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Clinical care map for the ambulatory laparoscopic cholecystectomy patient
Clinid Care Map for the Ambulatory Laparoscopic Cholecystectomy Patient SUSAN D. BUMGARNER, MSN, RNC, CPAN MARILYN L. EVANS, PhD, RN Shortened hospital stays, expectations of quick recovery and rapid turnaround times in surgical services challenge perioperative nurses to be creative and innovative providers of essential and appropriate patient education. Nurses need approaches that enable them to meet these challenges. One such approach is the adaptation of a clinical care map to the development of a perioperative patient care guide. This article describes the rationale behind the use of this approach and its application to the education of the patient undergoing laparoscopic cholecystectomy. Steps in the process are described. Nurses can use these steps to develop patient care guides suited to their specific practice setting. o 1999 by American Society of PeriAnesthesia Nurses.
T
HE DELIVERY site of postoperative care has shifted from the hospital into the community. Advanced technology is available and supports the demands of health care consumers to shorten hospital stays, decrease costs, and decrease recovery time.’ Compliance with regimens and satisfaction with care result from a well-organized educational plan to meet the needs of short-stay surgical patients. Management of pain and nausea, care of incisions, dietary and activity needs, signs and symptoms of infection, and resources for questions or concerns are key concepts that each patient must understand on discharge. Nurses are challenged to provide education about these key concepts as effectively as possible. Well-informed patients tend to have less anxiety, lower postoperative pain
Susan D. Bumgamel: MSN, RNC, CPAN, is the Organizational Learning Director; at Catawba Memorial Hospital, Hickory, NC; and Marilyn L. Evans, PhD, RN, is an Associate Professor and Director of the BSN/MSN Outreach Programs, School of Nursing, The University of North Carolina at Greensboro, Greensboro, NC. Address correspondence to Susan D. Bumgamer; MSN, RNC, CPAN, 289 Harbor Dr; Taylorsville, NC 28681. 0 1999 by American Society of PeriAnesthesia Nurses. 1089-9472/99/1401-0003$03.00/0 12
levels, fewer complications, and quicker recoveries2 An effective perioperative educational plan for surgical patients empowers them by building their self-confidence, describing what they can expect to experience in the perioperative period, and offering reahstic management strategies for at-home self-care. LITERATURE
REVIEW
Clinical care maps are outcome-focused plans that offer a mechanism to health care providers to enhance quality of care while reducing costs or resource use.3 In health care, resource use refers to length of stay, number of clinical services provided, timing of services, and supplies used. In the acute care setting, clinical or outcome-focused care maps have proved successful in reducing length of stay, increasing patient satisfaction, decreasing documentation time, reducing costs, improving patient education, enhancing collaboration among health care providers, reducing readmissions and complications, conserving resources, and helping standardize practices.3-11 Clinical care maps, developed by interdisciplinary teams, are timed sequences of patient care interventions that are planned for achievable and desirable outcomes. There is no standardized plan Journalof
P&Anesthesia
Nursing,
Vol 14, No 1 (February),
1999: pp 12-76
CLINICAL
13
CARE MAP
for the development of a clinical care map. A common approach is to list the care interventions down the left side of the form, and the time sequence across the top. The desirable outcomes focus on the clinical aspects first and the financial aspects second. They serve to map the patient’s progress through a health care service.3 The use of clinical care maps has proven useful in promoting patient and family education. Patient and family education are integrated at every step of the clinical care map to teach patients about the treatment plan and expected outcomes. This integration stresses the importance of patient and family involvement in the delivery of care and the prevention of complications. Transforming clinical care maps into educational materials explains to the patient what will be taught at each step of the care map. De Jong I2 described using “pictorial pathways” that present concepts of education in simple pictures. The success of clinical care maps to guide health care providers, patients, and families through the process of healing efficiently and effectively served as the framework in the development of the patient care guide for laparoscopic cholecystectomy patients. The educational plan that was developed is called a patient care guide to promote patient understanding, rather than using clinical terminology such as found in clinical care maps. The patient care guide increases the quality of care for the laparoscopic cholecystectomy patient by empowering them through education. APPLICATION
OF THE CLINICAL MAP CONCEPT
CARE
