Patient Engagement research

Cardiovascular Disease CMS……………………. Centers for Medicare and Medicaid Services EBP……………………. Evidence-Based Practice EB………………………. Evidence-Based CINAHL………………. Cumulative Index to Nursing and Allied Health Literature FHL……………………Functional Health Literature TOFHLA………………Test of Functional Health Literacy in Adults REALM………………. This DNP project will involve determining whether health literacy educational interventions increase the nurses’ knowledge levels as evidenced in the posttest health literacy assessment tool and whether health literacy educational interventions for the nurses help to increase awareness of the health literacy rates of their patients as evidenced in the patient’s post-discharge follow-up telephone calls. The posttest HL assessment tool addresses health literacy and complexity of patients in today’s world. The project will involve the determination of readmission rates for patients suffering from heart failure before and after educational interventions.

This will help in determining if there is a correlation between the readmission rate of patients and educational intervention for both nurses and patients. The process of empowering both patients and nurses through improving delivery of health education is believed to bring positive social transformations to the community and healthcare setting via promotion of healthcare. Yet, some healthcare information is seemingly impenetrable and very complicated. Even some people who can proficiently use text and numbers can sometimes fail to understand some health information especially in cases where faced by vulnerability emotions or entirely challenged by illness (Rikard, Thompson, McKinney, & Beauchamp, 2016). Research shows that health literacy involves more than just understanding or reading health information among patients and nurses. It also involves patient expectations/preferences, educational, healthcare provision that meets patient’s preferences and socio-cultural factors influencing such preferences.

Nurses and other health care providers ought to understand patient’s background such as their beliefs, traditions and cultural values which have influence on sharing of health information. Research shows that employee empowerment takes different dimensions such as meaningfulness which refers to capturing relevance of activities that are judged based on one’s ideal life. Secondly is self-efficacy which refers to belief in the personal ability to produce based on one’s actions to get the desired outcome. The third dimension is self-determination which shows that one’s choices and decisions are personal and not influenced by anyone (Van Dop, Depauw, & Driessens, 2016). The last dimension is impact which refers to the idea that one is able to make difference in the midst of many things.

Health empowerment framework shows that best results are only achieved whenever a competence-based element regarding health literacy combines together with health empowerment volitional element. It is a process that basically depends on the ability of a patient to access, process, pass information and have a proper understanding of primary health information. Research shows that patients have a significant towards their personal healthcare. This approach is characterized by the amount of information that passes between a nurse and a patient. It is also determined by the extent of patient involvement in health care decision making as well as his/her active roles in the decision-making process. Patients endeavor to have safe and reliable healthcare services as well as receiving respect, dignity, and compassion from the healthcare provider.

Considering the number of people under Medicare health insurance scheme, a recent report by CMS shows that more than 27% of cases of heart failure diagnosed have been readmitted within one month after discharge. CMS has come up with a compulsory reporting of one-month readmission rates for patients suffering from heart failure so as to come up with different ways of improving patient outcome. The recent move of imposing readmission penalties within one month by CMS has forced different health facilities to look for alternative means of reducing the number of readmissions (CMS, 2018). It is important to prepare hospitalized people for personal health management after being discharged. During this era where readmission of heart failure cases is closely monitored and reported, it important for nurses to embrace effective healthcare education before patients are discharged.

Based on the proposed research questions, this project will be guided by the following objectives; 1. To determine the rate of patient readmission before health literacy educational interventions. To determine the rate of patient readmission after health literacy educational interventions. To determine the nurse-patient relationship before health literacy educational interventions. To determine the nurse-patient relationship after health literacy educational interventions. Readiness to learn by patients suffering from a heart attack and other chronic diseases is important because it helps in promoting transitional care and helps in the reduction of rates of readmission. Also, the ability of the concerned nurse to initiate self-care among heart failure patients with the help of EBP intervention such as teach-back is important to this research. Education of patients concerning health information ought to involve effective teaching approaches that aim at literacy challenges while improving retention of important elements of self-care among the patients.

Teach-back education approach aims at training patients in such a way that they can express what they have been taught, thereby enhancing comprehension. Effective teaching approach has a close relationship with theoretical concepts of personal care and provides in-depth exploration by the nurses as they plan to transform patients. This will make it difficult to determine the exact number of nurses who have no idea of what it means by assessment of health literacy. Secondly, some of the patients may not be willing to fill in the questionnaires or not interested in returning the filed questionnaires. In order to reduce such cases, the researcher will record the number of questionnaires administered and make follow up to ensure that all of them have been fully filled and returned.

