Patient education among nurses: bringing evidence into clinical applicability in Iran

La educación al paciente entre las enfermeras: brindando evidencia en la aplicabilidad clínica en Irán

A educação ao paciente entre a enfermeiras: brindando evidência na aplicabilidade clínica no Irã

¹RN Ph.D. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email: karimih@mums.ac.ir.

²RN, PhD Candidate. Mashhad University of Medical Sciences, Mashhad, Iran. email: EmamiZA911@mums.ac.ir.

³RN, PhD. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email:mirhaghia@mums.ac.ir.

Receipt date: June 15, 2015. Approval date:December 4, 2015.

Conflicts of interest: none.

ABSTRACT

Objective.The aim of this study was to present a comprehensive review of the literatures describing barriers and facilitators of patient education (PE) perceived by Iranian nurses in order to explain clinical applicability of patient education. Methods. Review of the literature was undertaken using the international databases including PubMed/Medline, Scopus, ScienceDirect, as well as Google Scholar. Also, Persian electronic databases such as Magiran, SID and IranMedex were searched. Electronic databases were searched up from conception to September 2014 using search terms: "patient education", " patients education", "patient teaching", "patient training", "nurse", " nurses", " nursing", " and "Iran". Only studies were included that were related to barriers and facilitators of PE among Iranian nurses. Results. Twenty-seven studies were included. The main influential barriers were categorized into three major areas: 1) Nurse-related factors: nursing shortage 2) Administration-related factors: unsupportive organizational culture, and 3) Patient-related factors: low compliance. The most perceived facilitators were recognized as "increasing, selecting and training special nurses for providing PE" and "providing PE courses for nurses and appropriate facilities for PE". Conclusion. Iranian nurses encounter barriers in PE, and the most frequently encountered barriers were related to administration factors. These findings have implications for administrators and managers in health settings. In order to promote PE among nurses, administrators should create a supportive environment and use effective strategies to smooth the progress of PE by nurses in their practice in order to ensure optimal outcomes for patients.

Key words: patient education as topic; health services; nurses; Iran.

RESUMEN

Objetivo.Identificar las barreras y facilitadores de la Educación del Paciente (EP) percibida por las enfermeras iraníes con el fin de explicar la aplicabilidad clínica de la educación al paciente. Métodos. Revisión de la literatura que se llevó a cabo utilizando las bases de datos internacionales PubMed-Medline, Scopus, ScienceDirect y Google Scholar. Además, se realizaron búsquedas en las bases de datos electrónicas persas Magiran, SID e IranMedex. Se realizaron búsquedas desde la creación de las bases de datos hasta septiembre de 2014 usando los términos de búsqueda: "educación del paciente", "educación de pacientes", "enseñanza del paciente", "entrenamiento del paciente", "enfermera", "enfermeras", e "Irán". Solo se analizaron los estudios relacionados con las barreras y facilitadores de EP entre enfermeras iraníes. Resultados. Se incluyeron 27 estudios. Las principales barreras se clasificaron en tres grandes áreas: 1) Factores relacionados con la enfermería: escasez de este recurso humano, 2) Factores relacionados con la administración: inapropiada cultura organizacional y 3) Factores relacionados el paciente: bajo cumplimiento. Los facilitadores más percibidos se reconocieron como "el aumento, la selección y formación especial de las enfermeras para proporcionar EP" y "disponibilidad de cursos de EP para las enfermeras y la disponibilidad de instalaciones adecuadas  para brindar el EP". Conclusión. Las enfermeras iraníes encuentran barreras en la EP, siendo las más frecuentes  las  relacionadas con factores de la gestión de los recursos. Estos resultados tienen implicaciones para los administradores y directivos de las instituciones de salud, pues para promover que las enfermeras en su práctica brinden la EP, se debe crear un ambiente de apoyo y utilizar estrategias eficaces con el fin de garantizar resultados óptimos en los pacientes.

Palabras clave: educación del paciente como asunto; servicios de salud; enfermeros; Iran.

