Nurses' attitude to patient education barriers in educational hospitals of Urmia University of Medical Sciences.

BACKGROUND: The purpose of this study was to explore nurses' attitudes to the barriers of patient education as a right for getting information based on work situation of nurses, educational facilities in hospitals, and patients' situation.
MATERIALS AND METHODS: The study was conducted using a cross-sectional design. The populations consisted of 240 nurses affiliated in the Educational Hospitals. The data were gathered by a questionnaire. Demographic variables and three domains were studied. Twenty questions were about their working situation, 4 questions about hospital educating facilities, and 12 questions were about patients' situation in hospital. The type and frequency of education barriers were evaluated, and variables associated with reporting an obstacle were analyzed.
FINDINGS: In our questionnaire, we used a Likert scale for determining severity of three domains as the barriers of patient education that ranged from 0 to 4. Generally, it was obvious that educational condition in our hospitals was not good and most of the nurses believed that patient education is not their duties, facilities in hospitals are not sufficient and shortness of time is the most important cause of insufficiency of patient education.
CONCLUSIONS: The interactions of patient, physician and systemic factors have implications for the implementation of patient education. The failure of adequate patient education may be attributed to the lack of patient adherence, the failure of nurses' knowledge and skill level or the insufficient funding and organization of necessary programs in the current health care system.

INTRODUCTION

The number of patients has increased dramatically during recent years. Hospitalization, which is the major health care cost in community, consumes a considerable part of the health care budget in general.[1] Good education skills and strategies are particularly important in the diagnosis, treatment and management of diseases.[2] Few studies have explored the contextual dimensions and subsequent interactions that contribute to a lack of adherence in the application of guidelines for patient education that is the cornerstone of care for all patients with acute or chronic diseases. Patients’ education is a fundamental aspect of patient care and yet poor education is the most common source of patient's complaints in the health-care sector. Other work indicates that miscommunication in education often occurs because of cultural differences between the communicator and recipient. Problems of miscommunication and language may not only influence treatment but may also contribute to the reinforcement of stereotyped behavior.[3] There are increasing pressures within primary care requiring a rethink of roles, responsibilities and skill mix. The use of suitably trained nurses to extend their sphere of responsibility may be an appropriate way to manage the demand without compromising quality or patient satisfaction.[4]

Patient education is an essential nursing practice standard that meaningfully impacts a patient's health and quality of life. Education process is a systematic, sequential, logical, planned course of action consisting of two major interdependent operations, teaching and learning.[5] The education process has been compared to the nursing process as the steps of each process run parallel to one another.[3]

To provide thorough and appropriate education, each patient requires an ongoing teaching plan. Education is used to empower the patient and is an important aspect of quality improvement given that it has been associated with improved health outcomes. The nurses’ role has undergone historical change, shifting from imparting disease-oriented health education toward empowering patients to use their own resources to attain health. Essentials for effective patient education include use of an open communication style, written instructions and addressing barriers.[2] Demographic variables, such as ethnic background, formal education level, reading ability, and barriers to participation in education must be considered to maximize the effectiveness of self-management education outcomes. Nurses’ attitude to patient education barriers can help to elimination of many problems for practitioners who are well suited to provide care that facilitates behavior change and health-oriented patient education.[6]

The process of patient education can be described in 5 steps: 1) assessment of the patient's previous knowledge, misconceptions, learning abilities, learning styles, cognition, attitudes and motivation. This can be done through an interview, a chart review and tests. 2) The patient's recourses, barriers and learning needs can be diagnosed. 3) The planning of the education and goals are set and educational interventions are chosen. In the planning phase, the type of education, the frequency, who will deliver the education and when and how it should be given, should also be addressed. 4) Delivery of the education and 5) the evaluation.[7]

Historically, the teaching role of nurses within medical education has been largely unrecognized, although in the clinical ward areas expert nurses frequently educate and induct newly qualified doctors into routines and procedures. Barriers cited in the literature to adherence to guidelines for diseases management include: a need for education, lack of time and lack of confidence in clinical skills, complexity, and a need for effective charting systems. With patients requesting for information that is relevant to their own disease or recovery process, nurses must focus their attention on patient-tailored information resources, seeking information from a variety of resources including colleagues, the patient record, or other high quality sources.[8] The purpose of our study was to assess nurses’ attitude to patient education barriers in educational hospitals.

MATERIALS AND METHODS

Urmia city which is located in north-west of Iran, has a population of 3200000 individuals. During 2009-2010, this cross-sectional study was carried out. The study population was all nurses who work in university affiliated hospitals of Urmia. Census method was used for sampling and all nurses who filled the questionnaire entered into the study.

The data was gathered with a two part questionnaire: The first part included demographic variables such as age, marriage situation, ward, employment duration and kind of their shifts The second part assessed their attitudes to barriers of participation in education. Three domains were studied; 20 questions for their working situation, 4 questions for hospital educating facilities and 12 questions for patients’ situation in hospital. We used Likert scale for determining severity of three domains as the barriers of patient education ranged from 0 to 4.

