Survey of the success of communications between hospital staff and patients

Publ. H#h, Lond. (1976) 90, 203--209

Survey of the Success of Communications between Hospital Staff and Patients O. M. Parkin M.R.C.P.. Dip. Soc. Med.

Research Fellow, Royal College of Physicians, Edinburgh A survey of discharged hospital patients sought their opinions on the adequacy of the information which they had received during their stay. Fifty-seven percent expressed some degree of dissatisfaction. Half of the group knew their own diagnosis, and less than 30% could give the names or purposes of all the drugs that had been prescribed for them to take after discharge. The finding that over one-third o f the patients did not understand how to manage their own drug therapy at home may reflect one aspect of failure of communication during their hospital stay.

Introduction Previous workers have found that many patients recently discharged from hospital express dissatisfaction with .the information given to them during their stay ( M c G h e e , 1961; Hugh-Jones, Tanser & Whitby, 1964; Cartwright, 1964; Raphael, 1969). It may be that hospital staff fail to tell patients all that they might, but in addition it is known that some patients misunderstand or forget much of what they are told (Ley & Spelman, 1967; Joyce et al., 1969). What is the result of unsatisfactory communication ? Although it is not essential to tell the patient all about his diagnosis, prognosis and what investigations are to be done, this is now generally regarded as desirable (Central Health Services Council, 1963) if only in order to allay unnecessary anxiety. Once discharged, the patient's participation is required if therapy continues to be necessary; there may be dietary or exercise restrictions, or drug regimes to be followed. Successful communication becomes essential if the patient's cooperation is needed to achieve optimal treatment. This paper reports a study o f some aspects o f communication between hospital staff and patients who had recently been discharged from four general medical wards. The patients" opinions on the adequacy o f the information which they had received was assessed, and the success ofcommunication measured in terms o f what the patients knew about their diagnosis, and the drugs which they had been prescribed. The implications were judged by investigating whether the patients understood how to manage their own drug therapy.

Study Population and Methods The study population was a group of patients discharged home,, or to care of relatives, from four° general medical wards o f a Scottish teaching hospital. They had been under the care of eight different consultants. All patients discharged during a four m o n t h period who were taking one or more regular drugs were included. Eligible patients were asked if they would mind being visited ten days after discharge and answering questions about their hospital stay. Permission for the visit was sought from the general practitioners of those patients who agreed to participate. As well as socio-demographic data on all patients,

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information was recorded on diagnosis, duration of stay, and drugs taken before admission and after discharge. The ward staff were aware that a survey of discharged patients was taking place, but were not told that this included the gathering of information about communications in hospital. It is most unlikely that the patients discharged during the study period received any more or less informatio*n than would normally have been the case. The patients were interviewed at home approximately 10 days after discharge (range 7-14 days). A standard interview schedule was used to record information, which is summarized below: (!) The patient's definition of his own diagnosis (Q: Can you tell me what the illness was that caused you to be in hospital?) (2) The patient's description of his drug regime: (i) Which drugs he should take, when, and in what dosage, (ii) The names of the drugs he is taking, (iii) The purpose of each drug which he is taking. (3) Whether the patient had found out all that he wished to know about his illness, treatment and progress. Was there anything he would like to h~ive been told ? (4) Had the patient seen his general practitioner since discharge, and if so, when. (5) Did the patient remember receiving any instructions or advice about his treatment? (6) Patient memory; did he remember being interviewed in hospital, and the date of his discharge ? (7) Level o f " H e a l t h Concern" (Dunnell & Cartwright, 1972). (8) Attitude to doctors, scored on an eight-statement "Likert" scale. Scores for each statement ranged from 1 to 5. Minimum attitude score = 8 (highly unfavourable attitude), maximum score = 40 (highly favourable attitude). Statement 7 was "Doctors do not explain what is wrong with you as they think you won't understand". Statement 8 was " N o two doctors will agree on what is wrong with a person". (9) Personality Factors: Scores on scales for extroversion--introversion, and neuroticism --stability (Eysenck & Eysenck, 1964). The diagnosis given by the patient was compared with that entered in the discharge summary in the case records. The drug regime which the patient should have been taking (i.e. at the time of discharge, with modification made by the general practitioner) was compared with the patients description of his regime, and discrepancies recorded. Resadts

One hundred and thirty-four patients were successfully interviewed at home. Eleven patients refused to participate in the study, and 20 could not be traced for interview after their discharge. There were no statistically significant differences between the group interviewed and those who were missed in terms of age, sex, diagnosis, ward and number of drugs prescribed. There were 54 males and 80 females, with a mean age of 66-2 (s.o. 10-78), average duration of stay in hospital was 14-5 days, only 17 had been in for longer than four weeks. Almost all had chronic diseases, the largest diagnostic category being disorders of the circulatory system (ICD 390--458) with 103 patients in all. Eighty-five percent had been on some sort of regular medication at the time of admission, and by the time of interview the average number of drugs per patient was 2.82 (range 1-6).