RESUMO

Objetivo.Identificar as barreiras e facilitadores da educação do paciente (EP) percebida pelas enfermeiras iranianas com o fim de explicar a aplicabilidade clínica da educação ao paciente. Métodos. Revisão da literatura que se levou a cabo utilizando as bases de dados internacionais PubMed-Medline, Scopus, ScienceDirect e Google Scholar. Ademais, se realizaram buscas nas bases de dados electrónicas persas Magiran, SID e IranMedex. Se realizaram buscas desde a criação das bases de dados até setembro de 2014 usando os termos de busca: "educação do paciente", "educação de pacientes", "ensinamento do paciente", "treinamento do paciente", "enfermeira", "enfermeiras", e "Irã". Só se analisaram os estudos relacionados com as barreiras e facilitadores de EP entre enfermeiras iranianas. Resultados. Se incluíram 27 estudos. As principais barreiras foram classificadas em três grandes áreas: 1) Fatores relacionados com a enfermagem: escassez deste recurso humano, 2) Fatores relacionados com a administração: inapropriada cultura organizacional y 3) Fatores relacionados o paciente: baixo cumprimento. Os facilitadores mais percebidos foram reconhecidos como "o aumento, a seleção e formação especial das enfermeiras para proporcionar EP" e "disponibilidade de cursos de EP para as enfermeiras e a disponibilidade de instalações adequadas brindar o EP". Conclusão. As enfermeiras iranianas encontram barreiras na EP, sendo as mais frequentes as relacionadas com fatores da gestão dos recursos. Estes resultados têm implicações para os administradores e diretivos das instituições de saúde, pois para promover que as enfermeiras em sua prática brindem a EP, se deve criar um ambiente de apoio e utilizar estratégias eficazes com o fim de garantir resultados ótimos nos pacientes.

Palavras chave:educação de pacientes como assunto; serviços de saúde; enfermeiras e enfermeiros; Iran.

INTRODUCTION

Patient education (PE) is a fundamental aspect of patient care and increasingly recognized as an essential function and one of the professional standards in nursing practice.¹ It is considered as a dynamic and continuous process including formal and informal interactive activities performed to improve patients' knowledge and behaviors in ways to achieve better health care outcomes.^2,3 There is a growing body of research evidence that illustrates the effectiveness of PE on enhancing patients' levels of empowerment, self-care behaviors, compliance with health care recommendations, satisfaction in health care settings, and quality of their life, and reducing their levels of anxiety.^3,4

Nurses are the largest group of the health care providers. They are at the forefront of patient care, and spend the most time with the patients and their family members.  This extensive contact provides excellent opportunities for providing patient and family education.² In addition, providing PE is both a legal and ethical responsibility of nurses.^5,6 For all these reasons, PE is considered to be an integral part of high quality nursing care.³ Despite increasing availability of research findings and broad consensus on the importance of PE, there are many barriers to nurses' capacity to provide effective PE.²   PE needs strict adherence to educational principles,⁷ so all variables that have an impact on teaching-learning process play an important role. Patients usually get involved in some type of limiting conditions that was imposed by their disease, aging and etc. Conditions such as functional and cognitive limitations, misconceptions, low motivation and self-esteem should be carefully addressed.⁸ Other factors such as environment, organization, interdisciplinary cooperation, collegial teamwork that are related to health care context also have unique role.⁵ However principles of education have been well-defined and widely recognized, environmental factors are unique in that significant differences exist among healthcare systems worldwide. Therefore it`s necessary to investigate contextual factors effects on PE. Some studies even called for special attention to changing the environment in which patients care for themselves.⁹ It has been clearly demonstrated that contextual factors as a glass ceiling barrier could play a big role in PE, so it makes sense to investigate contextual factors in different countries in order to reveal the extent of potential discrepancy.

