Paterick et al (2017) argued that receiving education regarding a condition is the key to patients achieving positive health outcomes and engaging in treatment. The Nursing and Midwifery Council (NMC) Code requires that nurses respect the impact people can have on their own health. Subsequently, nurses should work in partnership with people, assisting them to access relevant health information when needed (NMC, 2018).
The aim of this quality improvement project was to improve patients' knowledge about their vitamin B12 deficiency by creating an information leaflet and engaging nursing staff in providing this educational tool to patients with the condition. An increase in patient knowledge following provision of the leaflet was predicted. The project targeted patients with vitamin B12 deficiency attending regular appointments. As part of their treatment regimen, patients attending the treatment room received intramuscular hydroxocobalamin injections administered by nursing staff.
Patients with a vitamin B12 deficiency should receive education on their condition as part of its management (Orton, 2012). A vitamin B12 deficiency can cause a variety of symptoms, such as fatigue, glossitis and neurological manifestations (Langan and Goodbred, 2017). Through an initial patient questionnaire, with a sample of 105 patients, it was established that patients' knowledge about their condition was very low. Additionally, a baseline audit measuring whether nurses were providing vitamin B12 deficiency information to patients showed only 10% compliance. Furthermore, nursing staff reported not having an educational tool available, and this resulted in the verbal information given to patients being inconsistent and not always evidence based.
Following these results and discussions with the nursing staff, a solution to the problem was established: creating an educational leaflet to provide patients with increased knowledge about their condition. The use of information leaflets increases patient knowledge and satisfaction, according to a systematic review conducted by Sustersic et al (2017). Moreover, the use of these leaflets has been associated with increased adherence to treatment (Sustersic et al, 2017). The nursing role has evolved throughout the development of the profession, and evidence suggests that well-trained nurses can have a substantial effect on patients' satisfaction and adherence to treatment (Coster et al, 2018).
Planned changes tested
To devise the processes to test nurse compliance in providing educational information to patients and the solutions to improve this, it was considered important to understand why educational information was not being provided to patients. During the first 5 weeks of the project, observing practice and meeting with the nursing staff helped the researchers evaluate the problem. Baseline data on nurses' compliance with providing information to patients with vitamin B12 deficiency were measured via weekly audits in a 2-week period. The result of this showed a low compliance of only 10%. This information was organised, and a fishbone diagram was created to display and analyse the underlying causes of the problem. The identified common reasons why nurses were not providing patients with educational information were the lack of educational material available and the lack of structure on when and what information to give patients. The creation and introduction of an educational leaflet was considered as a beneficial solution. The leaflet was created using information from the NHS website (2019) on a vitamin B12 deficiency. It also incorporated a lifestyle advice section, as diet and smoking have been associated with development of vitamin B12 deficiency (Damayanti et al, 2018; Laird et al, 2018) (Box 1).
Following the Model for Improvement (Langley et al, 2009), a plan was created that set the outcome, process and balancing measures for the project. The desired outcome was 100% compliance of nurses providing educational information to patients with vitamin B12 deficiency. Further, patients' knowledge was expected to increase after receiving the leaflet. Additionally, a balancing measure was set to measure if receiving the leaflet had any effect on patients' desire to change aspects of their lifestyle to benefit their condition.
Two plan, do, study, act (PDSA) cycles were run to test the introduction of the leaflet. PDSA cycle 1 was developed in week 6, and nurses were asked to give a leaflet to every patient with vitamin B12 deficiency who wanted information. A folder with printed leaflets was positioned on the shelves at the nurses' desks in the three treatment rooms. Compliance of nurses providing educational information was measured through weekly audits. The results of this PDSA cycle over a 3-week period showed a mean of 67% compliance compared with the 10% compliance at baseline. This was a significant increase, but as it did not meet the goal of 100% compliance, a second PDSA cycle was initiated in week 9. Through discussion with nursing staff, it was recognised that some nurses were not handing out the leaflet on occasion because there was no visual prompt to the location of the leaflets. Therefore, the printed leaflets were positioned in the three treatment rooms in a clear pocket stuck to the notice board located directly above the injection trolley. This was to provide a visual prompt when the nurse was about to administer a hydroxocobalamin injection. This change resulted in the mean compliance increasing to 93% during the 3-week period. The goal of 100% compliance was consistently met in the last 2-week period of this cycle.