Some participants may fail to fill in the questionnaires because of the language barrier. In such a case, the researcher will make use of a bilingual research assistant to interpret the questions where necessary. It can be achieved through patient engagement as well as empowerment to take part during decision making. Overestimation of HL by nurses has become a challenge in healthcare sector. For instance, considering the number of people under Medicare health insurance scheme, a recent report by CMS shows that more than 27% of cases of heart failure diagnosed have been readmitted within one month after discharge. The purpose of this project will be to determine the effect of pre and post educational interventions on nurse-patient relationship, which will be achieved by answering the PICOT question; what will be the impact of the post and pre-health literacy educational interventions among telemetry day nurses to s one-month readmission rate among patients suffering from heart failure? This research will contribute a lot toward nursing practices as nursing professionals gain an understanding of different discharge objectives that will help in preparing patients on how to manage their illness after being discharged.

Some of the common terms that will be used all through the project are; health literacy, health empowerment, patient engagement and satisfaction as well as readiness to learn and teach-back technology. Nutbeam Model of Health Literacy is the theoretical foundation for this project. It is comprised of health three sequential levels; functional, interactive, and critical (Nutbeam 2000). Functional health literacy (FHL) refers to basic HL skills that are enough for people to understand information related to their health issues (For instance, concerning health hazards involved and different ways of making use of health systems) and to be in a position to make use of that knowledge within limited activities prescribed by physicians. Interactive HL gives a detailed description of advanced literacy experience that helps different people to access information and interpret meaning based on the information presented as well as making use of that information to change circumstances.

Acquiring this skills is vital because it helps one to act independently in case of new information and develop high levels of confidence during interaction with information providers such as nurses and other healthcare practitioners (Nutbeam 2000). Show self-efficacy (confidence) for making use of relevant health information in taking positive actions and making decisions that are beneficial to their health. Considering different complications, tools used for measuring health literacy have been designed with “more specific foci” even in cases where the concept structure remains unchanged. This involves special measurement tools depending on a particular group of people, communication channel, country of origin/background (Chinn & McCarthy, 2013) and health content to be delivered (Al Sayah, Williams, & Johnson, 2013). These assessment tools also help in carrying out a complicated analysis of challenges of low HL as well as offering a foundation for evaluating interventions that can help in addressing health literacy.

Application of Nutbeam Model in improving health literacy The levels of health literacy in the society can be improved by educating people which can be termed as a measurable outcome in delivering health-related education just the same ways that literacy assessment tools are used in determining the extent of schools education success. Observing such simple processes may result in improvement in health outcomes. The above figure describes an overview of how functional HL can be improved in a healthcare setting. The model focuses much on developing literacy skills and the ability to make use of them in daily decision making concerning personal health. Also, it describes the significance of different ways in which improvement in the organization of services can promote nurse-patient relationship within a clinical setting.

However, time constraints which tend to limit the period of clinical consultation hinder communication of factual information related to health risks involved, and proper way of using medication as well as prescribed health services (Skre et al. This refers to methods and contents that that help one to differentiate between different information sources, analyze their relevance and meaning and later use such information to gain control over different determinants of health. In such a case, health education will become less deterministic and more interactive. It may involve the development of skills or information communication to support different health activities for addressing social and personal health determinants. In this case, health-related education would be aimed at improving the community and personal ability to act on economic and social health determinants.

According to Inoue, health education content should not only focus on changing the lifestyle of patients or enhancing their compliance with approaches to self-management. Review of literature Patient Engagement Patient engagement is a field that has been broadly researched in health community since the 2001 publication of the report “Crossing the Quality Chasm” by the Institute of Medicine. According to this report, the institute grouped patient-centered care among the different reform approaches in national health care community (Tak, Ruhnke, & Shih, 2014). Engagement of patients in decision making concerning their healthcare issues has been termed as a critical catalyst for reforming health care programmes and it is centered on taking care of a patient. It is important to engage patients during the implementation of different healthcare practices which involve “coordination and integration of personalized care as well as the provision of financial information and education and shared decision-making about health care between the patient and physician” (Wyrwich, 2016).

