Is There Enough Time for Patient Teaching and Teach-Back in Fast Paced Acute Care Settings

  1. I've been nursing for 20 yours in an acute care setting and love my profession and always looking for ways to improve. Please see how you can help me below:

    I work on a Medical Telemetry Unit where the nurse to patient ratio is 4 to 1 and at times 5 to 1. Our length of stay averages 2.8 day and there are 36 beds. With the business of the unit I find nurses are unable to reach out to teaching so that it is effective. On an average day it looks like nurses are focusing on completing all their tasks, Meaningful Use and Public Reported documentation... which leaves minimal time for teaching. With the Federal Government wanting hospitals to decrease readmission by 20% it seems more time is needed with our patients and families for teaching. An example is a new heart failure patient. During your first morning round you assess the patient knowledge and management of heart failure. The patient knows nothing but to decrease his salt intake. You provide teaching sheets and DVD to view. You also pull up information about new medication like Coreg, Lasix, Potassium... The next nurse comes in and teaches information about the side effects of Coreg only. The next nurse comes on shift and talks about reading nutritional labels to determine the amount of sodium per serving. All teachback by the patient was done properly with each nurse. On the 3rd day this patient is discharged. Did any have time to share with this patient to weigh daily, write it down, and when to notify MD of weight gain? NO!. This patient is given a follow up visit to PCP within 3 days but doesn't go and is readmitted with SHOB after 9 days. After review of readmission it was identified that this patient didn't have a scale at home and didn't know he was to weigh daily. The process starts all over again because the nurses still don't have the time to reach out to teaching.

    What are your thoughts about the time staff nurses have to devote to quality education to our patients? Share what you are doing differently in your organization to allow more time with patients and families for teaching and teachback?
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  2. 12 Comments

  3. by   dudette10
    For CHF, we have a packet that we give with a succinct "refrigerator sheet" for what to do with weight and SOB symptoms. My teaching is focused on the most important parts. I always say, "There are really only three things to know: Weigh yourself daily, low sodium diet, and take your medications as prescribed." Then I pull out the sheet and review when to call the doctor and when to go to the ER.

    As I'm giving the CHF meds, I do teaching there too and focus on the beta blocker and diuretic, identifying them as heart failure meds, emphasizing their importance. Teach back is done a couple times throughout the day. "Hey, time for your quiz! What do you need to do every day to manage your heart failure?" "When should you go to your doctor outside of regular appointments?" It takes only a couple minutes each round. If the sheet is hidden during rounds, I always pull it out and tell them, "This could very well keep you out of the hospital."

    I might not do hourly rounds just for pt satisfaction scores, but I do do rounds to meet my patients' needs, based on my judgement of their nursing needs.

    You know, there is a good chance that a hospitalized who doesn't go to a follow up appointment isn't managing his/her condition anyway. I impress upon my patients that CHF is a manageable condition but it requires their diligence and participation in managing it. If they don't manage it, it will get worse faster, and they will be in the hospital more.
    Last edit by dudette10 on Dec 31, '14
  4. by   MissM.RN
    "Is there enough time for patient teaching?"

    NO.

    I think about this every time I go to work...
  5. by   Gooselady
    There has to be time made for patient teaching, it's as much a part of our job as passing meds and changing dressings.

    Our hospital had specific hand outs we had to chart as given on admission. Whether or not we had time to sit down and go through the hand outs is another story. Apparently JCAHO and/or state guidelines for patient education have no problem handing out written material and calling that patient teaching.

    We don't do patient teaching as a separate 'chunk' of our duties. Assessment, reassessment, teaching, monitoring, observing -- it all happens at the same time in the experienced nurse. An assessment particular leads to on-the-spot teaching. Passing a med involves on-the-spot teaching.

    No one ever said we'd have blocks of time of such holy ground to provide teaching. It is ongoing and opportunities for it while peeling open meds or checking patient's bottoms or clearing the IV pump happen all the time. This 'rhythm' comes with time, so if you feel like you can't do your teaching in the time allotted, change your expectations of the teaching 'moment' as something separate from your nursing tasks.

    My last job was medical oncology, and teaching pts about chemo, side effects, what to expect . . . endless. We provided hand outs and during the chemo hang itself, there was quite a bit of time while spiking bags, taping ports, draping yourself in all the protective garb, to provide teaching and reminders. I've done chemo teaching while wiping bottom countless times.

    So it's a matter of perspective, and regarding patient teaching as NOT in any way 'optional'.
  6. by   dudette10
    Very well said Gooselady. Teaching is as basic to nursing as passing meds or assessments.
  7. by   Gooselady
    Thanks. I hope I didn't come across as 'thou shall'. This is something that any nurse can do, including brand new nurses, just by lowering those too-high expectations on yourSELF. Teaching cannot be avoided unless you refuse to speak to the patient We put so much pressure on ourselves besides the pressure put on us, which can be unrealistic.

    I've had a few patients who plainly refused teaching as well. Information overload does happen. They let me or whoever know when they are ready for more. This may have had a lot to do with their diagnosis of cancer.
  8. by   Loo17
    Quote from brcanda3
    I've been nursing for 20 yours in an acute care setting and love my profession and always looking for ways to improve. Please see how you can help me below:

    I work on a Medical Telemetry Unit where the nurse to patient ratio is 4 to 1 and at times 5 to 1. Our length of stay averages 2.8 day and there are 36 beds. With the business of the unit I find nurses are unable to reach out to teaching so that it is effective. On an average day it looks like nurses are focusing on completing all their tasks, Meaningful Use and Public Reported documentation... which leaves minimal time for teaching. With the Federal Government wanting hospitals to decrease readmission by 20% it seems more time is needed with our patients and families for teaching. An example is a new heart failure patient. During your first morning round you assess the patient knowledge and management of heart failure. The patient knows nothing but to decrease his salt intake. You provide teaching sheets and DVD to view. You also pull up information about new medication like Coreg, Lasix, Potassium... The next nurse comes in and teaches information about the side effects of Coreg only. The next nurse comes on shift and talks about reading nutritional labels to determine the amount of sodium per serving. All teachback by the patient was done properly with each nurse. On the 3rd day this patient is discharged. Did any have time to share with this patient to weigh daily, write it down, and when to notify MD of weight gain? NO!. This patient is given a follow up visit to PCP within 3 days but doesn't go and is readmitted with SHOB after 9 days. After review of readmission it was identified that this patient didn't have a scale at home and didn't know he was to weigh daily. The process starts all over again because the nurses still don't have the time to reach out to teaching.