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Satisfaction with commwtications The patients were asked "While you were in hospital, were you able to find out all you wanted to know about your condition, your treatment, and your progress, or not?". Fifty-one patients (38%) said that they had not done so. However, a further 25 patients, in response to the question "'Was there anything you would like to have had explained to you in more detail", or occasionally in other parts of the interview, indicated dissatisfaction with the information which they had received. A total of 76 patients (56-7 %) were therefore of the opinion that they had received inadequate information whilst in hospital. The replies and comments made indicate the areas in which communication was felt to be lacking. The largest number (31) said that their diagnosis, or the cause of their symptoms, had not been fully explained. "What caused the blood pressure to come on, and why does it take so long to go down ? I wasn't told anything before going home, I never saw the doctor before leaving". "They didn't tell me much, 1 had a lot of baths and pills--they believe in that you see. I would like to know what was really wrong". "I don't know what was wrong, l'm no wiser as to why I was admitted". Eight patients said that they were not given sufficient advice or information about their drug therapy. "I got new tablets, but they didn't say whether I have to continue them: 1 have only got enough for another three days". "They lay pills beside the bed--I should like to know what they are and what they are f o r . . . " . Four patients were worried about their prognosis: "'They didn't tell you much, you ~qonder when you'll get better when you've done everything they've told you without improvement". Three patients were confused over the need for restrictions in their diet or their activities as part of treatment. Only two patients said they were nat given sufficient information about the nature or results of investigations which had been performed. Seventeen patients claimed that they had been told nothing o f value at all: "l wasn't told anything, they just listened to my leaky valve, but nothing was said". "The doctors evaded all my questions, they never told me a thing". Many o f these patients appeared to ha~?e rather low expectations o f the amount o f information which they would receive while in hospital. In particular it was often assumed that if they did not ask for information, they would not be given any: "I never asked nothing and they never told me, I ' m not a good asker". "I don't know much, never bothered myself. I d o n ' t ask things, just take my meals when they come". Fifty-eight patients (43-3%) were satisfied with communications, and said that they had found out all they wished to know. Twenty-three o f these patients made favourable comments: "I heard every day how I was getting on". "They told me what it was and everything". However several patients said that th&y had received adequate information only because

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they were prepared to ask questions. Four patients said that they had no interest in acquiring knowledge about their illness. Satisfaction with communications was not related to the age, sex, social class or education of the patient. The ward in which the patient had been, and the consultant in charge made no difference. Patients who remembered receiving instructions and advice about treatment were more satisfied with communications, but the difference was not significant (P<0"2). It was found that patients with "'favourable'" attitudes to doctors more frequently said that they had found out all that they wished to know (Table l). TABLE 1. A t t i t u d e to doctors and satisfaction with communication

Number of patients who claimed to be: Score on attitude Satisfiedwith Dissatisfiedwith scale communications communications <21 22-25 26-29 ~30

6 8 24 15

18 18 19 I0

Total

53

65

X~ = 10-32, D.F. = 3, P < 0 . 0 2 5 .

In part this difference can be explained by differing responses to statements (7) and (8) (see Methods section). For statement (7), satisfied patients had a mean score of 3.491 (s.a. 1.06) and dissatisfied patients a score of 2.97 (s.o. !-24), a significant difference (P<0"025, Student's t-test)~ On statement (8), means scores were 3"49 (s.o. 0.97) for satisfied patients, and 2-98 (S.D. 1"097) for dissatisfied, again a significant difference (P<0-02, Student's t-test).

Patient knowledge Patient knowledge was assessed firstly by asking if they knew what their own diagnosis was. Naturally the precise medical definition was rarely given, but it was considered acceptable if the patients could describe the nature o f their illness in layterms. Sixty-seven patients (51 ~o) had a reasonably good idea oftheirdiagnosis,and 65 (49 ~)'had only poor knowledge, or no idea at all. Knowledge was considered poor if the patient was only able to describe his symptoms ("pains in the chest", "shortness of breath") with no idea of their cause. Thirty-three patients said they did not know what was wrong with them, most were not even prepared to hazard a guess. Younger patients tended to be more knowledgeable than the elderly, but the difference was not quite significant ( 0 . 0 5 < P < 0 - I ) . Sex, social class and education were unrelated to knowledge, as were the hospital ward and consultant in charge. Patients who had visited their general practitioner after discharge did not know their diagnosis any more frequently than those who had not. Health concern, personality factors, and attitude to doctors were also unrelated. However it was found that those patients who had poor or no knowledge o f their diagnosis were more likely to complain o f not being given all the information that they would have liked (Table 2). Knowledge was also assessed by asking each patient if he knew the names o f the drugs which he had been prescribed, and what they were for. Seventy-one patients (53 ~o) did

