Patient care is a challenging concept to study, in part because it is the core on medical/healthcare professionals-to-patient relationship, but often without thoughtful parsing. What kind of care is health care? Contemporary interaction between medical professionals (especially doctors and clinical nurses) with patients have tended to emphasize an understanding of diagnosis and treatment, whether it uses pharmacological intervention or invasive medical intervention technique . One way of caring but often unnoticed, is through patient education.
Patient education has been recognized as a central component to ensure that patients are knowledgeable about treatment options, the management of their healthcare needs, and the effective use of medication. The Joint Commission on Accreditation of Hospital Organization (JCAHO) mandated that patient education programs have to be implemented to achieve these objectives. According to the American Academy of Family Practitioners (2000), “Patient education can be defined as the process of influencing patient behavior and producing changes in knowledge, attitudes and skills necessary to maintain or improve health.” . Patient education is a term that includes patient teaching, advice and information-giving, behavior modification techniques, and involves two-way communication between the clinical nurse and the patient aimed at maintaining or improving health, or learning to cope with their condition .
Patient education is a key intervention for promoting family health and empowerment of families with a person with chronic illness. The purpose of patient education is to provide knowledge, skills and increased self-awareness so patients or their family members can use the power to act in their own self-interest , self-efficiency and participation in decision-making , to then gradually build their own self-management.
• Bio-physiological: sufficient knowledge of the psychological signs and symptoms, and feelings of control over these problems.
• Functional: patients able to take functional control of the situation and daily activities.
• Cognitive: patients have enough knowledge and ability to use that knowledge for improving their health.
• Social: meaningful social interaction and contact with others.
• Experimental: patients able to use their past experiences and self-esteem.
• Ethical: patients feel unique, respected, and valued and believes that the care they are receiving ensures their well-being.
• Economic: patients able to afford technical aids and supports available.
Healthcare professional organization in America such as the American Hospital Association, the American Nurses Association, JCAHO, and others, are striving to improve the quality and frequency of patient education. Doctors and nurses as healthcare professionals now recognize that patient education can lead to improved outcomes, and it aids in necessary lifestyle changes for chronic illness, such as heart disease and diabetes [2,5,6].
Patient education is a critical element of diabetes management. Studies of children with type-1 diabetes have demonstrated that patient and family education in preparation for self-management at home is associated with reduced hospitalizations, fewer emergency room visits, and reduction of overall costs for the payer and patient .
Patient education in radiation therapy has been shown to help patients cope with their diagnosis, facilitate increased patient satisfaction with their treatment and related outcomes, reduce anxiety, and aid in symptom management. Standard written materials are often utilized within cancer programs as a source of educating patients about treatments and associated side effects .
A study by the Australian National Primary Healthcare Strategy, and Council of Australian Governments (COAG) Australian Better Health Initiative (ABHI), on chronic disease prevention and screening of those with at least one risk factor for chronic disease, determine the risk factors are smoking, nutrition, alcohol, physical activity, and weight (SNAPW) are major contributing factors of chronic disease worldwide . This study also use patient education by increasing health literacy, particularly in relation to modifying those behavioral risk factors, SNAPW.
By the Indonesian Standard of Hospital Accreditation (2011), patient and family education is also used to assist the process of care, in the informed consent procedure prior to invasive treatment (e.g., pre-operating and pre-anesthetic procedure), and it then be documented in the patient's medical record. In addition, if the patient or their family will get involved in the home care treatment (e.g., wound dressing, change of verban, giving medication, etc.), they need to be educated in a proper way .
Effective patient education program in hospital should enable the patient to make decisions about self-care behaviors and be more focus on patient's self-management in order to enable individual's ability to manage symptoms, treatment, physical and psychological consequences, and the lifestyle changes inherent in living with chronic condition, also manage their behavioral-associated health-risk problems successfully [6,9].
An individualized approach to patient education can be very time consuming. Nevertheless, benefits such as improved communication, patient outcomes, patient satisfaction, and documentation for accreditation purposes, as well as decreased litigation, may outweigh the cost of this implementation . Moreover, patient educator as the caregiver listens and tries to understand, acknowledging the patient's needs, recognizing elements where the patient may feel dependent and powerless due to their health status .
The aim of this systematic review is to analyze various methods of patient education in a way to improve patient care in hospital.
This systematic review is based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines in reporting the results. PRISMA is an evidence-based minimum set of items, aims to help author to improve the reporting of systematic reviews and meta-analyses .
Literatures search started on October 20 to 21, 2016 using several online journal database: ProQuest, JStor, and Science Direct, and SpringerLink (as shown in Figure 1). Keywords used on searching process were `patient education to improve patient care', `patient education method', `patient education', `educating patient', and `patient educator'. The next question begins with restricted filtered year between 2011–2016, then filtered by language in English, then filtered again by Full Text Journal Literature. Eight journal articles were chosen as eligible library to be reviewed for qualitative synthesis.
Each of the article is appraised from its study method and period, results obtained, kind of intervention mode, advantages and disadvantages of the intervention method.
Inclusion and exclusion criteria
Also shown in Figure 1, studies were included and assessed for the eligibility in this systematic review if they (1) study took place in a hospital, (2) assess methods of patient education, and (3) mention a positive result obtained from the study. Studies were excluded if the libraries that insufficient information to be compared with the other literatures, also if they (1) did not take place in a hospital, (2) did not assess methods of patient education, and (3) did not mention a positive result out of the study.
