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REFINING EDUCATIONAL NEEDS FOR STROKE PATIENTS 1

Refining the Education Provided to Patients Suffering from a Cerebrovascular Accident in the

Acute Care Setting

Jenni McRoy

Kim Nicholls

Jane Schmaltz

University of Mary


Acknowledgements

This University of Mary Stroke Project team would like to acknowledge the following

people for their efforts making this project possible. First, this project team would like to thank

Claudia Dietrich, faculty Project Advisor, who has been and continues to be a mentor for all

members of this group and helped guide the creative process for this evidence-based project

(EBP). The University of Mary has provided this Stroke team the opportunity to create an

evidence-based project that enhances the quality of patient care and education they receive at

Research Medical Center and other healthcare facilities alike. Without this opportunity, the

members of the University of Mary Stroke Project team would not have had the opportunity to

work and grow together to create the framework for this project. Sherry Bahr, APRN, CNRN,

Stroke Program Coordinator, has been a fundamental resource helping guide this project in the

direction that upholds the healthcare organization’s mission and values by refining the education

patients receive during an acute hospitalization. Through her consistent dedication to this

project, she has expelled an excitement within the executive leadership team, ancillary staff

member's, interdisciplinary team members, and most of all patients and family members at

Research Medical Center that would not have occurred without her support. Research Medical

Center has graciously allowed University of Mary’s Stroke Project team the opportunity to

become cohesive partners enhancing current processes to improve patient outcomes for stroke

patients. Jenni McRoy, the project lead for the University of Mary’s Stroke Project team, has

communicated the vision of Research Medical Center to all members of University of Mary’s

Stroke Project team. Her attention and dedication to the success of this project has been vital

helping guide the direction of the team. Without her efforts, this project would not have been

possible. Kim Nicholls and Jane Schmaltz have dedicated countless hours to the external


literature review, paper, and the Power Point presentation. Their dedication, support, and

effective communication have helped guide the direction for this project. The front-line core

staff members for their flexibility and constant acceptance to the implementation of change

ensuring the patient’s educational plan of care is top priority.


Table of Contents

Acknowledgements…………………………………………………………………………….….2

Executive Summary……………………………………………………………………………….9

Problem Statement…………………………………………………………………………….....12

Significance of Clinical Problem at the Organizational Level………………………………......14

PICO(T) Question………………...……………………………………………….………….….15

Purpose Statement…………………………………………………………………………….….16

Review of Literature………………………………………………………………………….….17

Literature Search…………………………………………………………………………17

Synthesis of Current Literature……………………………………………………….….33

Organizational Recommendations……………………………………………...………..39

Project Problem Identification…………………………………………………………………...40

Internal Evidence………………………………………………………………………...40

External Evidence………………………………………………………………………..41

Project Recommendations……………………………………………………………………….44

Project Implementation Plan…………………………………………………………….……….47

Change Theory………………………………………………………….……………......47

Key Stakeholders…………………………………………………………………….…..50


Barriers and Facilitators/ Drivers and Resistors to Change……………………………...53

Business Impact…………………………………………………………….……………55

Organization Planning Process……………………………………………………...…...56

Implementation Plan……………………………………………………………………………..57

Project Measurement Plan……………………………………………………………………….63

Human Subject Protection Statement……………………………………………………………66

Implementation and Measurement…………………………………………………………….…68

Implementation…………………………………………………………………………..68

Measurement……………………………………………………………………………..70

Handoff…………………………………………………………………………………..77

Conclusion...………………………………………………………………………………..........78

References……………………………………………………………………………………......81

Appendix…………………………………………………………………………….……...…....85


List of Tables

Table 1: External Data: Importance of the Nurse Role in Patient Education……………………18

Table 2: External Data: Importance of the Nurse Role in Patient Education/Level of

Evidence……………………………………………………………………………………….....19

Table 3: External Data: Stroke patient perception of educational needs………………………...23

Table 4: External Data: Stroke Patient Perception of Educational Needs/Level of Evidence…….

……………………………………………………………………………………24

Table 5: External Data: Benefits & Effectiveness of Education………………………....…....…27

Table 6: External Data: Benefits & Effectiveness of Education/Level of Evidence…………….28

Table 7: Internal Data Needs…………………………………………………………………….40

Table 8: Attendance vs. Stroke Census for Weeks 1-10…………………………………………71

Table 9: Pre and Post Survey Questionnaire Results…………………………………………….72


List of Figures

Figure 1: The Johns Hopkins Nursing Evidence-Based Practice Model………………………49


List of Appendices

Appendix A: Permission Granting the Use of Johns Hopkins Nursing Evidence-Based Practice

Model……………………………………………………...……………………………………..85

Appendix B: Flyer for Huddle…………………………………………………………………...86

Appendix C: Pre-Education Informative Questionnaire for Patients………………………..…..87

Appendix D: Post-Education Informative Questionnaire for Patients…………………...………88

Appendix E: Stroke Education Course Flyer…………………………………………………….89

Appendix F: Nurse Education Feedback…………………………………………………….…..90

Appendix G: Institutional Review Board (IRB) Application…………..………...……….……..91

Appendix H: IRB Approval……………………………………………………………………...99


Executive Summary

This University of Mary's Stroke Project team has worked in collaboration with Research

Medical Center (RMC) in Kansas City, Missouri, to implement evidence-based practice (EBP)

interventions, such as a structured stroke support and educational class and enhanced nurse

education regarding the teach-back method, to improve patient understanding of their stroke risk

factors. RMC identified an organizational problem as needing to enhance the educational

understanding of stroke patients and their families through the utilization of a hospital initiated

stroke support and educational program, as evidenced by recurrent admissions and a verbalized

lack of understanding from previous patients and their families.

The purpose of this EBP project was to evaluate and refine the educational process at

RMC in order to enhance the educational understanding stroke patients receive regarding their

individualized specific type of stroke, risk factors, and care. Guided by this information, the

University of Mary's Stroke Project team performed an extensive literature search to assist

RMC's Stroke Program in the refinement of their educational offerings through the most current

and successful evidence-based practices. The themes that were used to complete the literature

review were the importance of the nurse role in patient education, the patient's perspective of

educational needs, and the benefits and effectiveness of education. As the external data provided

supportive documentation, the internal data from RMC supported the recurring themes noted

during the external literature review; as well as provided an exclusive insight suggesting a great

need for refining education provided to patients during an acute hospitalization.

The University of Mary's Stroke Project team proposed their recommendations for a

formalized structured classroom setting; where a weekly education class dedicated to providing

stroke education to patients and their families in order to reduce the patient’s risk of suffering


from an subsequent stroke. In addition, the proposed recommendation was to review the stroke

booklet in detail with front line staff and all new orientees with a member of the University of

Mary's Stroke Project team, the Stroke Program Coordinator, the Stroke educators, or the Stroke

Registered Nurse Navigators.

The Stroke Team’s Nurse Navigators initiated the required weekly staff re-education of

stroke patient education to all nursing staff delivering direct care to stroke patients. The

education occurred during morning and evening huddles on each unit that house stroke patients

ensuring all front-line staff attend this education can attend. The front-line staff was re-educated

on the stroke booklet that all patients receive at the time of admission when diagnosed with a

stroke.

Through collaborative efforts, a weekly stroke support and educational class was

designed and implemented. The project lead referred to the stroke booklet during a PowerPoint

presentation, expanding on the written content. Alternative methods to promote attendance and

compliance to the stroke support and education class were discussed and implemented. These

included announcing every Thursday during bed huddle the time and location of the stroke

support and education class, along with overhead paging a reminder one hour prior to the class

start time. Overall, the two superior strengths after implementation included the enhanced

understanding the patient and family members have verbalized, and the self-confidence and

empowerment nurses have verbalized. Incorporating the baseline metrics revealed through the

internal data review, project measurements were identified utilizing the mnemonic acronym

S.M.A.R.T. Pre and post-education questionnaires were administered and tracked using an excel

spreadsheet. During the introduction of each class a questionnaire was completed to evaluate

their understanding of strokes, risk factors, and signs and symptoms. After the presentation, a


questionnaire was completed asking the same initial six questions along with asking for an

explanation of what benefits they received from this intimate disease-specific education, as well

as what could be improved on the class.

To measure the efficacy of this training of the education that was provided to nursing

staff, a routine post education survey was distributed which resulted in 100% of nurses feeling

like the nurse patient education and teach-back method were an imperative aspect to evaluating

patient understanding. The nurses expressed feelings of empowerment and self-confidence

through the education and use of the nurse-patient teach-back tool. This aspect continues to be

crucial for nurse retention and loyalty for any healthcare organization.

Implementing an educational opportunity in a safe environment that provides a

personalized approach to the patients and their family members has promoted a cohesive

learning environment. This opportunity enhanced the knowledge level of the patient and family,

and promoted and encouraged healthier lifestyle choices potentially extending the longevity of

their life. Implementing these interventions helped make patients more knowledgeable about

their disease process so they are less likely to experience negative outcomes and less uncertainty

related to their stroke diagnosis. A handoff plan was developed so RMC could continue on with

the implementation of these interventions that will continue to improve the lives of individuals

and their family members suffering from this devastating, life-altering diagnosis.


Refining the education provided to patients suffering from a Cerebrovascular Accident in the

Acute Care setting

In the United States, approximately 800,000 people suffer from cerebrovascular accidents

(CVA) a year (American Stroke Association, 2016). As a result of this, CVA’s, also known as

stroke or transient ischemic attack (TIA), are the 5th leading cause of death in the United States

and are also the number one cause of long term disability (ASA, 2016). Evidence-based research

suggests that when a patient is able to speak to their current status, know their personal risk

factors and how to prevent future strokes, they are less likely to experience future CVA’s while

improving their disability from current deficits. Due to the substantial need for understanding,

the focus of this University of Mary’s Stroke Project team has been directed towards reducing

future strokes in patients that have already suffered from a CVA by improving their knowledge

level regarding their specific risk factors affecting their personal disease process.

The following will identify common themes that were found while conducting a review

of literature for improving education for patients that have recently experienced a stroke. This

University of Mary’s Stroke Project team has worked in collaboration with Research Medical

Center to implement evidence-based practice (EBP) interventions, such as an organized and

structured stroke support and educational class and enhanced nurse education regarding the

teach-back method, to improve patient understanding of their risk factors. By understanding

these risk factors, patients can incorporate preventative techniques into their lifestyle to reduce

the likelihood of the patient experiencing additional CVA’s in their lifetime.

Problem Statement

From a global perspective, strokes do not discriminate against who they affect. Patients


are affected by CVA’s everywhere around the world; proving an imperative need for enhanced

educational opportunities and a comprehensive understanding of this particular disease process.

The more patients and their families understand about personal stroke risk factors, signs and

symptoms, and care, the more likely they are at implementing an interventional strategic plan to

help reduce their risk for recurrent strokes or recurrent hospital admissions.

When a stroke occurs, patients and their families are often in shock and only retain a

portion, if any, of what the healthcare professionals are explaining to them. Leaving a hospital

after suffering a stroke can be frightening and quite possibly overwhelming. Having a plan in

place to assist patients and their families with thorough education personally geared towards

their specific type of stroke, will help facilitate an understanding of what to look for and what to

expect.

Problem statements encompass the concerns or problems that are acknowledged in a EBP

project. Sherry Bahr, APRN, CNRN, Stroke Program Coordinator, along with Research Medical

Center’s executive leadership team have identified the organizational problem as needing to

enhance the educational understanding of stroke patients and their families through the

utilization of a hospital initiated stroke support and educational program, as evidenced by

recurrent admissions of stroke patients and a verbalized lack of understanding from previous

patients and their families. Guided by this information, The University of Mary’s Stroke Project

team performed an extensive literature search to assist Research Medical Center’s Stroke

Program in the refinement of their educational offerings through the most current and successful

evidence-based practices.

A coordinated educational process dedicated to chronic disease education such as this

should be a priority; not only for the organization this project is benefitting, instead a national or


worldwide focus to help combat CVA’s being one of the highest leading causes of death and

long-term disability. With extensive education programs, this will help to consistently provide

the knowledge necessary to facilitate an understanding of strokes and stroke care. Furthermore,

this educational understanding will help to reduce future readmissions or potentially help prevent

future strokes.