A well-designed patient care guide, adapted from a clinical care map, provides vital information for the surgical patient and serves as a teaching guide for perioperative nurses. Clinical care maps used as patient education tools are called patient care guides and provide guided information for patient expectations. The use of patient care guides is helpful in promoting patient and family education. Patient and family education is integrated at every step of the patient care guide to teach patients about the treatment plan and expected outcomes. This integration stresses the importance of patient and family involvement in the delivery of care and the prevention of complications. It also promotes the achievement of clinical goals for the patient and
lowers costs by reducing lengths of stay and readmissions. Use of patient care guides contributes to decreased nursing time spent on documentation because the plan also serves as a documentation tool. Standardization of patient education is achieved through the use of teaching plans developed from clinical maps and has increased nursing staff satisfaction.6 A time-sequenced approach is used to map the key concepts in relation to the expectations of the surgical process and recovery. Also, pictures or images that can assist the low-literacy patient or the patient with a language barrier are found on the patient care guide. Simple pictures or images and easily read words are necessary to increase the usability with all patients. Simplifying the guide ensures that a larger segment of the population understands the written information. Nurses realize that patients are often discharged before adequate education can take place and must rely on written educational materials to reinforce teaching. Use of patient care guides enhances the patient’s understanding and compliance with treatment plans.13 There are many obstacles to patient education, one being the hospital or same-day surgery process. After the decision to undergo surgery, the patient begins preparation by visiting the preadmission department. Much information is shared between the patient and the staff to facilitate the planned surgery. Ideally, patients should not feel rushed, overwhelmed, or confused by the bombardment of information, but often they do. At times, patients have taken time off from work, have small children with them, or do not feel well during this visit. They may become preoccupied with. thoughts of how this surgery will affect their home and work lives. Preoperative education must be conducive to teaching for learning to be effective. The day of surgery is frequently filled with hurried preparation for the surgical patient. A preoperative injection is often used to reduce anxiety and produce sedation that can alter the patient’s comprehension capability. The preoperative nurse is faced with the challenge to provide education to the patient and family during this phase. Postoperatively, patients may be anxious, in pain, and recovering from anesthesia that interferes with their ability to comprehend complex clinical information and learn self-care skills. Surgical same-day nursing units have high patient turnover
BUMGARNER
14
rates because of short stays. Shortened hospital stays may reduce costs, but the lack of time for patient teaching can place patients at risk for negative outcomes while challenging nurses to prioritize patient needs and care.14 Fragmented education, rapid movement through the various sites, and the physical and emotional stress and strain of surgery can reduce the “functional literacy” of patients.15 Functional literacy is the ability to apply what is read to everyday life. Doak et alI6 identified low-literacy skills as an obstacle to patient education. They state that “23 million American adults may not be able to comprehend what health professionals are talking about.“16 When people with low-literacy skills become ill and are hospitalized, they, like all patients, want to become well and prevent complications. Effective patient education is essential for positive outcomes for short-stay surgical patients. Using patient care guides is a method of providing organized, easily understood information to patients. Clinical care maps are typically written for health care providers and contain medical terminology unfamiliar to patients and families. Patient care guides must be developed in lay terms so that patients and famihes can understand and use the information. Transforming clinical care maps into patient care guides fosters patient involvement in the educational process and provides the information for which they are so eager. l3 LAPAROSCOPIC CHOLECYSTECTOMY PATIENT CARE GUIDE DEVELOPMENT AND EVALUATION
Development of a patient care guide for the patient undergoing laparoscopic cholecystectomy reflects the application of the clinical care map concept to education. Typically, the patient undergoing laparoscopic cholecystectomy is discharged the day of surgery or early the first postoperative day. As more surgical procedures are performed laparoscopically, nurses are becoming aware of the special needs of patients who are discharged early. These patients must be prepared to “nurse” themselves at home based on the education they receive. Shortened stays challenge the nursing staff to provide comprehensive patient education in an environment that may be less than ideal. The nursing coordinator in an ambulatory surgery center in a 260-bed community hospital assessedthe need for a guide (Fig 1) to use with the