    What are your thoughts about the time staff nurses have to devote to quality education to our patients? Share what you are doing differently in your organization to allow more time with patients and families for teaching and teachback?
    Dobyour patients get set up with a visiting nurse? As a previous visiting nurse I find this is a crucial part of the puzzle and can be a great opportunity to reinforce hospital teaching in their home and follow them for a short time to make sure they understand and provide further teaching. Medicare will pay for this in most cases of new diagnosis.
  9. by   Libby1987
    Our local hospital sends a chf kit along with a scale home with their CHF patients and has given us (HH) the same kit.

    We we either see the patient, call or pt had me appt for the first 7 days.

    Biggest problem that I have encountered preventing ER visits and readmissions is a patient going home with no MD to take responsibility for chf mgmt. PCP hasn't seen patient in over a month and doesn't want to adjust meds. New cardiologist hasn't seen patient yet and won't mske treatment changes. Hospitalist unavailable 2 days later on Saturday.

    And that's with me on the phone trying to track someone down. A patient without a HH nurse will have less success regardless of their compliance or teaching rec'd in the hospital.

    But to OP's question, 3 things to repeat ad nauseum until they say I KNOW I KNOW ALREADY!! ...

    -Make sure you understand your new med schedule and don't miss any.
    -Limit processed food and obvious salty foods, avoid take out, go fresh as much as possible
    -weigh same time everyday and report over 2lb weight gain to MD.

    Its uncommon IME for newly discharged patients to watch a dvd or read any of the handouts, try to get them in the hands of their spouse/family.
  10. by   RainMom
    For new CHF, we have "chf nurses" from cardiology who are consulted to come up & do teaching. Also have a diabetes nurse educator. For everything else, we have education sheets that print out. Our pharmacists also come up to do teaching with pts being dc on anticoags.
  11. by   anh06005
    The lack of time to educate was what I hated most about the floor. When I went to home health I got plenty of time to focus on one patient and educate. It's the side of nursing I was missing when on the floor.

    3 things I always (or usually) touch on first visit with a CHF patient:

    -quick overview of meds (many patients and family wonder why the patients needs several BP meds..."their BP has always been ok!"). When I explain this set of meds can help the heart get stronger and lower BP = less stress on the stressed heart they're ok

    -daily weights daily weights daily weights. Call MD if gain 3 lbs in a day or 5 lbs in a week or less (we have an action plan to give them stating this also)

    -avoid anything out of a box or can (covers most processed foods)

    Home health nurses can really impact the patients and their disease mgmt. Maybe the patient forgets to weigh. Well let's put the scale and a calendar on the wall in your bathroom. So you pee in the am, get up and weigh and you're done.

    I really WISH floor nurses had the time but they just don't.
  12. by   MissM.RN
    Goose lady - yes, brief moments of patient teaching can occur during med pass. I find it difficult to believe that quality teaching sessions are occurring while wiping someone's buttocks. And how much information is a patient getting while you're for example peeling open a dilantin dose? Is that really enough time to thoroughly discuss regimen adherence and oral care to prevent gingival hyperplasia? You're talking about "teaching in passing". So many other complex learning need examples I'm thinking of.....anyway......it basically comes down to nurses need lower ratio's to provide quality teaching and prevent errors.
  13. by   kmaryniak
    There is definitely not enough time that is needed for bedside nurses to provide quality education. When the average length of stay was 7 days, there was time. Teachback strategies are helpful when they are done consistently- which means the staff need the education first. If there is a list of "need to know" topics in bullet points, then each time a nurse goes into the room, one topic can be covered, and have the patient repeat it back. This reduces the time at discharge, because instead of reviewing a long list of educational material, the patient can demonstrate his or her knowledge of the bullet points covered during his admission.

    The other consideration is dedicated resources for patient teaching. Some hospitals have invested in groups of patient educators, with expert knowledge of specific topics (e.g. cardiac, diabetes, etc.). This could be a worthwhile investment that may be strategy to reduce readmissions.
  14. by   Cordee2010
    Hello, I retired from the VA last summer. During my last 6 years I worked as Outpatient Case Manager and Inpatient Case Manager using Internal criteria to manage my load. Chronic diseases such as CHF and Diabetes are a big deal in the hospital. At the VA we identify those patients on day#1 and refer them to the CHF clinic or Diabetic educator. They have a more comprehensive teaching tool that is also provided to the patient in writing. It is very important the communication with the PCP and the education that the patient is receiving as outpatient. As an outpatient CM I had "Nurse Appointments" to see CHF, Diabetic and Hypertension patients. Weight, medication adherence, barriers of treatment and nutrition education assessed. I believe that what you describe is more of a System (institution problem than an individual problem. As per Interqual Criteria a CHF patient have 3 days as inpatient, but if education is not completed Home health Care can be order for Medication and disease process education. A nurse will go to the home and reinforce and/or complete what was initiated at the hospital. HHC services scan start day 2 after discharge with the goal of reducing readmission.

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