Significance of Clinical Problem at the Organizational Level

Research Medical Center of Kansas City has identified an increased admission rate for

recurrent stroke victims for individuals suffering from a CVA. During daily rounding and

conversations with these individuals and their family members, a lack of understanding

regarding personal specific risk factors and necessary interventional implementations for

improved health wellness have been identified by the executive and direct leadership teams.

Lack of education and a comprehensive understanding of personal risk factors are interrelated

and are measured through a verbalized lack of ability to restate personal specific risk factors

leading to their primary stroke. Along with an inability to verbalize personal risk factors is an

inability to state an optimal personalized interventional implementation plan to improve upon

current risk factors reducing their chance of suffering from a secondary CVA.

On an organizational level, these interrelated factors are measured through an increased

readmission rate for secondary strokes leading to potential financial organizational burden and

increased individual mortality and morbidity rates. In fact, 1 out of 4 individuals suffering from

a primary diagnosis of a stroke will suffer from another stroke in their lifetime (Furie, 2011).

Recently designated as a Comprehensive Stroke Center places an imminent organizational need

to refine educational processes enhancing patient knowledge. This enhanced knowledge level

will assist and lead the patient and their family to an improved health status post discharge.


Improving the quality of care provided in health care organizations is of key significance.

Reimbursement methods are based off a multitude of key factors including readmissions rates

and patient satisfaction scores. Identified patient and family dissatisfiers include lack of

education and an increased fear of not being prepared to provide necessary cares post-discharge.

This fear, as noted from verbal conversations with patients and family members, is based off an

undesirable lack of confidence in understanding personal specific risk factors and how to

implement lifestyle changes. Therefore, refining the education and enhancing educational

opportunities for patients and families suffering from a primary or secondary diagnosis of a CVA

can provide the individual and their family the crucial information to make a more informed

interventional strategy improving their overall health wellness by decreasing their risk for

disease induced mortality and morbidity.

PICO(T) Question

For the purpose of this EBP project, the PICO(T) question format was utilized to

formulate a well-rounded researchable question. The EBP project clinical question follows

wording that includes (P) the population or patients, (I) the intervention or influence, (C)

comparison, and (O) the outcomes (Polit & Beck, 2017). Often times the utilization of (T) time is

added to the question to indicate the timeframe representing in the question.

The University of Mary’s Stroke Project team has identified the need to enhance the

educational understanding for patients that were recently diagnosed with a stroke for this project.

In order to ensure the group met the needs of the organization, a PICOT question was developed.

The question written for this EBP project is “How are recent stroke patients (P) who complete a

coordinated educational process in a formal organized hospital stroke program (I), compared to

the current practice of no formal organized hospital stroke program (C), impact understanding


(O) within the first 6 weeks(T)?”

Purpose Statement

The purpose of this EBP project was to evaluate and refine the educational process at

Research Medical Center, a comprehensive designated Stroke Center and Level One Trauma

hospital in Kansas City, Missouri, in order to enhance the educational understanding stroke

patients receive regarding their individualized specific type of stroke, risk factors, and care. This

evaluation of current processes and offered educational opportunities Research Medical Center is

presently practicing would include personalized specific health and wellness interventions,

comprehensive understanding of medication compliance, therapy treatments, and utilization of

organized support systems and local community resources.

The EBP project has initiated a more comprehensive educational process for patients

suffering from a CVA beginning upon admission. The goal was to identify the health care needs

that include education to the patient and family regarding their specific risk factors, the type of

stroke they suffered, the location of the stroke, and how it will affect their life moving forward.

This EBP project was intended to improve the patient's comprehensive understanding of their

personal specific risk factors, medication compliance, therapy treatments necessary for

improving their personal outcomes, lifestyle modifications, and utilization of organized support

and educational systems, and local community resources. Educational opportunities for current

and newly hired staff members were also been identified as an area of opportunity; along with a

more in-depth process necessary to educate patients and families suffering from a stroke.


Review of Literature

Literature Search

Nurses are one of many members of the multidisciplinary team that assist in providing

patient education. As the literature review was completed by the University of Mary’s Stroke

Project team, a common recurring theme was the importance of patient education by nurses and

all interdisciplinary members of the team. The goal of this education is to provide the patient

with the tools they need to successfully understand their personal diagnosis and how to better

themselves. The themes that were used to complete the literature review were the importance of

the nurse role in patient education, the patient’s perspective of educational needs, and the

benefits and effectiveness of education.

A literature review was conducted to find adequate data to support the need for this

project. The search engines that were used for this review were The Cumulative Index to

Nursing and Allied Health Literature (CINAHL), Cochrane Database, and MEDLINE. The key

search words that were used to capture the needs of this project and the results of those searches

in each database are listed in tables 1-6 below. A filter was placed to capture data between 2010

and 2017 to ensure the most up to date data was collected. Another filter was added to only

include full text articles. It was found that the abstract of an article provides a summary of the

article that is being reviewed, but without the data within the research articles it is difficult to

find supporting evidence for this project.


Table 1

External Data: Importance of the Nurse Role in Patient Education

CINAHL MEDLINE Cochrane

Nurse education 1,328 498 315

Patient education 5,979 9,097 4,705

Nurse empowerment 51 13 7

Stakeholders and stroke

45 61 0

Nurse empowerment and education

19 5 1


Table 2

External Data: Importance of the Nurse Role in Patient Education/Level of Evidence

Full APA Citation Research Purpose

Study Design

Sample (Setting)

Data Collection/

Measures

Analysis/

Outcomes

Strengths/

Limitations

Joanna Briggs Level of Evidence

Study Quality

Aslani, Z., Alimohammadi, N., Taleghani, F., & Khorasani, P. (2016). Nurses’ empowerment in self-care education to stroke patients: An action research study. International Journal of Community Based Nursing & Midwifery, 4(4), 329-338.

The purpose of this study was to evaluate if there was a link between the level of nurse empowerment and patient outcomes.

Action research design

23 nurses who volunteered from an inpatient neurology unit.

Semi-structured group and individual interviews were conducted until data was saturated.

Nurses felt they were better prepared to answer questions with concise answered after the educational session

Based on the results of this research, the study was able to support the importance of providing additional education for nurses in their primary field of work. Limitations included nurse resistance to change due to increased workload and lack of nurse

Level 6

Low quality


understanding related to the research process.

Blauer, C., Frei, I. A., Schnepp, W., & Spirig, R. (2015). Implementation of a nurse-led education programme for chronic heart failure patients during hospitalisation and strategies supporting their self-management at home: A practice development project in the context of the Swiss healthcare system. International Practice Development Journal, 5(1).

The purpose of this study was to see if creating nurse led education programs could meet the need of patients.

Mixed method design

15 CHF patients that received CHF education from nurses at the time of discharge.

Recorded interviews

Patients were well equipped for the transition home, but the patients individual living situations were not accounted for and were unprepared to deal with those challenges.

Patients felt they were prepared for their transition home. Some limitations to this study was the sample size was limited and the education did not anticipate challenges patients experienced in their home environment.

Level 6

Low quality

Håkanson, C., Sahlberg-Blom,

To find a relationship

Evaluative research

51 patients

Two self-assessment

Statistical analysis

Positive outcomes were

Level Low


E., Ternestedt, B., & Nyhlin, H. (2011). Learning to live with irritable bowel syndrome. The influence of a group-based patient education programme on peoples' ability to manage illness in everyday life. Scandinavian Journal Of Caring Sciences, 25(3), 491-498.

between group based education and management of a chronic disease.

design with irritable bowel syndrome that participated in the group visits

questionnaires were used to gather data. The first one was prior to group education and the second was sent out about 2-3 months following the education.

with software.

reported via patient survey. Limitations were noted as not having a controlled group and there was a high dropout rate from the first survey to the second.

6 quality

Sherman, J.R. (2016). An initiative to improve patient education by clinical nurses. MEDSURG Nursing, 25(5), 297-333.

The purpose of this study was to review simulations about patient education to see if nurses developed a better understanding of

Cross-sectional design.

66 RN’s that were going through annual training.

Utilized pre-and-post tests to identify areas of improvement.

Pre-and-posttest that were evaluated by statistical analysis.

Reviewers collected 66 pre-and-posttests from RN’s. The simulations found statistically significant improvements to nurses’ knowledge regarding

Level 6

Low quality


performing patient education.

teaching patient education and identify proper teach-back technique.

Limitations that were identified were a small sample size and the statistical significance of tools were not determined to be reliable.


Table 3

External Data: Stroke patient perception of educational needs


Stoke education 346 793 13

Patient needs 15,180 10,064 8

Patient perception 4,771 2,984 3

Stroke awareness 176 505 2

1&2 11 5 23

1&3 2 1 92

1&4 51 77 28

2&3 434 41 22

2&4 4 18,306 19

3&4 4 1 24


Table 4

External Data: Stroke Patient Perception of Educational Needs/Level of Evidence

Full APA Citation Research Purpose

Study Design

Sample (Setting)

Data Collection/

Measures

Analysis/

Outcomes

Strengths/

Limitations


Study Quality

Sowtali, S. N., & Harith, S. (2014). Educational Needs among Stroke Patients Admitted to Hospital Universiti Sains Malaysia: Preliminary Findings. Jurnal Sains Kesihatan

The purpose of this study was to gather basic information about the types of educational needs among

A cross-sectional survey in the format of a preliminary descriptive correlation study design.

41 stroke patients diagnosed and confirmed with CT scan were chosen from the Universiti Sains Malaysia Hospital’s Medical and

A questionnaire consisting of five domains related to stroke; each domain contains questions that reflect a topic related to stroke was

The results showed a perceived need from the patients for more education needed on general information about stroke, and on prevention and causes of strokes; needs on the risk factor management of stroke; needs on treatment of stroke from medicine, surgery and traditional medicine

Strengths included were the study’s highlighted points that stroke patients were more interested to know about prevention, causes and risk factors of stroke. The limitations to this study were the difference of

Level 3

Moderate quality was determined based on content validity and internal consistency for questionnaire using Cronbach’s alpha.


Malaysia, 12(1), 67-73. doi:10.17576/jskm-1201-2014-09

stroke patients admitted to Hospital Universiti Sains Malaysia, in order to get preliminary information to help design further educational interventions.

Surgical floor between September to December 2012.

given to the patients prior to discharge.

aspects; need to know for all listed post-stroke problems, including the post-stroke diet management. Data obtained were analyzed using SPSS 20.0 descriptively. Ethical clearance was obtained from HUSM Human Ethical Committee prior to study.

medical history background might impact the degree of educational needs; only one stroke patient had no previous medical disease prior to stroke; and there is still an uncertainty whether single morbidity or multiple morbidities had impact on the stroke education needs.

Yonaty, S., & Kitchie, S. (2012). The Educational Needs of Newly Diagnosed Stroke Patients. Journal of Neuroscience Nursing, 44(5),

To determine if there is a change in the perceptions of what individuals

Descriptive correlational study design.

71 newly diagnosed, first-time stroke patients from two metropoli

A questionnaire with eight domain related to stroke; each domain contains

Analysis through descriptive statistics, t tests, and repeated measures ANOVA.

Satisfaction levels were below level 4 on Likert’s scale; making the overall perception of education not

Level 3

High quality was determined based on content validity,


E1-E9. doi:10.1097/jnn.0b013e31826663f2

newly diagnosed with stroke perceive as important to learn about stroke during different times of their stroke recovery.

tan hospitals in the Northeast.

questions that reflect a topic related to stroke. Initial questionnaire given within 24-72 hours of admission, again upon discharge, and 2 weeks post discharge.

The outcomes determined the medical knowledge and medication treatment were rated the most important to learn; however, treatments with herbal or alternative medicine and dietary habits were the least important to learn about.

satisfactory. Limitations of the primary researcher being the only one involved in selection of patient participation, some patients unable to complete second questionnaire due to early discharge, only two designated stroke centers, the study was self-reporting, and the number of patients could have been larger.

internal consistency for questionnaire using Cronbach’s alpha, no assumptions were violated, reading level was at a grade 6, eligibility and sampling procedures followed.


