients are at an increased risk of being readmitted which stretches healthcare facilities (McCarthy et al., 2012). Even with the available information pointing to the rampancy and effects of poor comprehension adequate changes to improve comprehension have not been instituted. It is necessary to identify that the failure to comprehend care instructions during discharge does not squarely fall on the nurse. Sometimes, the nurse may do their best but the patient has inhibiting factors, which make comprehension difficult. At times, the nurse may not be aware of such factors and thus may fail to go that extra mile in explaining to ensure comprehension (Clarke et al., 2005). Besides, some barriers are difficult to break, and this may at times describe poor comprehension. Looking at the patient, research identifies that the majority of the ninety million Americans who do not understand prescriptions and other instructions on medical care have limited literacy and numeracy. In other cases, the patient or the accompanying person, often a friend or a family member can be under some physical and emotional discomfort (Zeng-Treitler, Kim & Hunter, 2008). At other times, the patient might just be anxious and eager to get home thus paying little interest in the instructions. Finally, the busy nature of hospitals might distract the patient making it impossible for them to comprehend the instructions being issued. The observations highlighted here are brought into perspective by looking at an actual study conducted on 851 people who were hospitalized at Brigham and Women’s and Vanderbilt University Hospital (Godman, 2012). Fifty percent of these individuals were issued with standard discharge instructions while the rest received two standard visits from a pharmacist. The first visit by the pharmacist came two days following admission while the second visit came during the day of discharge. During the second visit, the pharmacist went through issued medication and provided each of the patients with a pill card. The pill card had medication listed and a pictorial representation made elaborating the reason for each of the medication (Godman, 2012). Following discharge, a call was placed to each of the patients to determine progress. Any problem with the recovery process would be referred to the pharmacist. In summing up the observations after discharge, it was apparent that a good number of the patients had a problem with the discharge instructions. Statistically, 50% of the patients had experienced a problem with the discharge instructions, out of this population, 23% of the problems were serious whereas 2% were fatal. All of the reported problems were preventable (Godman, 2012). One of the emerging questions is why does communication breakdown in issuance of discharge instructions occur? Why do patients have a problem with comprehending their ED care? It should be noted that the highlighted case represents the best scenario partly due to the intervention by the pharmacist and the prompt follow up. In the absence of these interventions, most studies have reported up to 78% of the patients’ demonstrating a comprehension deficiency in at least one domain of their ED visits (Engel et al., 2008). In answering the two questions posed in the previous paragraph, this study focuses on past researches on a misunderstanding of discharge instructions. According to one of these researches, miscommunication and misunderstanding of ED instructions can be blamed on the healthcare systems or the individual practitioner. A variety of studies show that physicians’ level of communication, as represented by complex medical terms combined with patient’s limited health vocabulary, translates into inadequate and at times confusing communication. The study noted that most of the ED instructions are written at an 8-13 grade reading level this is quite complex for most patients who can on average read at the 6th grade level (Chugh et al., 2011). Furthermore, most physicians and nurses overestimate the patient’s capacity to understand ED instructions (Chugh et al., 2011). Statistically, physicians and nurses believe that 89% of the patients have an absolute understanding of their medication. This is flawed as only 57% of the patients report to have understood the instructions. Additionally, physicians are convinced that 95% of the patients understand when to resume normal activities, in the actual sense only 58% of these patients agreed to have understood (Chugh et al., 2011). Lack of comprehension is also blamed on health literacy problems which include a problem in reading and interpreting medical instructions, medication labels, and appointment slips, and poor understanding of chronic conditions and accompanying management (Chugh, 2011). Besides inadequate health literacy, poor comprehension can also be attributed to impairment of cognitive abilities. This impairment largely results from delirium. In studies examining the effects of impaired cognitive abilities on