Digital Repository Masters Projects Spring 2023 Improving Satisfaction Among Colonoscopy Patients Sandi Wood Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Wood, S. 2023. Improving satisfaction among colonoscopy patients. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Improving Satisfaction Among Colonoscopy Patients Project Title by Sandi Wood Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 3/28/2023 Date Sandi Wood, RN, BSN, MSN Student 3/28/2023 Student Name, Credentials Date (electronic signature) Tressa Quayle, PhD, RN 4/21/23 MSN Project Faculty Date (electronic signature) 05/25/2023 Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Date 1 Improving Satisfaction Among Colonoscopy Patients Sandi Wood, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract It is widely understood that medical procedures cause people to feel anxious. Unfamiliar surroundings, the potential for pain or discomfort, and a lack of understanding about procedures contribute to pre-procedure anxiety. Patient anxiety is especially problematic for colorectal cancer screening as it has been shown to reduce compliance with colonoscopy screening programs. In addition to deterring screening compliance, research shows that procedure-related anxiety negatively impacts patient satisfaction scores. This is significant as satisfaction scores determine reimbursement from federal health insurance agencies, directly impacting wages, organizational budgets, and quality of care. To increase compliance and improve satisfaction scores, the Cedar City Hospital endoscopy department endeavors to combine video-based patient education with verbal and written techniques. Implementing a patient education video will help patients see what they can expect from the care team and better understand the procedure and recovery details. A patient education video is a cost-effective way of improving the patient experience that can be easily integrated into patient care. Enhancing pre-procedure education has the potential to decrease patient anxiety, thereby improving future screening compliance and patient satisfaction scores. Keywords: colorectal cancer screening, patient satisfaction, procedure-related anxiety, patient education, multimodal education, education videos 3 Introduction Colorectal cancer is the third most common cancer diagnosed in the United States and the second highest cause of cancer deaths in men and women combined. According to the American Cancer Society (2022), there will be more than 150,000 new cases of colorectal cancer in the United States in 2022, and it is estimated that more than 52,000 people are expected to die from colorectal cancer in 2022. Despite these alarming statistics, the rate of diagnosis and death has declined over the last 20 years, primarily due to effective screening programs. The American Cancer Society reports that when colorectal cancer is found early and removed, the 5-year survival rate is approximately 90 percent. Even though the case for colorectal cancer screening is convincing, only about 1 in 3 people who should get tested have ever been screened. Low participation in screenings may relate to health illiteracy, lack of health insurance, procedurerelated anxiety, or poor patient satisfaction (American Cancer Society, 2022). Statement of the Problem Even though evidence shows the importance of colorectal screening, many people avoid colonoscopies due to pre-procedure anxiety. Additionally, procedure-related anxiety negatively affects patient satisfaction scores, which determine reimbursement (Tyser et al., 2018). When patients are well informed and know what to expect before procedures, they feel calm and content, have a better experience, are likely to return for follow-up screenings and refer their friends and families to be screened (Rosvall et al., 2021). Educated patients are more compliant with screening participation, decreasing the prevalence of people who become ill or die from colorectal cancer (Yang et al., 2018). When patients are given thorough teaching, they potentially rate their satisfaction higher on surveys which will benefit hospital budgets, nursing compensation, and quality of care (Tyser et al., 2018). Through multimodal education, reducing pre-procedure stress in the endoscopy environment will increase participation in screening 4 programs and improve satisfaction scores. Therefore, this MSN project aims to integrate a prescreening video into the standard patient teaching process, which includes a written handout and verbal script. Ways Project Contributes to Intended Recipients One way that colonoscopy providers can improve patient satisfaction is through enhanced pre-procedure education. Research shows that when patients know what to expect, they have less procedure-related anxiety and stress (Lemos et al., 2018; Ravindran & Binutha, 2017; Rosvall et al., 2021). While fear of the unknown is a primary source of anxiety in the outpatient setting, educating patients about the planned procedure, anesthetic procedures, and what to expect afterward can reduce anxiety levels (Lemos et al., 2018). To have the most significant impact on patient satisfaction and future compliance, educational efforts should focus on providing information about the procedure in a way that patients understand and retain. Multimodal education is a successful approach to patient education in healthcare settings (Li et al., 2021; Resmi & Binutha, 2017; Thompson et al., 2019). Offering a combination of written, visual, and verbal instruction, this methodology has been shown to reduce patient anxiety in Intensive Care, Cardiology, Orthopedics, and Endoscopy (Bored Teachers, n.d.; Li et al., 2021; Resmi & Binutha, 2017; Thompson et al., 2019). Multimodal instruction engages the learner and improves retention better than traditional teaching, using only one type of communication, making it an effective teaching technique (Bored Teachers, n.d.). Introducing video-based education into the written and verbal patient education curriculum in outpatient Endoscopy will benefit patients and their families by easing their fears and keeping them informed. 5 Rationale for the Importance of Project Colonoscopy is the preferred screening procedure for colorectal cancer because it is both exploratory and interventional. A colon polyp can take up to 15 years to develop into cancer, but during a colonoscopy, a physician can identify potentially cancerous polyps and remove them before they mature. This procedure can effectively prevent colon cancer from ever developing. Despite this impressive outcome, participation in colorectal screening programs is lower than in other cancer screening programs, such as those for cervical and breast cancer (American Cancer Society, 2020). One reason for this disparity may be that colonoscopy is a longer, more invasive process than other screening options, and due to its complexity, there are potential complications. Additionally, anxiety about the risks, bowel preparation, possible discomfort, and the use of sedation have been reported to affect screening compliance (Wangmar et al., 2018). Because colonoscopy is a successful screening and prevention procedure, examining how to improve the patient experience and promote participation is crucial. While procedure-related anxiety affects patient participation, it also impacts patient satisfaction. According to Tyser et al. (2018), patient satisfaction scores depend on more than quality care. Their study showed that patients with pre-visit pain and anxiety had lower overall satisfaction with their care provider (Tyser et al., 2018). Patient satisfaction scores are widely used to measure the patient experience, define reimbursement, and make procedural decisions. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are utilized by the Centers for Medicare and Medicaid Services and other payers to determine how much healthcare organizations are compensated for services (Tyser et al., 2018). HCAHPS surveys are the national standard for collecting and reporting data about patient care. Thus, it is imperative that providers continually evaluate factors that influence patient 6 satisfaction to improve the patient experience, promote compliance, and secure financial compensation (Centers for Medicare and Medicaid, 2021). A final rationale for the importance of this MSN project is the need for more research regarding multimodal education in the area of Endoscopy. While studies support video-based teaching in Cardiac, Ob/GYN, Orthopedics, Vision, Dental, ICU, and other specialties, a scant amount of information exists to illustrate the importance of a high-quality, multi-visual educational protocol for patients experiencing a colorectal cancer screening (Ahmed et al., 2018; Akca et al., 2020; Li et al., 2021; Thompson-Bastin et al., 2019). This project seeks to connect the gap between pre-procedure patient anxiety, practical multimodal education, and increased patient satisfaction scores in an Endoscopy department. This project also aims to show that integrating written, visual, and verbal instruction makes patients feel less anxious, thereby scoring their satisfaction with the colonoscopy experience high on the HCAPHS survey. Improved HCAPHS scores after implementing a multimodal teaching approach before colonoscopies will directly correlate audiovisual patient education and patient satisfaction in outpatient Endoscopy. Literature Review and Framework Despite the high incidence of colorectal cancer in the United States, regular screening is an effective intervention to identify and remove precancerous polyps that could eventually become cancer (American Cancer Society, 2022). Unfortunately, patient participation in screening programs can be affected by pre-procedure anxiety (Yang et al., 2018). Likewise, procedure-related stress can negatively influence patient satisfaction with colonoscopy procedures, hindering screening programs and reflecting on standardized satisfaction scores (Tyser et al., 2018). Therefore, providers must address patient concerns to ensure that adults 7 schedule preventative colonoscopies and are satisfied with their experience. To this end, preprocedure education has been identified as an area of care that significantly improves patient outcomes. Research shows that patients want to feel educated about what to expect during their procedures, and patient education reduces procedural anxiety (Yang et al., 2018). Therefore, this project aims to integrate high-quality video-based education into the colonoscopy experience. This section discusses the evidence-based practice (EBP) change model considered for quality improvement in patient education before colonoscopies and the foundation of research that supports this project. Framework The Johns Hopkins EBP Nursing Model involves three main phases that direct the education-based quality improvement efforts in an Endoscopy Department. This model asks a practice question, evidence is gathered, and evidence is translated into practice improvements (Gawlinski & Rutledge, 2008). Guided by the first phase of this model, a question was identified: "Does a multimodal pre-procedure patient education protocol in the endoscopy department facilitate improved patient satisfaction?" Next, best practice evidence was gathered by reviewing the literature on improving colonoscopy patients' satisfaction. The research demonstrates that pre-procedure anxiety affects satisfaction and that this anxiety could potentially be lessened through video-based education. This evidence-based knowledge can then be translated into an action plan to implement pre-procedure, and multimodal patient education, including written instruction, an educational video, and verbal teaching. Implementation of an EBP change in a complex endoscopy environment requires interprofessional collaboration. This focus on teamwork, congruent with the John Hopkins model, is a practical approach to evidencebased change. Once the project is implemented, processes are evaluated, and the findings are 8 communicated to the department, the institution, and other nursing professionals. According to the Johns Hopkins EBP model, sharing evidence-based findings across the nursing profession is essential in supporting practice improvements (Johns Hopkins University and Medicine, 2020). Strengths and Limitations This simple, straightforward problem-solving approach is easy to use and works well with the process of this quality improvement project. The Johns Hopkins model is concise and organized logically. Its three-phase design covers the initial problem recognition through implementation and evaluation, and its broad scope can be applied to various EBP nursing projects (Gawlinski & Rutledge, 2008). The Johns Hopkins Nursing EBP model aims to promote best practices in patient care and improve patient outcomes. However, because this framework is specifically designed for nursing practice, it is limited only because it is a clinical resource used in healthcare settings (Daemen Library, 2022). As healthcare is the area of focus for this project, this model is an appropriate framework. Analysis of the Literature Evidence suggests that patients considering screening colonoscopies experience preprocedure anxiety that can deter them from participating in colorectal cancer screening (Carter, 2021). This procedure-related anxiety can also affect patient satisfaction scores, impacting care delivery and reimbursement (Tyser et al., 2018). Although patient anxiety levels are high on the day of their procedure, better-informing patients about their colonoscopy has proven effective in reducing patient anxiety (Lemos et al., 2019; Yang et al., 2018). Literature suggests that adopting a multimodal approach to pre-procedure education, including written, verbal, and visual instruction is more effective than any of these methods alone (Thompson-Bastin et al., 2019). The literature supports implementing a video-based education protocol, in conjunction with 9 written and oral teaching, to decrease patient anxiety and improve patient satisfaction scores (Ahmed et al., 2018; Akca et al., 2020; Lemos et al., 2017; Li et al., 2021; Ravindran & Binutha, 2017; Thompson-Bastin et al., 2019). This literature review addresses research on the factors related to patient satisfaction, how education decreases pre-procedure anxiety, and how multimodal teaching is an effective patient education model in healthcare. Search Strategies Professional healthcare databases were searched to find evidence discussing patient anxiety, education, and satisfaction in Endoscopy. These databases include CINAHL, Google Scholar, PubMed, MEDLINE, and Weber State University's Stewart Library Advanced Search (which includes many databases). Keywords used in the search were endoscopy, education, patient, multimodal, multimedia, audiovisual, video, health, anxiety, teaching, strategies, preprocedure, satisfaction, and colorectal cancer screening. These keywords were