Table 5

External Data: Benefits & Effectiveness of Education


Stoke education 782 435 13

Patient education 69,386 26,282 122

Benefits of education 2,672 1,287 5

Effectiveness of education 2,637 2,039 35

1&2 225 67 85

1&3 16 3 100

1&4 22 17 117

2&3 539 210 4

2&4 605 448 17

3&4 67 40 1


Table 6

External Data: Benefits & Effectiveness of Education/Level of Evidence

Full APA Citation

Research Purpose

Study Design

Sample (Setting)

Data Collection/

Measures

Analysis/

Outcomes

Strengths/

Limitations


Study Quality

Ing, M. M., Linton, K. F., Vento, M. A., & Nakagawa, K. (2015). Investigation of stroke needs (INVISION) study: Stroke awareness and education. Hawai’i Journal of Medicine & Public Health,

The purpose of this study was to assess the overall understanding and effectiveness of current inpatient stroke

A qualitative study design.

21 participants consisting of 10 patients who were recently hospitalized with intracerebral hemorrhage and their caregiver

Data was collected by two trained research staff members conducted face-to-face, semi-structured interviews with caregivers and patients

The voice-recorded interview data was transcribed and content analysis was performed. The content was placed into codes that grouped the data into recurrent and prominent themes across participants. The researchers developed a codebook to display the broad themes that were apparent;

Strengths of the study show that the qualitative methods that were utilized to capture the complexity of stroke education and awareness experienced by specific individual patients and their caregivers. Limitations for this study

Level 6

Low quality


74(4), 141-145. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4407457/

education practices.

s (11 participants) during the follow-up visits were interviewed at the Queen's Medical Center; which is located on Oahu, the largest hospital in Hawaii.

utilizing scripted questions developed by the research team. The scripted questions consisted of open-ended questions with a focus on nine major subjects related to strokes.

based on the frequency, emotion, and extensiveness of the narrative. The two authors then discussed and created the final analysis codebook. The analysis codebook revealed three themes presented as concerns; lack of stroke knowledge or awareness, need for stroke education, and fear of stroke recurrence due to inefficient education while hospitalized. This study suggests a need for increased continuity and communication with health-care providers to address the evolving educational and practical needs of

include the small number of participants limits the generalization of the results, limiting the participation selection due to geographic locations of the Hawaiian Islands made it difficult to expand to other areas within the Hawaiian Islands, limitations of participants due to language barriers due to the caregivers and patients being required to speak English in order to participate in this study, which could


stroke patients and their caregivers after hospital discharge.

have possibly overlooked certain populations due to the narrative properties of the qualitative study.

Sanders, K., Schnepel, L., Smotherman, C., Livingood, W., Dodani, S., Antonios, N., ... Silliman, S. (2014). Assessing the impact of health literacy on education retention of stroke patients. Preventing Chronic Disease, 11, 1-10. http://dx.doi.o

The purpose of this study was to assess the relationship of patient’s health literacy to stroke education outcomes, following stroke education in an acute stroke unit at a hospital

A prospective cross-sectional qualitative study.

The sample consisted of 100 patients who were admitted to the hospital stroke unit with a diagnosis of acute ischemic stroke at the University of Florida Health in Jacksonville Florida. Participants were

Health literacy levels were measured by using the short form of Test of Functional Health Literacy in Adults (S-TOFHLA). Standard Joint Commission patient education protocols were utilized to provide patients with appropriate standardized

Statistical analyses and modeling were conducted using SAS version 9.3. Continuous variables were described by using means, standard deviations (SDs), and medians. Category variables were analyzed using Pearson χ or Fisher Exact tests, when appropriate. Univariate and multivariable analyses were used to identify factors independently associated with Stroke Patient Education Retention (SPER) score. For

Strengths for this study was the link formed between heath literacy and educational retention for stroke patients. Thus determining the need for education based on literacy levels. The limitations to this study was the lack of evidence validating the stroke patient educational outcomes, such as long-term retention and patient adherence or compliance to medical

Level 6

Low quality


rg/10.5888/pcd11.130259

in Jacksonville, Florida. A secondary intention of the study was to assess the relationship between patient demographics and other characteristics associated with the patient’s levels of health literacy and to explore their relationship to education

identified and recruited by the treating neurologist or a stroke unit nurse manager.

stroke education. The post stroke care educational outcomes and knowledge retention was assessed for each participant upon discharge through the utilization of a questionnaire that consisted of a series of 5 questions that were derived from the Joint Commission’s stroke performance measures on stroke education. The effect of health

univariate analysis, the differences in the SPER scores among the 3 S-TOFHLA groups were assessed using the nonparametric Kruskal–Wallis. For multivariate analysis, analysis of covariance (ANCOVA) was used to model the data and estimate the least squared means. Even after receiving the Joint Commission standardized recommended education, only 12% of the patients could identify all 5 warning signs for a stroke, 43% could name all of their personal risk factors, and fewer than half could identify the type of stroke they suffered. The study showed ineffective education of patients; all of which can be influenced by health

treatments. The other limitations the authors recognized was the small sample size for such a large population, to be able to detect the effect of many demographic factors on stroke occurrence.


al outcomes in ischemic stroke patients at the time of their hospital discharge.

literacy on the Stroke Patient Education Retention scores was assessed by using univariate and multivariate analyses.

literacy and knowledge retention, which was the focus of the study. The patients’ inadequate health literacy had a significantly lower stroke education retention rate than patients with marginal or adequate literacy. The analysis displayed an overwhelming connection between health literacy and stroke education outcomes.


Synthesis of Current Literature

After completing the review of literature, three major themes were found in the data.

These themes were elevating the nurse’s role in patient education, understanding the patient’s

perception of education needs in stroke patients, and the benefits and effectiveness of patient

education. The following sections will expand on the external data that was found to support

these major themes.

Elevating the Nurse’s Role in Patient Education. There have been major shifts in the

way patient education is managed during a hospital stay over the past 10 years and changes will

continue to occur. Since change is happening at a rapid rate, it is important for nursing staff to

understand their role and how it relates to patient outcomes. The literature review revealed that

nurses are not adequately prepared to provide patient education during hospitalization.

In order for nurses to provide adequate education to patients, they must feel empowered

to do so. The feeling of empowerment allows nurses to have the impression that they have

benefitted the patient while also feeling a sense of accomplishment (Aslani, Alimohammadi,

Taleghani, and Khorasani, 2016). In order for the organization to support this, the nurses must

have the resources and skills to provide sufficient patient education. If the nurses feel there are

barriers hindering their ability to provide education, the nurses can become frustrated and may

not support the initiative (Melnyk & Fineout-Overholt, 2015).

Another way for an organization to better support the empowerment of nurses is to

provide sufficient knowledge regarding patient education topics. The lack of knowledge by

nurses in understanding and providing patient education was also a common theme recognized

during the external literature review. In nursing school, nurses are prepared to manage patients

at all levels of care throughout the spectrum of life. Due to this, it is difficult to educate nurses


on the intricate details of specialty units. One study found that patients had better outcomes

when nurses had several training sessions related to disease specific education (Blauer, Frei,

Schnepp, & Spirig, 2015).

One challenge for nurses in becoming proficient at administering patient education is that

there is no one way to provide patient education because there are so many factors to consider

such as patient’s health literacy and resources (Sherman, 2016). Even within a single

organization, it can be difficult to find continuity among the different units. Based on a study by

Sherman (2015), it was found that nurses felt more confident when a consistent method of

providing patient education was used. The author recommended staff provide education using

the teach-back method while using similar patient education tools as it allows the nursing staff to

gain insight into the patient’s understanding of the education (Sherman, 2015). The teach-back

method allows the patient to explain to the educator the information that was just reviewed

(Tamura-Lis, 2013). By allowing the patient to explain the education to the nurse or other

member of the multidisciplinary team, the team member will know whether the patient fully

understands the teaching. These skills can also instill confidence in the nurse’s abilities.

When nurses feel they have confidence in their ability to teach, they can share their

knowledge with patients in larger group settings such as group visits. This concept has gained

traction in recent years and is now being offered more consistently across the healthcare

spectrum. In a study conducted by Håkanson, Sahlberg-Blom, Ternestedt, and Nyhlin (2011), it

found that patient’s “experience of the illness is most certainly influenced by his or her level of

knowledge about the disease” (p. 496). Developing a safe group setting allows patients the

confidence to discuss their experiences and knowledge which can be beneficial for all members

of the group while also having a healthcare professional guide the discussion. Another key


factor identified was the use of a multidisciplinary team approach to provide patient education

assisting in improving the patient’s ability to cope with their illness; while also improving their

understanding of symptom severity (Håkanson, et. al., 2011). Nurses can use these platforms as

a way to provide education to several patients allowing patients to teach and learn from one

another with the guidance of nurses and other multidisciplinary team members.

Stroke Patient Perception of Educational Needs. The stroke patient’s perception of

their personal educational needs becomes vitally important in their willingness to learn and retain

the material being taught to them. There are many different topics to teach stroke patients and

their caregivers in order to help increase their level of educational understanding of their disease

process. The subjects that pique the interest of different patients at different intervals of their

recovery are the subjects or information that the staff need to pay particularly close attention to.

These areas typically hold an element of fear due to the unknown; these areas of focused learning

will help ease their fears and enhance their learning.

The overall findings from the external data indicate that education for stroke patients is

nothing short of lacking. Patients relay their dissatisfaction with the education they received and

deemed many specific topics as being very important to know and understand about their stroke

diagnosis. “Stroke patients often express a lack of understanding about the nature of their illness,

treatment, and recovery, and they perceive information from healthcare professionals to be

inadequate and too complicated” (Choi-Kwon, Lee, Park, Kwon, Ahn, & Kim, 2005, p. 86). This

lack of understanding regarding their disease process leads to many thought provoking questions.

Gaining the “answers to such questions and educating newly diagnosed stroke patients about

stroke-related information that is presumed to be important to them to learn is vital in the

prevention of further illness and complications after a stroke as well as in the recovery phase”


(Yonaty & Kitchie, 2012, p. E1).

Choi-Kwon, et. al., (2005) developed a questionnaire that has been utilized in many

studies to determine what stroke patients want to learn about or what they find as an important

topic to learn about and understand. Two of the studies that cited the utilization of this

questionnaire, incorporated several of the domains listed on the original questionnaire. These

domains included but not limited to: medical knowledge, risk factors, treatments with

medication, treatment with surgery, treatment with herbal or alternative medicine, rehabilitation,

dietary habits, and other topics such as ability to think, talk, work, drive, and understand (Yonaty

& Kitchie, 2012). These domains were listed in congruence with several subcategories listed

under each domain. The domains were then worked into the two studies to determine what

patients thought were the most important domains to learn about for them personally. In the

Yonaty & Kitchie, (2012) study, medical knowledge and medication treatment were rated the

most important to learn; dietary needs and treatments with herbal or alternative medicine were

considered the least important to learn. In the study by Sowtali & Harith, (2014), educational

needs highlighted that stroke patients were more interested to know about prevention, causes and

risk factors of strokes, than any other domains listed on the questionnaire. The essential need for

further education continues to be of the utmost importance stroke patients and their families.

Educational needs and enhanced understanding of strokes and stroke care, can be deemed a

necessity as evidenced by the external supportive data for further education.

Benefits & Effectiveness of Education. In a world where the hospital length of stay

seems to be getting shorter by the day, educating patients beginning upon their admission

becomes a necessity. The elements of knowledge and understanding are essential for patients to

feel comfortable and confident recovering at home. There are many fundamentals of education


that benefit the patients, especially those patients with a recent stroke diagnosis.

The benefits to stroke education can be life changing if the education given is effective

and memorable. In order for stroke education to be beneficial or effective, there must be a great

deal of attention placed on individualizing the approach necessary to help each patient

individually. There must be consideration taken towards comprehension through the patient's’

health literacy, as well as any residual deficits that could inhibit understanding and retention of

materials being taught. The health care professionals must pay close attention to the efficacy of

their teaching styles and if the patient is benefiting from the educational sessions. Often times an

alternative method of teaching would need to be utilized in order to ensure the patient and their

caregiver is receiving effective education providing the fundamental foundation assisting in their

post-discharge care.

There are multiple barriers to the benefits and effectiveness of educating a patient and

their families; health literacy positions itself at the top of the list. Health literacy is a major

barrier that hampers the ability of stroke patients to reduce their risk of strokes by the inability

“to obtain, process, and understand health information and services needed to promote better

health” (Sanders, Schnepel, Smotherman, Livingood, Dodani, Antonios, Silliman, 2014, p.2). In

patients with a lower health literacy understanding, they are less likely to understand their

medical condition, comply with recommended treatments, or reduce the modifiable risk factors

associated with stroke recurrence, thus making their stroke education ineffective and not

extremely beneficial.

