1 Clinical Nurse Specialist-Driven Communication Bundle to Improve Patient Satisfaction Lesley Nido College of Nursing, Michigan State University NUR 997: Doctor of Nursing Practice Project III Dr. Iseler April 28, 2023 2 Table of Contents Abstract…………………………………………………………………………………........……5 Introduction……………………………………………………………………………………..…6 Background…………………………………………………………………………,….…6 Significance of Problem……………………………………………………………..…….7 Problem Statement…………………………………………………….…………...….…..8 Review of the Literature……………………………………….…………………...………......…9 Search Strategy………………………………………………………….………......…….9 Literature Synthesis……………………………………………………………...…..……9 Communication Tools……………………………………………………...…….10 Rounding……………………………………………………………………...….11 Education………………………………………………………………………...11 Summary……………………………………………………………………...………….12 Theoretical Framework………………………………………………………………………..…12 Jean Watson’s Theory of Caring……………………………………………….….….….12 . Change Theory…………………………………………………………………..….……13 Root Cause Analysis……………………………………………………...………………..….…14 SWOT Analysis……………….……………………………………………………....…………15 Methods…………………………………………………………………..………………… ...…16 Ethical Considerations ……………………………………………………………...…...16 Project Site and Population………………..…………………………………...….……..16 Facilitators…………………………………………………………….………………….17 Barriers………………………………………………,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,…...….…..17 3 Action…………………………………………………………………………………….18 Timeline……………………………………………………………………………….…20 Measurement Instrument/Tools………………………………………………………….21 Cost-Benefit Analysis/Budget…………………………………………………..….……21 Analysis………………………………………………………………………………,….22 Recommendations/Sustainability Plan……………………………………………….…,,,,….….23 Discussion/Implications of Nursing……………………………………………...…………..…..24 Conclusion……………………………………………………………………………………….24 References………………………………………………………………...…………….………..26 Appendices Appendix A (Modified PRISMA Diagram)……………………………..,…….......……30 Appendix B (The Johns Hopkins Evidence Level and Quality Guide)………...………..31 Appendix C (Evidence Critique Table)………..………...………………………………32 Appendix D (Literature Synthesis Table)…………………….…………………...……..37 Appendix E (Fish Bone Diagram)………..……………..…………………….…………38 Appendix F (SWOT Analysis)……………...……………………………………………39 Appendix G (NQCPQ)……………………………...…………....…..…………………..40 Appendix H (Modified SMART Phrase)……….………..……..………..……...……….42 Appendix I (Patient Handouts)…………...…………………..……………….…………43 Appendix J (Modified SMART Flyer)………...…….……..………….……………...…46 Appendix K (Modified SMART PDF)…………….……………….…………..………..47 Appendix L (GANTT Chart)………………………………...…………………..……....48 Appendix M (Cost Benefit Analysis Table)………………………………………..…....49 4 Appendix N (Pre and Post Survey Charts)…………………………………..……..……50 5 Abstract Background: Patient satisfaction provides valuable insight on how to improve the patient experience. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a method that measures patient satisfaction which includes nursing and provider communication. Ineffective communication is detrimental to patient satisfaction as it can lead to medical errors and sentinel events. Additionally, acute care hospitals are required to collect and publicly report HCAHPS data to receive their full Inpatient Prospective Payment System (IPPS) annual payment. Therefore, it is imperative for hospitals to have initiatives in place to ensure there is effective communication between the nurse and patient. Methods: Based on a midwestern hospital’s HCAHPS data in 2021, all inpatient units were found to have an average of 16 points below the national benchmark of patient and nursing communication. During this 12-week quality improvement project, a communication bundle was implemented on a unit within this midwestern hospital. Components of the bundle included: unit rounding, and informative sessions, a modified SMART communication tool, and patient handouts. The Change Theory and Jean Watson’s Theory of Caring were used to guide this project. Patient satisfaction was obtained through patient verbal feedback at the bedside by the CNS. The Nurse Quality of Communication with Patient Questionnaire (NQCPQ) was used to measure the quality of patient-nurse communication. Results: Patient feedback was positive overall regarding the modified SMART communication tool. Based on the nursing staff perspective, there was an improvement in the quality of communication between the nurse and patient. Conclusion: Further research is necessary to determine the best interventions to improve patient satisfaction. Keywords: patient satisfaction, communication, plan of care, healthcare, bundle 6 Improving Patient Satisfaction through Nurse and Patient Communication Effective communication between the patient and the healthcare provider is critical to delivering high quality patient centered care. Improved communication within the healthcare team is linked to better patient outcomes, a safer work environment, decreased adverse events, decreased transfer delays, and shortened length of stays (Disch, 2021). The dynamics of the healthcare setting creates communication challenges such as multiple specialists presenting to the patient’s bedside at different times throughout the day, various communication styles, and a lack of teamwork or communication skills (Dingley et al., 2008). The purpose of the paper is to explore techniques and tools to improve patient satisfaction through communication between the patient and nurse at a 530-bed midwestern hospital. Background According to Jun, Stern, & Djukic (2020), patient satisfaction provides a valuable insight into how healthcare systems can improve patient’s experience. A positive patient experience results in positive outcomes, therefore, patients are more likely to maintain long-term relationships with their health care team. Subsequently, the patients are more committed to treatment plans and inclined to endorse the hospital (Jun, Stern, & Djukic, 2020) One way of measuring patient experience is with the Centers for Medicare and Medicaid Services’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. A random sample of adult patients are selected to receive the HCAHPS survey within 48 hours to six weeks after discharge. The survey consists of 29 questions pertaining to their recent hospital stay (CMS, 2021). Of these 29 questions, seven questions are related to the patient’s experience with nurses and physicians. 7 To provide an incentive to acute care hospitals participating in HCAHPS, acute care hospitals are required to collect and submit their HCAHPS data to receive their full Inpatient Prospective Payment System (IPPS) annual payment (CMS, 2021). IPPS is also known as a Medicare payment for acute care hospital inpatient stays which are based upon set rates (American College of Surgeons, n.d.). This is significant as IPPS hospitals are subject to reduction in their annual payment update if they fail to publicly report required quality measures, including HCAHP surveys. Public reporting of hospitals HCAHPS results is noteworthy to the patient, healthcare providers, and community. The data provides an objective and meaningful comparison between hospitals, creates an incentive to implement quality improvement measures, and improves accountability of patient care through transparency (CMS, 2021). For these reasons, it is imperative that hospitals refocus their approach to healthcare from volume-based to value-based. Significance of Problem Ineffective communication between healthcare providers and patients can be detrimental to patient care as it can lead to medical errors and sentinel events. A sentinel event is defined by the Joint Commission as “a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life” (The Joint Commission, n.d., para 3). Based upon review of the Joint Commission reports, over 70% of sentinel events were related to communication failures (Dingley et al., 2008). The financial costs of medical errors are staggering as medical errors cost approximately $20 billion a year (Rodziewicz, Houseman, & Hipskind, 2022). Ineffective communication can also lead to increased length of stay, increased resource use, caregiver dissatisfaction, and higher turnover of medical staff (Dingley et al., 2008). Increased length of stay can lead to increased hospital costs. 