AND EVANS
patient undergoing laparoscopic cholecystectomy. Rapid movement through the health care system before surgery, a large number of different people providing education to the patient and family, and variations in the length of time that patients remained in the hospital postoperatively contributed to the fragmentation of perioperative education for this patient population. In addition, some patients were discharged on the day of surgery while others remained hospitalized. To clearly identify gaps in education and to make decisions about what to include on the patient care guide, data were collected from a variety of sources. Physicians’ offices were contacted to determine what information was being provided preoperatively. Several patients undergoing laparoscopic cholecystectomy were followed through the system on the day of surgery, and patient teaching was observed at different points on the care continuum. Printed educational materials and methods of patient teaching currently in use were reviewed. Data were used to develop a proposed patient care guide. A poster presentation approach was used with all hospital nursing staff involved with educating the patient undergoing Iaparoscopic cholecystectomy during hospitalization to inform them of the proposed patient care guide project. Input was sought from the surgeons performing the procedure at the hospital. After this, an initial proposal for the patient care guide was developed and presented to the hospital’s Patient and Family Education Committee. This committee is a multidisciplinary team that oversees patient education for every discipline in the hospital. The committee corroborated the issues identified with education for short-stay surgical patients, particularly those undergoing laparoscopic cholecystectomy, and supported development of the patient care guide. Steps in the development process included identification of topics to be addressed, determination of appropriate graphic symbols to match each topic, and writing of specific content. Graphics closely linked to content areas help patients locate the necessary information quickly. Content was written at an eighth grade reading level, the level at which the average person reads.16 Preadmission nurses, surgeons, and postoperative care nurses served as consultants. Content was limited to information agreed to be essential for all patients undergoing the procedure. Collaboration with other
Fig 1.
Patient
care guide
developed
for patients’
undergoing
laparoscopic
for pain.
cholecysectomy.
*Ask your doctor or nurse.
*You may take medicines
ill be put in your hand or
(Printed
with
permission
*Eat light, low-fat meals. Drink a lot of fluids -Eat normal meals after the 1st day as you can.
YOUR GALLBLADDER OPERATION (Laparoscopic Cholecystectomy)
from
Catawba
Memorial
Hospital,
u m?y still need medicine
food and drink
Hickory,
NC.)
*Your incisions should be healed. There may be some soreness.
-Normal food and drink
BUMGARNER
16
members of the health care team encourages “buyin” to the concept of using a patient care guide and “ownership” of the final product. Standards of care are also more likely to be met when the patient care guide is a collaborative effort. The patient care guide is not meant to stand alone. It should be part of the overall patient and family education plan. There should be space on the patient care guide to write additional material as needed to individualize the care guide. The patient care guide in Figure 1 has been reduced in size. To use with patients, additional space is provided. Keeping the patient care guide with the patient throughout the perioperative period permits individualization of the guide at any time. Evaluation of the patient care guide was interwoven throughout the planning and implementation process. Feedback from surgeons and nursing staff was used during the initial development phase to refine the patient care guide. The guide was then pilot tested with a selected group of laparoscopic cholecystectomy patients. Patients were able to comply with the treatment plan. Patients felt confident in
AND EVANS
managing their care at home and reported a high level of satisfaction. CONCLUSION
The patient care guide for the patient undergoing laparoscopic cholecystectomy is designed to provide comprehensive, easy-to-read, visually appealing educational material to patients. The guide mirrors a clinical care map but uses patient-friendly language and images. It provides concrete and factual information describing expectations beginning with the day before surgery and concluding 2 weeks postoperatively. Shortened hospital stays, early discharge, the hospital process, fragmented education, and low literacy have been identified as obstacles to teaching and learning. A well-designed patient care guide provides vital information to patients and serves as a teaching guide for perioperative nurses. Empowering patients through education enables the perioperative staff to meet the demands of health care consumers to shorten hospital stays, decrease costs, and decrease recovery times as evidenced by positive outcomes.
