Nurses Are Talking About: Sending Home Patients Who Don't Understand Hospital Discharge Instructions

Troy Brown, RN

Disclosures

June 22, 2016

The Problem With Discharge Instructions

A recent Medscape article hit home with many nurses. The article described a study that showed that only one fourth of patients understood their discharge instructions because they were tailored to people with higher reading levels and more education. Many nurses and physicians commented on these findings, and a selection of those comments is presented here. [Note: some comments have been edited for clarity or length.]

The American Medical Association recommends that written health information be at a sixth-grade reading level, but this study of instructions that were given to 500 trauma patients found that the instructions were written at a tenth-grade reading level.

Health Illiteracy

Health literacy is "the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions."[1] Only 36% of working-age adults in the United States have adequate health literacy skills. In Canada, that figure is only slightly better, at 46%, according to the Canadian Council on Learning.[2]

Literacy is the ability to read and write. Illiteracy is a major—but not the only—reason patients are unable to understand their discharge instructions.

The Joint Commission explains how low literacy affects patients. "Many patients who have low literacy skills mask what they feel are their inadequacies. For them, there is too much shame in admitting that they do not read well, or that they do not understand. Physicians, nurses, and other health professionals may never know that among the patients they have seen for years, some have suffered silently, grasping far less than others would have expected."[3]

One nurse commented:

People will not "cop" to illiteracy, but it is easy to turn a conversation to "some people are verbal learners." Of course, then you need to tailor the oral presentation to the patient's abilities and strengths, and the nurse must have the time to spend on education.

"It comes as a surprise to many, but people who are illiterate often have developed superior memory skills. They don't forget what has been satisfactorily explained to them," another reader observed.

Some patients may be able to read and write but not in English. "Once, to my surprise, a patient perfectly fluent in English was illiterate," one nurse commented. "She could read in Greek but not in English. She had attended local schools, and it was never detected that she could not read. I suspect that the same can happen to anyone who has grown up in a culture that does not use the Latin script."

Electronic Health Records—A Mixed Bag

The article proposed that electronic health records could help clinicians determine the patient's ability to read instructions in real time and prompt them to change the wording of instructions to make them easier to understand.

But there is a downside to electronic health records. One nurse who had been treated for chest pain in an emergency department recalled the instructions she received. She related her experience as a patient receiving discharge instructions:

Electronic records have made discharge instructions so much more difficult. When it was determined that I could be released, I was handed 20 pages of absolute gibberish such as, "Your diagnosis is chest pain, you may have this, you may have that, muscle sprain, maybe it is a heart attack, we can't be sure," and on and on. The nurse actually told me, "This is all just nonsense, we are killing trees to print all this garbage, just sign here."

Another reader echoed those thoughts: "Patient literacy is only part of the issue. Most discharge instructions are too many pages yet contain very little information that is of actual use to patients, their families, or even clinicians who provide follow-up care."

Age, Illness, and Language Complicate the Picture

Only 12% of adults older than 65 years have adequate health literacy skills.[2] Trouble hearing and difficulty with memory and concentration can interfere with a person's ability to understand discharge instructions.

"The discharge instructions are too wordy for the elders and undereducated patients. They get lost and confused when they read them. A short and simple discharge instruction sheet would improve outcome," one nurse wrote.

Another nurse explained:

People in the hospital want to leave and will often say "yes" to anything so they can go home. Psychiatric patients, like those with head injuries, often have difficulty with cognitive processing. I currently work with a pharmacy where we have been piloting a number of programs to address care transitions, including filling prescriptions and delivering them the hospital before discharge, then doing an in-home follow up. I can't tell you how many patients' discharge instructions never make it into their homes.

"Education is just one part of a complicated equation that determines comprehension of directions during highly stressful periods," a reader said. "Patients may believe they understand their instructions at the time they are given but become confused after discharge as a result of medications they received, the stress of being hospitalized, or their illness or injuries."

"As a former home health nurse and a patient myself, I can attest that even well-educated people get confused or do not follow through," wrote one nurse.

A reader observed that patients may have difficulty understanding verbal instructions when the person giving the instructions is not fluent in English. "I have encountered many patients who have said, 'What did she/he say because I couldn't understand.'...We need to be mindful that the person handling discharge can also speak clearly and understand what they are telling their patient."

Not Enough Time

Nurses just do not have enough time to educate their patients as thoroughly as they would like, many nurses reported.

One nurse commented:

As any bedside nurse knows, there is very little time allowed for actual face-to-face with the [patient]. Any time a patient is discharged, you know there is an admission coming your way immediately. The paperwork involved in any admission or discharge is extremely time consuming for those two patients, and the nurse has how many other patients as well.

"One of the biggest issues, aside from the reading and comprehension level, is the time allotted to discharging patients. This is a time-consuming activity if done right, and hospitals have historically ignored the impact of both discharges and admissions in their staffing plans," another reader wrote.

What to Do?

Ideally, discharge teaching should begin at the time of the patient's admission. One study[4] of 30-day mortality rates in hospitals where patients were treated for myocardial infarction found that most successful hospitals start the discharge process immediately upon hospital admission. Also, once patients are released, they are followed up by their primary care physicians 2 days after discharge.

Nurses are accustomed to teaching informally while they care for their patients. Teaching in this way allows the patient and their family time to process the information and ask questions. It also helps the nurse establish trust with the patient and family.

Many nurses said that they use the "teach-back" method—asking the patient to repeat their instructions back to them or demonstrate skills such as testing their blood sugar—when educating their patients.[5]

One nurse wrote: "When giving discharge instructions, I find it helpful to have the patient repeat back to me what I just said. Then I pose a few scenarios of problems that could arise and ask the patient what he or she should do. The next day, I try to call these patients at home to see how things are going."

"In practice, I have found that giving the notes to the patient to read and then asking them to repeat in their own words what they mean discloses the level of their understanding and literacy," another nurse commented.

Nurses said that they find it helpful to present the information in writing and verbally.

As a nurse, I've done many discharges. I highlight the important information that patient needs to remember and follow up and take time explain in simple language. Even when the patient or family member said they understood the instructions, I still get about 20% calls back to the hospital, asking the same questions that I answered multiple times.

"I let the patient read the instructions first, and then I sit down with the patient and we have a conversation," one nurse commented.

"As an emergency department nurse, I make sure that I sit down with each patient and explain the discharge instructions and medications in detail until I am sure that the patient completely understands them," wrote another nurse.

Many nurses commented on the importance of follow-up phone calls after discharge.

One nurse explained: "I believe that every patient who is discharged from the emergency department should receive at least two follow-up calls from the hospital, one at 24 hours and another at 72 hours. The person making the call should ask the patient or caretaker to read the instructions out loud and then in their own words."

Follow-up calls were recommended by another nurse as a solution to this problem:

I work at the VA in a primary care setting, and one of our performance measures is a two-day follow-up call to patients who have been discharged from the hospital. This enables us to make sure the patients understand their instructions, are taking medications as prescribed, and know that we are available to answer any questions they may have.

Nurses widely agreed that optimal patient education requires time and is more effective when instructions are simple, given in writing as well as verbally, and when the patient is asked to repeat those instructions back to them.

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