8 In 2016, there were 35.7 million hospitals stays with the cost per stay averaging about $11,700. (Freeman, Weiss & Heslin, 2018). The causes of communication failures between patient and provider are multifactorial as the healthcare setting is a complex environment. Miscommunication may occur due to the hierarchical structure such as differences in power between physicians and other healthcare professionals. A hierarchal structure can lead to restraints in communication, differences in education and training of healthcare providers, lack of teamwork and communication skills, and multiple disciplines with different priorities of patient needs (Dingley et al., 2008). Human factors can also contribute to ineffective communication. This includes cognitive overload, stress, multiple interruptions throughout the day, poor decision making, and fatigue (Dingley et al., 2008). Based upon this midwestern hospital’s HCAHPS scores in 2021, the hospital has not met national benchmarks related to patient satisfaction and patient-nurse communication across all units. The questions below the national benchmark were, “How often did nurses treat you with courtesy and respect?”,” How often did nurses listen carefully to you?”, and “How often did nurses explain things in a way you could understand?” All inpatient units within this midwestern hospital were found to have an average of 16 points below the national benchmark of all other hospitals. Problem Statement Effective communication in the healthcare setting is critical to reducing medical errors and providing quality patient care. This midwestern hospital’s HCAHP scores related to nurse communication are below the national benchmark, the administration has deemed improving 9 communication between the patient and nurse as a priority. With this considered, what evidence- based strategies would improve communication between the patient and the nurses? Review of the Literature Search Strategy A search strategy was conducted using two databases, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed of the U.S. National Library of Medicine National Institutes of Health on April 30, 2022. The search was limited to peer reviewed articles only in the English-language within the last five years, 2017 to 2022. Keyword terms used for both databases [communicat* AND nurse AND patient AND inpatient OR hospitaliz* OR “acute care” AND HCAHP OR “Hospital Consumer Assessment of Healthcare Provider”]. A total of 32 articles were identified from CINAHL and 37 identified from PubMed. Of the articles obtained, 67 were reviewed based on title and abstract. After removing two duplicates, 65 articles were reviewed based on title and abstract. Exclusion criteria included interventions related to pediatric patients, pain management, preoperative setting, emergency setting, and discharge follow ups/phone calls. After exclusion criteria were applied, 10 articles were retrieved and reviewed. In addition, one article was selected suggested by CINAHL when reviewing a previously selected article. From there, eight articles were then selected through inclusion. The exclusion and inclusion criteria is depicted in a modified PRISMA diagram (see Appendix A). Inclusion criteria consisted of adult population, acute care setting, patient-nurse communication, and use of HCAHP scores to assess outcomes. The level of evidence and quality of articles were based on the John Hopkins Evidence Level and Quality (see Appendix B). Literature Synthesis 10 The aim of this literature review is to identify interventions implemented to improve communication between the nurse and the patient, and patient satisfaction within the acute care setting. Application of exclusion and inclusion criteria yielded seven articles for review. The seven reported studies were all quantitative studies published between 2017 and 2022 and undertaken within the United States of America. The sample sizes were not identified in three studies (Austin et al., 2021; Prosser, Andrews, & Wheatley, 2020; McAllen et al., 2018) Two studies had sample sizes that ranged from 100-115 participants (Allenbaugh et al., 2019; McMillan et al., 2017). One study had a sample size of less than 60 (Davis, 2017) and one study had a sample size between 60-80 (Lemire, 2017). The duration of the interventions for all studies ranged from three to seven months. All studies considered both patients and registered nurses as participants and within an inpatient setting. In addition, medical residents were included as participants in one study (Allenbaugh et al., 2019). Data was described in an evidence critique table according to Author Citation, Design/Purpose, Sample/Setting, Measurement/Instruments, Results, Level of Evidence and Quality, and Relevance of Problem (see Appendix C). Based on review of the literature, three themes were identified which include communication tools, rounding, and education (see Appendix D). Communication Tools Checklists and tools used to improve communication included paper form, bedside communication board, and tool to assess health literacy (Prosser, Andrews, & Wheatley, 2020; Lemire, 2017; Davis, 2017). Whether or not nurses had been using the written communication tools, there was improvement in nurses verbalizing the plan of care with their patients routinely (Prosser, Andrews, & Wheatley, 2020; Davis, 2017). Increase in verbal communication of the patient’s plan of care can improve patient satisfaction scores (Prosser, Andrews, & Wheatley, 11 2020). Similarly, a health literacy protocol for patient assessment and engagement provided a verbal approach to nurse and patient communication (Davis, 2017). This is significant as assessing a patient’s health literacy increases the perception of satisfaction regarding communication between the nurse and the patient (Davis, 2017; Austin et al., 2021). Based on the literature, all different forms of communication tools showed a significant improvement to nurse-related patient satisfaction scores (Prosser, Andrews, & Wheatley, 2020; Lemire, 2017; Davis, 2017). Rounding Various versions of rounding have shown to improve patient satisfaction (Austin et al., 2021; McAllen et al., 2018). Based on the literature, there is better engagement and communication between the patient and the nurse with rounding as nurses can spend more time with the patient (Austin et al., 2021; McAllen et al., 2018). Not only does rounding improve patient satisfaction but can also improve quality of care. Nurses can identify potential errors and perform safety checks at the bedside in real time (Austin et al., 2021; McAllen et al., 2018). Rounding provides better communication between the patients’ healthcare team. The literature shows that providers and nurses that participate in rounding are better at interprofessional collaboration (Austin et al., 2021; McAllen et al., 2018; Maloy, 2021). In all cases, patient satisfaction improves when nurses are involved and perform bedside rounding (Austin et al., 2021; McAllen et al., 2018). Education Education related to patient communication and communication skills provided to nurses has also been shown to improve patient satisfaction (Austin et al., 2021; Davis 2017; Allenbaugh et al., 2019; McMillan, 2017). When educating nurses on how to clearly communicate and health 12 literacy techniques there is also improvement with the nurse’s knowledge, attitude, and communication skills at the bedside (McMillan, 2017; Allenbaugh et al., 2019; Austin et al., 2021; Davis, 2017). Communication skills that are mentioned in the literature include but are not limited to making eye contact with the patient, assessing what the patient understands about their diagnosis or what they want to know about their diagnosis, and avoiding medical jargon. Through this education, nurse related patient satisfaction scores improve significantly (McMillan, 2017; Allenbaugh et al., 2019; Austin et al., 2021; Davis, 2017). Summary Interventions range from a