REFERENCES 1. Kleinbeck SV, Hoffart N: Outpatient recovery after laparoscopic cholecystectomy. AORN J 60:394-402, 1994 2. Turner LJ: Putting patient education on a new path. RN 58:42-44,1995
3. Adams DE, Biggerstaff N: Reduced resource utilization through standardized outcome-focused care plans. J Nurs Adm 25:43-49,1995 4. Bums JM, Tiemey DK, Long GD, et al: Critical pathways for administering high-dose chemotherapy followed by periphera1 blood stem cell rescue in the outpatient setting. Oncol Nurs Fomm 22:1219-1224,1995 5. Capuano TA: Clinical pathways: Practical approaches, positive outcomes. Nurs Manager 26:34-37, 1995 6. Newel BA: Our new system makes nurses better teachers. RN 57:21-24, 1994 7. Patterson P: Critical pathways care paths cut length of stay, reduce charges. OR Manager 10:12, 1994
8. Stahl DA: Critical pathways in subacute care. Nurs Manager 26:16-18, 1995 9. Windle PE: Critical pathways: An integrated documentation tool. Nurs Manager 25:80F80P, 1994 10. Yetter D: Critical pathways in the emergency department. Nurs Manager 26:60-62,1995 11. Zander K, McGill R: Critical and anticipated recovery paths: Only the beginning. Nms Manager 25:34-40, 1994 12. De Jong RL: This path has pictures. RN 5844-45, 1995 13. Guthrie S: To involve patients in their care, give them user-friendly critical paths. Patient Educ Manager 2:105-116, 1995
14. Rankin SH, Stalling KD: Patient Education Issues, Principles, Practices. New York, NY, Lippincott, 1990 15. London F: Teach your patients faster, better. Nursing 95 25:68-70,1995
16. Doak Low Literacy
CC, Doak LG, Root JH: Teaching Skills. Philadelphia, PA, Lippincott,
Patients 1996
with
T
HE DELIVERY site of postoperative care has shifted from the hospital into the community. Advanced technology is available and supports the demands of health care consumers to shorten hospital stays, decrease costs, and decrease recovery time.’ Compliance with regimens and satisfaction with care result from a well-organized educational plan to meet the needs of short-stay surgical patients. Management of pain and nausea, care of incisions, dietary and activity needs, signs and symptoms of infection, and resources for questions or concerns are key concepts that each patient must understand on discharge. Nurses are challenged to provide education about these key concepts as effectively as possible. Well-informed patients tend to have less anxiety, lower postoperative pain
Susan D. Bumgamel: MSN, RNC, CPAN, is the Organizational Learning Director; at Catawba Memorial Hospital, Hickory, NC; and Marilyn L. Evans, PhD, RN, is an Associate Professor and Director of the BSN/MSN Outreach Programs, School of Nursing, The University of North Carolina at Greensboro, Greensboro, NC. Address correspondence to Susan D. Bumgamer; MSN, RNC, CPAN, 289 Harbor Dr; Taylorsville, NC 28681. 0 1999 by American Society of PeriAnesthesia Nurses. 1089-9472/99/1401-0003$03.00/0 12
levels, fewer complications, and quicker recoveries2 An effective perioperative educational plan for surgical patients empowers them by building their self-confidence, describing what they can expect to experience in the perioperative period, and offering reahstic management strategies for at-home self-care. LITERATURE
REVIEW
Clinical care maps are outcome-focused plans that offer a mechanism to health care providers to enhance quality of care while reducing costs or resource use.3 In health care, resource use refers to length of stay, number of clinical services provided, timing of services, and supplies used. In the acute care setting, clinical or outcome-focused care maps have proved successful in reducing length of stay, increasing patient satisfaction, decreasing documentation time, reducing costs, improving patient education, enhancing collaboration among health care providers, reducing readmissions and complications, conserving resources, and helping standardize practices.3-11 Clinical care maps, developed by interdisciplinary teams, are timed sequences of patient care interventions that are planned for achievable and desirable outcomes. There is no standardized plan Journalof
P&Anesthesia
Nursing,
Vol 14, No 1 (February),
1999: pp 12-76
CLINICAL
13
CARE MAP
