Abstract
OBJECTIVES: To identify caregiver preferences for discharge education components, content, and techniques.
METHODS: Before discharge education, a 9-question structured interview was performed with caregivers of children from 2 populations admitted to the hospital medicine service: patients with asthma (age 2–17 years) or children who were not dependent on technology (age <2 years). McNemar’s tests were used to evaluate for significant differences between response options. Open coding was used for theme development to interpret qualitative responses about information caregivers wished to receive before leaving the hospital.
RESULTS: The interview was administered to 100 caregivers. More than 90% of caregivers believed that instruction regarding follow-up appointments, medications, and reasons to call the pediatrician or return to the emergency department were important aspects of discharge education. Caregivers also identified a desire for education on their child’s condition, care at home, and illness prevention. Most caregivers reported that teach-back, early discharge education, and a postdischarge phone call would be beneficial. Caregivers varied in their preferences for written, verbal, and video instruction, whereas live demonstration was rated almost universally as an effective method by 97% of caregivers (P < .0001).
CONCLUSIONS: In our study, we provide insight into caregivers’ perspectives on the content, timing, and style of education needed to promote a safe transition of care from the hospital to the home. These findings add caregiver support to the expert consensus in Project Improving Pediatric Patient-Centered Care Transitions and elucidate additional themes to aid in further study and optimization of discharge education.
Hospital discharge presents a safety risk for pediatric patients. Inadequate discharge preparedness can lead to missed follow-up appointments, medication errors, and failure to recognize complications.1–5 Several discharge initiatives are used to promote the use of evidence-based strategies to improve the discharge transition, such as comprehensive education of the contingency plan, the use of teach-back for confirming discharge instructions, and a postdischarge phone call.6–8 In preparation for the American Academy of Pediatrics, Section on Hospital Medicine Transitions of Care Collaborative’s Project Improving Pediatric Patient Centered Care Transitions (IMPACT), primary care providers and hospitalists were surveyed to gain consensus regarding which information is essential for discharge education.9–11 Providers concurred that follow-up appointments, medications, and reasons to call medical providers or go to the emergency department are essential elements of discharge education.
Caregivers of pediatric patients (parents, guardians, or the primary person present with the child during the hospital stay) likewise acknowledge the need for thorough and complete discharge education and report dissatisfaction when this is not provided. However, caregivers also report that comprehensive discharge education can be overwhelming because of the volume of material, mental exhaustion, and competing concerns during the hospitalization and at the time of discharge.12 As a result of these barriers, caregiver assimilation of discharge material may be limited. Hence, information provided at discharge needs to be patient centric and individualized to the needs of the recipient.13,14 Discharging providers are challenged to provide comprehensive information in a manner that is readily understood, remembered, and able to be executed postdischarge.
There is a developing body of literature in which the efficacy of different teaching styles for patient and family education is examined. Instructional methods that are investigated include written and verbal education, visual aids, demonstration, and teach-back.15–30 Although little is known about caregiver educational preferences, we inferred that aligning learner preferences with proven teaching methods could facilitate improved communication of important discharge content.
With increasing importance placed on improving discharge instruction, investigation of caregivers’ attitudes regarding recommended strategies and learning styles is the next logical step in improving the discharge transition. Our objective for this study was to investigate caregiver preferences and attitudes regarding discharge education learning styles, content, techniques, and strategies to optimize the educational approach.
Methods
Study Design
In this descriptive mixed-method study, we used a structured interview to assess caregiver preferences regarding discharge education. A 9-question interview was developed via consensus of the study group on the basis of a review of the literature and discussion with local discharge transition experts. Questions were focused on assessment of caregiver perceptions of the importance of various components of discharge educational content, preferred teaching styles and timing, and attitudes regarding teach-back. Interview questions were reviewed by a member of the hospital’s family advisory council and worded at a fifth-grade reading level. A single study group member read the questions aloud to caregivers of children at any point during their hospitalization before the onset of discharge education. The responses were summarized in writing during the interview and reviewed immediately after the interview to ensure accuracy. Responses were then transcribed into REDCap. In this article, we discuss the findings of the 6 questions that were focused on caregiver perspectives on discharge education.
Setting
The study took place at an urban, free-standing, tertiary-care pediatric hospital with 306 beds, 16 436 admissions per year, and an average daily census of 215 patients. The average daily hospital medicine census was 27 patients with an average length of stay of 3.11 days. Previous local work revealed that 55% (276 of 495) of caregivers presenting to the emergency department had low health literacy, as determined by the Newest Vital Sign, a 6-question test used to assess health literacy.31,32
Caregiver Selection
Potential participants were selected to align with patients enrolled in our local Project IMPACT study group and included caregivers of children <2 years of age who were not dependent on technology and children between the ages of 2 and 17 years with asthma admitted to the hospital medicine service on an acute care unit. Selection was based on mutual caregiver and interviewer availability. Interviews were performed during an 8-week period 7 days per week during daytime hours. Interpreter services were available for the interview in many non-English languages. Project IMPACT is supported by the American Academy of Pediatrics and is a multisite quality improvement initiative and research collaborative formed to promote partnership between patients, caregivers, and medical teams to improve discharge transition outcomes.