formal education tool, formal education, to interdisciplinary rounding, all of which showed improvements in nurse related HCAHPS scores. Since there is a lack of a formal communication tool used for rounding within the inpatient units, a combination of these interventions may provide improvement in nurse communication with patients. Implementing a nurse driven standardized tool that is used to assess patient’s knowledge and engagement at the beginning of each shift may lead to a better understanding of the patient’s level of knowledge. This will also allow the nurses to assess patient’s health literacy which has shown to improve patient’s perception of satisfaction in communicating with nurses (Davis, 2017). Therefore, nurses may be able to address patient concerns in real-time, making the patient feel heard. Providing a brief education session to nurses about communication skills, along with a communication tool, may enhance the nursing staff’s communication skills with patients and in turn patient satisfaction. Theoretical Framework Jean Watson’s Theory of Caring 13 Jean Watson’s Theory of Caring was utilized for this quality improvement project. Theory of Caring addresses how nurses express care to their patients with an emphasis on a holistic approach to nursing practice (Nursing Theory, n.d.). The theory considers four major concepts which include human beings, health, environment/society, and nursing. In this case, the patient is the focus of practice (Nursing Theory, n.d.). Caring is based upon 10 factors which include “forming humanistic-altruistic value systems, instilling faith-hope, cultivating a sensitivity to self and others, developing a helping-trust relationship, promoting an expression of feelings, using problem-solving for decision-making, promoting teaching-learning, promoting a supportive environment, assisting with gratification of human needs, and allowing for existential-phenological forces” (Nursing Theory, n.d., para 10). These factors provide a nurturing, trusting relationship between the nurse and the patient which can allow for better communication for both parties. For these reasons, the Caring Theory aligns with the goals of this project, to improve nurses effectively communicating with their patients. Change Theory Phases of Change was utilized as a guide for this quality improvement project as a key component to the theory is knowledge building (Udod & Wagner, 2018. para 14). The theory is modified from Lewin’s Model of Change which consists of six phases: building a relationship, diagnosing the problem, acquires resources for change, selecting a pathway for the solution, establish and accept change, and maintenance and separation, respectively (Udod & Wagner, 2018, para 14). These components parallel with providing education to nursing staff about communication skills and importance of health literacy assessment. The first phase is described as “precontemplation” where there is a determination of a need for change within an organization (Udod & Wagner, 2018, para 15). The second phase, 14 diagnosing the problem where there is contemplation to determine if the change is desired or needed (Udod & Wagner, 2018, para 15). “Contemplation” is done in the second phase, diagnosing the problem where the change agent determines if the change is needed (Udod & Wagner, 2018, para 15). The need for change was identified through the organization’s nurse related HCAHP scores below the national average. After determining a need, further information was gathered to develop solutions to the problem. This is described as the third phase “acquires need for change” which is to understand the need for change (Udod & Wagner, 2018). Through gathering information an intervention was selected based upon the literature review and unit specific needs. The fifth phase, establish and accept change considers strategies to combat resistance from individuals and organization to new change (Udod & Wagner, 2018) These strategies include effective communication, staff response, and education (Udod & Wagner, 2018). Through providing education on goals for intervention and speaking with staff this is achieved. In the last phase the change agent is to monitor the intervention to ensure success and stabilization of the project (Udod & Wagner, 2018). Monitoring was completed through observational surveys by the DNP CNS student and through feedback obtained from nursing staff and patients. The goal at this point is to establish an intervention where the change agent can then separate from the project (Udod & Wagner, 2018). Root Cause Analysis A Fishbone Diagram (see Appendix E) was developed to depict the root causes of miscommunication in the pilot unit. Categories identified through observation, rounding at beginning of shifts and through informal conversation with bedside nurses. As a result, four categories were identified: environment, patient, nurse, and physician. The current state within 15 the unit is that no universal rounding tool related to the patient’s plan of care in place. The only formal communication tool within the unit is a white board within each patient’s room which include their name, diet, level of activity, names of the nurse and nurse aid for the shift, and a small area labeled as “important” for free writing. During observation and informal discussion, nurses do not assess for health literacy prior to discussing the patient’s plan of care. This can hinder the patient’s comprehension about their plan of care. Another concern identified was the lack of communication between the physician and nurses about the patients plan of care. In addition, there are delays with physicians signing their note within the patient’s chart, creating a barrier for nurses to communicate updates to the patient regarding their plan of care. Environmental related factors are higher acuity patients which prevents nurses from taking time to discuss the plan of care and answer questions the patient may have. Strengths, Weaknesses, Opportunities, and Threats A tool used for strategic analysis is called SWOT analysis which stands for Strengths, Weaknesses, Opportunities, and Threats. This tool considers external developments and internal capabilities of an organization (van Wijngaarden, Scholten & van Wijk, 2010). External developments are opportunities and threats to the organization and internal capabilities are identified as strong and weak components of the organization. Through analysis, alternative strategies to combat these factors are identified (van Wijngaarden, Scholten & van Wijk, 2010). A SWOT analysis for implementation of a brief educational session and communication tool is depicted in Appendix F. Strengths and Opportunities. Strengths identified within the organization that contribute to the success of this evidence-based practice (EBP) project. Bedside staff, unit secretaries, and managers maintain a positive attitude which creates a healthy work environment. 