Patient education is a critical component of successful patient outcomes and an integral part of professional nursing practice. Education of the health care consumer provides the benefits of enhancing patient autonomy, increasing confidence in the patient's self-care, and decreasing complications. Education related to health maintenance and promotion has become an expectation of the knowledgeable health care consumer.
Oermann and Templin (2000) reported on patients' expectations for health education by health care providers. The patients surveyed expected nurses to answer health care questions knowledgeably. Patient education benefits the health care institution by improving patient outcomes, reducing costs, improving patient compliance, and increasing customer satisfaction (Abbott, 1998; Bartlett, 1995; Kok, Van Den Borne, & Mullen, 1997; Sutherland, 1980). Bartlett (1995) writes that for every dollar spent on patient education, three to four dollars are saved.
Traditionally, the RN has had the greatest access to and spent the most time with the patient and family, providing frequent opportunities for educational interventions (Bratcher & Eberle, 1993; Honan, Krsnak, Peterson, & Torkelson, 1988). Unfortunately, increasing acuities of hospitalized patients, decreasing length of stay, and staffing shortages are compromising educational opportunities for patients (Barrett, Doyle, Driscoll, Flaherty, & Dombrowski, 1990; Bratcher & Eberle, 1993; Honan et al., 1988; Karlsen, 1997; Kruger, 1991; Lipetz, Bussigel, Bannerman, & Risley, 1990; Murdaugh, 1980; Stanton, 1988; Turner, Wellard, & Bethune, 1999). Yet, nurses continue to be held accountable for providing patient education (Idaho State Code of Regulations, 2000).
National health care standards mandate education for all patients (American Nurses Association [ANA], 1998; Joint Commission of Hospital Accreditation [JCAHl, 2000). Local standards such as the Idaho Nursing Practice Act (2000) and Idaho State Nursing Regulations (2000) further describe nursing accountability for patient teaching. These legal boundaries direct that nurses who fail to properly educate the patient may be held liable for poor patient outcomes (ANA, 1998; Bratcher & Eberle, 1993; Honan et al., 1988). Despite these standards, research continues to recognize deficits in the provision of patient education. A search of Medline since 1987 revealed more than 6,000 articles on the topic of patient education.
This study was designed to examine the professional nurse's perceptions of patient education and to determine those factors inhibiting or enhancing the educational process. This information will allow institutions to identify interventions to promote nursing engagement in patient education activities.
The literature review focused on research surrounding factors affecting nurses' engagement in patient education activities. Contributing factors identified by these studies included nurses' attitudes and beliefs toward patient education, educational preparation of the nurse to teach, environmental and resource issues, and patient attitudes toward educational interventions.
Factors Affecting Patient Education
Attitudes and beliefs. Many researchers found that nurses placed a high priority on patient education and perceived patient education as an important part of their professional practice (Barrett, et al., 1990; Bratcher & Eberle, 1993; Honan et al., 1988; Lipetz et al., 1990; Murdaugh, 1980; Sigurdardottir, 1999; Stanton, 1986; Trocino, Byers, & Peach, 1997; Turner et al., 1999). In addition, nurses frequently reported that the responsibility for completing and coordinating patient education was theirs (Bratcher & Eberle, 1993; Honan et al., 1988; Kruger, 1991; Tilley, Gregor, & Thiessen, 1987). When provided the option, however, nurses preferred clinical nurse specialists or nurse educators to be responsible for the coordination of patient education (Stanton 1986; Trocino et al., 1997). Although viewed as an important responsibility, nurses in two studies perceived that patients were inadequately educated (Barrett et al., 1990; Kruger, 1991). Nurses' attitudes are also influenced by the emphasis that managers place on patient education activities (Karlsen, 1997; Stanton, 1988; Trocino et al., 1997), particularly when this competency is incorporated into performance evaluations (Bratcher & Eberle, 1993; Honan et al., 1988).
Educational preparation of the nurse to teach. The nurse's ability to teach patients is perceived as more effective if nurses receive education on teaching-learning strategies (Barrett et al., 1990; Bratcher & Eberle, 1993; Honan et al., 1988; Turner et al., 1999). When nurses in varied settings were provided education on improving teaching strategies, actual improvements in patient's knowledge and skills were reported (Boswell, Pichert, Lorenz, & Schlundt, 1990; Boswell et al., 1996; Murdaugh, 1980; Turner et al., 1999).