Variables and Outcomes
The structured interview contained Likert scale and yes or no questions, with an open-ended response option available on the basis of the initial answer (see Fig 1). Questions were formulated to investigate caregiver attitudes and preferences regarding the following: (A) goals of hospitalization, (B) concerns about discharge, (C) learning styles, (D) teach-back, (E) discharge education content, and (F) timing of discharge education. For the sake of this mixed-methods study, responses to questions related to items C to F above are presented and analyzed in this report and correspond to questions 1 to 6 (Fig 1).
Selected structured interview questions.
Categorical data, including insurance type, study population (ie, children <2 years of age who were not dependent on technology or children between the ages of 2 and 17 years with asthma), previous hospitalization at our institution within 3 years, and length of stay, were collected via a chart review.
Data Analysis
Frequency counts were used to show distributions of the responses to the Likert scale–based questions. The McNemar’s exact test was used for paired comparisons of learning style preferences to determine superiority. Fisher’s exact test was used to analyze the association between preference for teach-back and other variables. A 2-sided P value of <.05 was considered statistically significant. All analyses were conducted by using SAS 9.4 (SAS Institute, Inc, Cary, NC).
To analyze the open-ended responses to question 2 (“Are there any other things that you would like to learn about before you leave the hospital? If so, what are those things?”), 1 researcher with qualitative experience formulated coding principles and provided instruction to 2 additional members. Two of the members of the coding team reviewed the responses and performed open coding to identify categories and then grouped the categories into 3 themes. The study team leader independently reviewed the results to provide feedback and arbitrate discrepancies.
Ethical Issues
The study was approved by the Children’s Hospital of Wisconsin Institutional Review Board.
Results
Patient and Caregiver Characteristics of Interview Participants
Of 101 caregivers who were approached to complete the structured interview, 100 caregivers agreed. Eighty-seven interviews were completed with just 1 caregiver (70 with just the mother and 17 with just the father), and 9 interviews were completed with both caregivers. Two interviews were completed with the patient’s grandmother, and 2 interviews were completed with a foster mother. Each interviewee completed the entire interview. All caregivers who were interviewed designated English as their primary language. For patient demographics and other information, see Table 1.
Patient Characteristics
Discharge Education Content Preferences
In response to the Likert scale questions used to determine caregiver attitudes regarding discharge education content, the majority of caregivers rated each of the elements as extremely important, as shown in Fig 2.
Caregiver ratings of Project IMPACT discharge education elements. ED, emergency department.
Additional Desired Information Caregivers Would Like to Learn Before Leaving the Hospital
Caregiver responses regarding additional information they would like to learn before leaving the hospital were analyzed by using open coding. Forty-four distinct responses from 28 different respondents were categorized into 3 themes (Table 2). Themes included understanding care at home (50% of responses), understanding clinical condition (31.8% responses), and illness prevention (18.2% of responses).
Selected Examples of Caregiver Responses About What Else They Would Like to Learn Before Leaving the Hospital
Learning Style Preferences
In response to the question about learning style preferences, most caregivers (90%) rated live demonstration (someone shows you) as a very good way to learn how to give a medication. Between 34% and 37% of the time, the other 3 methods (video instruction, verbal instruction, or written directions) were rated as a very good way to learn (Fig 3). When live demonstration was compared with the other learning styles individually by using McNemar’s exact test, preference for live demonstration over each was statistically significant with a P value of <.0001 for all 3 comparisons.
Caregiver ratings of the effectiveness of different learning methods.
Preferences for Teach-back, Timing of Discharge Education, and Postdischarge Communication
Most caregivers (90%) agreed that repeating what they had learned (teach-back) would be beneficial. The majority (92%) also believed it would be helpful to receive a follow-up phone call. Lastly, 97% of caregivers believed that it would be helpful to begin discharge instruction before the day of discharge. There was no difference between the rate of teach-back preferences between study groups (children <2 years of age versus children 2–17 years of age with asthma; Fisher’s exact test P value = .644).