16 In addition, the bedside staff are adaptable and open to change within the unit. Their adaptability is reflected in their participation with past EBP projects. Managers are also supportive for improving patient satisfaction within the workplace. Bedside nurses willing to participate and are open to change are opportunities for this organization. Weaknesses and Threats. Weaknesses within the organization include absent standardized communication tool related to patient plan of care and lack of a formal health literacy assessment. These weaknesses may present threats to the nurse’s adherence of utilizing the communication tool and patient’s willingness to participate due to lack of time, higher acuity of patients, and inadequate staffing. Methods Ethical Considerations/Protection of Human Subjects The project was deemed non-human research by the Michigan State University’s and the organization’s Internal Review Board (IRB) prior to implementation of this project. No personal health information was collected and will be optional and anonymous for patients. The survey completed by hospital staff was optional and anonymous. All data is protected within a password secured laptop or stored within a locked cabinet within a locked office. Project Site and Population The quality improvement project was implemented within a 530-bed midwestern hospital on a clinical decision unit with patients ranging from young adult to geriatric population. The unit has 24 beds consisting of medical surgical to progressive care patients and is part of the emergency services for the hospital. There is a high turnover of patients within this area as the concept of the unit is to temporarily hold patients while they wait for an inpatient bed 17 assignment. However, due to the recent high census of admissions, patients are remaining in this unit for longer periods of time or are discharged prior to being transferred to an inpatient room. The population within the unit included the patients and nursing staff on the unit. The patient- related exclusion criteria will be patients with severe dementia or altered mental status. The assistant nurse manager (ANM) and nurse manager along with the nursing staff were significant to implementing this intervention as they were the sole proprietors facilitating adherence and utilization of the intervention. With managerial support, there was encouragement for nursing staff to participate in the intervention. Facilitators The stakeholders for this project included the clinical nurse specialist (CNS), patients admitted to the clinical decision unit, and the bedside nurses. Departmental leadership for nursing within the unit contributed to disseminate the information regarding the EBP project and encouraged participation of the bedside nurses. The CNS established a collaborative relationship with the unit staff and leadership to facilitate project interventions. Barriers Barriers to this intervention includes collecting patient feedback. The outcomes related to patient satisfaction of this project were initially to be evaluated through a modified HCAHPs survey that would be provided to patients. This was due in part to the pilot unit being under emergency services which does not collect HCAHPs data. Moreover, the DNP student was unable to utilize the modified survey as there were specific requirements the DNP student would need to meet for approval by the organization. These requirements could not be met due to time restraints. Patient satisfaction was then determined by the DNP student and the organization’s 18 Evidence Based Research Committee that the DNP student would obtain patient satisfaction through verbal feedback about the modified SMART tool from patients on at the bedside. Action The intervention of this quality improvement project is a CNS-driven communication bundle. The bundle includes informative sessions for the bedside nurses provided by the DNP student, a communication tool, and the DNP student rounding on the unit. The goal of this project was to improve patient satisfaction and communication between the nurse and the patient. Preintervention. Two weeks prior to implementation, an email comprised by the DNP student was sent out by the nurse manager to nursing staff about the quality improvement project. The email included goals of the project, how it will be implemented, expected timeline and expectations of nurses prior to, during, and after implementation. The DNP student collaborated with the community partner and developed online pre and post surveys. The survey consisted of the six-item Nurse Quality of Communication with Patient Questionnaire (NQCPQ), see Appendix G. In addition, the DNP student created a handout with a QR code linked to the questionnaire. The handout was placed throughout the unit where it would be easily visible and accessible for nurses. The handout prompted nurses to scan the QR code to access the online questionnaire. If nurses did not have the ability to scan QR code, the link for the questionnaire was sent to the nurses’ work email by the manager. The DNP student visited the unit two to three times within the two weeks prior to implementation to encourage nurses to participate in survey. At the end of the two weeks, the online questionnaire was closed prior to the start of the implementation phase and handouts distributed around the unit were removed by the DNP student. 19 Intervention. The CNS-driven communication bundle was centered around a mnemonic called SMART. The mnemonic used in the intervention was modified and based on a SMART rounding checklist created by Maloy (2021) and implemented within a pediatric medical surgical unit. The rounding mnemonic was presented as a checklist to address patient related between nurses and multiple disciplines. The SMART mnemonic created by Maloy which stands for: Situational Awareness, Medications, Access, Routine, and Transition. The checklist addressed discontinuation of drains and lines, discharge criteria, review for medication adjustment, and labs/imaging results (2021). To address the patient plan of care, the DNP student created a modified version of SMART: Specialties, Medications, Assess, Routine, Transition (see Appendix H). This includes review of the patient’s medical team, new medications that are ordered during their admission labs and testing that are pending or to be completed, addressing health literacy by asking what they patient would like to know about their diagnosis, and goals for their discharge. Copies of the SMART tool were printed and laminated then placed in each patient room near or around the whiteboard that is utilized by the nursing staff. For the first two weeks, the DNP student provided two to three informative sessions regarding the intervention each week to bedside nurses on the unit. Two of the three sessions was presented to night shift and four sessions were presented to the day shift. The informative sessions were each approximately five minutes long and presented 10 to 15 minutes prior to the start of nursing staff shift. During the informative sessions, the DNP student verbalized the importance of assessing a patient’s health literacy, evidence-based communication skills such as active listening, a description of the modified SMART tool, how to utilize the modified SMART tool during the their shift, and patient handouts developed by the DNP student that nurses could provide. The handouts were created in correspondence to the modified SMART tool with a goal 20 for patients use during their admission (Appendix I). The DNP student emphasized to nurses that they could provide these handouts to their patients at their discretion. Patient feedback was gathered through the DNP student speaking with patients on the unit in real time at the bedside. Further, the DNP student created a flyer with a QR code (Appendix J) that was linked to an informative PDF that was placed within the unit. For nurses to access the PDF the QR code would be scanned with the smart phone camera. Once scanned, a PDF opens which describes the SMART tool (see Appendix K). Additionally, the flyers were provided via email which were also sent to the nurses’ work email by the unit nurse manager. A modified SMART folder put together by the DNP student was placed at the charge nurse desk. The folder was provided for nurses to utilize the printed version of the PDF and the additional patient handouts. After the two weeks of providing informational sessions, the DNP student rounded for about two to three hours on the unit to observe communication between the bedside nurses and patients. In addition, the DNP student obtained verbal feedback from patients after the nurse had discussed the plan of care with their patient. Post Intervention. After the implementation phase, the post survey was distributed for nursing staff to complete. An email including a link to the post-survey from the DNP student was sent out to the nursing staff by the unit manager. A handout with a QR code linked to the post- survey was also distributed throughout the unit for nursing staff. Timeline The pre-survey was distributed to nursing staff from December 29th to January 8th. The implementation phase began on January 9th and concluded on March 6th. During the implementation phase, the DNP student