In Iran, nursing is the largest healthcare profession which is directly responsible for the care of their patients and has a central role in PE.¹⁰ Nevertheless; PE is a growing concern for the Iranian healthcare system as well. The results of conducted studies about the topic in Iran have been demonstrated that the implementation of PE in nursing practice is often an undervalued intervention, thus poor education is one of the most common source of patient's complaints in the health-care sector.^3,6 A study with aim to evaluate Iranian nurses' perceptions about PE showed that the majority of nurses believed that one of the major and important parts of their responsibility in caring of patients in daily clinical practice is PE. Nevertheless, they give a lower priority to it as compared to other nursing tasks such as medication administration, physical patient care, nursing care planning and documentation.⁸ Because contextual and country-specific factors may influence the implementation of PE, it is important to study facilitators and barriers to PE specific to the Iranian context.^6,11,12 So the aim of the current study was to presents a comprehensive review of the literatures, exploring barriers and facilitators of PE among Iranian nurses, in order to identify strategies to promote enhanced PE within the Iranian healthcare system context.

METHODOLOGY

systematic search of the relevant literature were performed within international databases including PubMed/Medline, Scopus, ScienceDirect as well as Google Scholar search engine using the following search terms or their combinations: >"patient education", " patients education", "patient teaching", "patient training", "nurse", " nurses", " nursing", " and "Iran". These keywords equivalents in Farsi were searched in Persian electronic databases such as Iranian Journal Database (Magiran), Scientific Information Databases (SID) and IranMedex (Iranian Biomedical Journal Database). In addition, a hand search of article references was done to ensure completeness of the search. The search was limited to the English and Persian languages. Applying no time limit, all articles having the selected keywords in the title, abstract and text, including quantitative as well as qualitative approaches in Iranian context, from conception up to September 2014 were included and evaluated. The articles had to be focused on the barriers or facilitators of PE among Iranian nurses as inclusion criteria. We did not actively search the gray literature to find studies not in the peer-reviewed literature and excluded studies published exclusively in abstract form (e.g., conference proceedings), because they are not typically peer reviewed, and only partially report results which may change substantially when fully published.

The search strategy generated 4 000 titles and abstracts. After initial screening and evaluation by two researchers independently (HKM and AEZ), 3 933 articles were rejected and 67 articles were identified as potentially eligible for the review. These articles were retrieved for full text review. Removing duplicates and using secondary screening resulted in 26 articles to be included for the review. Also, a manual search of article references added a further one paper. In total, 27 peer-reviewed articles were eligible for final inclusion (Figure 1). Two authors independently extracted data from the studies including author and year, objective, method and data collection, sample and setting and key findings. Data were summarized into tables and compared to reveal organizing categories. Any disagreements were discussed and resolved by consensus. Extracted data were also coded and organized in order to facilitate analysis and weight categories. Coding process was employed using MaxQDA 10. This review included 27 studies which, including 20 that used quantitative designs, six that used qualitative designs, and one that used a mixed method design. All articles included in this review had been published between 2002 and 2014 and were published in peer-reviewed journals. Seven of the studies were conducted at the Tehran University of Medical Sciences affiliated hospitals. Sixty-two per cent (17 out of 27) of PE studies has only focused on barriers while 10 studies have reported both facilitators and barriers regarding PE simultaneously. Seventy-four per cent (20 out of 27) of PE studies have been designed cross-sectional descriptive method and other studies were used qualitative methods including content analysis (18%), grounded theory and mixed method. Researcher-generated questionnaire has been used by all quantitative research that they were content validated.

Most studies have used convenience or stratified sampling. Some of them included only participants who had at least two years work experience. Eighty per cent (22 out of 27) of studies have collected only nurses` viewpoints and only five studies have included in other participants such as physicians, patients and patients` family members. Ninety-nine per cent of total sample were nurses (4281 out of 4340). All studies have collected their data in hospital. Thirty per cent of studies were originated from capital city of Tehran as most common place and only three cities have involved in twice. Figure 1 includes a summary of the articles that were included in this review.

Figure 1.

RESULTS

Perceived barriers to PE
The main barriers reported in the most papers can be categorized in three overall areas: 1) Nurse-related factors 2) Administration-related factors and 3) Patient-related factors. Overall, nurses have placed greater emphasis on nurse and administration related factors and less on patient-related factors.