Discussion
With the results of our study, we provide insight into caregivers’ educational preferences regarding discharge education. With our findings, we confirm that caregivers agree with medical providers regarding the content of information deemed essential to be communicated before discharge. In accordance with the survey of primary care physicians and hospitalists that was used to inform the content of the Project IMPACT bundle, most caregivers agree that information about follow-up appointments, medications, and reasons to call medical providers or go to the emergency department are essential elements of discharge education. When given an opportunity to express what other information may be helpful at the time of discharge, desired content generally fit into the following 3 themes: care at home, information about the child’s condition, and illness prevention. These additional themes reinforce the need to allow families time and opportunity to ask questions specific to their child’s situation.
In addition to tailoring content, teaching style preferences should also be considered to maximize learning. In response to the question about learning method preferences, caregiver responses varied widely. Although 1 caregiver may feel that video instruction is a good way to learn, another may prefer written directions. We found that most caregivers desired live demonstration as a technique for learning about medication administration. Involving caregivers in deciding on their discharge education methods and supplemental content could help families better assimilate this information before they leave the hospital.
Regardless of the teaching style used, confirmation of understanding is essential to ensure caregiver readiness for transition of the care plan to home. Teach-back as a method of confirming understanding has gained attention as an important educational tool among health care providers. Previous studies have revealed teach-back to be an effective method for discharge education in both the emergency department and inpatient settings.23,24,29,30 As part of our local Project IMPACT efforts, a hospital-wide initiative to promote the use of teach-back was undertaken. However, a chart review of discharge education documentation revealed that compliance by nursing personnel was poor.33 Nursing personnel identified 1 cause of poor compliance as their perception that home caregivers found the practice insulting or tedious. Contrarily, the findings from this work reveal that most caregivers of children in the hospital reported that teach-back would increase their comfort with the content of discharge education. We have used this information locally to promote the use of teach-back with significant success, as revealed by increased rates of teach-back use on the follow-up chart review.33
Almost all caregivers reported that beginning discharge education before the date of discharge would be helpful for their hospital-to-home transition. Evidence from the educational literature suggests that the instructional strategy of spaced repetition promotes effective learning.34 Multiple discharge initiatives, including Project IMPACT, have been used to promote the initiation of discharge education before the date of discharge. With our study, we confirm that caregivers are open to this strategy. By starting discharge education earlier and spreading it throughout the hospitalization, caregivers may have improved retention of the discharge information.
Previous work has revealed that postdischarge phone calls can be beneficial in reinforcing both the discharge plan and use of home medications in pediatric patients.35,36 The fact that most caregivers thought a postdischarge phone call would be helpful reinforces the importance of these calls as a component of complete hospital-to-home care. However, routine practice of placing postdischarge phone calls is labor intensive, representing significant organizational commitment and cost. More research is needed to determine if certain populations would benefit more than others in receiving postdischarge calls.
As a descriptive mixed-methods study, our approach has limitations related to validity and sample population. The interview questions were developed by study group consensus to address questions related to local practice and are not validated. Additional open-ended questions may have allowed for interviewees to elaborate more fully on specific learning style preferences; however, this would have limited the ability to perform comparative statistical analyses. Although language spoken other than English did not exclude participation, because of caregiver and interviewer availability, only English-speaking individuals were included in the study. In addition, caregivers were chosen on the basis of whether their child met the criteria for the previously defined Project IMPACT study populations; thus, the results may not be generalizable to all caregivers. Although these results serve to reveal that variations in teaching style preferences by individuals and populations may exist, a survey of caregivers of a broader population of patients would be necessary to make more global conclusions.
With our findings, we provide insight into caregivers’ preferences for discharge education content and methods. Caregivers endorsed the Project IMPACT discharge elements and additionally identified a desire for education on the child’s condition, care at home, and illness prevention. Caregivers supported starting education early during hospitalization and following-up with a postdischarge phone call, suggesting a preference for a comprehensive program of education. In line with adult learning theory, caregivers’ preferences for methods of instruction varied across verbal, written, and video instruction. Caregivers almost universally endorsed a preference for live demonstration and teach-back during discharge education. Overall, we provide with our study important insight into caregivers’ perspectives on the timing, content, and style of education needed to promote a safe transition of care from the hospital to the home. In future studies, comparing these approaches to determine which patients benefit most could help guide resource allocation.
Acknowledgments
We thank the Project IMPACT National Collaborative for allowing us to perform this study within the larger study, in particular, Drs David Cooperberg, Leah Mallory, and Snezana Osorio (national Project IMPACT project leaders); our local Project IMPACT working group for their contributions to interview development and data analysis; Kelsey Porada for assistance with tables and figures after the creation of the article; the pediatric hospital medicine faculty for allowing the caregivers of their patients to be interviewed; and the parents and caregivers for their participation in our study.
Footnotes
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Mr O’Day was funded by the Medical College of Wisconsin Summer Research Program with a summer research internship that allowed for him to perform caregiver interviews.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
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