Research shows that the quality of healthcare extended to patients is depends on the successful engagement of patients. The process of patient activation refers to the way someone understands the importance of being directly involved in his/her health care issues and ability to do the same. This activation is basically determine through PAM which is represented into different stages such as “ believing the patient role is important, having the confidence and knowledge necessary to take action, actually taking action to maintain and improve one’s health, and staying the course even under stress” (Hibbard et al. , 2004, p. In 2013, Hibbard and Green discovered how activation can be boosted with time while some interventions can be adopted to develop different skills for supporting activation.

On the hand, Shivley et al. proved the existence of different dimensions of decision making and consumer choice which need different efforts and skills. Another research found that patients who are much activated stand a better position of using comparative information even if they have low levels of skills in literacy and numeracy understanding. Therefore, activation may serve as a proxy for patient motivation. According to Hibbard et al. , activation of patients helps in predicting amount to be spend on healthcare provision as well as readmission rate because patient’s motivation and ability to manage personal health is important to nurse’s ability to lower expenses incurred and reduce chances of readmission while improving patient care (Hibbard, Greene, & Overton, 2013). According to this research, 186 patients out of the total 197 wished to be engaged in the process of making a decision concerning their health status, with taste being common between anesthetists and patients (Flierler et al.

Also, another research which involved adult participants proved that decision making is directly associated with patient satisfaction, especially in cases where patients have been involved. Little has been done on the satisfaction of patients, especially in terms of patient engagement with only one research which has focused on patient activation and experience levels (Hibbard, Greene, & Overton, 2013). This research involved 5,002 patients from 49 centers that offer primary care and noted that patient activation is related to their experience. Patients who are highly activated gave their caregivers 0. PCC should involve a therapeutic relationship which plays a significant role in personalizing delivery of healthcare. This relationship is characterized by different components such as loyalty and trust between the two parties. For insistence, based on audiologist survey conducted by Grenness et al.

, the concerned audiologist expert ought to engender trust so as to develop a relationship that will lead to loyalty in the long run (Grenness, Hickson, Laplante-Lévesque, & Davidson, 2014). A professional clinician is only trusted by patients if he/she has shown professionalism through communication, technical competence, and good interpersonal skills. , nurses use incorrect approaches in assessing levels of literacy in different healthcare settings and most of them have been overestimating the level of health literacy. Nurses are healthcare experts who have the role of making patients understand dietary restrictions, medical appointments, and activity level after they are discharged and newly proposed medications (Dickens, Lambert, Cromwell, & Piano, 2013). Therefore, overestimating levels of health literacy among patients makes it difficult for patients to understand the information taught by such nurses.

Research by Dickens et al. further recognizes the role of education level attained in determining health literacy level among patients. This can only occur if management in healthcare organizations train their employees and make necessary adjustments aimed at promoting health literacy. There is no evidence that supports health literacy screening. In fact, a study conducted by Paasche-Orlow et al. found very limited evidence to support HL screening among patients in different settings and acknowledged dangers associated with the same (Paasche-Orlow & Wolf, 2007). Another study which involved the use of RCT examined the impact of notifying nurses of the low HL among their patients. A 2007 report “What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety. ” Published by Joint Commission proposed different interventions such as using teach-back approach in teaching patients concerning health-related education, avoiding jargon, encouraging questions from patients and use of illustrations and simplified language while handling patients with low levels of HL.

The increased rate of patient readmission as a result of medication errors has raised a lot of issues concerning levels of health literacy by nurses because it keeps safety of patients at stake. Research has proved that most of the nurses (graduates and registered nurses) do not have enough knowledge for bringing changes in HL (Mosley & Taylor, 2017). Different researchers have proved that knowledge of effects associated with evaluation of HL interventions and poor HL skills is very low, indicating that most of the graduate nurses join the workforce having insufficient knowledge related to identification of patients with low levels of literacy skills, carrying out HL screenings and implementing recommended HL interventions (Cafiero, 2013). For instance, a study conducted by Lieu et al.

which involved 21 consumers of health care proved three instances that consumers incur additional out-of-pocket expenses that can be addressed by increasing practices of patient engagement such as medical emergencies, medical services that people thought were catered by insurance policy and failure to discuss health costs with physicians. However, scholars such as Loewenstein et al. and Yegian et al. proposed different ways of increasing practices of patient engagement concerning management of out-of-pocket costs to cater for their healthcare services. The most important interventions proposed is educating patients about making financial decisions and enhancing public awareness concerning the effect of financial decisions (Sommers et al. The authors Kelly and Huckman argued about the efficiency of today’s efforts of public reporting concerning making informed decisions by consumers based on cost and quality information.