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TABLE 2. Knowledge of diagnosis and satisfaction v;~th communicalion Knowledge of diagnosis: Poor/none Good Dissatisfied with communications Satisfied with communications Total

45

30

20 65

37 67

~-" := 7.079, D.F. : 1, P<0~05 not know the names o f any o f their drugs, and only 28 (21 ~ ) knew them at all. A vague idea of purpose was considered to constitute satisfactory knowledge (e.g. digoxin "'for the heart", diuretics "water pills"), but even with such criteria 49 patients ( 3 7 ~ ) did not know what any of their medicines were for, and only 37 (28 ~o) knew the purpose o f t h e m all. Knowledge about drugs was significantly better in younger patients ( P < 0 - 0 5 ) but was unrelated to other patient variables. Patients who said that they had received instructions or advice about treatment had a better knowledge o f the purpose o f their drugs (P<0.0005) than those who did not. There was however no relationship between knowledge o f diagnosis, and knowledge about drugs, and the latter was not associated with the patient feeling satisfied with communications. TABLE 3. Knowledge of name and purpose of drugs prescribed

Purl~aSe known Purpose not known Total X: ~ 41.51, D.F. =

l,

Name known

Name not known

Total

99 51 ! 50

70 152 222

169 203 372

P(00005

Three hundred and seventy-two drugs were prescribed, the patients as a group knew the names o f 150 (40 %) and the purpose o f 169 (45 %) (Table 3). The actual type o f drug made little difference, though the names o f diuretics were a'arely known, as was the purpose of potassium and calcium supplements. When the drug had been taken by the patient prior to his hospital admission, both name and purpose 'were known significantly more often than when the drug had been recently commenced (P<0-0005).

Mistakes with the drug regime Forty-six patients (35 ~ ) were unable to describe correctly the drug regime which their medical attendants thought they were following. Twenty-six patients did not know the corre~et dosage o f one or more o f their drugs, took thorn at incorrect times, or omitted them entirely. Twenty-six patients were taking, at least omce daily, drugs which were not part o f their correct regime. Inadequate understanding o f t h e regime was not related to patient knowledge o f diagnosis, or knowledge of the names ,or purposes of drugs. Those patients who said that they had received instructions and advice about treatment, o r who said that they had found out all that they h a d wished to, made mistakes with their regimes as frequently as those who did not.

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Discussion Previous surveys have found that patients are more critical about the difficulty they find in obtaining information than about any other aspect of hospital care (McGhee, 1961 ; Cartwright, 1964; Raphael, 1969). The 57 ° / o f patients who said that they had not found out all that they had wanted to know may be regarded as being dissatisfied with communications, a proportion similar to that reported by McGhee (1961), 65~, and by Cartwright (1964), 61 ~. Like Spelman, Ley & Jones (1966) we found that patients complained most frequently about lack of information on diagnosis, and of being told nothing o f value at all. The patients' satisfaction with communication was related to their attitude to doctors, a finding similar to Cartwright's (1964) observation that satisfaction was related to the patients' overall attitude to the treatment which they had received. The patients had a rather poor level of knowledge as far as their diagnosis and the names and purposes of their drugs was concerned. Patients with poor knowledge of their diagnosis were more critical of communications in hospital, although Spelman et al. (1966) had been unable to demonstrate such an association. Fletcher (1973) emphasizes that misunderstanding of, or failure to remember instructions about treatment is the most serious potential consequence of poor communication between physician and patient. Pratt, Seligman & Reader (1957) found that patients given thorough explanations were more likely to accept the doctors suggestions, and follow advice about treatment. Several previous studies have been concerned with the mistakes made by patients with their drug regimes (see reviews by Francis, Korsch & Morris, 1969; Stewart & Cluff, 1972). We found that about a third o f patients were unable to correctly describe the regime which had been prescribed for them. There was no association between knowledge of diagnosis, or names and purposes of drugs, and making mistakes with the regime. Patients who were satisfied with the information which they had received were just as likely to make mistakes with their drugs as those who were not. Clearly it is not possible to assume that a patient knows how to take his drugs even when he appears well informed about his illness, and claims to have received all the instructions and information that he wants. Patients in hospital may not always be told all that they might+ However, even when doctors make an effort to see that their patients are informed, many will remain dissatisfied with communication (Hugh-Jones, Tanser & Whitby, 1964; Spelman et al., 1966). Patients may misunderstand much of what is said to them; lay people often have bizarre ideas of the meanings of simple medical terms (Boyle, 1970), and doctors may overestimate the extent of patient's knowledge (Pratt et al., 1957). Patients may misinterpret instructions concerning drugs, even when these are clearly written on the labels (Hermann, 1973; Mazzullo, Lasangna & Griner, 1974). Patients may forget much o f what they are told; certain memory' aspects of communication are reviewed by Ley & Spelman (1967). They found that the percentage of information recalled was proportional to the amount given. Instructions were recalled much less well than statements about diagnosis. Patients tend to retain information which they regard as important, and consistently rated instructions and advice as being less important than diagnostic, and other information. Another factor contributing to poor recall of instructions is that these are usually-presented late in a series+of-statements made to the patient, and items which appear early in such series are usually remembered best. Joyce e t aL (1969) also found that patient- had difficulty in remembering explanations about treatment, they noted that older patients forgot more than the young. Certainly our results demonstrate that the younger patients knew more about their diagnosis and drugs than the older. There have been many suggestions of ways to improve doctor-patient communications (Ley & Speiman, 1967; Central Health Services Council, 1963; Fletcher, 1973). Patients