During the 6-week period running the two PDSA cycles, post-intervention questionnaires were administered to a sample of 25 patients in total, who had received the leaflet from the nurses and completed the baseline questionnaire in the first 5 weeks of the study. The results were analysed and showed a significant increase in patients' mean knowledge score after receiving the leaflet. This met the aim of improving patient knowledge with the use of an educational leaflet. Additionally, the balancing measure recorded in the post-intervention questionnaire showed positive results, as a number of patients expressed the desire to change aspects of their lifestyle to benefit their condition after reading the leaflet, such as incorporating foods with vitamin B12 into their diet, attending appointments for injections regularly and reducing smoking.
Nurses' and patients' views on the usefulness of the leaflet were also compiled. Patients' views were gathered in the post-intervention questionnaire, which showed they rated the usefulness of the leaflet a mean of 9.28 on a scale of 0–10. Nurses' views and comments were collected during the two PDSA cycles and the final meeting following the test, where they reported that they found the leaflet extremely useful and that it assisted them in providing reliable education to patients in a timely manner. They were also very happy with the effect the leaflet had on patient knowledge and desire to change aspects of their lifestyle to benefit their condition.
Data
The run chart (Figure 1) displays percentage compliance of nurses providing B12 information to patients. Baseline compliance measured during weeks 4 and 5 was at 10%. The goal was to accomplish 100% compliance during the following 6-week period. PDSA cycle 1 introduced leaflets in folders, increasing percentage compliance to a mean of 67% during weeks 6–8. Although there was a substantial increase in compliance, the data points at weeks 6 and 8 were below the median. PDSA cycle 2 with leaflets positioned on notice boards increased percentage compliance to a mean of 93% during weeks 9 to 11. All data points during this period were above the median. The 100% compliance goal was reached consistently during weeks 10 and 11.
Figure 2 shows the mean vitamin B12 knowledge score (on a scale of 0–10) in a patient sample before and after receiving the leaflet. The baseline data show that the mean knowledge of a sample of 105 patients was 2.21 during the 5-week period before introduction of the leaflet. The score in a sample of 25 returning patients shows that after introduction of the leaflet, knowledge scores increased to a mean of 7.96 during the 6-week period of running PDSA cycles 1 and 2, when the leaflet had been introduced. This was a substantial increase of 5.75 in mean knowledge score.
Figure 3 shows the balancing measure of desire to change aspects of lifestyle after reading the leaflet—data were gathered in the post-intervention questionnaire from a sample of 25 patients during PDSA cycles 1 and 2.
Discussion
Nurses should work in partnership with people, assisting them to access relevant health information when they need it (NMC, 2018). This quality improvement project achieved the aim of improving the knowledge of patients with vitamin B12 deficiency. Following the introduction of a new leaflet, the nursing team met the goal of 100% compliance in providing educational information to patients, in the last 2-week period. Further, receiving the educational leaflet led to an increase of 5.75 in the mean knowledge score of a sample of patients. The balancing measure results showed that 36% of patients reported wanting to change aspects of their lifestyle to benefit their condition after having received the leaflet. Thus, the improvement in patients' knowledge achieved the desired person-centred care approach while building a therapeutic relationship to increase satisfaction and involvement in care (Doherty and Thomson, 2014). The preliminary results were successful, although gathering follow-up data would have been beneficial in assessing whether or not the change is sustainable.
Arrangements for hand-over of the project were discussed and organised with the nursing team at the final meeting during the last week of placement. The leaflet was saved on the computers of the treatment rooms to print as needed. The nurses reported feeling motivated to keep providing the educational leaflet to any patients who required information, and they said that they were happy with the visual prompt of placing the leaflets on the notice boards above the injection trolley. When newly diagnosed patients or new patients with vitamin B12 deficiency first visited the treatment room, nurses would systematically provide them with the leaflet and discuss any queries. Further, the community and district nursing team showed great interest in the leaflet, as they, too, had patients with vitamin B12 deficiency on their caseload. Going beyond the scope of the original project, the leaflet was put on the electronic community-shared folder so that the community nursing staff had easy access to it. Nursing staff were very positive and enthusiastic about the use of the tool on a day-to-day basis in the treatment room and beyond. However, continued implementation following the quality improvement project cannot be guaranteed without further monitoring of compliance. Therefore, nurses were provided with the audit form and run chart to continue monitoring compliance.
Conclusion
The introduction of a new patient leaflet on vitamin B12 deficiency produced a favourable improvement in the knowledge of patients attending treatment rooms for hydroxocobalamin injections. In view of the success rate obtained in this project, the use of this educational tool in caring for patients with vitamin B12 deficiency might be beneficial in other healthcare settings, such as the community and acute care.