obtained patient feedback and completed rounding. The 21 post-survey was distributed nursing staff from March 7th to March 22nd. Data analysis took place at the end of March. The timeline of this project is depicted in a GANTT chart (see Appendix L). Measurement Instruments/Tools The Nurse Quality of Communication with Patient Questionnaire (NQCPQ) was selected to measure the quality of communication from the nursing perspective (Appendix G). The NQCPQ is a 6-item questionnaire that uses a rating grade of 1 through 6, like a Likert scale (Vuković, Gvozdenović, Stamatović-Gajić, Ilić, & Gajić, 2010). A Likert scale is a five-point scale that measures different aspects such as attitudes or frequency of an event (McLeod, 2019). Each item of the questionnaire is categorized into kinds of communication. The classifications include verbal communication, non-verbal communication, communication in general. The reliability of NQCPQ was evaluated in a 130-subject study with an alpha of 0.81 (Marhamati, Amini, Mousavinezhad, & Nabeiei, 2016). The validity of NCQPC was also evaluated in the previous study which was determined as high (Marhamati, Amini, Mousavinezhad, & Nabeiei, 2016). The questionnaire will not include any demographic data to ensure survey responses remain anonymous. The anonymity of the nursing surveys and use of the Likert scale results in a reduction of social disability bias (McLeod, 2019). A pre and post survey format was used to compare the quality of communication prior to and after implementation of intervention. Regarding patient feedback, there was no formal instrument or tool utilized. The DNP student collected feedback through informal conversation with patients at the bedside prompting if the patient found the SMART tool helpful regarding their plan of care. Cost-Benefit Analysis The evaluation and implementation of the communication bundle did not have additional costs to the organization. Resources for this project included laminated posters, flyers, and 22 patient handouts. There were no additional costs to the organization as rounding and informative sessions were provided by the DNP student. The CNS within this organization does not have billing privileges and reports the average wage of an experienced CNS is estimated to be about $50 per hour. Further, the informative sessions provided to nursing staff were approximately five minutes and unit of time rounding by the CNS ranged from 2 to 3 hours. The cost analysis of unit rounding, informative sessions, and resources used is depicted in Appendix M. Interventions related to improving patient-nurse communication have the potential to indirectly decrease costs through reduction in length of stay. Freeman, Weiss & Heslin (2016) reports that the average cost per stay is about $11,700 (Freeman, Weiss, & Heslin, 2018). Therefore, improving patient satisfaction can also provide value to Medicare funding for organizations. According to Centers for Medicare and Medicaid Services, the total of available value-based incentive payments was projected to be approximately $1.5 billion in the fiscal year of 2016 (Centers for Medicaid and Medicare, 2015). Analysis After implementation of a communication bundle, there was an improvement in quality of communication between the patient and nurse. The results of the pre and post surveys are depicted in Appendix N. Of the nursing staff, the sample size for the surveys were 19 and 14, respectively. The question “how helpful did you find the communication tool?” was also included within the NQPCQ post-survey question. The nursing staff were asked to rate the tool with five stars being very helpful and one star being not helpful at all. The average rating of the communication tool was 4.6 out of 5 stars. When looking specifically at the pre and post results of item six there is a slight improvement in quality of communication. The item describes the level of communication the nurse has with the patient as they monitor the patient’s 23 pharmacotherapy. The modified SMART tool can have played a factor into the difference in the pre and post results as majority of the nurses were observed utilizing the modified SMART tool during medication passing during rounding. In addition, informal feedback from nursing staff was obtained during rounding by the DNP student. Nursing staff verbalized that the tool provided a formal, standardized approach to addressing the plan of care. They also voiced that the tool addressed questions commonly asked by patients throughout their shift. Through observation, the nurses tended to utilize the communication tool more often during new admissions to the unit which provided a “better flow” for the nursing staff. However, other nurses stated they were using the communication tool at the beginning of their shift and revisiting the tool if there were changes to the patient’s plan of care throughout the day. The patient handouts that were developed by the DNP student were not utilized by the nursing staff. Nurses did not utilize the handouts due to time restraints during their shift. The consensus of patient feedback on the communication tool was an overall positive response. Patients found the tool useful specifically related to what specialists were consulted and tests that were ordered. The tool was not only noted as valuable by the patient but also family members at the bedside. After observing a bedside nurse utilize the tool while admitting a patient, the patient’s daughter at the bedside stated, “I appreciated that because no one had told us what would happen once she was admitted.” While there was no quantitative data gathered for patient satisfaction, this depicts that the tool provide value to patients regarding their plan of care. Recommendations and Sustainability Plan 24 The outcomes of this project are to be disseminated to stakeholders i.e., director of education and evidence-based research committee within this midwestern organization. The sustainability of this project will depend on the buy-in and prioritization of the stakeholders. Another clinical nurse specialist or qualified personnel would be needed to reimplement intervention and collect feedback. This intervention could be used for future DNP students to implement as their DNP project. For future studies, it is recommended to select a unit that is already collecting unit specific HCAHPS data. Discussion/Implications for Nursing The outcomes of this quality improvement project provide an insight into the unique role the Clinical Nurse Specialist can have in improving patient experience. Through participating in HCAHPS, healthcare organizations are incentivized to improve patient satisfaction. Therefore, it is imperative for the Clinical Nurse Specialist to identify gaps between the literature and nursing at the bedside. Based on the literature, communication related interventions that have shown to improve patient satisfaction include rounding, various tools or checklists, and education (Austin et al., 2021; Davis 2017; Allenbaugh et al., 2019; McMillan, 2017; Prosser, Andrews, & Wheatley, 2020; Lemire, 2017; Davis, 2017; McAllen et al., 2018). These interventions and this quality improvement project should be considered by the Clinical Nurse Specialist should consider when implementing initiatives to improve patient satisfaction. Conclusion In summary, there is a continuous need to improve patient satisfaction within a healthcare organization. The results of this project depict potential interventions to create a positive experience for the patient. A communication tool like the modified SMART tool in combination with collaboration of the Clinical Nurse Specialist can enhance communication between the 25 nurse and patient. However, the dynamics of a healthcare organization should be considered when developing solutions related to patient communication (Disch, 2021). Additionally, further research is necessary to determine if utilizing a communication bundle such as this project can directly improve patient satisfaction. 