combined to create a variety of phrases that expanded the search results. The search was limited to articles published between 2017 and 2022. Factors Influencing Patient Satisfaction Scores Patient satisfaction scores in healthcare measure patient experience and quality of care. The results of patient surveys affect the delivery of care, reimbursement, and caregiver compensation (Tyser et al., 2018). While these scores are used to make decisions, the factors influencing satisfaction are not fully understood. Research in an outpatient upper extremity clinic compared patient-reported pre-visit pain, anxiety, and physical function to patient satisfaction with the provider. They found that patient satisfaction was significantly lower in patients with more pain and anxiety and less functioning before their appointment. These results indicate that patient satisfaction is not necessarily tied to the quality of patient care. Other factors unrelated to 10 medical care can influence satisfaction scores (Tyser et al., 2018). Akca et al. (2020) found that the satisfaction of female patients undergoing office hysteroscopy was significantly related to anxiety about the procedure. Their study demonstrated that pre-procedural anxiety is a critical issue affecting satisfaction. Consequently, evaluating and addressing pre-procedure patient anxiety levels in healthcare settings is essential, as these symptoms can affect overall patient satisfaction and experience (Lemos et al., 2019). Another factor that influences patient satisfaction scores is the delivery of pre-procedure information. Patient satisfaction scores were higher for those who received video-based multimedia information before the procedure than for those who received only written information (Akca et al., 2020). According to Ahmed et al. (2018), "studies have shown that information provision is a substantial factor influencing overall patient satisfaction, with perceived lack of information correlating to poorer satisfaction outcomes" (p. 477). As most patients want to understand what will happen during the procedure and the risks involved, Minciullo & Filomeno (2022) site clarity and completeness of preprocedural information as key to patient satisfaction. Hence, identifying an effective patient education model is essential to promoting ongoing satisfaction. Patient Education Decreases Pre-procedure Anxiety Patient anxiety before procedures is well documented, as is the effective use of education to reduce this anxiety. For example, in a study of cancer patients undergoing surgery, patient education decreased preoperative anxiety levels, as demonstrated by hemodynamic values and The Beck Anxiety Inventory. This patient education, including computer-based teaching about the procedure, anesthesia, perioperative care, and pain control, reduced anxiety levels from mild to minimum (Lemos et al., 2019). Similarly, research involving cataract patients found that a 11 patient information video shown before surgery improved the overall patient experience by significantly reducing anxiety levels and meeting information needs (Ahmed et al., 2018). While anxiety is a common reaction to colonoscopy screening, adequate patient education is a realistic solution. Although physicians recommend colonoscopy for colorectal cancer screening, patients may delay or avoid getting a colonoscopy due to anxiety related to bowel preparation, sedation, or the possibility of pain (Carter, 2021). After completing an uncomfortable prep at home to cleanse the colon, many patients feel anxious when they arrive at the endoscopy facility. There is the potential for additional anxiety related to waiting time, IV placement, modesty, or possible cancer diagnosis (Rosvall et al., 2021). According to Lemos et al. (2018), fear of the unknown is among the most common causes of anxiety in surgical outpatients. However, evidence shows that patients report less anxiety when they know what to expect and their questions are answered (Rosvall et al., 2021). Research shows a direct correlation between a lack of procedural knowledge and procedure-related anxiety in colonoscopy patients (Ravindran & Binutha, 2017). Therefore, it is essential to ensure that patients receive comprehensive information about their procedure in a visually appealing and easy-to-understand format to ease their minds as they prepare for the colonoscopy experience. Multimodal Education While the evidence clearly shows that preoperative education can reduce patient anxiety, the specific delivery of this education plays a crucial role in patient-centered care (ThompsonBastin et al., 2019). Health education delivered with audiovisual technology helps patients understand the teaching, accept the information, and integrate the knowledge into their recovery (Li et al., 2021). One study evaluated the use of video to teach a standardized exercise plan to a convenience sample of Total Knee Arthroscopy (TKA) patients after surgery compared to oral 12 education of the same standardized method. This study found that the video-assisted health education given to the intervention group was more effective than the verbal information provided to the control group in promoting recovery after TKA (Li et al., 2021). Similarly, Thompson-Bastin et al. (2019) found that educational videos were preferred over other Intensive Care Unit (ICU) modalities. In their study, ICU patients and families received television-based education as a standard admission process. On a 5-point Likert Scale, patients agreed that the videos were high quality, easy to understand, and helped them make informed health decisions. Survey results concluded that patient/caregiver respondents felt the videos increased their satisfaction and knowledge and reduced anxiety (Thompson-Bastin et al., 2019). Educational videos are a practical, cost-effective, time-sensitive way to deliver preprocedure information (Ahmed et al., 2018). Literature supports video-based education as it improves patient retention and leads to better knowledge outcomes than verbal or written information (Ahmed et al., 2018; Li et al., 2021; Thompson-Bastin et al., 2019; Tyser et al., 2018). Standardized videos can show patients details about their healthcare experience in a way that verbal or written information cannot. Providing details of the procedure itself, safety protocols, virtual tours of the procedure environments, and previous patient testimonials, audiovisual education improves the patient's understanding of their experience and lessens anxiety (Ahmed et al., 2018). Discussion While colorectal cancer screening is a vital prevention activity for older adults, many choose not to be screened or fail to comply with follow-up screenings (Carter, 2021). Patient experience and satisfaction with screening programs are two factors that affect patient adherence (Selva et al., 2021). Pre-procedure anxiety hurts patient satisfaction. However, effective patient 13 education can help alleviate these feelings of distress (Ravindran & Binutha, 2017; Tyser et al., 2018). Institutions should, therefore, focus on creating quality education protocols that are clear and comprehensive. Evidence supports implementing multimodal education to ensure patient understanding and retention of pre-procedure education (Li et al., 2021). This patient-centered practice reduces anxiety and promotes ongoing screening participation and better satisfaction outcomes (Minciullo & Filomeno, 2022). The body of research reviewed