Considering the increased need to address specific concerns and interests among the patients, additional time could be required to communicate information to patients. According to this research, “consumers are paying a growing share of costs given that prevalence of high-deductible health plans has grown by 24% from 2006-2012 and copayments have had similar growth” (Huckman & Kelly, 2013). This transitions to consumerism ought to ensure that patients are much involved in financial decision making. The following framework from the institute of medicine illustrates various health contexts in health literacy. Figure 1: HL: A Prescription to End Confusion Literacy is made up of different contextual pieces and many people who have a lot of effect on the achievement of intended personal skills. As this literacy transitions to health literacy model, it is changed by another array of contexts and the person with acquired experiences to develop another literacy level, which is health literacy.

The following sections give a brief description of health literacy. Historical overview of health literacy Although research shows that health literacy began in 1974, there are high chances that this field could have existed earlier than thought. During 1950s, a scholar published a book “Why Johnny Can’t Read,” which brought awareness to health professionals that people who have low literacy experience and others from different cultural backgrounds had a lot of needs that needed their attention as far as current healthcare is concerned (Smith, Curtis, O’Connor, Federman, & Wolf, 2015). Although this author was not specifically targeting health literacy, it was found that some people needed a specialized approach to healthcare. The evolution of healthcare brought a lot of complications concerning effective means of communicating health information so that it can be understood by people with low literacy skills.

During the 1970s, it was not yet clear among health community stakeholders that the use of “plain language” was the only effective and convenient approach for communicating health information to the public. One of the articles during this era researched on consumer understanding of different diets and it was found that “American consumers are not equipped by prior training to effectively interpret and use nutrition information” (Miller & Cassady, 2015). Some other elements associated with reduced literacy levels include; being a female person, incarceration history and low-income status (Weiss & Palmer, 2004). Also, increased expectations from healthcare systems which result to nurse-patient interaction during provision of care call for an increase on personal skills among health care professionals concerning life experiences, diverse culture and how to communicate health information effectively.

Although most scholars focus much on patients, some health care providers are not properly trained in how to teach patients about health education, bring more shadow to health literacy. Health Literacy Assessments The level of education among individuals is not an effective indicator for measuring the ability to read but it has an effect on health outcomes. It does not show the real ability of a person to read and internalize information before making informed decisions. According to 2013 IOM research, “While health literacy measures in current use have spurred research initiatives and yield valuable insights, they are indicators of reading skills, rather than measures of the full range of skills needed for health literacy (cultural and conceptual knowledge, listening, speaking, numeracy, writing, and reading)” (Pleasant et al.

Therefore, increasing awareness among nurses and other professionals beyond reading ability of a patient will and accepting the fact that there exist different experiences in life that matter a lot to health, would transform caring approaches and research towards a positive direction. The most common approaches for assessing levels of literacy among patients are REALM and TOFHLA. REALM approach is easily applicable, takes very little time and involves the oral reading of 66 medical terminologies. The patient’s score is determined based on the number of terms pronounced correctly and then graded from third grade to ninth grade. People who fall under the adequate category have the ability to read, comprehend and interpret information related to their health. People who fall under the remaining two categories will be in need of healthcare education to boost their mode of communication (Wong et al.

Assessment of skills of literacy through self-assessment has been studied widely and all the scholars involved found specific questions that seem to be accurately predicting patients who have inadequate literacy. The questions focused on the need for assistance concerning understanding of medical information, reading hospital information, and filling of medical form. The NVS (Newest Vital Version) is the most recent approach for determining levels of literacy. These areas were properly addressed by the committee but raised new questions that stimulated future research and thinking concerning HL field. The HL-based principles governing nurse-patient communication were developed in 2007 by the Joint Commission. According to these standards, the information ought to be understood by the patient via capabilities, readiness and assessed needs. In the case of ambulatory care setting, information provided should be timely and be within different tactical fields which address the needs of a patient across the health continuum.

The assigned accountability areas involve interdisciplinary caring groups such as clinical staff, providers, professional schools, administrators and researchers. Interactive HL gives a detailed description of advanced literacy experience that helps different people to access information and interpret meaning based on the information presented as well as making use of that information to change circumstances. Functional health literacy (FHL) refers to basic HL skills that are enough for people to understand information related to their health issues and to be in a position to make use of that knowledge within limited activities prescribed by physicians. The critical health literacy gives a description of advanced level concerned with cognitive skills, together with social experiences which are applicable in critical analysis of information as well as using the same to control different situations and events in personal life.