Ineffective educational experiences need an approach that would modify the material in

order to accommodate differences in literacy and understanding. “Developing approaches to

education that adjust to the individual circumstance of each patient are likely to be needed, given


the variation in patient being served” (Sanders et al., 2014, p.5). In order to improve the efficacy

and understanding to all ranges of health literacy, the external data shows a need for

modifications in the educational delivery that focus on the patient's overall understanding on a

personalized level.

Educational materials that are difficult to understand or that are not very effective can

create a communication barrier between the patients, caregivers, and their healthcare providers.

Despite providing the stroke education materials to the patients and caregivers, these materials

are often not actually utilized by the patients if there is not comprehensive information regarding

care for their current state, as well as care that will be needed throughout their recovery. “While

presenting information just prior to discharge may be a practical time for stroke care providers to

educate caregivers and patients, there are studies that demonstrate patients need information

pertaining to care after discharge” (Ing, Linton, Vento, & Nakagawa, 2015). The lack of

comprehensive education can lead to anxiety, unanswered questions, and ineffective education to

the patients and their families.

Similar to other areas of chronic illnesses, educational needs change over time during the

illnesses, and the optimal timing and mechanism of effective delivery of stroke education needs

to be further considered; especially since occasionally stroke patients cannot remember the

hospitalization or education at all (Ing, Linton, Vento, & Nakagawa, 2015). In order to facilitate

beneficial and effective education, the patient’s education must begin upon their admission, and

often times there is a need for repeating the material throughout their hospital stay to ensure

understanding. The external data shows that the efficacy of the education provided to stroke

patients and their family’s needs to be refined. Healthcare organizations and stroke teams have a

great need to perfect their educational materials and delivery methods, in order to capture this


powerful moment to provide an all-inclusive education to their patients and caregivers.

Organizational Recommendations

As the external data provides supportive documentation, the internal data from Research

Medical Center provides an exclusive insight suggesting a great need for refining education

provided to patients during an acute hospitalization (see table 7). Moreso, the preparation for

home beyond the hospital, after a life-altering experience, is proving to be inadequate. Thus

stating, patients and families are ill prepared to provide care for themselves, or a loved one, once

they are discharged from the acute care facility.

For Research Medical Center, this had become visibly evident with an increase of

hospital readmissions, and a verbalized discomfort from patients in regards to their provided

education. Therefore, the University of Mary’s Stroke Project team in collaboration with the

Stroke Program at Research Medical Center recommended to refinement of the education

provided to patients suffering from a stroke diagnosis, starting with the design and

implementation of a formal structured stroke support and weekly educational class for all

inpatients. The next recommendation was to provide the nursing staff, along with

multidisciplinary team members, the skills and tools necessary to provide adequate education for

this vulnerable population through a re-education of cerebrovascular disease and the associated

risk factors during morning and evening huddle times. Refined education utilizing the already

implemented stroke booklet was also provided to the front-line nursing staff that incorporated an

organizational verbal teach-back method in order to evaluate patient and/or family understanding

of their specific disease process and personal risk factors.


Project Problem Identification

Internal Evidence

Table 7

Internal Data Needs

Data Need Special Considerations Source

Improved Stroke Education Patients diagnosed with cerebrovascular accident (CVA) or TIA

The Joint Commission guidelines for Comprehensive Stroke Designated Centers as identified from the Joint Commission, American Heart Association, & American Stroke Association; identified need from patient and family expert opinion.

Improved understanding of personal risk factors

Patients, as well as family members opinions affected by the diagnosis of CVA

Patient and family verbalized lack of understanding; staff recognition of improved educational materials and classes to better prepare for a more focused to chronic disease education.

Compliance with National Guidelines for Organizations Designated Comprehensive Stroke Centers

Certification for Excellence in stroke education and treatments.

The Joint Commission Guidelines; The American Heart Association; The American Stroke Association; Get with the Guidelines

Patient Satisfaction with quality and service of measures.

Analytical measurements of patient sensitive measures via patient satisfaction surveys.

Organizational patient survey report; quality department


External Evidence

A comprehensive literature review was conducted to evaluate the importance and

necessity for improved discharge education with attention to individuals suffering from a stroke.

As described throughout this paper, the evidence was consistently repeated. A common theme

throughout the comprehensive literature review revealed nurses associated a lack of

empowerment to their inability to provide appropriate and detailed education to patients. First,

providing nurses with the resources, tools, education, and skills fostering a culture of

empowerment is positively associated with organizational respect and nurse satisfaction.

Second, as change occurs rapidly, accessibility to essential resources and additional educational

materials specific to the specialty unit they are working, are vital to the personal and professional

success of the nurse (Blauer, Frei, Schnepp, & Spirig, 2015). Third, enhancing the nurses’

knowledge base empowers their ability to educate patients, elevating their ability to effectively

communicate. Providing individual patient education is only one-way nurses can provide

education. Group settings allow for patients and their families to participate in group

discussions. This form of education has the ability to enhance the patient’s coping mechanisms

and their understanding of their disease process (Håkanson, et. al., 2011). This is especially vital

for individuals suffering from the life-altering diagnosis of a stroke. There is life after stroke,

and initially this devastating diagnosis can intimidate the healing process and coping skills

necessary to participate in progressive and preventative treatments. However, during group

therapies, education, and discussion patients can converse with others affected by the same

diagnosis, and, in turn, create a supportive, safe environment assisting their healing and learning

processes. This type of environment also aids patients and family members with information for

therapies, coping skills, regimens for medication or exercise, etc. that have personally helped


themselves or others during this time.

This comprehensive literature review also revealed patient dissatisfaction with the

education and materials provided at discharge stating “the information provided was inadequate,

too complicated, and difficult to understand” (Choi-Kwon, et. al., 2005, p. 86). First, a

diagnosis, such as a stroke, is shocking to the patient and their family promoting extreme

anxiety, fear, and inability to retain provided education and information. Therefore, addressing

education must be done gently with finesse. Second, education must be repetitive to be receptive

and retained. Third, education must be provided in an atmosphere conducive to learning, and at

their health literacy level. Providing front line nursing staff, and multidisciplinary team

members, the accessibility to resources enabling their ability to provide sufficient and

exceptional education to patients and their family members fosters a positive, safe, and satisfying

atmosphere.

Internal evidence supported the recurring themes noted during the external literature

review. Nurses revealed their dissatisfaction with their accessibility to sufficient educational

resources to provide patients and their families. Time constraints were also a recurrent

verbalized dissatisfier for the front line multidisciplinary team members, as they are

overwhelmed with their task duties limiting their available time at the bedside. Further internal

evidence revealed a disruptive educational experience affecting patients and their family

members. Patient satisfaction surveys divulged an expressed dissatisfaction with their level of

comfort in providing home care once discharged directly related to their lack of education during

hospitalization. Given the organization has recently received Comprehensive Stroke designation,

refining the discharge educational process is vital to the organization’s ability to not only meet

the initial 8 stroke core measures (STK) for a primary stroke center; however, the additional 8


comprehensive stroke core measures (CSTK) as mandated by the Joint Commission (American

Heart Association, 2015). These additional 8 stroke core measures elevate the performance of

the organization illuminating the organization’s ability to provide extensive, yet exceptional care

to individuals suffering from a complex stroke diagnosis at any time. Serving as a guideline for

provisionary care for individuals suffering from the potential life-altering diagnosis of a stroke,

the additional set of 8 CSTK measures were “developed for the management of both ischemic

and hemorrhagic stroke patients in hospitals equipped with the clinical expertise, infrastructure,

and specialized neuro interventional and imaging services needed to provide the next level of

stroke care” (The Joint Commission, 2017). In essence, the 16 CSTK provide a foundational

guideline to the exceptional care provisions necessary to implement and enhance the care and

outcomes for individuals suffering from a stroke diagnosis utilizing organizational clinical

expertise and exclusive neuro interventional techniques.

Receiving the prestigious nationally recognized certification for elite status in providing

exceptional care for the most complex stroke patients is no easy feat. Therefore, on an

organizational level maintaining this elite nationally recognized certification is vital to the

organization’s success. Stroke education provided to patients and their family members is

crucial to their ability to enhance their own health wellness through essential therapies,

medication regimens, and ability to prevent recurrence. The hospital is experiencing a decrease

in satisfaction from both patients and family members, as well as nurses expressing their

unhappiness with their ability to sufficiently educate. The organization, although lower than the

national standard for preventable readmission within 30 days (Litchman, Leifheit-Limson, Jones,

Wang, & Goldstein, 2013), is also experiencing an increase in readmissions for recurrence of

stroke signs and symptoms directly relating to expressed lack of education and understanding of


their personal risk factors and disease process. Enhancing the discharge process for patients

suffering from a stroke is vital to elevate nursing and patient satisfaction scores. Therefore,

implementing a weekly stroke support and educational class for suffering patients and their

family members will decrease the potential financial impact the organization could experience by

maintaining current certification, retaining current nursing staff, and increasing patient and nurse

satisfaction.

Implementing process improvements is organizational development. However, this is not

always an easily implemented task. Although, addressing multiple avenues to enhance the

discharge process for stroke patients have been attempted, both the internal and external data

collection prove an imperative need to implement a more structured form to deliver vital patient

education and ensure patient or family understanding. The following section will detail project

recommendations developed from the internal and external data collection.

Project Recommendations

Through an expressed desire and need to enhance and refine educational opportunities

provided to patients diagnosed with an ischemic or hemorrhagic CVA, or TIA the University of

Mary’s Stroke Project team identified formalized structured classroom setting to be a principal

recommendation. A recent designation to hold the title Comprehensive Stroke Center, Research

Medical Center, along with all other Comprehensive Stroke Centers, have made the

“commitment to treat stroke patients effectively and efficiently with the goal of improving care

and outcomes” (The Joint Commission, 2014, para 2). Accomplishing comprehensive stroke

designation requires hours of dedication to ensure the organization’s stroke program is equipped

with the skills, tools, and educational materials necessary to provide care to individuals suffering

from the most complex stroke diagnosis at any time. Therefore, along with all other


organizations holding this certification, establishing a culture of enhanced quality and safety

warranting a specialized personal focus to all individuals suffering from a stroke as directed

through their guidelines meeting all specialized criteria, provide the organization foundational

basis to remain an elite designated Certified Comprehensive Stroke Center. This University of

Mary’s Stroke Project team has experienced complete support from all interdisciplinary team

members and executive leadership to initiate and implement a structured formalized educational

weekly classroom teaching.

Organizational frontline nursing staff members, for specialized stroke units, had

expressed a lack of knowledge in providing educational materials personalized to the patient and

their specific risk factors. Individuals suffering from a stroke diagnosis, also affecting their

family members, had verbalized a desire to have a more personalized approach to their health

wellness plan of care. A desire to understand their specific risk factors and ways to implement

positive healthier choices was a verbalized top priority for patients and their families. The

requests verbalized from organizational members and patients identified with a diagnosis of

CVA have influenced the University of Mary’s Stroke Project team to divulge this information to

the executive leadership team, enlisting their assistance and advice for opportunities to enhance

educational opportunities offered to both staff members and patients.

Educating Front-Line Nursing Staff. Through the review of literature there was a

significant amount of support to provide detailed education for front-line nursing staff (Blauer,

Frei, Schnepp, & Spirig, 2015). The proposed recommendation was to review the stroke booklet,

that all stroke patients receive, in detail with front line staff with a member of the University of

Mary’s Stroke Project team, the Stroke Program Coordinator, the Stroke educators, or the Stroke

Registered Nurse Navigators. This time allowed nurses the ability to ask questions that may


have arose and also provided a detailed explanation of the education and why it is important for

nursing staff to have thorough knowledge in this area. This education has also been incorporated

in orientation for all new staff members starting on the stroke units at Research Medical Center

to ensure they have detailed knowledge and understanding of stroke patient education.

The second part of the nursing education that the University of Mary’s Stroke Project

team is proposed is education related to the teach-back method. This teaching method allows

the patient to explain, in their words, the education that was just provided. This teaching method

allows the nurse to assess the comprehension and health literacy levels of the patient and re-

explain or reiterate areas the patient may not have understood (Sherman, 2015).