for this paper suggests that an education protocol combining written, visual, and verbal instruction is preferred to oral education alone (Thompson-Bastin et al., 2019). Because healthcare today is driven by satisfaction scores, which affect reimbursement, policy decisions, and patient loyalty and compliance, endoscopy units must prioritize ongoing education improvement efforts to decrease patient anxiety and increase satisfaction. Project Methodology This MSN project aims to implement a newly created pre-procedure education video for patients admitted to the endoscopy department. This project will be a combined effort between the endoscopy department’s engagement council, the hospital’s marketing team, and a thirdparty video production company. Using a multi-modal approach, the video will supplement patients’ written and oral instructions before procedures. It will educate patients about what to expect from their care team, respond to common questions, and address peri-procedure concerns such as pain, nausea, and infection. Presenting these key satisfaction drivers in an audio-visual setting will illustrate details about the healthcare experience in a way that just verbal or written information cannot. Ultimately, this innovative project seeks to improve patient outcomes and satisfaction scores. 14 Description and Development of Project Deliverables Four deliverable resources were created to aid this project's approval, production, implementation, and evaluation. These resources include an SBAR project summary, a patient video script, a staff training presentation, and a Quick Response (QR) code survey poster. These deliverables are described below and found in the appendices to follow. The actual patient education video is not presented in the deliverables section, as a third party will lead the production. SBAR Project Summary The first item created for this project is an SBAR project summary (Appendix A) which identifies the situation, background, assessment, and recommendations for this project. This document will be sent to Hospital Administration, Compliance, Corporate Marketing, and Corporate Surgical Services to offer background information about the project. This summary provides critical decision-makers with evidence-based rationale for the project. It cites the importance of education in improving patient satisfaction scores (Lemos et al., 2019; Yang et al., 2018) and the benefits of multi-modal education strategies in healthcare (Thompson-Bastin et al., 2019). This evidence will help generate corporate and facility approval and support for the project. Patient Video Script The second deliverable is the video script (Appendix B). This script is the foundation of the patient education video. The script's first draft was written by a member of the endoscopy department engagement council, a front-line endoscopy nurse. This initial draft was reviewed and edited by the two other members of the engagement council, and the engagement council shared leader (also front-line nurses), who know and understand the endoscopy process. The 15 edited script was sent to the endoscopy department manager and the hospital marketing director for review. In addition to explaining what patients can expect before, during, and after their procedure (Lemos et al., 2018), it emphasizes key drivers of patient satisfaction, such as how well the team works together, information about pain, nausea, and infection, and responding to questions or concerns. As patient education has been shown to decrease anxiety and improve scores (Rosvall et al., 2021), this script was written with an education focus. Endoscopy Staff Training Presentation A staff training presentation (Appendix C) will be given to endoscopy staff at a staff meeting before the patient education video goes live. The training presentation allows all endoscopy staff to be educated about the evidence supporting video-based learning (Li et al., 2021) and the importance of decreasing patient anxiety to improve patient satisfaction scores (Lemos et al., 2019). The training presentation will identify how the video will be integrated into the endoscopy pre-procedure routine and the project evaluation methods. Patient QR Code Survey and Poster The final resources created for this project are a patient QR code survey (Appendix D) and a poster (Appendix E) which will be hung on the wall near the TV in each patient room in the endoscopy department. When patients are oriented to their room and the video process, they will be instructed to scan the QR code and complete the survey on their personal devices. The pre-procedure nurse will follow up with these instructions when they come into the room to get the patient ready for their procedure. This QR code poster asks patients to participate in a brief patient survey, a formative tool to gather patient feedback regarding the use and quality of a patient video in the endoscopy department. While literature shows that patients prefer audiovisual education to written or verbal instruction alone (Ahmed et al., 2018; Li et al., 2021; 16 Thompson-Bastin et al., 2019; Tyser et al., 2018), assessing patient response to video-based education is important. Further evaluation of the video will be evaluated quarterly by analyzing HCAHPS and Press Gainey patient satisfaction scores. Plan and Implementation Process This MSN project largely depends on the approval and support of various facility and corporate parties. After a planning meeting of the project team, including the endoscopy department engagement council, department manager, and hospital marketing director, assignments were given to present the SBAR Project Summary and video script to key decisionmakers within the organization. The hospital Information Technology (IT) Manager was consulted to discuss technological options for playing the educational video in patient rooms. Once Compliance, Quality, Administration, and Marketing approve the project, marketing will begin consulting with a third party for video production. When the video is complete, the IT staff will upload the footage onto flash drives purchased by IT for this project. The flash drives will be installed on the TVs in patient rooms. The next step in the implementation process is to provide staff training during a regularly scheduled departmental staff meeting. The meeting will be held in the Endoscopy department so that the video can be shown on a patient TV for all staff to view. The engagement council chair will conduct the training with the help of the other engagement council members. The endoscopy staff training presentation will be shown to educate staff about the research supporting videobased learning and the need to improve patient satisfaction scores. Staff will be shown how the patient video fits into the pre-procedure flow, how to watch the video on patient TVs, and how to chart that the video was used for patient education. 