Environmental and resource issues. Inadequate time and staffing is repeatedly cited as a factor hindering patient education (Barrett et al., 1990; Bratcher & Eberle, 1993; Honan et al., 1988; Karlsen, 1997; Lipetz et al., 1990; Murdaugh, 1980; Stanton, 1988; Turner et al., 1999). Only one study disagreed, reporting 91% of nurses surveyed felt they had adequate time for patient education activities (Trocino et al., 1997). Availability and organization of teaching materials are important factors facilitating patient education (Barrett et al., 1990; Bratcher & Eberle, 1993; Honan et al., 1988).
Ninety percent of nurses surveyed by Honan et al. (1988) indicated a central teaching location equipped with patient education materials and more inclusive guidance sheets would improve patient education efforts. Although documentation is reported as a significant part of nurses' duties (Bratcher & Eberle, 1993; Honan et al., 1988), it is often the weakest area of the patient education process (Kruger, 1991). Other studies report that informal education is frequently performed, but it is often not documented (Bratcher & Eberle, 1993; Honan et al., 1988; Turner et al., 1999).
Patient attitudes toward educational interventions. Lipetz et al. (1990) surveyed nurses regarding their perceptions of patient attitudes toward education. The nurses reported a lack of patient interest in: changing behavior (93%), learning self-care skills (83%), and learning about their disease (75%). These attitudes were viewed by nurses as barriers to patient education (Lipetz, et al., 1990; Sprague, Schultz, Branen, Lambeth, & Hillers, 1999; Woody et al., 1984). The effect of the nurse's attitudes and beliefs, educational preparation, the environment, and the patient in the teaching-learning process for patient education was recognized in the literature.
This study examined the following research questions:
* How do nurses rank factors inhibiting patient teaching?
* How do nurses rank factors enhancing patient teaching?
This study is a replication of the work of Bratcher and Eberle (1993) and Honan et al. (1988). The setting was a metropolitan, northwestern city and the surrounding area. A randomized convenience sample was used, including 800 RNs licensed in the state. Exclusion criteria were those professional nurses not currently employed in acute care hospitals.
A questionnaire developed by Honan et al. (1988) entitled "Survey of Factors Influencing Patient Teaching" was used as the survey tool. The questionnaire included 7 demographic questions and 28 Likert, multiple-choice, dichotomous, and rank-order questions addressing nurses' attitudes surrounding patient education issues. For the purpose of this study, a demographic question regarding place of employment was added to the original questionnaire.
A panel of experts at South Dakota State University determined content validity of the original survey tool (Honan et al., 1988). Bratcher and Eberle (1993) used the tool in their replication study, which revealed similar findings in a different setting and with a different sample size. Reliability has been determined by the similarity of results from the original and two replication studies (Bratcher & Eberle).
Eight hundred questionnaires and an explanatory letter were mailed to professional nurses licensed in the study state, followed by a second mailing in 1 month. Participants were randomly selected from a State Board of Nursing list of all licensed RNs in the study area. Consent was implied by the return of the survey. Research approval was obtained from the Human Welfare Committee of St. Luke's Regional Medical Center.
Of the 800 questionnaires mailed, 219 surveys (27%) were returned. One hundred and twenty-four of these surveys (57%) were eligible for inclusion in the data analysis. Measures of central tendency, correlational statistics, and one-way analysis of variance (ANOVA) were used in data analysis.
Demographics of the study population are reflected in Table 1. On average, respondents had more than 10 years' nursing experience, were educated with an associate degree in nursing (ADN) or bachelor of science in nursing (BSN), worked full-time on the dayshift, and were women in their 40s. No demographic differences were found among institutions or in responses to the survey questions.
Questionnaire findings were categorized with regard to question topics. These categories included nursing attitudes and beliefs, educational preparation of the nurse, environmental and resource issues, and patient factors.