for the development of a clinical care map. A common approach is to list the care interventions down the left side of the form, and the time sequence across the top. The desirable outcomes focus on the clinical aspects first and the financial aspects second. They serve to map the patient’s progress through a health care service.3 The use of clinical care maps has proven useful in promoting patient and family education. Patient and family education are integrated at every step of the clinical care map to teach patients about the treatment plan and expected outcomes. This integration stresses the importance of patient and family involvement in the delivery of care and the prevention of complications. Transforming clinical care maps into educational materials explains to the patient what will be taught at each step of the care map. De Jong I2 described using “pictorial pathways” that present concepts of education in simple pictures. The success of clinical care maps to guide health care providers, patients, and families through the process of healing efficiently and effectively served as the framework in the development of the patient care guide for laparoscopic cholecystectomy patients. The educational plan that was developed is called a patient care guide to promote patient understanding, rather than using clinical terminology such as found in clinical care maps. The patient care guide increases the quality of care for the laparoscopic cholecystectomy patient by empowering them through education. APPLICATION
OF THE CLINICAL MAP CONCEPT
CARE
A well-designed patient care guide, adapted from a clinical care map, provides vital information for the surgical patient and serves as a teaching guide for perioperative nurses. Clinical care maps used as patient education tools are called patient care guides and provide guided information for patient expectations. The use of patient care guides is helpful in promoting patient and family education. Patient and family education is integrated at every step of the patient care guide to teach patients about the treatment plan and expected outcomes. This integration stresses the importance of patient and family involvement in the delivery of care and the prevention of complications. It also promotes the achievement of clinical goals for the patient and
lowers costs by reducing lengths of stay and readmissions. Use of patient care guides contributes to decreased nursing time spent on documentation because the plan also serves as a documentation tool. Standardization of patient education is achieved through the use of teaching plans developed from clinical maps and has increased nursing staff satisfaction.6 A time-sequenced approach is used to map the key concepts in relation to the expectations of the surgical process and recovery. Also, pictures or images that can assist the low-literacy patient or the patient with a language barrier are found on the patient care guide. Simple pictures or images and easily read words are necessary to increase the usability with all patients. Simplifying the guide ensures that a larger segment of the population understands the written information. Nurses realize that patients are often discharged before adequate education can take place and must rely on written educational materials to reinforce teaching. Use of patient care guides enhances the patient’s understanding and compliance with treatment plans.13 There are many obstacles to patient education, one being the hospital or same-day surgery process. After the decision to undergo surgery, the patient begins preparation by visiting the preadmission department. Much information is shared between the patient and the staff to facilitate the planned surgery. Ideally, patients should not feel rushed, overwhelmed, or confused by the bombardment of information, but often they do. At times, patients have taken time off from work, have small children with them, or do not feel well during this visit. They may become preoccupied with. thoughts of how this surgery will affect their home and work lives. Preoperative education must be conducive to teaching for learning to be effective. The day of surgery is frequently filled with hurried preparation for the surgical patient. A preoperative injection is often used to reduce anxiety and produce sedation that can alter the patient’s comprehension capability. The preoperative nurse is faced with the challenge to provide education to the patient and family during this phase. Postoperatively, patients may be anxious, in pain, and recovering from anesthesia that interferes with their ability to comprehend complex clinical information and learn self-care skills. Surgical same-day nursing units have high patient turnover
BUMGARNER
14