17 Finally, staff will be oriented to the process of evaluating video-based education in the endoscopy department. Front-line staff will be instructed on using the QR patient survey and will practice filling out the survey on their personal devices. A QR code poster with instructions will be printed and hung in each patient room. Staff will be reminded to chart all education activities, including the new video, and the process for random chart audits will be explained. Quarterly summative evaluation of patient scores will also be discussed. Finally, the go-live timeline will be announced, and staff can ask questions or discuss concerns. Interdisciplinary Teamwork Collaboration is critical to a successful project, especially in healthcare—stakeholder input fosters support, understanding, and buy-in. Creating a team that includes front-line staff and decision-makers is essential to the project’s success (Anderson & McFarlane, 2019). The team for this project consists of the endoscopy department manager, the engagement council shared leader, engagement council members, the hospital marketing director, and the hospital IT manager. Endoscopy Department Manager. The endoscopy department manager oversees the department budget and can approve any costs associated with the project. The manager also advocates for departmental needs and ideas with administration and corporate surgical services. The department manager approves time to work on project details and supports the engagement council during staff training and video rollout. Engagement Shared Leader. The engagement-shared leader organizes and runs meetings, coordinates communication between team members, and presents staff training. The shared leader monitors and interprets patient satisfaction scores and works closely with the department manager and front-line staff to delegate responsibilities. 18 Engagement Council Members/Endoscopy RNs. Three endoscopy RNs are also members of the engagement council. These RNs bring essential patient care experience to the team. They also play an important role in supporting the project among their coworkers. These team members wrote the SBAR summary and contributed to the script. The production crew will seek their ideas for the video production, and the engagement shared leader will collaborate with them regarding the staff training and rollout. Hospital Marketing Director. The marketing director is an essential administrative member of the team. They directly interact with compliance, quality, and administration and can advocate for the project. Their experience and expertise will guide the production of the video. IT Manager. The IT manager will help coordinate the equipment and supplies to display the video in patient rooms. They will be a resource to troubleshoot technical problems and advise on budget questions. Timeline (Appendix E) This MSN project began in November when an initial team planning meeting was held. Assignments were made, and by the end of December, the script had been written, reviewed by the project team, and edited. The engagement council also wrote an SBAR in preparation for presenting the project to corporate partners. Finally, the IT department was consulted on the best process for patient viewing. The SBAR and script were submitted to Compliance, Quality, Administration, Corporate Marketing, and Corporate Surgical Services in January for approval. The team also created a QR patient survey and drafted posters with the QR code to hang in patient rooms. With corporate and local approval in February, the marketing directing will seek third-party support for video production. The video will be reviewed by the project team, Compliance, Quality, Administration, Marketing, and Corporate Surgical Services. In March, the 19 IT department can set the video up on patient TVs once the video is complete. QR code posters can also be printed for patient rooms, and the staff will be trained using a PowerPoint presentation at Staff Meeting. The projected Go Live for both the video and QR survey is April. During May and June, the engagement council will review QR survey feedback and conduct random chart audits to assess if nurses are correctly charting the use of video. In July, the team will assess quarterly patient satisfaction scores from the HCAHPS and Press Gainey tools. Plan for Evaluation of Project Formative and summative assessments will evaluate this project’s success. The first formative evaluation will be the script and video editing process by the engagement council, department manager, and marketing director. The script and video will also be sent to Compliance, Quality, Hospital Administration, and Corporate Surgical Services before going live in the endoscopy department. This thorough review will ensure the content is accurate, inclusive, comprehensive, and non-offensive. Once the video is implemented in the endoscopy department, the engagement council will use random chart audits to assess whether the pre-procedure nurses are showing the video to patients and documenting the education. The RNs will be educated on completing video charting in the training presentation at the staff meeting before the video goes live. Another formative evaluation technique will be nursing staff asking patients and family members to complete a short online survey after watching the video. This survey will assess patient responses to the video and its effectiveness in pre-procedure endoscopy education. Patients will be shown a QR code on a poster in their room. They can scan the QR code on their personal device and complete a short survey if they choose to. Finally, quarterly patient satisfaction scores from HCAHPS and Press Gainey will be 20 compared to pre-video satisfaction scores in a summative approach to project evaluation. The process of reviewing, analyzing, and disseminating score information falls under the scope of the engagement shared leader. The department manager or engagement council members will be utilized if additional assistance is needed. Ethical Considerations Ethical considerations for this project fall into three categories: integrity, nondiscrimination, and privacy. First, the project team is fully aware that the endoscopy department, the anesthesia providers, and the doctors will be held accountable for the care described in the pre-procedure video. Therefore, the script and video must be reviewed by Compliance, Quality, Administration, Marketing, and Surgical Services before being shown to patients. The hospital and the corporation want to avoid misrepresentation and ensure services are provided as the video depicts. Next, accommodation must be made for vulnerable groups such as patients with hearing loss or those not speaking English. The video will include closed captioning, benefiting all patients who can read English. A hospital-certified translator will be provided in person or via iPad for those who do not speak English. If translation during the video proves technologically difficult, the nurse, with translator assistance, may use a printed copy of the script to educate the patient. The project team looks forward to offering a Spanish version with a Spanish voice-over after the initial English video goes live. Finally, actors will be used in the video to protect patient privacy. The team will use actors that represent the diversity in the patient population, such as gender, age, and race. Additionally, the patient and family QR survey will not require personal identifiers; answers will be confidential. Patients always have the right to decline to watch the video. In those situations, 21 the nurse will review the written handout and give verbal instructions, and the QR survey will not be offered. Discussion Innovative healthcare solutions can have far-reaching effects on patient outcomes when shared across the healthcare industry. This section will discuss the dissemination of project findings, the impact on nursing practice, project implications, and recommendations for the future. Evidence-based Solutions for Dissemination