Nursing attitudes and beliefs. Ninety-seven percent (n = 124) of the nurses surveyed responded that patient teaching is an important part of every nurse's responsibility. Eighty-eight percent (n = 124) indicated that patient teaching is an important part of nursing practice for them. Seventy-seven percent (n = 124) of those surveyed responded that nurses should assume responsibility for the coordination of patient teaching, and 54% (n = 122) responded that doctors and nurses equally share responsibility for identifying patient teaching needs. Eighty percent (n = 124) responded that more involvement by other disciplines would improve patient education (Table 2).
STAFF NURSE PERCEPTIONS ABOUT PATIENT EDUCATION
Educational preparation of the nurse to teach. Seventyfive percent of the respondents (n = 124) indicated inservice classes on teaching and learning techniques should be held to facilitate patient education. Educational opportunities about teaching and learning principles were ranked fourth as a factor that would enhance patient education (Table 3). More than 60% (n = 98) answered that classes on specific clinical knowledge would also assist their efforts in providing education to their patients (Table 2).
Environmental and resource factors. Time and resources were included in the category of environmental and resource factors. Seventy-nine percent of respondents (n = 124) disagreed or were undecided that they had sufficient time to perform patient education. Sixty-nine percent (n = 123) were undecided or disagreed that adequate nursing staff was available to teach (Table 2). The most frequently cited factor that would enhance patient education efforts was more time. Lack of time was the number one factor hindering patient education. Lack of staffing was listed as the second most common factor that hindered this activity (Tables 3 and 4). Nurses were asked to rank nursing activities requiring the most time. Participants indicated that other nursing activities take priority over providing patient education, the top three being patient care, documentation, and administering medications (Table 5).
Two of the Likert questions on the survey showed the effect of the supervisor on nurses' patient education activities. These questions were correlated to another question asking about the nurses' perception of the priority of patient education. A Spearman rank-order correlation showed the employer's emphasis on the importance of patient education and emphasis on recognition of teaching in the yearly evaluation. A strong correlation occurred with higher prioritization of patient education by the nurse (r = .346, p <. 01 and r = .327, p < .01). Yet, when nurses listed factors that would enhance patient teaching and documentation, importance of patient teaching in the yearly evaluation was ranked seventh in importance in contrast to other items such as time, education, and resource materials (Table 3).
Documentation issues are environmental and resource factors affecting patient education. Sixty percent of nurses (n = 121) indicated their documentation system for patient education was satisfactory, and 40% (n = 121) found their documentation system inadequate. The length of time needed to complete the forms and confusion about which forms should be used were reasons cited for inadequate documentation systems.
RANK ORDER OF FACTORS THAT ENHANCE PATIENT TEACHING
Seventy-five percent of nurses (n = 123) reported that more informal teaching is performed than formal teaching and that informal teaching is not documented as reliably as formal teaching. Eighty-six percent (n = 124) surveyed identified a central area for patient education materials as an enhancement to patient education. The number two ranked enhancer was providing teaching forms to guide teaching efforts (Table 3).
Patient factors. An unreceptive patient was the third most frequent reason patient teaching was not conducted (Table 4). Sixty-one of the 121 participants (50%) agreed that patients were adequately taught prior to discharge, while 29 (24%) of the participants disagreed, and 37 (26%) were undecided.
RANK ORDER OF GREATEST AMOUNT OF TIME SPENT IN PERFORMING NURSING DUTIES
Finally, nurses were asked to prioritize factors that would enhance their patient teaching efforts. The top three factors were (Table 3):
* Providing more time for nurses to teach.
* Developing more inclusive guidance sheets.
* Making patient education resource materials more available.
The most frequently cited factors that hindered patient education efforts were (Table 4):
* Lack of time.
* Inadequate staffing.
* Patient unreceptive to teaching.
The sample used in the current study included a larger number of participants from a wider variety of institutions than the Honan et al. (1988) and Bratcher and Eberle (1993) studies. For the most part, this study corroborated the findings of Honan et al. and Bratcher and Eberle. Respondents in all three studies valued patient education as part of their professional practice and professional responsibility. They also described many factors hindering their ability to provide adequate patient education, including lack of time to perform patient education and inadequate staffing.