rates because of short stays. Shortened hospital stays may reduce costs, but the lack of time for patient teaching can place patients at risk for negative outcomes while challenging nurses to prioritize patient needs and care.14 Fragmented education, rapid movement through the various sites, and the physical and emotional stress and strain of surgery can reduce the “functional literacy” of patients.15 Functional literacy is the ability to apply what is read to everyday life. Doak et alI6 identified low-literacy skills as an obstacle to patient education. They state that “23 million American adults may not be able to comprehend what health professionals are talking about.“16 When people with low-literacy skills become ill and are hospitalized, they, like all patients, want to become well and prevent complications. Effective patient education is essential for positive outcomes for short-stay surgical patients. Using patient care guides is a method of providing organized, easily understood information to patients. Clinical care maps are typically written for health care providers and contain medical terminology unfamiliar to patients and families. Patient care guides must be developed in lay terms so that patients and famihes can understand and use the information. Transforming clinical care maps into patient care guides fosters patient involvement in the educational process and provides the information for which they are so eager. l3 LAPAROSCOPIC CHOLECYSTECTOMY PATIENT CARE GUIDE DEVELOPMENT AND EVALUATION
Development of a patient care guide for the patient undergoing laparoscopic cholecystectomy reflects the application of the clinical care map concept to education. Typically, the patient undergoing laparoscopic cholecystectomy is discharged the day of surgery or early the first postoperative day. As more surgical procedures are performed laparoscopically, nurses are becoming aware of the special needs of patients who are discharged early. These patients must be prepared to “nurse” themselves at home based on the education they receive. Shortened stays challenge the nursing staff to provide comprehensive patient education in an environment that may be less than ideal. The nursing coordinator in an ambulatory surgery center in a 260-bed community hospital assessedthe need for a guide (Fig 1) to use with the
AND EVANS
patient undergoing laparoscopic cholecystectomy. Rapid movement through the health care system before surgery, a large number of different people providing education to the patient and family, and variations in the length of time that patients remained in the hospital postoperatively contributed to the fragmentation of perioperative education for this patient population. In addition, some patients were discharged on the day of surgery while others remained hospitalized. To clearly identify gaps in education and to make decisions about what to include on the patient care guide, data were collected from a variety of sources. Physicians’ offices were contacted to determine what information was being provided preoperatively. Several patients undergoing laparoscopic cholecystectomy were followed through the system on the day of surgery, and patient teaching was observed at different points on the care continuum. Printed educational materials and methods of patient teaching currently in use were reviewed. Data were used to develop a proposed patient care guide. A poster presentation approach was used with all hospital nursing staff involved with educating the patient undergoing Iaparoscopic cholecystectomy during hospitalization to inform them of the proposed patient care guide project. Input was sought from the surgeons performing the procedure at the hospital. After this, an initial proposal for the patient care guide was developed and presented to the hospital’s Patient and Family Education Committee. This committee is a multidisciplinary team that oversees patient education for every discipline in the hospital. The committee corroborated the issues identified with education for short-stay surgical patients, particularly those undergoing laparoscopic cholecystectomy, and supported development of the patient care guide. Steps in the development process included identification of topics to be addressed, determination of appropriate graphic symbols to match each topic, and writing of specific content. Graphics closely linked to content areas help patients locate the necessary information quickly. Content was written at an eighth grade reading level, the level at which the average person reads.16 Preadmission nurses, surgeons, and postoperative care nurses served as consultants. Content was limited to information agreed to be essential for all patients undergoing the procedure. Collaboration with other
Fig 1.
Patient
care guide
developed
for patients’
undergoing
laparoscopic
for pain.
cholecysectomy.
*Ask your doctor or nurse.