This master of nursing education project potentially affects endoscopy patient care processes, patient satisfaction scores, and hospital reimbursement. Therefore, the findings herein should be presented to those affected by the results. Introducing this project within the endoscopy department at a staff meeting before the video goes live will create understanding and buy-in from the staff facilitating the video-based patient education. In addition, as the creation of this project is a direct result of low patient satisfaction scores, the Hospital-wide Engagement Council should be educated about this effort to improve patient engagement within the hospital and the project’s results. Another avenue for dissemination is through the Intermountain webbased newsletter published regularly and sent to every Intermountain employee. This newsletter often highlights innovative ideas and processes within the corporation. Presenting this project at a regional or national nursing conference is another meaningful avenue for dissemination. Low satisfaction scores are a concern throughout the healthcare industry, and video-based education may offer a solution to other institutions. Finally, the Cedar City Hospital contributes articles to the Iron County Today newspaper to inform the local community about their high-quality care. The endoscopy patient video and its intended outcomes would be an exciting announcement. 22 Significance to Advance Nursing Practice Nurses interact with anxious patients daily, and this procedure-related anxiety can negatively affect patients’ healthcare experiences. This emotional response can present as physical symptoms such as raised blood pressure, cardiac arrhythmias, or elevated pain levels. In addition to physiological outcomes, it is widely known that anxiety also impacts patient satisfaction (Akca et al., 2020). Because hospital compensation is based on high patient satisfaction scores, improving patient engagement will benefit hospital resources, nursing benefits, and employee wages (Centers for Medicare and Medicaid, 2021). Additionally, anxious patients may require additional nursing care, time, and intervention if they have abnormal physical responses. This attention may include frequent vital sign monitoring, medication administration, and emotional support. Alleviating patient anxiety through multimedia education can help prevent nurse burnout and improve efficacy and job satisfaction (Li et al., 2021). Therefore, offering patients a pre-procedure education video and verbal and written instructions can improve nurse compensation, retention, and satisfaction. Implications The benefits of this project include low cost, effective teaching modality, and work efficiency. Production of a patient education video is a cost-effective solution with a potentially high return on investment. Once the initial cost of production is met, playing the video for patients does not require ongoing financing. Next, the video will reinforce verbal and written instructions given to the patient. Research shows that a multi-media approach helps patients better understand, accept, and retain the information than any one form of education alone (Li et al., 2021; Thompson Bastin et al., 2019). Finally, once produced, patients will watch the video while waiting for their nurse; therefore, the video will not take additional nursing time. In theory, 23 it will increase the efficiency of the pre-procedure process by answering patient questions or speaking to concerns before the nurse enters the room. Unfortunately, patient education is not one size fits all. Language, culture, race, age, disability, and gender are among the many factors that influence how a person learns. Therefore, the producers will consider these differences when creating the video. However, there may be patients for whom the video is not practical. In those situations, accommodations will ensure that the patient and family receive the most patient-centered education possible. Recommendations The first recommendation for improvement to this project is to ensure that a Spanish voice-over version of the video is created in a timely manner. It is important to offer this educational video to Spanish-speaking patients in their native language to ensure comprehension. While Cedar City Hospital employs a part-time translator, they are not always available for endoscopy patients. Additionally, the language line iPad translation service is beneficial for realtime interaction, but video translation would be difficult. Another recommendation would be to expand the project to include a similar patient education video highlighting the Same Day Surgery process and recovery. The Endoscopy and Same Day Surgery Departments comprise the Cedar City Ambulatory Care Center, with the same nursing staff working in both areas. A consistent pre-procedure process within both care areas would promote efficiency. Additionally, heightened patient anxiety and education needs are equally as concerning in same-day surgery as in endoscopy. Therefore, the same effort should be given to improving patient outcomes in same-day surgery to increase satisfaction scores. 24 Conclusions Patient satisfaction scores are widely used to measure the patient experience, define reimbursement, and make procedural decisions (Tyser et al., 2018). Thus, it is imperative that providers continually evaluate factors that influence patient satisfaction to improve the patient experience, promote compliance, and secure financial compensation (Centers for Medicare and Medicaid, 2021). Literature supports implementing a video-based education protocol, in conjunction with written and oral teaching, to decrease patient anxiety and improve patient satisfaction scores (Thompson-Bastin et al., 2019). Health education delivered with audiovisual technology helps patients understand the teaching, accept the information, and integrate the knowledge into their recovery (Li et al., 2021). Educational videos are a practical, cost-effective, time-sensitive way to deliver pre-procedure information (Ahmed et al., 2018). This MSN project proposes the development of a pre-procedure patient education video to be shown to patients admitted to the endoscopy department. The video would supplement patients’ written and oral instructions before surgery. It will educate patients about what to expect from their care team, respond to common questions, and address peri-operative concerns such as pain, nausea, and infection. Presenting these key drivers in an audio-visual setting will show patients details about their healthcare experience in a way that just verbal or written information cannot. Ultimately, this innovative project will decrease patient anxiety and improve screening compliance and satisfaction scores. 25 References Ahmed, K. J., Pilling, J. D., Ahmed, K., & Buchan, J. (2018). Effect of a patient-information video on the preoperative anxiety levels of cataract surgery patients. Elsevier Inc., 45(4), 475479. Doi.org/10.1016/j.jcrs.2018.11.Q11 Akca, A., Yilmaz, G., Esmer, A. G., Yuksel, S., Koroglu, N., & Cetin, B. A. (2020). Use of video-based multimedia information to reduce anxiety before office hysteroscopy. Videosurgery, 15(2), 329-336. Doi.org/10.5114/wiitm.2019.89378 American Cancer Society. (2022). Key statistics for colorectal cancer. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html Anderson, E. T., and McFarlane, J. (2019). Community as partner. Wolters Kluwer. Bored Teachers. (n.d.). Multimodal learning: What is it and how can you use it to benefit your students? https://www.boredteachers.com/post/multimodal-learning-what-is-it-andbenefits Carter, K. (2021). A practical approach to selecting a colorectal cancer screening test. Journal of the American Academy of PAs, 34(11), 18-23. doi:10.1097/01.JAA.0000794976.41120.ee Centers for Medicare and Medicaid. (2021). HCAHPS: Patient's perspectives of care survey. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalHCAHPS Daemen Library. (2022). Nursing: Evidence-based practice. https://libguides.daemen.edu/EBP/johns-hopkins-EBP Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice changes. AACN Critical Care, 19(3), 291-300. 26 Johns Hopkins University and Medicine. (2020). Johns Hopkins nursing evidence-based practice model resources. Welch Medical Library. https://browse.welch.jhmi.edu/nursing_resources/jhnebp Lemos, M. F., Lemos-Neto, S. V., Barrucand, L., Vercosa, N., & Tibirica, E. (2019). Preoperative education reduces preoperative anxiety in cancer patients undergoing surgery: Usefulness of the self-reported Beck anxiety inventory. Revista Brasileira De Anestesiologia, 69(1), 1-6. doi:10.1016/j.bjane.2018.07.004 Li, P., Li, X., Meng, H., Huang, L., Zhang, L., Wang, S., & Chen, S. (2021). Video-assisted health education promotes rehabilitation training of total knee arthroplasty patients and reduces stress and burnout in nurses compared to oral education. BioMed Research International, 1-6. doi:10.1155/2021/5058899 Minciullo, A., & Filomeno, L. (2022). Assessment of patient satisfaction in digestive endoscopy: A narrative review of the literature. The Society of Gastroenterology Nurses and Associates, 45(1), 43-51. doi:10.1097/SGA.0000000000000605 Ravindran, R., & Binutha, V. P. (2017). Effectiveness of video assisted teaching regarding colonoscopy procedure on knowledge and pre procedure anxiety among patients undergoing colonoscopy. International Journal of Nursing Education, 9(4), 116-120. doi:10.5958/0974-9357.2017.00107.6 Rosvall, A., Axelsson, M., Toth, E., Kumlien, C., & Gershater, M. A. (2021). Patients' experiences before, during, and after a colonoscopy procedure. Society of Gastroenterology Nurses and Associates, 44(6), 392-402. doi:10.1097/SGA.0000000000000569 27 Thompson-Bastin, M. L., Short, G. T., Cook, A. M., Rust, K., & Flannery, A. H. (2019). Patients' and care providers' perceptions of television-based education in the intensive care unit. American Journal of Critical Care, 28(4), 307-315. doi:10.4037/ajcc2019156 Tyser, A. R., Gaffney, C. J., Zhang, C., & Presson, A. (2018). The association of patient satisfaction with pain, anxiety, and self-reported physical function. The Journal of Bone & Joint Surgery, 100-A(21), 1811-1818. doi:10.2106/JBJS.17.00372 Wangmar, J., Von Vogelslang, A., Hultcrantz, K., Wengstrom, Y., & Jervaeus, A. (2018). Are anxiety levels associated with the decision to participate in a swedish colorectal cancer screening programme? A nationwide cross-sectional study. BMJ Open, 1-8. doi:10.1136/bmjopen-2018-025109 Yang, C., Sriranjan, V., Abou-Setta, A., Poluha, W., Walker, J., & Singh, H. (2018). Anxiety associated with colonoscopy and flexible sigmoidoscopy: A systemic review. The American Journal of Gastroenterology, 113, 1810-1818. doi:10.1038/s41395-018-0398-8 28 Appendix A Cedar City Hospital Endoscopy Department Patient Education Video SBAR Summary Situation: Healthcare is an environment of constant change, and Cedar City Hospital’s endoscopy department recognizes that innovation and forward-thinking are required to meet increasing expectations of healthcare performance. Intermountain Healthcare encourages its staff to look for ways to improve patient outcomes and promote quality care through a culture of evidence-based research practice. The endoscopy staff have created a feasible plan to address the key drivers of patient likelihood to recommend scores, decrease patient anxiety before procedures, and improve the overall patient experience in the Cedar City Hospital endoscopy department. Background: Patient satisfaction scores are widely used to measure the patient experience, define reimbursement, and make procedural decisions. For example, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems surveys are utilized by the Centers for Medicare and Medicaid Services and other payers to determine how much healthcare organizations are compensated for services (Tyser et al., 2018). Thus, it is imperative that providers continually evaluate factors that influence patient satisfaction to improve the patient experience, promote compliance, and secure financial compensation (Centers for Medicare and Medicaid, 2021). Assessment: Literature supports implementing a video-based education protocol, in conjunction with written and oral teaching, to decrease patient anxiety and improve patient satisfaction scores (ThompsonBastin et al., 2019). Health education delivered with audiovisual technology helps patients understand the teaching, accept the information, and integrate the knowledge into their recovery (Li et al., 2021). Educational videos are a practical, cost-effective, time-sensitive way to deliver pre-procedure information (Ahmed et al., 2018). Recommendation: The Cedar City Hospital’s endoscopy department proposes the development of a pre-procedure patient education video to be shown to patients when admitted to the department. The video would supplement patients’ written and oral instructions before surgery. It will educate patients about what to expect from their care team, respond to common questions, and address perioperative concerns such as pain, nausea, and infection. Presenting these key drivers in an audiovisual setting will show patients details about their healthcare experience in a way that just verbal or written information cannot. Ultimately, this innovative project will improve patient outcomes and satisfaction scores. Ahmed, K. J., Pilling, J. D., Ahmed, K., & Buchan, J. (2018). Effect of a patient-information video on the preoperative anxiety levels of cataract surgery patients. Elsevier Inc., 45(4), 475-479. Doi.org/10.1016/j.jcrs.2018.11.Q11 Centers for Medicare and Medicaid (2021). HCAHPS: Patient's perspectives of care survey. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/HospitalQualityInits/HospitalHCAHPS Li, P., Li, X., Meng, H., Huang, L., Zhang, L., Wang, S., & Chen, S. (2021). Video-assisted health education promotes rehabilitation training of total knee arthroplasty patients and reduces stress and burnout in nurses compared to oral education. BioMed Research International, 1-6. doi:10.1155/2021/5058899 Thompson-Bastin, M. L., Short, G. T., Cook, A. M., Rust, K., & Flannery, A. H. (2019). Patients' and care providers' perceptions of television based education in the intensive care unit. American Journal of Critical Care, 28(4), 307-315. doi:10.4037/ajcc2019156 Tyser, A. R., Gaffney, C. J., Zhang, C., & Presson, A. (2018). The association of patient satisfaction with pain, anxiety, and self-reported physical function. The Journal of Bone & Joint Surgery, 100-A(21), 1811-1818. doi:10.2106/JBJS.17.00372 29 Appendix B Cedar City Hospital Endoscopy Department Patient Education Video Script Drone flyover footage of the hospital campus Voiceover: Welcome to the Intermountain Cedar City Hospital, where excellent care is our highest priority. We are rated among the top rural hospitals in the nation because we provide quality care, affordable