Structured formal weekly patient and family education. The recommendation for this

project to incorporate a structured formal weekly education dedicated to providing stroke

education to patients and their families has provided a foundation that has enhanced their overall

knowledge level. This dedicated avenue of personalized information has enable their ability to

make a more informed decision regarding personalized healthier lifestyle choices and

compliance with their current health wellness plan. Evidence identifies and supports the need for

established education for patients, a personalized approach to health wellness plans, improved

educational opportunities for specially trained stroke nurses, and an interdisciplinary team

approach for stroke victims and their families. After all, excellence in provided stroke care is

comprehensive and team based.

Throughout this literature review, evidence has proven that an enhanced avenue

providing specific education dedicated to stroke patients is imperative to their ability to make

informed health wellness decisions. Incorporating their family members into the teaching and

education provides an opportunity for enhanced retention and learning. Guided from the Joint


Commission, the American Heart Association, the American Stroke Association, and the Brain

Attack Coalition measures have been implemented for all Comprehensive Stroke Centers as a

roadmap to enhance the effectiveness, quality, and efficacy of stroke treatments. In addition to

those measures, a structured formal weekly educational opportunity has enhanced the patient’s

ability to recognize specific signs and symptoms, verbalize their personal risk factors, enhance

their overall health status through the implementation of interventional methods and

recommendations, and help create their personalized plan of care.

Project Implementation Plan

Change Theory

Change, while inevitable, is a process that must be handled with finesse and strategic

implementation to achieve the desired long-term goals of the organization. The concept of

change theory intimately relates to project implementation plans providing a road map necessary

for successful integration of obligatory changes. For this project, a comprehensive

understanding of change theory was imperative to ensure successful project implementation.

The John Hopkins Nursing Evidence-Based Practice (JHNEBP) model is a powerful tool

assisting health-care professionals in clinical decision making (The Johns Hopkins Hospital/The

Johns Hopkins University, n.d.). This model was chosen due to its simplicity and easy to follow

three step process empowering bedside nurses to safely and quickly implement processes

enhancing patient care while providing the most current evidence-based practices. Utilizing their

three-step process more commonly known as PET (practice question, evidence, and translation)

(The Johns Hopkins Hospital/The Johns Hopkins University, n.d.) the JHNEBP model helps

“bedside nurses translate evidence to clinical, administrative, and educational nursing practice”


(Melnyk & Fineout-Overholt, 2015, p. 302).

The first step of this three-step process is the collaboration from organizational team

members to identify a process or question needing further investigation. The organizational team

members describe and refine the practice in question in order to define the scope for the process

or question identifying key stakeholders (The Johns Hopkins Hospital/The Johns Hopkins

University, n.d.). Through this initial step the project leader(s) are identified and a timeline for

project implementation is developed, along with a scheduled meeting plan.

The second step entails the collection of data, both external and internal proving the need

for an improved or newly implemented process. Many factors have the ability to affect the

collection, evaluation, and integration of best evidence practices; therefore, proving to be the

most crucial step in this process, the collection of data is an integral key component to the

identification, integration, and implementation of the highest quality evidence into daily

practices enhancing patient care (Figure 1). Throughout this step, the evidence is evaluated,

depicted, and appraised detailing the strength and quality ensuring the most updated strong

evidence is utilized for process improvement. In this model, the pyramid of three steps have also

identified external and internal factors potentially affecting the implementation and integration of

process improvement (The Johns Hopkins Hospital/The John Hopkins University, n.d.).

Permission was granted to use The Johns Hopkins Nursing Evidence-Based Practice Model and

tools (Appendix A).


Figure 1. The Johns Hopkins Nursing Evidence-Based Practice Model

©The Johns Hopkins Hospital/The Johns Hopkins University.

The third and final step of this model involves translation and an organizational action

plan for implementation (Brooks-Staub, 2005). In order to translate the need for enhanced

process improvement, an organizational support system consisting of executive and primary

direct leadership team members, as well as supportive multidisciplinary team members must be

present. Ensuring the appropriate and correct interdisciplinary team members dedicated to the

refinement of the educational materials offered to stroke patients and frontline nursing staff,

consist of the Stroke Program Coordinator, Stroke Registered Nurse Navigators, direct

leadership members for the stroke units, and multidisciplinary team members to be present

empowering the change process paving the way for organizational success. Another important

aspect for this final step is to ensure the necessary resources are gathered and available. This

will ensure the action plan can be implemented according to the project designated time line.


One of the most imperative elements is project outcome measurement. This key step evaluates

the implemented project allowing for an in-depth examination of the process and allows for

restructuring, if desired, to improve or alter the projects process. The project findings are then

reported to the key stakeholders allowing for further determination if the improved or newly

initiated process provided will promote the best evidence-based practices enhancing provided

services and cares to patients.

Key stakeholders

Achieving excellence in the culture leads to excellence in service, and excellence in

service saves lives. Recently, achieving Comprehensive Stroke Designation, along with multiple

American Heart Association and American Stroke Association awards, Research Medical Center

is dedicated to augment upon the education stroke patients receive. Their mission is “above all

else we are dedicated to the care and improvement of human life” (Research Medical Center,

2017). This organization developed the stroke program devoted to maintaining and enhancing

stroke survivor’s health and wellness. Education is the key strategic element. Knowledge begets

power, and one who holds the knowledge holds the power to achieve greatness.

A multitude of essential stakeholders have been identified through this project. The

program coordinator, Sherry Bahr APRN, CNRN, remains a key stakeholder in this project. Her

support, dedication, and excitement uphold the organization’s mission and value statements;

therefore, her support brings top level organizational support. Sherry’s ability to determine the

needs of the organization provides a foundational guideline and direction for patients and staff

members. Her advanced knowledge and education for stroke patients help guide strategic

interventional methods dedicated to enhancing the education and care patients and family

members receive.


The support of Nisha Mills, MBA, Director of Neurophysiology, is crucial for her

guidance and support for funding and budget implementation. The Assistant Chief Nursing

Officer (ACNO) and Chief Nursing Officer (CNO) are imperative team members as they guide

and promote changes within the nursing practice. The Chief Executive Officer (CEO) also plays

a vital role in the promotion and advancement of the stroke program. Her top-level support and

dedication to the enhancement of the Stroke Program is essential for the implementation loyal to

the stroke population within the organization and community. The front-line staff members are

an absolute essential aspect as they promote the education, answer questions, and guide patients

and family members to the Stroke team for further education. Nursing staff providing daily

bedside care also help ensure patients receive essential therapies, medications, and treatments

necessary to maintain, enhance, and progress upon their health wellness. The certified nursing

aides (CNA’s), essential front-line staff members, are another important stakeholder as they will

be helping transport patients to the proposed weekly education.

The Neurologists are a vital key stakeholder as they guide the treatment for individuals

suffering from a stroke to ensure timely administration of life saving medications, procedures,

and testing are in correlation with The Joint Commission and Centers for Medicaid and Medicare

(CMS) guidelines. The team of neurologists ensure that the most current evidence-based

practices are promoted within the organization remaining on the cutting edge of treatment

therapies for the stroke population. They promote educational opportunities for organizational

members ensuring everyone has the ability to remain informed; while also guiding educational

information provided to patients and their family members.

The Director of Research Medical Center’s quality department provides necessary matrix

and data information regarding the stroke patients. Along with her, the quality department is


vital to the overall success and stability of the program by ensuring all essential and vital

concepts are provided the attention to detail necessary for overall program success. Their

department also provide assistance with chart audits and nursing quality compliance. This data

will help support whether the interventions that were implemented were effective in improving

patient understanding of their diagnosis and expected outcomes.

Physical, occupational, and speech therapies ensure a personalized comprehensive

evaluation is completed and their recommendations guide treatments dedicated to the safety of

the patient. Their therapy programs are imperative to build patient strength and mobility

enhancing their quality of life. These therapies also provide education to the patient and their

family regarding any new physical deficits and how to work with or overcome the loss of these

essential functions.

The educators for units housing acutely ill patients suffering from a stroke are vital to the

success of this project. They will help deliver pertinent educational information to nursing staff,

as well as ensuring a comprehensive understanding of essential tasks to be completed. These

educators will also provide one-on-one assistance for any staff member needing guidance in

performing the National Institute of Health Stroke Scale (NIHSS), or ensuring care plans are

completed properly and discharge information is completed and documented meeting the

standards guided by The Joint Commission and Centers for Medicaid and Medicare accordingly.

Patients and their families will remain the key stakeholders in this project. Ensuring they

possess a comprehensive understanding specific to their stroke, their risk factors, and their plan

of care post discharge is the ultimate goal. The patient and/or their family members play a vital

role in their personalized post-discharge treatment and care plan. A strategic planning process

along with interventional methods specific to the patient and their lifestyle is imperative to their


overall success. A complete comprehensive understanding and ability to verbally teach back

specific risk factors and how to implement lifestyle changes is crucial to a patient’s compliance.

Encouraging family participation with education, therapies, medication regimens, post discharge

planning, and support groups, etc. is essential for the patient to implement the changes and

remain dedicated to the change in order to enhance their health and wellness.

Barriers and Facilitators/ Drivers and Resistors to Change

Barriers are directly related to the internal and external factors associated with The Johns

Hopkins Hospital/The Johns Hopkins University change theory model. A multitude of barriers

exist when implementing changes in process, policies, or any aspect of life. Change, while

innately inevitable, produces a fear within individuals constructing an invisible barrier.

Therefore, understanding the factors which foster an environment that is acceptable and

conducive to change is indispensable. Inadvertently, examined traditional barriers are often

directly the source for an undesired effect for change implementation.

Barriers to change related to this project, are illuminated through The Johns Hopkins

Hospital/Johns Hopkins University change model noted by internal and external barriers (The

Johns Hopkins University/John Hopkins University, n.d.). Internal barriers for front-line staff

members include a decreased confidence in providing education to patients regarding specific

disease processes. Potential additional barriers include the nurse’s inability to appropriately

evaluate the level of understanding for the patient and their families, and an inability to locate

appropriate written educational materials dedicated to the patient’s level of understanding.

These were expressed by verbal opinion during weekly rounds for tenured employees and during

orientation classes for newly hired employees. Consistent verbal agreement was noted during a

monthly leadership meeting, as well as during administrative and stakeholder meetings for this


project.

Barriers represented through patient expression remain explicitly important, as they are

the key stakeholder for this project. Fear of the unknown and the unexpected riddle patients who

have been diagnosed with this life-altering disease process, while also affecting their family

members’ lives. An assortment of barriers are present from the beginning including the initial

mind blowing detrimental diagnosis of a CVA to the degree of resulting deficits. Patient

determination and current overall health wellness are vital barriers potentially affecting their

ability to remain compliant with their personalized plan of care post discharge.

Barriers identified during internal investigation illuminate aspects impeding successful

implementation. Organizational cultural acceptance, fear of the unknown, and potential loss or

failure are fundamental aspects needing pertinent attention. For this project, one extremely

imperative organizational barrier includes acceptance from a multitude of physician teams who

play an important part of the patient’s personalized health wellness plan of care. These teams

include Neurology, Neurosurgery, Pharmacy, Hospitalists, Internal Medicine Residents, Family

Practice Physicians, and teams of Nurse Practitioners. Constructing a timeline conducive for all

team members, including patients and their family members is essential to achieving attendance.

Acquiring a meeting room sized to incorporate an estimated group of individuals is imperative to

produce a comfortable learning environment. The resolution of said barriers has been an aspect

with direct attention from the initiation of the project. This group enlisted the aid of Sherry

Bahr, APRN, CNRN, Stroke Program Coordinator as an influential leader and mentor. The

mentorship and aid she has provided throughout the beginning phases of this project have been

exceptional. An additional behind the scenes influential leader and mentor has been the interim

Director for the acute inpatient Oncology Unit, Deborah Wooten, RN, BSN, MBA-HA. The


help she has provided to the team has been educational and exceptional. These two mentors

have been exemplary facilitators in assisting the forward movement of the team. Additionally,

many organizational leaders, including the CEO, CNO, ACNO, Director of Medical Services,

the Neurology team, Rehabilitation therapy member's, primary unit educators, and the Director’s

for the primary care units providing essential care for stroke patients have become an

indispensable asset to this project.