RANK ORDER AND MEAN SCORES OF FACTORS THAT INHIBIT PATIENT TEACHING
All three studies indicated lack of patient receptiveness to learn as another inhibiting factor, but only the current study found this to be one of the top three factors. This finding may be indicative of changes in the health care environment from 1988 and 1993 to the present. Decreased hospital stays, managed care, cost-containment, changes in the staffing mix with fewer clinical nurse specialists and nurse educators, increasing family and patient responsibility for care, and time constraints are part of the ever-changing environment of health care.
Shorter lengths of stay result in decreased opportunities for education, and patients who are sicker on discharge may be less receptive to teaching and learning (Lipetz et al., 1990; Turner et al., 1999). In spite of these hindrances, approximately half of the nurses surveyed in this study perceived that patients are being adequately taught prior to discharge.
Despite limitations and constraints to their efforts, nurses are providing patient education (Trocino et al., 1997). The factors that hinder the nurse's educational efforts and those that optimize the environment of care to facilitate patient education should be examined. Recommendations that may enhance patient education efforts include:
* Re-evaluating numbers and mix of nursing staff to plan for adequate availability of professional nurses to perform education functions.
* Ensuring patient education is emphasized as a nursing value by the employer and that it is reflected in position descriptions.
* Clearer delineation and coordination of education responsibilities between disciplines.
* Re-establishment of the clinical nurse specialist and nurse educator roles to facilitate and model educational efforts.
* Prioritization of teaching and learning principles as a focus for staff development efforts.
* Development of teaching guidance sheets on a variety of patient teaching topics centrally located on each unit.
* Use of computer technology to enable staff nurses to access patient education resources, such as fact sheets on common topics.
* Development of efficient, multidisciplinary documentation methods incorporating patient education in the continuum of patient care.
* Use of home health agencies and outpatient education programs to provide continuity by educating patients post-hospitalization.
Although this study provided valuable information on the perceptions of nurses in the community, several limitations were identified. The mailing list obtained from the State Board of Nursing was too broad for the purposes of this study. The randomized list included nurses who were retired or working in capacities other than hospital staff nurses, so 95 of the returned questionnaires had to be eliminated. A better method would have been to obtain Institutional Review Board (IRB) approval from each hospital in the study area and then obtain a mailing list of staff nurses from each institution.
Although the response rate was poor, the sample population was still greater than that of the two previous studies. A shorter interval for the repeat mailing may have resulted in an improved response rate. A limitation of the survey tool was that several types of questions were used, including Likert, multiple-choice, dichotomous, and rank-order items, requiring participants to change their method of response. The rankorder questions required varied methods of prioritization by respondents, which could result in response error if the questions were not interpreted correctly.
This study provided evidence that improving efficiencies in patient care, supporting the staff nurse educational role, and providing essential resources may enhance the provision of patient education. Although it is clear that staff nurses value patient education and make it a priority in their nursing care, external factors often impede their efforts. Institutions can potentially improve patient education efforts by evaluating the responses of nurses from these three studies (Bratcher & Eberle, 1993; Honan et al. 1988) and incorporating practical recommendations.
Future research questions include:
* What effects do incorporating specific strategies, such as patient teaching guidance sheets or emphasizing patient teaching in the staff nurse's yearly evaluation, have on the effectiveness of patient education?
* What are patient's perceptions of factors that enhance or impede the health care education they receive?
Health care institutions must respond to the challenge of ensuring that patients and families receive information about their conditions to enable them to provide self-care and promote healthy lifestyles. The challenge to the nurse researcher is to evaluate patient outcomes based on the current state of knowledge about health education. The challenge for nursing administrators is to motivate and encourage the professional nurse in the nurse educator role by providing the infrastructure for effective patient education.
- Abbott, S.A. (1998). The benefits of patient education. Gastroenterology Nursing, 21(5), 207-209.
- American Nurses Association. (1998). ANA standards of clinical nursing practice. Washington, DC: American Nurses Publishing.
- Barrett, C., Doyle, M., Driscoll, S., Flaherty, K., & Dombrowski, M. (1990). Nurse perceptions of their health educator role. Journal of Nursing Staff Development, 6(6), 283-286.
- Bartlett, E.E. (1995). Cost-benefit analysis of patient education. Patient Education and Counseling, 26(1-3), 87-91.
- Boswell, E.J., Pichert, J.W., Lorenz, R.A., & Schlundt, D.G. (1990). Training health care professionals to enhance their patient teaching skills. Journal of Nursing Staff Development, 6(5), 233-239.