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should be presented with clear and simple information, and encouraged to write it down. Booklets may help. The order is i m p o r t a n t ~ p e r h a p s it should be more general practice to present instructions about treatment first, before giving a diagnosis and explaining what it means. An attempt should be made to give consistent information, it has been suggested that one person should be designated as responsible for informing each patient. Fletcher (1973) advocates a "check-list" for the case notes which should record exactly what the patient has been told, and whether he has understood. Perhaps the most important thing is for doctors to be aware o f the problem, especially when prescribing drugs which the patients must administer themselves. As Stewart & Cluff (1972) point out, better instructions are provided when purchasing a new c a m e r a or automobile than when the patient receives a lifesaving antibiotic or cardiac drug. References Boyle, C. M. (1970). Difference between patients" and doctors' interpretation of some common medical terms. British ,~ledical Journal ii, 286-9. Cartwright, A. (1964). Human Relations and Hospital Care. London: Routledge & Kegan-Paul. Central Health Services Council (1963). Communication between Doctors, Nurses and Patients. An Aspect o f Human Relations in the Hospital Service. London: Her Majesty's Stationery Office. Dunnell: K. & C.artwright: A. (1972). Medicine Takers, Prescribers and Hoarders. London: Routledge & Kegan-Paui. Eysenck, S. B. G. & Eysenck, H. J. (1964). An improved short questionnaire for the measurement of extroversion and neuroticism. Life Sciences 3, 1103-9. Fletcher, C. M. (1973). Communications in Medicine. London: Ntrffield Provincial Hospitals Trust. Francis, V., Korsch, "B. M. & Morris, M. J. (1969). Gaps in doctor-patient communications. New England Journal of hqedicine, 280, 535--40. Hermann, F. (1973). "ihe outp,~tient prescription label as a source of medication errors. American Journal of Hospital Pharmacy 30, 155-9. Hugh-Jones, P., Tanser, A. R. & Whilby, C. (1964). Patients' views of admission to a London Teaching Hospital. British ~¢edical Journal ii, 660-4. Joyce, C. R. B., Caple, G., Mason, M., Reynolds, E. & Mathews, J. A. (1969). Quantitative study of doctor-patient communication. Quarterly Journal of Medicine 38, 183-94. Ley, P. & Spelman, 1M. S. (1967). Communicating with the Patient. London: Staples Press. Mazzuilo, J., Lasangna, L. & Griner, P. F. (1974). Variations in interpretation of prescribing instr~ac~ions~-.Journai of the American Medical Association 227, 929-31. McGhee, A. (1961). The Patients" Attitude to Nursing Core. Edinburgh & London: E. & S. Livingstone. Pratt, L., Seligrnan, A. & Reader, G. (1957). Physicians views on the level of'medical information among patients. American Journal of Public Health 47, 1277-83. Raphaet, W: (1969). Patients and Their Hospitals. London: King Edward's Hospital Fund. Sl~iman, M. S., Ley, P. & Jones, C. (1966). How do we improve doctor-patient communication in our hospitals? World Hospitals 2, 126-34. Stewart, R. B. & Cluff, L. E. (1972). A review of medication errors and compliance in ambulant patients. Clinical Pharmacology and Therapeutics 13. 463-8.