Reducing the resistance met from internal and external factors is crucial for organizations

as they implement change process. For this project, the driving forces of external factors include

standards to maintain Comprehensive Stroke designation from The Joint Commission. This

organization must continually evaluate opportunities for improvement and excellence when

providing stroke education to patients and family members. Additional external factors

associated with this project include utilization of current resources as a measure to reduce out-of-

pocket costs, maintain a standard of excellence in quality, and improve the facilitation of quality

metrics, core measures, and fundamental standards from front-line staff members. Improving

their ability to include the vital information delineated for quality metrics remains imperative to

not only meeting standardized guidelines, but surpassing them striving for excellence. The

Stroke team with a combined effort from the leadership team and essential interdisciplinary team

members continue to reduce and eliminate both internal and external barriers influencing the

enhancement of imperative educational opportunities for this patient population and their family

members.

Business Impact

By improving the quality of patient care through an enhanced educational program that

increases the patient's understanding regarding their individual stroke and stroke care, Research


Medical Center will help to improve patient outcomes and enhance patient satisfaction; which, in

turn, can improve the financial successes of the facility. Enhancing the quality of care provided

to the patients through an improved educational understanding can reduce hospital readmissions

and unreimbursed costs, and improve patient outcomes by providing the organization with return

customers and increased funding. By the organization linking funding and expenditure, closely

following the American Heart Association and The Joint Commission guidelines, to the quality

of the care provided, this helps in improving financial gains along with patient satisfaction.

With increased patient satisfaction scores, the organization could utilize internal and

external marketing to increase the community awareness of the advances in education that have

led to increased patient satisfaction. An institution that increases the satisfaction of its patients,

will increase the number of referrals through a word-of-mouth reputation. “Research has shown

that good service quality leads to the retention of existing customers and the attraction of new

ones, reduced costs, an enhanced corporate image, positive word-of-mouth recommendation,

and, ultimately, enhanced profitability” (Alrubaiee & Alkaa’ida, 2011, p.103). This

organization's willingness to focus on enhancing the quality of educational understanding with

their stroke patients will help the organization increase their patient satisfaction scores, moreover

enhancing the business impact through the implementation of this project.

Organization Planning Process

The implementation plan of this project upholds the standards set by the mission, vision,

and values of Research Medical Center. Research Medical Center’s mission is “above all else,

we are committed to the care and improvement of human life” (Research Medical Center, 2017).

The goal of this project is to reduce the morbidity and mortality of patients suffering from a

stroke diagnosis by better preparing nurses to meet the needs of patients and also enhance the


knowledge and understanding of the stroke disease process for patients that have recently

experienced a stroke. As Research Medical Center has continued to strive for excellence in their

ability to provide exceptional stroke care, they have received the prestigious honor of becoming

a Certified Comprehensive Stroke Center. By striving for excellence in stroke patient care,

guided by the specific guidelines dictated from the American Heart Association, the facility is

working towards their vision of the health system which is “together, we will be the premier

healthcare destination for all we serve” (Research Medical Center, 2017). This is accomplished

through integrity, compassion, respect, and excellence by all members of the multidisciplinary

team which are the values that help guide the care that is provided on a daily basis.

Implementation Plan

Guided by Research Medical Centers executive leadership team, the focus of the

University of Mary’s Stroke Project team was to focus on patient education in the stroke unit(s)

of Research Medical Center in Kansas City, Missouri which had recently achieved

Comprehensive Stroke Center Certification. The specified stroke unit is a 34-bed unit that

houses the less-critical patients suffering from a current stroke diagnosis. Research Medical

Center also has critical care units, the Intensive Care Unit (ICU) and Progressive Care Unit

(PCU), that provide care to the more critically ill patients suffering from a more extensive or

traumatic stroke, or have recently received thrombolytics. Therefore, having patients potentially

housed in multiple units, a direct need for specialized and specific disease education remained an

imperative concept. When creating the implementation plan, the University of Mary Stroke

Project team kept the PICO(T) question at the forefront guiding the discussion. The PICO(T)

question was designed to identify whether patients had enhanced knowledge of their stroke

diagnosis after receiving specialized disease specific education. The educational


recommendations to Research Medical Center has been presented in a group setting designed to

enhance the understanding of the stroke disease process. In order to make these educational

opportunities possible, the University of Mary’s Stroke Project team had earned the support of

key stakeholders within Research Medical Center.

Gaining support of key stakeholders. In order for the University of Mary’s Stroke

Project team to gain support, the project lead for the University of Mary’s Stroke Project team

openly communicated, built relationships with the front-line staff and the key stakeholders not

directly involved in the educational process. Utilizing transformational and servant leadership

skills, the project lead promoted these initiatives with passion, engagement, and strong

communication skills. The skills associated with these leadership styles assisted the project lead

in listening, empathizing, and supporting patients and nursing staff while also showing how the

importance of their actions today can shape future outcomes (Melnyk & Fineout-Overholt,

2015). These leadership styles have assisted the project lead to “develop teams, to better

collaborate, and to work cohesively” with all members of the multidisciplinary team (Roussel,

Thomas, & Harris, 2016, p. 101). Implementing these leadership styles has proved beneficial for

both the patients and team members involved in this process.

In collaboration with Sherry Bahr, APRN, CNRN, Stroke Program Coordinator, the

project lead worked diligently to gain the support of key stakeholders throughout the facility. A

main focus for meeting with the executive leadership team and key stakeholders was to promote

this phenomenal opportunity to refine the educational opportunities for patients suffering from a

stroke or presenting with signs and symptoms securing their support and expertise. The

meetings were successful as team members exuded excitement to implement a program where all

multidisciplinary team members will be educated the same way promoting a consistent


educational process for patients and their family members plagued with a stroke diagnosis. This

educational opportunity has been successful for enhancing patient education and understanding

in regards to stroke; therefore, additional opportunities for refined education for chronic diseases

would prove beneficial for the organization.

Educating Front-Line Nursing Staff. Research Medical Center has identified patient

education as an area of opportunity within the stroke program. In order to refine this process, the

Stroke Team Nurse Navigators, which is comprised of the project lead Jenni McRoy, RN, BSN,

Amy Goodson, RN, Sherri Bahr, APRN, CNRN, the team of Neurologists, and the unit stroke

educators, initiated the required weekly staff re-education of stroke patient education during the

second week of September. The second week of September was selected to help meet the needs

of Research Medical Center but also work in conjunction with the requirements of the academic

semester. Research Medical Center granted the request to require all nursing staff delivering

direct care to stroke patients to attend this education and have highly encouraged other members

of the multidisciplinary team to attend as well.

Seven days before the re-education of front-line staff, a flyer regarding the staff education

was passed through report to inform them of this elite educational opportunity (Appendix B).

The education did occur during morning and evening huddle times on each unit that house stroke

patients to ensure all front-line staff attending this education had the opportunity to attend.

During the staff education, the project lead, Sherri Bahr, APRN, CNRN, and stroke

educators have re-educated front-line staff on the stroke booklet that all patients receive at the

time of admission when diagnosed with a CVA or neurological deficits potentiating a stroke

workup. The teach-back method was used during the re-education process. By using this

teaching method, it allowed the project lead, Sherri Bahr, APRN, CNRN, and the stroke


educators to verify that the front-line staff understood the materials reviewed. The teach-back

method was also taught to members of the front-line staff so they were aware and able to use this

teaching method to improve patient knowledge and understanding of education. As time

allowed, the front-line nursing staff received the opportunity to practice using the teach-back

method on each other to improve confidence in their ability to provide specific disease

education. The project lead, Sherri Bahr, APRN, CNRN, and the stroke educators were available

to answer questions for front-line staff throughout the education and were able to answer

questions regarding the education materials.

The knowledge gained through reviewing the stroke booklet and the delivery method for

patient education was a change compared to RMC’s previous patient education process.

Previously, front-line staff were taught by other front-line staff during orientation. This resulted

in decreased staff and patient understanding as not all front-line staff are proficient at teaching

other members of the multidisciplinary team to deliver patient education or they lack the

understanding of the educational material to provide quality education. Providing this

opportunity and ensuring all new front-line staff attend this educational session in the future will

build a strong foundation and help create a more confident multidisciplinary team that will be

more adept to answer unpredictable patient questions. Additionally, executive leadership have

supported the need to incorporate this disease-specific education into the orientation for newly

hired licensed professionals on the stroke units. As support from the executive leadership team

is elevated, the chance for sustaining this beneficial education is guaranteed, especially due to the

positive outcomes from this refined educational opportunity.

Implementing a Stroke Support and Educational Class. Research Medical Center had

expressed interest to start an inpatient stroke support and educational class for patients that have


been diagnosed with a stroke or neurological deficit potentiating a stroke workup and evaluation.

Due to this, the University of Mary’s Stroke Project team worked in conjunction with Research

Medical Center’s Stroke team to design and implement a stroke support and educational class.

Patients and their families that are hospitalized at the time of the group visit will be highly

encouraged to attend by front-line staff members, and members of the multidisciplinary team.

All members of the multidisciplinary team, including all therapy groups, agreed to assist with

transporting patients to and from the stroke support and educational class. This class is held

weekly on Thursdays in the rehabilitation education and dining room on the rehab unit at 1500.

This class is led by the University of Mary’s Stroke Project team project lead and Research

Medical Center’s Stroke team.

As the stroke support and educational class began, a safe, secure environment free from

judgement, prejudice, and ridicule was established by Research Medical Center’s Stroke team

and the project lead for the University of Mary’s Stroke Project team allowed for patients and

their family members to freely express their personal experiences, opinions, and ask questions.

Once the environment was created, the project lead referred to the stroke booklet during a

PowerPoint presentation, which expanded on the written content provided to patients and family

members. The booklet addresses stroke risk factors, common side effects for stroke patients, and

also lifestyle changes that reduce the elevated risk of patients experiencing additional strokes in

the future. The stroke support and educational class was taught using the teach-back method and

encouraged patient and family participation in the visit. This allowed the organization’s Stroke

team to evaluate the effectiveness of the education. Questions that had been asked throughout

the stroke support and educational class were collected to ensure the information is incorporated

into future stroke support and educational classes.


Another factor incorporated was having stroke survivors, that participate in the already

implemented outpatient stroke support group, attend the inpatient stroke support and educational

class. This allowed the stroke survivor to expand on their daily struggles sharing their

experience of living life after a stroke. The hope was that the patients and families would

develop a connection with the stroke survivor and find benefit in attending the inpatient class

which increased the likelihood of patients attending the monthly outpatient stroke support group

meeting. Patients did find value in this group session and RMC was able to see positive results

related to this education; therefore, the likelihood of sustaining this group education was high.

Implementing additional education for front-line staff and the stroke support and

educational class assisted Research Medical Center to meet some of the stroke core measures set

by the Joint Commission. These core measures have been established to help guide the care for

patients hospitalized for a stroke or neurological deficit potentiating a stroke workup. Two of the

core measures this EBP project has assisted Research Medical Center to reach included

education addressing risk factors for stroke along with education that addressed the warning

signs and symptoms of stroke (The Joint Commission, 2017). In these measures set forth by the

Joint Commission no specific benchmark has been established. The goal is to continue to see

growth and organizational improvement in these areas along with the rest of the core stroke

measures.

Financial Insight. A majority of this project is focused on education; therefore, the fiscal

impact to RMC is very minimal. Resources that will need to be included is cost for nursing staff

to attend, and the cost of the Stroke Teams Nurse Navigators and Sherri Bahr, APRN, CNRN, to

provide the education. Stroke booklets are already being produced in large quantities as they are

handed out to all patients diagnosed with a stroke. Patients are encouraged to bring their stroke


booklet, personalized with their specific information, to be reviewed during the stroke support

and education class. Additionally, the PowerPoint presentation slides, based off the stroke

booklet, are printed off and provided to each patient and family attending to provide for

additional space for note taking and questions. This particular handout also provides the patient

and/or family with a more in-depth disease specific education, while also proactively answering

questions and stating facts that might otherwise be overlooked.

Project Measurement Plan

Refining processes enhancing the care provided to patients is not only important;

however, vital to their morbidity and mortality. Discharge education is crucial to patient

preparation for home beyond the hospital. Empowering the patient with all necessary education

and materials promote an ability to make well educated, informed decisions regarding their

health wellness. Incorporating the baseline metrics revealed through the internal data review,

project measurements were identified utilizing the mnemonic acronym S.M.A.R.T (specific,

measurable, attainable, realistic, and time-limited). Researching, designing, and implementing

an organizational wide one-hour weekly education program providing essential stroke

information for patients, family members, and caregivers to better prepare them for life after a

stroke has been implemented within Research Medical Center. This weekly class supports

Research Medical Center’s mission, vision, and values statements of “above all else we are

committed to the care and improvement of human life” (RMC, 2017). Research Medical

Center’s vision “together, we will be the premier healthcare destination for all we serve” was

illuminated through increased education provided to the stroke population (RMC, 2017).