26 References Agency for Healthcare Research and Quality (n.d.). Frequently Ask Questions About CAHPS. https://www.ahrq.gov/cahps/faq/index.html Allenbaugh, J., Corbelli, J., Rack, L., Rubio, D., & Spagnoletti, C. (2019). A brief communication curriculum improves resident and nurse communication skills and patient satisfaction. Journal of General Internal Medicine, 34(7), 1167–1173. https://doi.org/10.1007/s11606-019-04951-6 American College of Surgeons. (n.d). Inpatient Prospective Payment System Rule. https://www.facs.org/advocacy/regulatory/medicare- payment/ipps#:~:text=The%20system%20for%20payment%2C%20known,Medicare%20 beneficiaries%20in%20those%20groups. Austin, S. , Powers, K. , Florea, S. & Gaston, T. (2021). Evaluation of a nurse practitioner–led project to improve communication and collaboration in the acute care setting. Journal of the American Association of Nurse Practitioners, 33 (9), 746-753. doi: 10.1097/JXX.0000000000000402. Burdyk, Z. (2016). Healthcare miscommunication cost $1.7B – nearly 2,000 lives. FierceHealthcare. https://www.rmf.harvard.edu/about-crico/media/in-the- news/news/2016/february/healthcare-miscommunication-cost-dollars-and-lives Centers for Medicare and Medicaid Services. (2021). HCAHPS: Patients' Perspectives of Care Survey. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS Centers for Medicare and Medicaid Services. (2015, October 26). Fiscal Year (FY) 2016 Results for the CMS Hospital Value-Based Purchasing Program. Retrieved from 27 https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2016-results-cms-hospital- value-based-purchasing-program Davis, J. (2017). Engage: implementing a health literacy protocol for patient assessment and engagement. Journal of Consumer Health on the Internet, 21(4), 338-349. https://doi.org/10.1080/15398285.2017.1361278 Dingley, C., Daugherty, K., Derieg, M. K., & Persing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements. In K. Henriksen (Eds.) et. al., Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Agency for Healthcare Research and Quality (US). Disch, J. (2012). Teamwork and collaboration. In G. Sherwood & K. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (1st ed.) Ames, Iowa: John Wiley & Sons, Inc. Freeman, W. J., Weiss, A. J., & Heslin, K. C. (2018, December). Overview of U.S Hospital Stays in 2016: Variation by Geographic Region. Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-Hospital- Stays.jsp#:~:text=In%202016%2C%20there%20were%20about,104.2%20stays%20per% 201%2C000%20population. Lemire, L. C. (2017). Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Communication with Nurses and Patient Communication Boards. Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) Communication with Nurses & Patient Communication Boards.1. Maloy, C. I., (2021). "SMART Rounding: development of a nurse-driven rounding checklist as a sustainable intervention for improved care communication.” Research Days. 3. 28 https://scholarlyexchange.childrensmercy.org/researchdays/GME_Research_Days_2021/r esearchday1/3 Marhamati, S., Amini, M., Mousavinezhad, H., Nabeiei, P. (2016). Design and validating the nurse-patient communication skills questionnaire. Health Management & Information Science, 3(2), 57-63. McAllen, E. R., Stephens, K., Biearman, B. S., Kerr, K., & Whiteman, K. (2018). Moving shift Report to the Bedside: An Evidence-Based Quality Improvement Project. Online Journal of Issues in Nursing, 23(2), 1. https://doi.org/10.3912/OJIN.Vol23No02PPT22 McLeod, S. A. (2019, August 3). Likert scale. Simply Psychology. www.simplypsychology.org/likert-scale.html McMillan, M. O. (2017). The Effects of Watson’s Theory of Human Caring on the Nurse Perception and Utilization of Caring Attributes and the Impact on Nurse Communication. Effects on Watson’s Theory of Human Caring on the Nurse Perception & Utilization of Caring Attributes & the Impact on Nurse Communication, 1. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097. Nursing Theory. (n.d.). Jean Watson – Nursing Theorist. https://nursing-theory.org/nursing- theorists/Jean-Watson.php Prosser, D. M., Andrews, D., & Wheatley, C. (2020). Improving Communication of the Plan of care in the Acute Care Setting. Nurse Leader, 18(4), 364-369. https://doi.org/10.1016/j.mnl.2019.05.014 29 Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical Error Reduction and Prevention. In StatPearls. StatPearls Publishing. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy. Agency for Healthcare Research and Quality. Retrieved Octobter 13 2022 from https://www.ahrq.gov/cahps/surveys-guidance/item- sets/literacy/suppl-healthlit.items.html The Joint Commission. (n.d.). Sentinel Event Policy and Procedures. Retrieved April 30 2022 from https://www.jointcommission.org/resources/patient-safety-topics/sentinel- event/sentinel-event-policy-and-procedures/ Udod, S. A. & Wagner, J. (2018). Common Change Theories and Application to Different Nursing Situations. In J. Wagner (Ed.), Leadership and Influencing Change in Nursing. Regina, SSK:URPress van Wijngaarden, J. D. H, Scholten, G. R. M., & van Wijk, K. P. (2012). Strategic analysis for health care organizations: The suitability of the SWOT-analysis. The International Journal of Health Planning and Management, 27(1), 34-49. https://doi.org/10.1002/hpm.1032 Vuković, M., Gvozdenović, B. S., Stamatović-Gajić, B., Ilić, M., & Gajić, T. (2010). Development and evaluation of the nurse quality of communication with patient questionnaire. Srpski arhiv za celokupno lekarstvo, 138(1-2), 79–84. https://doi.org/10.2298/sarh1002079v Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). Boulder, CO: University Press of Colorado. 30 Appendix A Identification CINAHL PubMed Additional Articles 2017-2022 2017-2022 identified through other (n = 32) (n = 37) sources (n = 1) Articles after duplicates removed (n = 68) Screening Articles screened Articles excluded (n = 68) (n = 57) Full-text articles assessed Full-text articles excluded, for eligibility with reasons Eligibility (n = 11) (n = 3) Studies included in qualitative synthesis (n = 8) Included Articles included in literature synthesis (n = 8) 31 Appendix B 32 Appendix C Author Design/Purpose Sample/Setting Measurement Results LOE and Relevance of Problem Citation and Instruments Quality Allenbaugh et Quasi-experimental, 112 internal Knowledge, 76 of 112 medical LOE = II/Quality Implementation of a al (2019) Pre/Post study design medicine residents attitudes, residents and 85 =B brief training session medical service confidence was out of 120 nurses related to Improve knowledge 120 nurses measure through participated Strengths: Large communication can and attitudes towards General medicine pre and post number of improve resident and health literacy, ward surveys using Knowledge and observation nurse knowledge, bedside Wilcoxon signed attidue scores (n=675); use of attitudes, and communication skills rank test improved for both HCAHPS data, communication skills with patients, and groups (P<0.001) low cost and patient satisfaction inpatient Knowledge- (Allenbaugh & et al., communication- related was Confidence Weaknesses: 2019) specific patient measured with a 7- increased in Bias in satisfaction through a question quiz nurses (P<0001) observation of curriculum based on health but did not communication literacy change for skills; does not residents include attending Attitude and physicians; confidence was Communication survey and measured through skills: time of evaluation items related to residents at the checklists not importance of bedside averaged previous validated communication 9.6 min pre and (Allenbaugh & et and patient 8.4 min post. al., 2019) satisfaction with a Nurses averaged 5-point Likert 7.8min pre and scale (1 = not 8.7 post important/not at (Allenbaugh & et all confident and al., 2019) 5= very important/very HCAHP score: confident) percent of “top box” questions Communication related to nurse skills measured and physician through pre and communication post standardized items increased in checklists and post curricular observed by group period. From of clinicians, resident-run nursing educators, surgical units, one and local of eight items communication improved and the experts scores for the remaining 