Nurse-related factors. The most reported barrier in this area was "nursing shortage, excessive workload and inadequate time". The other barrier was "lack of knowledge among nurses about PE" including "lack of awareness of nurses about educational methods and teaching/learning principles", "lack of awareness and appropriate knowledge of nurses regarding patient's educational needs", "insufficient attention of nurses to the educational, cultural and habitual needs of patients and their families", "negative attitude to PE", "believing that patient teaching is not nurses responsibility", "lack of knowledge about illness" and " nurses' lack of communication skills".
 
Administration-related factors. The most barriers that perceived by nurses in this area were "inappropriate organizational culture" and "inappropriate place and facilities for PE". Nurses believed that there is not a supportive culture among managers as well as hospitals, so there is no effective management and collaboration either. They have reported "inadequate support from the managers", , "lack of appropriate educational facilities in hospital", "lack of specialized nurse for PE", "no division of labor", "lack of financial incentives for nurses",  "poor cultural adaptation for  educator and patients in terms of sex", "lack of coordination by other members of the healthcare professionals with nurses" and "lack of evaluating PE activities".

Patient-related factors. The main patient-related barrier perceived by nurses in PE was patients have low compliance and readiness to receive PE. This barrier includes "Patient's low literacy or illiteracy", "lack of awareness of patients about the educational responsibility of nurses", "knowledge deficit of patient about their rights", "lack of patients' interest to change their behavior", "inconsistencies in the culture, social and mental status of patients and their families", and "unwillingness to adhering to comments" were the most perceived barriers in this area. 

Perceived facilitators to PE

DISCUSSION

There is a growing body of research literature that focuses on the barriers to and facilitators of PE perceived by nurses in Iran. The result of the present review showed that the inadequate time and nursing staff, heavy workload, inadequate support of managers, inappropriate organizational culture, and lack of appropriate educational facilities in hospital were reported as an administration related barriers to PE by Iranian nurses. The findings were supported by other studies have been conducted in other countries such as United States, China and Colombia that pointed out the nurses' heavy workload as a major barrier to PE.^38-41 Also the result of the study by Barret et al. referred to additional time to teach patients, more educational materials, peers feedback regarding teaching effectiveness, and sufficient medical information as effective factors for PE based on nurses' perspective.⁴² Nursing shortage is a serious issue in many Asian countries such as Iran; and nurses are practicing under an overwhelming workload.^43,44 This issue results in less nurses being available for patients, and the resulting time restriction dissuade the nurses from providing the education for their patients.⁴⁵ In addition to the unbalanced nurse-patient ratio due to nurse shortage and large number of hospitalized patients, nurses are expected to do nonprofessional tasks such as coordinating, transporting patients and performing ancillary services which leading to increased workload. This excessive workload definitely affects the nurses' decision to allocate enough time to various tasks such as communicating with patients and their education.^46,47 The results of a study by Park et al. has been shown that although nurses consider PE as an essential part of their care planning, in the face of work limitations, they are not able to provide their education as needed. Also, patient education is basically informal and reactional. Therefore, this activity can be considered as a low priority when nurses faced with time limitations.²

Inadequate support of managers, particularly in case of appropriate time allocation for nurses' teaching activities and ineffective coordination of educational responsibilities among disciplines is a barrier to PE.^38,48 Managerial and organizational support is an important element for the implementation of high-quality PE.^49,50 The result of a study that was conducted in Iran showed that nurses were well informed of the importance of patient education and had accepted this role in clinical settings, but no managerial support was available to them for doing this activity.³ Moreover, other studies showed that hospital managers have less emphasize on PE.^2,51 Modifying administrational support is crucial for effective PE. The context in which care is delivered, such as staffing levels, prioritizing of different aspects of care, provision of resources and support of other healthcare team members, influence the quality of PE.³  It been shown that PE was a less important task of healthcare professionals from the nurse managers' perspective.⁵¹ PE was improved through changes in the management style, development of educative materials, and patient education protocols.³ Inappropriate educational facilities in hospital were one of the barriers perceived by Iranian nurses for PE. Accessibility of teaching materials is an important component to facilitate PE.⁴⁰ It is known that face-to face PE time can be reduced by using paper materials and facilitate what must be transmitted to patients.⁵¹ It is important to provide teaching materials which are easily understood and are consistent with cultural issues and social norms.⁵² Allocation of specific space in every work-place setting for PE and assigning responsibility for this activity to one specialist nurse in the each ward by managers are another recommendations to improve and develop PE.⁴⁹