Measuring the Efficacy of the Stroke Support and Educational Class. A pre-

education and post-education formative questionnaire (Appendix C & Appendix D) was


completed which evaluated the level of understanding for patients, families, and caregivers

regarding patient personal risk factors, signs and symptoms of stroke, and types of strokes for

patients and family members who attended the weekly structured formalized educational class.

In doing so, RMC’s Stroke RN Navigators evaluated the effectiveness and efficacy of education

provided during the stroke support and educational class. These surveys were completed at the

beginning and end of each stroke support and educational class. The pre-educational survey and

post-educational formative questionnaire were collected at the end of each weekly class and

evaluated by the Stroke team. The data results were reported to the Stroke Program Coordinator

for an intricate overview for necessary changes and potential restructuring of the education

provided during the weekly sessions. Research Medical Center’s Stroke team was solely

responsible for the collection of data. For the purpose of the academic semester, the data from

these surveys was gathered for ten weeks.

The weekly structured and formalized stroke support and education class was held in the

rehabilitation unit on Thursdays at 1500. This set time accommodated the patient’s daily

therapies, treatments, and medication regimens while positively accommodating the Stroke

Program Coordinator’s schedule, the Stroke RN Navigator’s schedule, and the rehabilitation

unit’s free time. The rehabilitation unit’s dining room houses approximately 35 individuals

which allowed for sufficient room for the estimated amount of 5-25 individuals weekly. Flyers

were posted promoting the weekly class to all staff members, providers, family members, and

patients (Appendix E). Physician providers were educated during their monthly meetings with

the Medical Director, as well as through the hospital organization email system. Incorporating

Social Workers and Case Managers assistance, support, and guidance through the discharge

process for patients and families suffering from a stroke is imperative to their recovery process.


As described in an earlier section, the University of Mary’s Stroke Project team gained the

unconditional support of Research Medical Center’s executive and nursing leadership team

members.

This class has helped provide relevant, realistic, and essential stroke education for

patients suffering from a stroke diagnosis with personalized information guided by their specific

diagnosis. This class has enhanced Research Medical Center’s culture of service commitment,

through a refined educational opportunity for stroke patients. Providing essential information

necessary to reduce the morbidity and mortality enhancing the health wellness of the stroke

population. The goal for this class was to ensure that patients, families, and caregivers have a

comprehensive understanding of their specific type of stroke, personal risk factors, and how to

implement healthier lifestyles.

The time frame suitable for implementation of this structured class was the second week

of September 2017. This allowed for the educational materials to be built and perfected before

initiation. This date also allowed for a sufficient amount of time to ensure all staff members,

including the primary physicians managing care for the stroke patient, were educated regarding

this educational opportunity. Flyers were prepared for promotion of this newly structured

formalized stroke support and education class that were strategically placed within waiting

rooms and acute inpatient units so that family members and patients can read them during their

visits (Appendix E). Building upon this designated time frame provided the Stroke Program

Coordinator the ability to promote this educational opportunity to members of the Stroke Support

Group so they had the opportunity to attend not only the ribbon cutting open house; however, to

also attend the first class which helped to provide a safe, supportive environment for newly

diagnosed stroke patients and their family members.


Measuring the Efficacy of Front-Line Nursing Staff Education. The education that

was provided to nursing staff and other members of the multidisciplinary team was vital to the

success of this EBP intervention. The method that was selected to measure the efficacy of this

training was through a routine post education survey (Appendix F). The questions in this survey

are open ended to encourage members of the team to provide feedback, whether it is positive or

it identifies an area of opportunity. This feedback allowed the group to evaluate the success of

the education and the method of teaching. With this feedback, the University of Mary’s Stroke

Project team and Research Medical Centers Stroke Program team were able to make changes

based on the feedback from the multidisciplinary team to refine the education and make it more

effective for the team.

Measuring the Efficacy of Patient Education. Through routine post-discharge calls, the

effectiveness and efficacy of the education provided to the patient and family members during

this weekly stroke support and educational class has been evaluated. Research Medical Centers

Stroke team have developed a post-call evaluation and satisfaction tool utilized during an already

implemented process of routine discharge calls. An additional metric measurement has included

the addition of supplementary questions on the previously mailed out post-hospitalization patient

satisfaction surveys. These added questions do include specific information regarding the

patient’s hospitalization and the reason for admission, i.e. stroke. If they mark yes, they are

prompted to answer an extra three to five questions illuminating their satisfaction on provided

care, treatments, and education.

Human Subject Protection Statement

The purpose for this EBP project presented by the University of Mary’s Stroke Project

Team was to refine the education provided to patients, during hospitalization, suffering from a


CVA. The University of Mary’s Stroke Project Team had the opportunity to work in

collaboration with RMC leaders to implement EBP interventions such as a formal, organized,

and structured stroke support and educational class, as well as nurse led teach-back patient

education. By understanding risk factors, disease process, and alternative implementation

methods, it is hoped that patients incorporate preventative techniques into their lifestyle to reduce

their likelihood of experiencing additional CVAs in their lifetime.

When implementing an EBP project, the individuals involved in the implementation

process can become highly involved in the presentation and outcomes. This can make it difficult

for members of the team to remain objective which could compromise the rights and care of the

patient inadvertently (Polit & Beck, 2012). In order to protect patient rights during these times,

many organizations have created an Institutional Review Board (IRB).

“The duty of the IRB is to ensure that the proposed plans meet federal requirements for

ethical research” (Polit & Beck, 2012, p. 166). The IRB process has a purpose of ensuring that in

fact an EBP project has a purpose for involving human participants in their data collection;

effectively ensuring that the project will gain some form of scientific data that is deemed

valuable. The IRB approval method essentially lets the writers know if they have violated any

rights, regulations, or laws in the process of initiating this research paper or evidence-based

project. Protection of the patients is the ultimate goal of the IRB approval process.

In order to protect the rights of the participants during the implementation phase of this

project, an IRB application was submitted and approved through the University of Mary’s IRB

approval process (Appendix G). Research Medical Center did not require this project to submit

an application to the facilities IRB since this is an EBP project. Ultimately, the University of

Mary’s IRB approval helped to detect any unintentional circumstances that may have been


missed in regards to the protection of the patients.

Implementation and Measurement

Implementation

During the second week of September Research Medical Center’s stroke team initiated

the nurse education regarding the teach-back method for all units housing patients suffering from

a Stroke diagnosis or neurological deficit potentiating a stroke workup. Over the next week, the

Stroke RN navigators along with the Stroke educators and Stroke program coordinator, attended

morning and evening huddles to provide intimate education for the nurse performing the teach

back method. Additionally, nurses were evaluated during their performance utilizing this key

tool with the patient and family members. Constructive feedback was performed after each

evaluation providing nurses an ability to ask questions to enhance their ability to provide explicit

education and resources personalized for the patient’s specific situation. During this time, the

Medical Director for the Neurosciences department educated the primary care teams providing

comprehensive care for the acute hospitalized patients with a stroke diagnosis or stroke workup.

This education was provided through email, direct conversation, and daily and monthly

conference meetings.

After the nurse education had been provided, the implementation of the stroke support

and education class began. A PowerPoint presentation was designed and developed to present

specific information regarding what a stroke is, the different types of strokes, implementation

measures, risk factors that can and cannot be modified, and what to expect after a stroke

physically, emotionally, and mentally. Additionally, our expert Clinical Rehab Specialist

attended the weekly class to provide information on the different types of rehabilitation available


post the acute diagnosis. Upon arrival to the class, patients and family members attending were

asked to complete a pre-survey in order to gain insight on their knowledge prior of strokes

(Appendix C). Once this is completed, the PowerPoint presentation begins. Patient’s and family

members are encouraged to ask questions or present self-stories during any part of the

presentation. After the presentation was given, all questions are answered, and stories were

shared, the post-education informative questionnaire was given evaluating the effectiveness of

the class and education provided. Additionally, an area for comments regarding their thoughts of

the class, the education provided, and what can be done to better improve the class was provided.

Responses help restructure and reformat the education provided to ensure a comprehensive

approach was provided for this disease specific stroke information.

Initially, the Stroke RN navigators were ensuring that all patients, charge nurses, and

primary nurses were rounded on each Thursday as an additional measure to promote class

attendance. As this promoted compliance and attendance, it soon proved difficult to get to all the

primary nurses on the day of the class due to increased census and different obligations, and as

such, attendance began to suffer. Alternative methods to promote attendance and compliance for

this crucial information provided in the weekly offered stroke support and education class were

discussed and implemented. These included announcing every Thursday at the morning bed

huddle meeting which charge nurses, managers, and directors attend that the class was being held

that day with the time and location, along with an overhead page from the operators one hour

prior to the class start time. Additionally, a professional and educational email was sent to all

managers, directors, and leadership executives stressing the importance of this class as a part of

the patient’s treatment plan to highlight our recent Comprehensive Stroke designation. The class

following these alternative implementation methods drastically improved for patient, family


member, and staff attendance. As such, these additional measures have become a permanent

addition to the promotion and success for this class.

Initially, the educating for new hires and orientees was to be completed during their

orientation period on their designated unit. However, once this was discussed and thought about

it became evident there was a better way to ensure all new hires are educated with this vital

information. Therefore, an additional measure the Stroke team has incorporated includes

attending bi-weekly orientation groups and educating the new hires on the importance of

utilizing the teach-back method when providing disease specific education. During this time,

education for the newly implemented stroke support and education class is provided stressing the

importance for attendance as part of the patient’s treatment plan diagnosed with stroke or stroke

workup. Moreso, this opportunity allowed for direct questions from newly onboarded staff

members.

Measurement

Prior to the implementation of this class, there was not a measurable method in place to

evaluate patient satisfaction for provided education. However, it was estimated, from routine

post-discharge calls and patient and family rounding, that approximately 90% were dissatisfied

with the disease specific education received. In fact, their dissatisfaction ranked so high, it

potentiated a comprehensive dissatisfaction for their entire stay. The patient's verbalized phrases

such as “I was not prepared to care for myself when I got home” and “I had so many questions

and was scared to even come home”. When asked about their ability to re-state the meaning for

the acronym F.A.S.T. they were not able to; therefore, additional education was provided over

the phone to ensure a basic understanding. Therefore, in order to keep track of attendance and

results from the pre and post-education questionnaires, an excel spreadsheet was created and


specifically designed to house the information collected weekly.

Initially, the first week of attendance brought two patients and three family members.

This correlated with the patient’s ability to attend and sit through the hour-long class and family

member presence during hospitalization. Table 8 below presents realistic attendance the

subsequent weeks:

Table 8: Attendance vs Stroke Census for weeks 1-10

During the initial meet and greet for each class, patients, family members, and caregivers were

asked to complete a pre-survey questionnaire to evaluate their understanding of strokes, risk

factors, and signs and symptoms. They were all encouraged to answer each of the six questions

to the best of their ability, as there is no right or wrong answer. Once this was completed, the

questionnaires were gathered and placed in a folder to be evaluated after the class. At this time,

the PowerPoint presentation began, during which it was paused for questions and concerns.


After the presentation, a post class questionnaire was completed asking the same initial six

questions along with asking for an explanation of what benefits they received from this intimate

disease specific education, as well as what can be improved on the class. Table 9 below

represents the statistical graph proving that this formalized and structured classroom experience

provided an intimate atmosphere for further understanding regarding stroke disease specifics;

while enhancing the patient, family, and caregiver’s ability to make a more informed decision

regarding their post-discharge care.

Table 9: Pre and Post survey questionnaire results

Additionally, patients have expressed gratitude, a deeper and enhanced knowledge base, a sense

of community, and excitement for the educational materials and insight provided through written

comments and verbal conversations.