*You may take medicines
ill be put in your hand or
(Printed
with
permission
*Eat light, low-fat meals. Drink a lot of fluids -Eat normal meals after the 1st day as you can.
YOUR GALLBLADDER OPERATION (Laparoscopic Cholecystectomy)
from
Catawba
Memorial
Hospital,
u m?y still need medicine
food and drink
Hickory,
NC.)
*Your incisions should be healed. There may be some soreness.
-Normal food and drink
BUMGARNER
16
members of the health care team encourages “buyin” to the concept of using a patient care guide and “ownership” of the final product. Standards of care are also more likely to be met when the patient care guide is a collaborative effort. The patient care guide is not meant to stand alone. It should be part of the overall patient and family education plan. There should be space on the patient care guide to write additional material as needed to individualize the care guide. The patient care guide in Figure 1 has been reduced in size. To use with patients, additional space is provided. Keeping the patient care guide with the patient throughout the perioperative period permits individualization of the guide at any time. Evaluation of the patient care guide was interwoven throughout the planning and implementation process. Feedback from surgeons and nursing staff was used during the initial development phase to refine the patient care guide. The guide was then pilot tested with a selected group of laparoscopic cholecystectomy patients. Patients were able to comply with the treatment plan. Patients felt confident in
AND EVANS
managing their care at home and reported a high level of satisfaction. CONCLUSION
The patient care guide for the patient undergoing laparoscopic cholecystectomy is designed to provide comprehensive, easy-to-read, visually appealing educational material to patients. The guide mirrors a clinical care map but uses patient-friendly language and images. It provides concrete and factual information describing expectations beginning with the day before surgery and concluding 2 weeks postoperatively. Shortened hospital stays, early discharge, the hospital process, fragmented education, and low literacy have been identified as obstacles to teaching and learning. A well-designed patient care guide provides vital information to patients and serves as a teaching guide for perioperative nurses. Empowering patients through education enables the perioperative staff to meet the demands of health care consumers to shorten hospital stays, decrease costs, and decrease recovery times as evidenced by positive outcomes.
REFERENCES 1. Kleinbeck SV, Hoffart N: Outpatient recovery after laparoscopic cholecystectomy. AORN J 60:394-402, 1994 2. Turner LJ: Putting patient education on a new path. RN 58:42-44,1995
3. Adams DE, Biggerstaff N: Reduced resource utilization through standardized outcome-focused care plans. J Nurs Adm 25:43-49,1995 4. Bums JM, Tiemey DK, Long GD, et al: Critical pathways for administering high-dose chemotherapy followed by periphera1 blood stem cell rescue in the outpatient setting. Oncol Nurs Fomm 22:1219-1224,1995 5. Capuano TA: Clinical pathways: Practical approaches, positive outcomes. Nurs Manager 26:34-37, 1995 6. Newel BA: Our new system makes nurses better teachers. RN 57:21-24, 1994 7. Patterson P: Critical pathways care paths cut length of stay, reduce charges. OR Manager 10:12, 1994
8. Stahl DA: Critical pathways in subacute care. Nurs Manager 26:16-18, 1995 9. Windle PE: Critical pathways: An integrated documentation tool. Nurs Manager 25:80F80P, 1994 10. Yetter D: Critical pathways in the emergency department. Nurs Manager 26:60-62,1995 11. Zander K, McGill R: Critical and anticipated recovery paths: Only the beginning. Nms Manager 25:34-40, 1994 12. De Jong RL: This path has pictures. RN 5844-45, 1995 13. Guthrie S: To involve patients in their care, give them user-friendly critical paths. Patient Educ Manager 2:105-116, 1995
14. Rankin SH, Stalling KD: Patient Education Issues, Principles, Practices. New York, NY, Lippincott, 1990 15. London F: Teach your patients faster, better. Nursing 95 25:68-70,1995
16. Doak Low Literacy
CC, Doak LG, Root JH: Teaching Skills. Philadelphia, PA, Lippincott,
Patients 1996
with