Patient's low literacy or illiteracy and cultural diversity of patients and nurses were among the most patient-related barriers perceived by Iranian nurses. Teaching is a dynamic process and is influenced by social and cultural factors. Thus, nurses must be sensitive to the effects of values, religion, language, cultural and socioeconomic factors.⁵² It seems that conflict among nurses and patients' beliefs can intensify the problems in PE.  People strongly protect their cultural values and also they expect everyone to respect it.⁵³ In a study that conducted by Heidari et al. have been shown that there is much cultural diversity among patients and concluded that all nurses are expected to be more sensitive to the cultural factors such as language, lifestyle, and social status of patients and their families in their education.⁵² Considering the cultural diversity backgrounds of patients and the health care providers, cultural sensitivity is an essential factor in improvement of comprehensive PE plans.⁵⁴ Patients' lower educational level and severity of illness prohibit their educational compliance.⁴⁰ Most of the hospitalized patients in Iran are elderly with inadequate level of health literacy.³ Patients' health literacy, as a resource which allows them to seek, understand and use health information, is an important determinant of their participation and engagement in their health care.⁵⁵ Many patients may be able to read and write, but have trouble to understanding basic health information. Health literacy, as a set of individual capacities may be improved through educational programs or declined due to aging and disease process.^3,56

Nurse-related barriers such as lack of awareness of nurses about educational methods and teaching/learning principles, believing that patient teaching is not nurses' responsibility, and lack of knowledge about illness, were mostly perceived by Iranian nurses. For PE, the nurses must be aware of the learning pattern of patients, which includes visual, auditory, and kinesthetic. Once the learning style is established, the nurse adapts the preferred teaching strategies and methodologies to that style.^56-58 Assessing patient learning style, in combination with the context in which learning occurs, allows for an individualized approach that incorporates teaching modalities to maximize patient learning.⁵⁹ Disagreement between patients, nurses, and physician regarding responsibility of PE is another perceived barrier to patients' education by nurses in Iran. Moret et al. found that nurses and physicians did not agree on patient information materials, so that nurses considered their role to be more important than what the physicians gave them.⁵⁰ However, this finding is inconsistent with that of Park's study, in which nurses stated that information about medicine and treatment was not their responsibility.² On the other hand, there is incongruence between nurses' and patients' perceptions regarding the nurses' role in PE. Patients acknowledged a general teaching function for nurses; but when they were asked who they prefer to teach them specific information related to their situation, they most frequently chose a physician. Whereas the nurses most frequently acknowledged a nurse as the most desired patient educator.⁶⁰

One potential limitation of this review was that we did not search the gray literature to find studies not in the peer-reviewed journals. Although we identified all papers that met our inclusion criteria, unpublished studies may be missed. However, our electronic search was extensive and complemented by hand-searches, so that the saturation was achieved. Another limitation was most of the studies have used investigator-developed instrument, so it may violate rigor of the studies.  The results of our review indicate that, Iranian nurse's encounter with somewhat high barriers in PE; so that of these, administration-related barriers were the predominant obstacle in order to bring evidence into clinical applicability. Therefore, health managers are expected to plan appropriate strategies to smooth the progress of PE by nurses in their practice.

Acknowledgement. We kindly thank Prof. Lynda Wilson for providing comprehensive comments and Dr. Reza Armat for his helpful comment on research methodology. 

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