During the week prior to the implementation of the class, nurse, staff, and physician

education was implemented and successful. Physician education was done through the

organizational email system, one-on-one conversations, and daily and weekly physician

conferences. Although, there have been some minor slip-up’s, the education has proved

beneficial overall. Both physician admission and discharge orders are being completed to reflect

a stroke admission workup or a stroke discharge. As each patient admitted for a neurological

deficit or stroke workup is followed by RMC’s Stroke team until either ruled out with the

definitive MRI or physician documentation stating the patient no longer requires a stroke

workup, necessary continued education was provided when a potential fall-out has been noticed

during chart audits. This allowed for real-time education and reflection, while also revising the

inconsistent documentation. In fact, physicians were much more aware of successful

documentation than ever before, and have reached out to our Stroke Program Coordinator,

Sherry Bahr, APRN, CNRN, as well as, both the Stroke RN Navigators for assistance and

clarification. This allowed for an enhanced collaborative working environment.

The nurse education was extremely successful. After review of the nurse education

survey, it was noted that 100% of nurses felt the education provided regarding the nurse-patient

teach-back method and tool was an imperative aspect to evaluate patient and family member

understanding of the provided education. Moreso, it allowed for nurses and therapeutic

disciplines to devise alternative methods for educational opportunities based off patient and

family needs. In essence, the teach-back education tool provided verbalized opportunities to

format a more personalized plan of care, disease specific education, and post-discharge teaching

catered to expressed patient needs and desires. This specifically has created an atmosphere

where nurses “feel” they are helping the patient. Additionally, the nurses have expressed


feelings of empowerment and self-confidence through the use of and education for the nurse-

patient teach-back tool. One of the comments by a bedside stroke nurse was the fact they now

have a face-to-face method to evaluate patient understanding, and; therefore, can provide

additional education, contact the physician or other disciplines for assistance in providing the

education the patient needs to enhance their overall health wellness and transition to post-

discharge therapies and treatment. Providing the knowledge, tools, and skill set to the bedside

nurses and multidisciplinary team members have proved successful through an increase in

patient satisfaction scores and a verbalized desire to remain at RMC while continuing to grow

professionally.

Through the implementation of the stroke support and education class, as well as the

nurse, staff, and physician education, there was a multitude of exposed positive factors. As

expected, there has also been a few minor alterations to the original implementation plan. Due to

an increased census, additional job requirements, and an inability to physically round on each

patient and nurse, the University of Mary Stroke Project team’s lead and clinical liaison added

minute additions. These additions included seeking approval for an overhead announcement to

be made each Thursday at 14:00 to remind staff, patients, and family members the class would

be beginning in one hour and to make their way to the 5th floor Rehab West dining room. This

approval was granted and takes place each week. Through verbalized feedback, directors,

managers, and staff members are grateful for this overhead reminder, as they can become tied up

with other tasks and lose track of time. Another measure was to announce every Thursday

during the bed huddle meetings that the class would be taking place that day, time, and place.

Through verbalized feedback, this too has proved to remind managers, directors, and charge

nurses that it is Thursday and they need to remind their direct patient care staff providing care for


the stroke patients of such. Additionally, a flyer (Appendix E) has now permanently been placed

in the stroke booklets provided to each patient at admission. This new implementation has

recently taken place and currently there has not been any staff feedback. However, the RMC

Stroke team foresees this as an additional opportunity to promote the stroke support and

education class, while minimizing the potential for the Stroke RN Navigators to formally request

the patient and family’s attendance at the class. As the patient is admitted and provided a

complimentary stroke booklet, the primary nurse educates and provides the strategically placed

flyer to the patient and family.

As with any change process, strengths and weakness are illuminated and potential

obstacles that need to be overcome are identified in order to promote a successful change.

Identified through the implementation of the stroke support and education class, as well as,

refining the educational materials provided to the patient and family, many strengths are

highlighted. The two superior strengths include the enhanced understanding the patient and

family members have verbalized, and the self-confidence and empowerment nurses have

verbalized. These two strengths alone create an atmosphere of positivity, self-confidence,

happiness, and empowerment where nurses know they are providing excellent, beneficial care,

and education to the patient ultimately enhancing the patient’s overall health wellness and

success once discharged home. This aspect is crucial for nurse retention and loyalty for any

healthcare organization.

As with the strengths, weaknesses too are illuminated. The weaknesses with the

implementation of this University of Mary graduate EBP project have been easily overcome with

additional reminders put in place, as well as, assurance that someone from RMC’s stroke team is

always accessible for questions or concerns. Moreso, the weaknesses have been strongly


overpowered by the strengths of this EBP project. This project has enlightened, enhanced, and

rejuvenated RMC’s core nursing team that despite one’s job title, all disciplines are there to

elevate the patient experience while providing the necessary needs for the patient with the same

common goal in place: the enhanced overall health wellness of our patient. Additionally,

through the refinement of educational materials for this life-altering disease process, stroke

readmissions have decreased by 2%. In fact, through routine rounding for patients suffering a

stroke diagnosis within the last 30 days, their readmission has been related to additional

comorbidities and disease process other than stroke.

Through the implementation of this EBP project, considerations for additional refined

disease specific education have been discussed. Moreso, through the review and outstanding

success for this EBP project, RMC is discussing additional positions for disease specific

education, i.e. STEMI RN Navigator, Infectious Disease RN Navigator, etc. Additionally, the

implementation of this EBP project have increased patient and nurse satisfaction scores, along

with an enhanced community reputation. Individuals seeking care at RMC have posted positive

feedback on national social media websites. Moreso, patients and family members are being

discharged with an enhanced knowledge base for how to implement interventions conducive to

improving their overall health wellness, as well as a sense of community. They are also

discharged with the confidence to recognize signs and symptoms of a stroke, when to call 9-1-1,

the realization they can provide care for themselves, and that there is hope and life after a stroke.

Patients and family members are being provided with the phone numbers of the Stroke RN

Navigators so that any question does not go unanswered. The sense of community, or that they

are not alone, is something that cannot be taught or educated, only felt. Therefore, the fact

patients and family members are verbalizing these once concerns they are no longer riddled by


prove the imperativeness, effectiveness, and efficacy for refined and enhanced disease specific

educational materials provided during acute hospitalization.

Handoff

The handoff of a project to the organization where it is implemented is a very important

stage in the projects future operational success. A well organized, efficient, and effective handoff

of information, practices, changes, and successes will help ensure the success and sustainability

of the project's future. At Research Medical Center, this project will be handed over to the

Stroke RN Navigator, Amy Ludwig and the Stroke Program Coordinator, Sherry Bahr, APRN,

CNRN.

The Stroke RN Navigator is working with the University of Mary’s Stroke Project team

project liaison to facilitate a smooth transition. The Stroke RN Navigator will be taking over the

very essence of the project by learning the educational material, reviewing the PowerPoint

presentation and educational notes, and visiting the classes to become more acquainted with the

teaching information. There will be a review of the project's current data, introductions to key

stakeholders of the project, and discussions on what did and did not work well with the project

implementation project. There will be a three-week transition and orientation period for the new

Stroke RN Navigator in order to facilitate a successful transition. The Stroke RN Navigator will

ultimately begin teaching the classes with the University of Mary’s Stroke Project team member

as their preceptor and eventually taking over the class and the project in its entirety. The

University of Mary’s Stroke Project team will remain available to the Research Medical Center

and the Stroke RN Navigator for any future questions or concerns.


Conclusion

In conclusion, designing and implementing a structured and formalized educational class

providing information on a specific disease process requires commitment from the organization

at all positions and managerial hierarchy. Executive leadership members must find merit in the

program in order to provide their direct support. Acute direct supervisors and leadership

members need to find value in the educational program ensuring adequate resources are

available, as well as individual and team mentoring ensuring all front-line team members possess

a comprehensive understanding of the programs exclusive goal and intent. The Stroke Program’s

team members must also find merit and value in the program to bestow their supportive

measures. Stroke leaders, while lending their support, must assist in providing an excitement

within their co-workers about the program and the exceptional opportunity it provides patients

and family members.

Beginning at admission, the Stroke booklets will continue to be provided to the patient

and their family member(s). The admission nurse will provide education regarding the details of

the workbook and ask the patient, if able, and family member(s) to familiarize themselves

directing them to write down any questions or concerns in the allotted section. This booklet will

contain a flyer, inside the left pocket, inviting the patient and family to the stroke support and

education class offered every Thursday at 1500. Primary nurses providing daily care to the

patient will assist the patient and family to enter their pertinent lab values, vital signs, current and

home medications, as well as patient centered goals, and answer any questions. Promoting the

weekly class will also be done through all multidisciplinary team members, including the Stroke

team. As close to admission as possible, the Stroke RN Navigators will visit the patient

answering any questions or concerns providing personalized education. The Stroke RN


Navigators will educate the patient and family about the stroke support and education class held

weekly encouraging their attendance.

Conversely, CVA’s affect thousands of patients per year in the United States and

worldwide. Strokes, unfortunately, will continue to be the number one cause of disability each

year unless patients become more knowledgeable about their personal risk factors and ways to

implement changes. The external evidence-based literature review, along with the internal

organizational need, suggests an innovative form of quality education that is both beneficial and

will effectively address patient’s personal and specific needs. The group project presented,

throughout this paper, displays an intriguing detailed plan implementing preventative technique

to reduce the ineffective education patients were receiving, by providing improved educational

opportunities that enhanced the patient’s understanding of their personal disease process.

A diagnosis of a stroke is not only a shocking, but frightening experience for patients and

their families; therefore, providing educational information that assists patients, family members,

and their caregivers in enhancing their understanding regarding their personal risks, needs, and

care will help to alleviate those feelings of uncertainty and fear. Implementing an educational

opportunity in a safe environment that provides a personalized approach to the patients and their

family members has promoted a cohesive learning environment. This presented opportunity has

not only enhanced the knowledge level of the patient and family; it has promoted and

encouraged healthier lifestyle choices potentially extending the longevity of their life.

Often times it is difficult to know the individual needs of patients; however, when nurses

are adequately prepared to provide quality patient education they are able to individualize and

personalize educational materials meeting the needs of the patients. The utilization of group

support and educational classes can be implemented to assist patients in boosting knowledge of


their disease process through group discussions. This setting allows patients to learn from

multidisciplinary team members while also providing an opportunity for patients to share their

personal experiences learning from each other. Group support and educational classes foster an

environment of comfort and safety for patients, family members, and caregivers knowing that

they are not the only one experiencing tragedy in relation to a stroke disease process.

Implementing these interventions provided by the University of Mary’s Stroke Project

team, has made patients more knowledgeable about their disease process so they are less likely to

experience negative outcomes and less uncertainty related to their stroke diagnosis. The

University of Mary’s Stroke Project team has developed a handoff plan so RMC can continue on

with the implementation of these interventions with excitement and positivity in the fact this

project will improve the lives of individuals and their family members suffering from this

devastating, life-altering diagnosis.


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Appendix A

Permission Granting the Use of Johns Hopkins Nursing Evidence-Based Practice Model

“We are happy to give you permission to use the model and tools as you described. The zipped

file of the tools are located here -

http://www.hopkinsmedicine.org/institute_nursing/_docs/Model_and_Tools_2013.zip

If you choose to use the Johns Hopkins Nursing Evidence-Based Practice Model and Tools in

any other way, please submit another request for that specific use. You may not modify the

model or the tools. All reference to source forms should include “©The Johns Hopkins

Hospital/The Johns Hopkins University.” Please note, this permission does not include any

commercial use.”

Kim Bissett

Evidence-Based Practice Coordinator

Institute for Johns Hopkins Nursing


Appendix B

Flyer for Huddle

Great Educational Opportunity!● Who: All nursing staff and members of the

multidisciplinary teams● What: Education on stroke booklet and how to

provide patient education using the teach-back method

● Where: Unit huddle locations● When: Unit huddle times● Why: So, nursing staff and members of the

multidisciplinary team can gain more confidence in their abilities to understand and educate on the stroke booklet and learn how to provide patient education using the teach-back method.


Appendix C

Pre-Education Informative Questionnaire for Patients, Families, & Caregivers


Appendix D

Post-Education Informative Questionnaire for Patients, Families, & Caregivers


Appendix E

Stroke Education Course Flyer


Appendix F

Education Feedback

Nurse Education Feedback

1. Was this educational opportunity helpful?Yes______ No______

2. What did you learn that you felt was beneficial?__________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. What area of education could be improved?__________________________________________________________________________________________________________________________________________________________________________________________________________________

Appendix G


Institutional Review Board (IRB) Application


Appendix H

IRB Approval

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