7 items Patient satisfaction remained stable measured through or worsened HCAHPs. The (Allenbaugh & et percentage of “top al., 2019) box” scores on 6 communication specific items was compared between 3 months prior and 3 months post intervention Austin & et al Quasi-experimental 20 bed medical Patient perceptions Nurse related LOE= II/Quality “Use of strategies that (2021) surgical unit at a of health care team HCAHP scores: =A promote patient nonprofit hospital communication increased from 2 engagement with the Determine if a nurse was measured to 12% from 2016 Strengths: ICCAS health care team can practitioner led through unit to 2017 and then has a 0.96 validity improve patient process promoting specific HCAHP increased from 1 (Star, 2021) and perceptions of patient involvement survey results pre HCAHPs is a communication, as 33 would improve Adults at least 18 intervention and to 5% from 2017 reliable and valid well as the team's HCAHP items years old with a post start of to 2018. measurement tool collaboration related to nurse and nonpsychiatric intervention competencies. doctor admitting diagnosis specifically Doctor related Weaknesses: “ (Austin 2021). communication and for at least one- looking at the six HCAHP scores HCAHPs survey perception of night hospital stay nurse and doctor improved from may have bias collaboration abilities communication 69% in 2016 to and skewed amongst healthcare domain 88% in 2017 results; low team members (88%) after NPs HCAHP response were hired, with a rate of 23.6%; slight decrease in other efforts were 2018 (85%) after implemented on Changes in IBR were unit to promote Process: staff collaboration implemented. communication; educated on process competencies NP was not one month prior to amongst team A statistically always present to implementation. members was significant determine if Rounding occurred measured with difference among checklist is with members of Interprofessional these years was completed health care team to Collaborative noted (F = 5.759; determine patients to Competency p = .040). be seen. Bedside Attainment Scale Rounds Checklist (ICCAS) consists For all three was used during of 21 questions doctor HCAPHS round for each and is questions scores patient which was administered prior increased 10 to about took about 10- to intervention and 30% from 2016 to 15 minutes. Checklist after using a Likert 2017, but all included the NP or Scale (poor = 1 dropped slightly physician present to and excellent = 5 in 2018 from 1 to review plan of care 4% with pt. Each team members contributed Of the 53 care to discussion about team members, 19 patient’s status. completed ICCAs Patient and family which showed a members encouraged 29% to participate in improvement and discussion. A safety was statistically check was completed significant to evaluate for DVT (Austin & et al., prophylaxis and 2021) necessity for central lines, catheters, and telemetry (Austin & et al., 2021) Davis (2017) Quasi Experimental Progressive Care Pre and post test to Through nurse LOE = II/Quality Two assessment Unit nursing staff to interviews with =C questions point to a Purpose was to identify areas of patients it was positive and improved determine if a Nurse interviews awareness and found that “28% Strengths: perception of nurse- standardized patient with 67 patients knowledge did not know the Verbal patient communication engagement strategy including two reason for their engagement to assess health questions which HCAHP scores hospitalization. allowed for Based upon results literacy would assessed the related to nurse “ valuable providers should improve nurse patients skill and communication Only 42% of interaction with consider developing communication motivation during patients had a patients, methods that provide related to HCAHP their hospital stay: clear HCAHPs patients greater scores understanding of improved during knowledge about their What do you know their diagnosis time of health concerns, about your and why they intervention satisfaction with their diagnosis (assessing were in the provider with skills)? hospital.” Weaknesses: activation and “25% of Lack of sufficient motivation, and What do you want respondents either statistical compliance with to know (assessing did not want or evidence medical advice (Davis, motivation)? need further 2017) information about their diagnosis. This was due to these patients 34 feeling their doctor had been clear on their illness and treatment plan. “23% of patients knew a list of their symptoms but either had not received a diagnosis or did not, at that moment, understand it as referenced in these quotes: “shortness of breath, heart problem,” “diabetic,” “chest pain and itching,” and “I have a lot of medical history and I am just sick.” “ The HCAHPS scores for quarter October– December 15, 2015, show a significant rise on the “Communication with Nurses” domain Lemire (2017) Quasi-experimental Medical surgical Outcomes were After LOE = II /Quality “Caregiver and patient unit based on the unit implementation, =C relationships To determine the specific HCAHP the developed from impact of Two time periods scores of nurse communication nonverbal implementation and (sample being Pre related with nurse Strengths: Short and verbal use of a intervention and communication composite time frame; no communication when communication Sample B being items. They were questions other initiatives the board content was boards on HCAHP post) each with a based upon pre increased by were being completed or updated” patient experience or sample size of 31 and post 9.7%. implanted during (Lemire, 2017) communication with patients implementation. intervention nurses (Lemire, Sub questions 2017). related to “nurses Weaknesses: treat with Small sample courtesy and size; had a low resect”, “nurses patient survey listen carefully to return rate; no you”, and “nurses monitoring for explain in a way daily completion you understand” of white boards increased by 12.9%, 9.7%, and 6.4% respectfully (Lemire, 2017) Maloy (2021) Quasi-experimental, Pediatric Medical Outcomes were Improved LOE=III / Quality “77% of respondents Pre/Post study design Surgical Unit based on use of multidisciplinary C perceived daily checklist and rounding for communication rounding patient’s plan of Strengths: Used improvement with care audit tool for SMART card” (Maloy, checklist 2021) 35 Weaknesses: Results were obtained by a McAllen et al Quasi-Experimental 3 units which Unit-specific 67 nursing staff LOE = II /Quality Patient satisfaction (2018) consist of patients HCAHP scores, completed =B was improved with undergoing general fall rates, Press education prior to BSR as measured by To determine if surgery or patients Ganey scores, and BSR Strengths: lack of the Press Ganey® incorporating bedside with orthopedic and nurse satisfaction implementation statistical survey (McAllen & et report (BSR) to neuroscience survey evidence in al., 2018) standard nursing care diagnosis (McAllen Audits depicted a HCAHP scores would increase & et al., 2018) 94% compliance related to nurse patient safety and rate; 46 shift communication patient satisfaction reports were BSR: tool used for observed and auditing timed prior to compliance of intervention and Weaknesses: bedside shift 48 reports were unable to apply to report observed and generalization of timed after findings to other implementation settings Patient falls Falls: number of decreased by 24% falls obtain after through hospital implementation in incident reporting comparison to pre system before and implementation after implementation Nurse Survey: 95% of nurses completed pre survey pre and 85% completed post survey. Having enough time for report went from 80% to 59.6%. Feedback from nurses on BSR felt that BSR took longer to give report and 44% felt it was inconvenient report. Press Ganey patient satisfaction improved with BSR McMillan Quantitative – quasi- 5 medical surgical Nyberg Caring CAS results:67 LOE=II/Quality = Effective (2017) experimental units with a total of Assessment Scale nurses responded B communication (CAS) – a 20 item to the pre CAS