The validity of the questionnaire was confirmed by content validity. Its reliability was assessed by internal consistency as Cronbach's alpha calculation was 0.89 and test-retest reliability was 0.91. After explaining how to fill in the questionnaire, the researcher asked the participants to complete it. Data were analyzed by SPSS version 16 and descriptive statistics used to show the barriers. In addition, we declare that have no conflict of interest in this study and subjects were surveyed in agreement with the research ethics.

FINDINGS

In general, 240 nurses were studied. Most of the participants (82.5%) were female, and duration of working was 1-5years in the most subjects. The age average was 32.39 (SD=6.2) years and most of them were in 30-35 years age group and 102 (72.8%) subjects worked in rotating shifts.

It was obvious that the education condition in our hospitals was not good and most of nurses believed that patient education was not their duty. Participants believed hospital facilities were not sufficient and shortness of time was the most important cause of insufficiency of patient education. Most of nurses (73.6%) were unaware about patient education importance and patient education in their job promotion was not important.

The most important barriers of patient education regarding nurses working situation were low knowledge of nurses about importance of education, feeling of ineffectiveness of it in quality of treatment, lack of interest of nurses to participation in patients’ education. It was also appeared that salary insufficiency was not so important.

The most important barriers of patient education in terms of hospital educating facilities were lack of educational resources and shift rotation. Regarding patients’ situation in hospital, the most important barriers were lack of interest in patients for learning, insufficiency of hospitalization time, patient inconvenience and feeling of lack of importance of learning in hospital. Table 1 shows the most common answers of nurses to patient educational barriers and scores.

Table 1

The mean scores based on the most common answers of nurses to patient educational barriers

DISCUSSION

Any combination of educational barriers might interfere with the plan being relevant and timely for the targeted learner. Education, often delivered by nurses, is an important part of all management programs for patients, both in clinical practice and research.[9] Patient education includes all educational activities directed at patients, including aspects of therapeutic education, health education and clinical health promotion.[10] It is obvious that interventions at multiple levels that address the demographic and socioeconomic obstacles to education are needed to ensure successful self-management training or self-efficacy.

It is interesting to note that many study participants expressed concerns with aspects of the primary care process that are typical of more generally held concerns about health care changes resulting from the “managed care revolution”. Perceptions that physicians and nurses are hurried and do not have the time to stop and talk with or listen to patients echo a common theme in discussions of contemporary health care quality.[11]

The interactions of patient, physician, nurse and systemic factors have implications for the implementation of patient education. The failure to education adequately for patients may be attributed to a lack of patient adherence, a failure of personnel knowledge and skill level, or insufficient funding and organization of necessary programs in the current health care system. However, our findings suggest that no single player is at fault and, with education; the integration of the three factors relevant to patients care is achievable through implementation of a patient education model. Interventions at multiple levels that address the demographic and socioeconomic obstacles to patient education are needed to ensure successful self-management training. In summary, essential principles for the education role include: acknowledge control as belonging to the patient, dialogue rather than monologue, use language the patient can understand, not overload with verbal instructions, use memory aids such as written instructions and mailed reminders, and suggest specific helps.[12]

Patients in hospital need education in order to adapt to their condition and perform self-care behavior. Despite the fact that many patients received education and perceived information about their treatment as important, they had low levels of knowledge and lacked a clear understanding of why they had developed diseases, how it was defined and what relevant self-care behavior should be performed. It is important to target barriers to learning such as functional and cognitive limitations, misconceptions, low motivation and self-esteem. Health care professionals need to be skilled in assessing the requirements and the level of education given to the individual. Education can be further improved by combining clinical experience with new technologies and nurse managers and must explicitly support the patient-teaching role of the inpatient nurses upon their employment, by providing the resources they need and rewarding their efforts.[13]

Continuing education for nurses during new employee orientation programs and periodically thereafter can include information applicable to ambulatory care. This will allow hospital nurses to convey accurate information to patients regarding their care after discharge. Continuing education offerings afford an opportunity to address the additional barriers for nurses who want to improve outcomes for their patients.[14] It is important that nurses develop and master information seeking skills so that they can access and find information resources they can offer directly to patients and caregivers. Some patients and caregivers, however, may doubt that their information needs are adequately addressed because the resources may not be available on the clinical unit.[15]

We believe our findings have exposed concerns that are likely to be held in similar general practice groups across the country and suggest that before nurses’ roles can become widespread, these concerns need to be addressed. Indeed, qualitative work amongst nurses may demonstrate equivalent concerns within the nursing profession. The exploration of professional attitudes towards the employment of nurse practitioners is an essential precursor to a debate about how barriers may be overcome, and about the appropriate skill mix and employment arrangements required to manage primary health care services in the future.