comprehension of ED instructions, it was apparent that individuals with moderate to severe cognitive impairment have a higher probability of at least one medication error when on a medication self-management program (Chugh, 2011). Most concern arises from the fact that this impairment is not defined or realized in a large number of older adults. Further, cognitive functioning is not routinely examined by use of standardized equipment/instruments in hospitalized patients (Chugh, 2011). At times, it is not always about health literacy and cognition, the patient’s interest, motivation and sense of priority for the recommendations also plays a crucial role. A patient who simply fails to listen or takes little interest in the nurse’s explanation stands a minimal chance of understanding the discharge instructions (McCarthy et al., 2012). Consequently, their capacity to manage their illnesses and ensure recovery is largely inhibited. This in the long run presents a greater cost both to the patient and to the healthcare system. Looking at the problem of comprehension and the contributing factors it is crucial to note that there is little that can be done from the patient’s end. The most responsibility lies with the nurses and physicians. The ED physician is responsible for much of the content of discharge instructions while the ED nurses are responsible for delivering information (Iyer & Aiken, 2001). By virtue of this role and the fact that the ED nurse is the last professional in contact with the patient, ED nurses are also accountable for ascertaining whether patients and caretakers comprehend what they are being told and are capable of carrying out instructions. In this sense, ED nursing notes form the basis for evaluating negligence in this area. To avoid blame and ensure delivery of quality patient care, the nurses have to undertake an individual and professional effort to improve comprehension (Iyer & Aiken, 2001). This is possible by adopting new approaches that have been developed to aid in this task. An example of such intervention measures includes use of understandable health terms, use of pictorial representations, being precise in issuing and explaining instructions etc. Rosenberg and Shure (2011) describe a bridge model which can be applied with considerable effect on improving comprehension. The model has three intervention phases. The first is pre-discharge this involves meeting up with a patient and determining unmet needs before a patient is discharged. This may also entail looking through medical records and consultations with various medical experts handling the patient. The second phase is post-discharge; this involves a follow-up through calling to identify any unidentified needs or surprises recognized on returning home. The last phase is follow-up this involves calling the patient thirty days after discharge to determine any emerging needs as well as carry out quality assurance surveys. This model represents an effective way of ensuring comprehension and delivering quality-after care. Conclusion The phenomenon of comprehension is not as deliberated or examined in most health studies. However, it is one that has wide ramification on the patient and healthcare system as this study has demonstrated. Even though the problem of comprehension results from patients and physicians and nurses shortcomings, the blame and responsibility squarely falls on the ED nurse. The ED nurses are expected to carry out adequate research and determine that best way to ensure comprehension of ED instructions. References Chugh, A., Williams, M. V., Gigsby, J., & Coleman, E. A. (2011). Better transitions: Improving comprehensions of discharge instructions. New York: American College of Healthcare Executives. Clarke, C., Friedman, S. M., Shi, K., Arenovich, T., Monzon, J., & Culligan, C. (2005). Emergency department discharge instructions comprehension and compliance study. Can J Emerg Med 7;(1) , 5-11. Godman, H. (2012, July 09). Medication errors a big problem after hospital discharge. Retrieved March 2, 2013, from Harvard Health Publications: http://www.health.harvard.edu/blog/medication-errors-a-big-problem-after-hospital-discharge-201207095012 Iyer, P. W., & Aiken, T. D. (2001). Nursing malpractice. Tucson, AZ: Lawyers & Judges Pub. Co. McCarthy, D. M., Engel, K. G., Buckley, B. A., Forth, V. E., Schmidt, M. J., Adams, J. G., et al. (2012). Emergency Department Discharge Instructions: Lessons Learned through Developing New Patient Education Materials. Emergency Medicine International Volume 2012 , 1-7. Rosenberg, W., & Shure, I. (2011). Social Work and the Bridge Model: The Key to Successful Transitional Care. Retrieved March 2, 2013, from National Association of Social Workers: http://www.naswil.org/news/networker/featured/social-work-and-the-bridge-model-the-key-to-successful-transitional-care/ Zeng-Treitler, Q., Kim, H., & Hunter, M. (2008). Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. New York: AMIA AnnuSymp Proc. . Read More