services, and a personalized experience. We appreciate you choosing us for your endoscopy procedure today. Shawn Garfield (Same Day Surgery Manager): On behalf of the Cedar City Hospital endoscopy team, I want to welcome you and say thank you for allowing us to take care of you and your loved ones. Every person on our team, those you will come in contact with today and those working behind the scenes, has committed to Intermountain’s vision to deliver extraordinary care. In the Same Day Surgery department, we work together to keep you safe, ensuring collaboration and continuity of care throughout your time here. We aim to provide you with the information, education, and resources to help make your endoscopy experience excellent. Voiceover: This video was made to educate you on what to expect from the time you arrive for your procedure and up to when you are sent home from the hospital. Thank you for coming early so we can take the necessary steps to prepare you for your procedure. You have already checked into the Same Day Surgery unit, and a member of our care team has taken your height and weight and asked that you change into a hospital gown. The room you are in now will remain your room until you are sent home. Your belongings are safe here, and if any family members or friends have accompanied you, they can stay in this room for any updates we may have along the way. A pre-procedure nurse will enter your room at the end of this video. They will verify your name, date of birth, and the procedure you have prepared for. You will be asked these same questions many times. Although this may seem repetitive, it is one of the many protocols we have to keep you safe. We appreciate your patience. Your pre-procedure nurse will also: (Bulleted list on slide) ● Take your vital signs: ○ Blood Pressure ○ Heart Rate ○ Respiratory Rate ○ Oxygen Level ○ Temperature 30 ● Update your health history ● Review your home medications ● Place an IV We will use the IV to hydrate you and give you the necessary medication to keep you asleep and comfortable during the procedure. The medication takes effect quickly and wears off quickly with few side effects. Your anesthesia provider will come into your room before surgery. They will go over the anesthesia you need for your procedure. They will ask you to sign a consent once you are comfortable with the plan you make together and your questions have been answered. You will also discuss your procedure plan with your doctor. He will review the procedure, and consent will be signed if you have not already done so in his office. One of your nurses will transport you in your bed to the endoscopy procedure room. The endoscopy room nurse will stay with you during your surgery to be sure you are positioned correctly, warm, and safe until your procedure is finished. You will be asked to turn to your left side in the endoscopy room. The procedure room temperature is kept cool, so you will be covered with warm blankets for comfort. You will be attached to vital sign monitors and positioned on the bed. Afterward, your anesthesia provider will administer medication through your IV to put you to sleep. Once you are asleep, a flexible tube will be inserted into your rectum and advanced through your colon. As the scope is gently removed, your doctor will look for polyps which are small growths on the lining of the intestine. Polyps are removed with an instrument called a snare. The snare has a wire loop, which is tightened around the base of a polyp. These polyps are sent to pathology to be examined under a microscope. Your provider’s office will call you with the results of the pathology exam in 5-10 days. When your procedure is finished, you will be transported back to the room where you started. Your post-procedure nurse will take over from here and continue to monitor your blood pressure and oxygen level. You may need oxygen through a nasal cannula in your nose while waking up. You will be given time to wake up, but you may feel groggy for several hours after your procedure. When you are awake and alert, you will be unhooked from the monitors, your IV will be removed, and you will be allowed to get dressed. Your post-op nurse will discuss your activity limitations, medication changes or restrictions, and dietary information you need to know. Your surgeon will visit you and discuss your procedure’s results before you leave. Please ask your post-op nurse if you have any questions, and they will find answers. Before going home, you will be given written discharge education and instructions. If you would like something clarified, please do not hesitate to ask. Questions are welcome and encouraged. Your post-operative nurse will discuss potential post-procedure pain and what to do about it. (Bulleted list on slide) ● Gas Pain (sharp, cramping) ○ Lie on your left side ○ Go for a walk ● Abdominal pressure pain (sore, achy) 31 ○ Cold or heat ○ Rest ● Severe Pain ○ Come to the Emergency Room Nausea is not a common side effect of the medication you were given in the endoscopy department today. Your post-procedure nurse will teach you what to do if you experience nausea or vomiting at home. (Bulleted list on slide) ● Ice packs to the back of the neck ● Stick to clear liquids ● Do not force yourself to eat/drink A small amount of bleeding from your rectum could be seen in the toilet if you had any polyps removed or biopsies taken. You will be instructed on how much bleeding is too much and what to watch for specific to your procedure. You will also be taught about possible signs of infection, what to watch for at home, such as drainage, severe pain, and fever, and when to call your Physician. (Bulleted list on slide) ● Signs of Infection: ○ Drainage ○ Severe pain ○ Fever If there are any staff members you would like to recognize or a process that helped make your experience extraordinary, please let us know by filling out the yellow card (picture) given to you when you arrived. The department manager reviews this feedback. Intermountain also wants to recognize extraordinary nurses through the Daisy Award. Nominations can be submitted by scanning the poster in your room (picture). Once you are home, you may receive a survey in your mail or email in about two weeks asking about your experience today. Your feedback helps us improve and compensates our hospital so we can provide the highest level of care. Shawn Garfield: Thank you for trusting Cedar City Hospital’s endoscopy department to care for you today. We appreciate your patience with the process and your loyalty to Intermountain. We sincerely appreciate your kindness and support as a department and an organization. My team is fantastic and will take excellent care of you! 32 Appendix C 33 34 Appendix D Cedar City Hospital Endoscopy Department Patient Education Video QR Survey Questions 1. The video addressed questions or concerns I had before my procedure. Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 2. Watching the video helped me feel less nervous and more at ease. Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 3. The video presented information in a way I could easily understand. Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 4. After watching the video, I knew what to expect from my healthcare team. Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 5. I prefer video-based education to traditional spoken or written communication. Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 35 Appendix E 36 Appendix F