- Boswell, E.J., Pichert, J.W., Lorenz, R.A., Schlundt, D.G., Penha, M.I., Alexander, S., et al. (1996). Evaluation of a patient teaching skills course disseminated through staff developers. Patient Education and Counseling, 27(3), 247-256.
- Bratcher, D.M., & Eberle, P.A. (1993). The nurse as patient educator: Nurses' perceptions of their health educator role and those factors that inhibit or enhance that role. Unpublished master's thesis, Spalding University, Louisville, KY.
- Honan, S., Krsnak, G., Peterson, D., & Torkelson, R. (1988). The nurse as patient educator: Perceived responsibilities and factors enhancing role development. The Journal of Continuing Education in Nursing, 19(1), 33-37.
- Idaho Code Regs. § 23. 01 Section 460 (2000).
- Idaho Nursing Practice Act § 54-14 (2000).
- Joint Commission of Hospital Accreditation. (2000). Education: Comprehensive manual of hospital accreditation: The official handbook. Oakbrook Terrace, IL: Joint Commission Resources.
- Karlsen, B. (1997). Hospital nurses' perceptions of patient teaching. Scandinavian Journal of Caring Science, 11(2), 97-102.
- Kok, G., Van Den Borne, B., & Mullen, P.D. (1997). Effectiveness of health education and health promotion: Meta-analysis of effect studies and determinants of effectiveness. Patient Education and Counseling, 30(1), 19-27.
- Kruger, S. (1991). The patient educator role in nursing. Applied Nursing Research, 4(1 ), 19-24.
- Lipetz, M.J., Bussigel, M.N., Bannerman, ]., & Risley, B. (1990). What is wrong with patient education? Nursing Outlook, 38(4), 184-189.
- Murdaugh, C. (1980). Effects of nurse's knowledge of teaching-learning principles on knowledge of coronary care unit patients. Heart-Lung, 9(6), 1073-1078.
- Oermann, M.H., & Templin, T. (2000). Important attributes of quality health care: Consumer perspectives. Journal of Nursing Scholarship, 32(2), 167-174.
- Sigurdardottir, A.K. (1999). Nurse specialist" perceptions of their role and function in relation to starting an adult diabetic on insulin. Journal of Clinical Nursing, 8(5), 512-518.
- Sprague, M.A., Schultz, JA., Branen, L.J., Lambeth, S., & Hillers, V.N. (1999). Diabetic educators' perspectives on barriers for patients and educators in diabetes education. Barriers for Patient Educators, 25(6), 907-915.
- Stanton, M. (1986). Nurses attitude toward patient education. Nurse Success Today, 3(3), 16-21.
- Stanton, M. (1988). Nursing time for patient education. Today's OR Nurse, 10(11), 26-30.
- Sutherland, M.S. (1980). Education in the medical care setting: Perceptions of selected registered nurses. Health Education, 11(1), 25-27.
- Tilley, J.D., Gregor, P.M., & Thiessen, V. (1987). The nurse's role in patient education: lncongruent perceptions among nurses and patients. Journal of Advanced Nursing, 12(3), 291-301.
- Trocino, L., Byers, J.F., & Peach, A.G. (1997). Nurses' attitudes toward patient and family education: Implications for clinical nurse specialists. Clinical Nurse Specialist, 11(2), 77-84.
- Turner, D., Wellard, S., & Bethune, E. (1999). Registeted nurses' perceptions of patient teaching: Constraints to the teaching moment. International Journal of Nursing Practice, 5(1), 14-20.
- Woody, A.F., Ferguson, S., Robertson, L.H., Mixon, M.L., Blocker, R., & McDonald, M.R. (1984). Do patients learn what nurses say they teach? Nursing Management, 15(12), 26-29.
STAFF NURSE PERCEPTIONS ABOUT PATIENT EDUCATION
RANK ORDER OF FACTORS THAT ENHANCE PATIENT TEACHING
RANK ORDER OF GREATEST AMOUNT OF TIME SPENT IN PERFORMING NURSING DUTIES
RANK ORDER AND MEAN SCORES OF FACTORS THAT INHIBIT PATIENT TEACHING