According to Wyrwich, patient engagement entails “coordination and integration of personalized care as well as the provision of financial information and education and shared decision-making about health care between the patient and physician” (Wyrwich, 2016). It involves different models such as the multidimensional model which focuses on the degree of involving patients in decision making and the importance of putting interventions into practice across different engagement levels. This tends to compromise the quality of services offered and keeps the safety of patients at stake. Financial management by patients refers to the ability to make sound decisions concerning finances. Some of the elements that determine patient engagement such as personal beliefs about responsibilities as a patient can have a lot of influence in personal understanding of financial roles in health management.

Research shows that most patients do not have any experience on how to consider different tradeoffs and alternative costs, others are not even interested in thinking about such issues as well as not aware of how finances could influence their personal health. Health literacy is basically defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Eyüboğlu & Schulz, 2016, p. To determine the rate of patient readmission after health literacy educational interventions. To determine the nurse-patient relationship before health literacy educational interventions. To determine the nurse-patient relationship after health literacy educational interventions. Project design/methodology The research will adopt quantitative methodology coupled with both pretest and posttest designs which will help in determining health literacy among nurses and patients before any intervention and after implementation of a teach-back intervention to nurses.

Quantitative method is preferred for this project because it helps in the identification of variables as well as the development of a relevant hypothesis. On the other hand, nurses who will participate in the project will be passed through a specific procedure. The researcher will meet with the nurses before pretest condition and let them know that the project will need their input concerning issues related with low health literacy, and propose that they will be passed through the teach-back program. During pretest condition, the nurses will not be alerted about specific patients targeted by the research and even their NVS scores will not be disclosed to anyone. The intervention will involve Health Literacy Universal Precautions Toolkit which was developed by the University of N.

Carolina (DeWalt et al. During the post-test stage, communication approaches, mostly the teach-back approach was reemphasized. The moment this second stage will kick off, NVS scores for every targeted patient will be reported to the concerned nurses before they interact with the patients. Just like in the case of the pretest stage, nurses will fill in questionnaires after interacting with patients. This will help in evaluating the performance of the nurses. Where the label of a patient indicates guardian or a parent as a participant, the nurse will tick either yes or no on the questions provided for them in the questionnaire. The questions will be structured using a very simple language that can be understood easily. The research will also rely on secondary data sources such as hospital records to record the rates of readmission prior to the educational intervention.

Questionnaires will be adopted as a primary source of data collection because they help in getting first-hand information from the participants. They will be administered to patients by the bilingual research assistant who will be explaining everything to the participants before filling in the questionnaire. Validity and Reliability of questionnaire A drafted questionnaire should always be tested for validity and reliability before it is administered to the research participants. It will help to correct any ambiguity or bias in the questionnaires before carrying out the actual data collection process. Procedures of Data Collection The data collected in this project will be guided by PICOT and research questions (Kettner et al. Data elements will be determined by considering nurses who are being educated concerning HL, efficiency, and effectiveness of education administered, nurse competency in the application of teach-back technology, data concerning readmission rate of patients with heart failure as well as resources applicable in administering health education.

Before teaching nurses on teach-back approach, readmission data concerning heart failure patients will be collected for the past two months. The data will be collected from quality improvement website. In the case of patients, their questionnaires and NVS scores will be put together and compared with nurses’ perception towards health literacy during and after the intervention. Procedure of Data Analysis Data analysis will be carried out by considering the context of data, “frame of reference, objectivity, and legal and ethical issues. ” The research questions will be answered by analyzing data through two processes; use of SPSS and a paired sample t-test which will help in determining the difference between pretest and posttest intervention (Statistical Solutions, 2017). The 2016 Excel will be used in developing a codebook that will show the meaning of each response by assigning names and values to responses.

The SPSS analysis will help in determining the effectiveness of educational intervention and t-test will be used to determine trends of readmission in the telemetry unit by comparing both rates of pre-education and post education. In the case of the nurses, their job security will be guaranteed since no one will disclose information concerning their behavior of overestimating health literacy among their patients. Chapter Summary The research will adopt quantitative methodology coupled with both pretest and posttest designs. Quantitative method is preferred for this project because it helps in the identification of variables. The participating patients and nurses will observe the same procedure during pre and post-intervention processes. It will involve a bilingual project assistant who will explain what is required of them during this project.

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