between the patient questionnaire with test and 47 and nurse can lead to /101 registered a 5-point Likert responded to post Strengths: a large increased patient nurses scale (1 = cannot CAS test. There number of satisfaction Determine if use in practice and was a 12.23-point respondents to (McMillan, 2017). implementation of an 5 = always use in increase between CAS survey. education program practice) the pretest and Education shows based upon Watson’s posttest surveys’ statistical Theory of Human overall average significant for Caring would composite scores. post survey positively impact The significance nursing perception Unit specific level of post test and caring attributes HCAHP scores scores was Weaknesses: CAS into daily practice related to nurse p<0.0001 may not be a and increase nurse- communication (McMillan, 2017) valid specific measurement 36 communication Nurse related tool; small sample HCAHP scores HCAHP scores: size There was a 43% increase from previous 52nd percentile score prior to education sessions (McMillan, 2017) Prosser, Quasi-Experimental Inpatient Oncology Department There was a LOE = II / “The improvement Andrews, & unit specific HCAHP 14.6% increase in Quality = B noted in HCAHPS Wheatley To determine if scores to HCAHPS scores might therefore (2020) formal Oncology patients determine communication Strengths: nurses be a result of increased communication tool HCAHPS return improvement of scores but did not had more discussions with (notepad and pen at survey post patient satisfaction reduce omitted frequently shared patients, but not beside) can improve intervention was care the plan of care necessarily a more communication of 15% in comparison MISSCARE with patients and accurate review of the patient’s plan of care to the year prior at survey used pre MISSCARE family, written overall plan of care by and thus increase 11% and post survey had a form or not the primary nurse.” patient satisfaction intervention to response rate of (Prosser, Andrews, & and reduce frequency measure nurses’ 40% prior to Weaknesses: low Wheatley, 2020) of missed care perception of the intervention and a response rate in frequency of and response rate of MISSCARE the reasons for 24% post survey for post missed nursing intervention. intervention, : care (Proser, Based on results plan of care form Andrews,& Basic care tasks was not always Wheatley, 2020). were more utilized frequently reported as missed in this pilot. (Prosser, Andrews, & Wheatley, 2020). 37 Appendix D Author Participants Design Theme Interventions Impact on Nurse Communication Related HCAHP Scores Allenbaugh & Nurses and Quasi- Education Health Literacy Improved et al., (2019) Residents Experiment Curriculum al Austin & et Nurses/physi Quasi- Education Beside Rounds Improved al., (2021) cian, nurse Experiment Checklist practitioner al Rounding Interdisciplinary collaboration during rounding Davis (2019) Nurses Quasi- Communication Assessment tool for Improved Experiment Tool health literacy al Education Lemire (2017) Nurses Quasi- Communication Bedside Improved Experiment Tool communication board al Maloy (2021) Nurses/Physi Quasi- Rounding A checklist utilized N/A cians Experiment during rounding with al multiple specialists and bedside nurses McAllen & et Nurses Quasi- Rounding Incorporating Improved al. (2018) experiment patient’s for bedside al shift report McMillan Nurses Quasi- Education Educational program Improved (2017) Experiment based upon Jean al Watson’s Caring Theory Prosser, Nurses Quasi- Communication Paper format with Improved Andrews, & experiment Tool pencil at bedside Wheatley al depicting patient plan (2020) of care 38 Appendix E 39 Appendix F 40 Appendix G No. Item Grade 1 2 3 4 5 6 1 The patient accepts Doesn’t accept Very Hampered Good Very good Excellent conversation with me difficulty about their illness in the following way 2 I fully understand the Conversation Very Hampered Good Very good Excellent severity of the patient’s impossible difficulty illness and I talk with them about it 3 The patient talks to me Conversation Answers Answers my Answers my Answers my Answers my about various themes but impossible as my questions questions questions very questions avoid or is not able to they do not questions hampered well well excellent answer my questions answer my extremely about their illness questions difficulty 4 The patient looks like they They resist or Does not Cooperates but Cooperates Cooperates Cooperate listen to what I am saying do opposite resist but with difficulties well very well excellent about their condition but form what has doesn’t do avoids or is not able to been told what I am adequately cooperate with telling me while talking to them: them 41 5 I fully understand the Not possible at Extremely Hampered Good Very good Excellent severity of patient’s all difficulty illness, therefore only by observing the patients gesture I conclude that my communication with them is: 6 The level of No Extremely Hampered Good Very Good Excellent communication with the communication difficult patient while I carry out or monitor their pharmacotherapy, I can describe as: 42 Appendix H 43 Appendix I Common Specialists Specialist What do they do? Cardiologist A provider who cares for diseases related to the heart Cardiovascular Surgeon A provider who cares for diseases related to the heart, arteries, and veins Endocrinologist A provider who cares for diseases related to diabetes or hormones Hematologist/Oncologist A provider who cares for diseases related to the blood or cancer Nephrologist A provider who cares for diseases related to the kidneys Neurologist A provider who cares for diseases related to the brain Pulmonologist A provider who cares for diseases related to the lungs Gastroenterologist A provider who cares for diseases related to the stomach Colorectal Surgeon A provider who cares for diseases related to the colon Infectious Disease Specialist A provider who cares for diseases related to infections within the body General Surgeon A provider who cares for diseases that need a surgical intervention 44 Medications This handout is to provide a template to keep track of new medications you may be placed on during your stay in the hospital Medication(generic/brand)_________________________ How much do I take? _____________________ How often do I take it? ____________________ This is for my_____________________ Medication(generic/brand)_________________________ How much do I take? _____________________ How often do I take it? ____________________ This is for my_____________________ Assessment What I know about my plan of care: ______________________________________________________ ______________________________________________________ One thing I would like to know about my plan of care: ______________________________________________________ 45 Routine This handout is to provide a template to keep track of blood work and testing that is ordered during your stay in the hospital Tests I am waiting to result: • ____________________ • ____________________ • ____________________ • ____________________ Blood Work I have scheduled bloodwork____ My labs are scheduled: § Morning ____ § Nighttime ____ § Every two hours ____ § Every four hours ____ § Every six hours ____ § Every eight hours ____ 46 Appendix J 47 Appendix K 48 Appendix L 49 Appendix M Expenses Type Source Cost 8” x 11” Printer Paper for MODIFIED Resource Direct $0.10/sheet SMART Handouts (50 sheets per handout) 16” x 20” Laminated Posters (20 posters) Resource Direct $7.32/poster Clinical Nurse Specialist Personnel Direct $50/hour Informative Session Time Personnel Direct 10 minutes to 15 minutes Unit Rounding Time Personnel Direct 1 hour (60 minutes) to 2 hours (120 minutes) per unit rounding Projected Cost of Unit Rounding at Personnel, Direct $50.00* 60 minutes Process Projected Cost of Unit Rounding at Personnel, Direct $100.00* 120 minutes Process Pre and Post Patient Survey Resource Direct $0.10/ sheet *Hospital does not currently credential/privilege clinical nurse specialists to bill for services; cost estimated based on hourly wage and time Appendix N 50