3. Results and Discussion
The search on identification level, yielded a total of 94,757 journal articles (ProQuest 62,771; JStor 10,599; ScienceDirect 9,321; and SpringerLink 12,066). Out of these 94,757 journal articles, 94,713 were screened using engine filter, provided by each source of online journal database. 44 journals were deemed relevant, then assessed manually for duplication and look-a-like journals, which comes down to 35 journals. Next step is manually assessed for eligibility by inclusion and exclusion criteria, first by heading and abstract leaving 16 journals, then read the full text journal which remaining 9 journal articles for qualitative synthesis.
Characteristics of included studies
In this systematic review was on 9 journal articles. The study methods from the articles reviewed varies, methods mentioned qualitative analysis (including evaluation on pre- and post-education), mixed method study (a combination of evaluation on qualitative study, and usage of media and written materials), and also observational.
Out of 9 studies from the journals articles, 5 studies were done in a hospital, one study was done in a Nurse University, whereas 3 others did not mention the location of the study took place. All 9 studies mention the methods used to gain a positive impact of patient education to improve the quality of patient care.
Effective education provides individuals with chronic illness and behavioral-associated health-risk problems with the knowledge and skills required to self-manage their condition and maintain health [8,12], increased self-awareness so patients and their family members can use the power to act in their own self-interests .
Patient education can be delivered using various methods and teaching strategies including traditional lecture formats, discussions, computer technology, printed materials, and audio/video with each strategy having various levels of effectiveness in practice [7,12]. Both physician and clinical nurse play a vital role as the healthcare professional in the delivery of patient education, and among healthcare providers as the patient educator, must have a collaborating process in delivering patient education [5,9,13].
As shown in Table 1, methods on patient education obtained from this systematic review are:
• Qualitative StudyAccording to study performed by Banning, M. & Gumley, V. (2013), a qualitative design used thematic analysis as an approach to capture the unique experiences, opinions, views and perceptions of nurses in relation to their caring role and its influence on their emotions and emotion management strategies they employ. Thematic analysis is a foundational method of qualitative analysis that focuses on the identification, analysis and reporting of themes within the data. Three themes emerged from the data, these included: (1) acknowledgement of patient's feelings; (2) professional behavior and patient's involvement; and (3) emotional control. The findings of this study indicate that nurses need educational support to raise awareness that having emotions related to caring is normal consequence of nursing patients. However, nurses need education and training to learn how to effectively manage their emotions .Another study performed by Reinhart et al. (2014), which evaluates the informational distress levels on pre- and post-education. The aim of this study was to determine the usefulness and the acceptability of the interprofessional group education sessions. Ensuring completeness of information within the education session was an important goal of this study. Providing tailored and specific information for the patient population that the education strategy was utilized by was important to decrease anxiety and improve preparedness for treatment. The pre-treatment education session enabled patients to ask questions that required clarification from a member their healthcare team and aided in enhancing their understanding of the treatment. In result, all patient felt prepared for the treatment, but half still experienced a significant amount of distress .Mikkonen, I. and Hynynen M. A. (2011)'s study on describing nurses' and other healthcare professionals' views about their patient education skills and how to develop them, collect and analyze their data using qualitative content analysis. The participants in this study experienced that, as patient educators, it is necessary for them to acknowledge their own abilities, beliefs and values in order to develop their patient education skills. Consequently, it is important to investigate the best ways of facilitating the development of healthcare professionals' skills with regard to patient-centered education. This study showed that, through education and training, healthcare professionals can recognize the need to develop their patient education toward patient-centeredness .Sy, V. (2016), details the clinical nurse's approach to supporting the bedside nurses who serves as the primary educators for pediatric patients with type-1 diabetes. With qualitative study, Sy considered some variables, such as: (1) educational preparation of nurses as patient educators; (2) educational tools and resources; (3) development of a teaching plan; and (4) development of diabetic ketoacidosis protocol through multidisciplinary collaboration. The study resulted in an increase in nursing confidence and expertise related to diabetes care as demonstrated by competencies met by nurses and anecdotal evidence from nurses and patients' caregivers .In line with a study by Reinhart et al. (2014); Sherman J. R. (2016), in this study, an initiative to improve patient education by clinical nurse, also use a qualitative study with pre- and post-education evaluation. As for evaluating, a number of variables were assessed, such as: (1) pre-test and post-test questions; (2) improvement needs; (3) quality indicators and data collection; and (4) action plan and data evaluation. This study come up with a result of patient education curriculum will contribute to provision of effective, efficient education by clinical nurses with the organization. The development of a standardized patient education approach for clinical nurses promoted improvement in patient education practices, which in turn may promote patient's ability in self-care in improve patient outcomes .In a literature review by Dennis et al. (2012), in determining the effectiveness of primary healthcare providers in developing health literacy of patients to make a smoking, nutrition, alcohol, physical activity, and weight (SNAPW) lifestyle changes. In the study, 52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different healthcare professionals. Most of the studies (71%) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity. Capacity to provide interventions to sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organization of primary healthcare .A method of pure qualitative study was used in six of the aforementioned studies. Different variables was taken into account in each of these studies, depends on what each author's aimed at. All studies have their own evaluation technique, in which they analyze and made a conclusion with their own findings, and finally they can come up with an objective planning for evaluating their delivery of patient education. An evaluation is essential for improvement on patient education.
• Mixed Method StudyIn a study by Kelo et al. (2013), by using qualitative study and multi-method, they (1) study qualitative critical incident technique was used by interviewing 45 nurses in pediatric units; (2) multi method: In implementation, the nurses used a combination of different methods cooperating with other professionals. The nurses used verbal counseling combined with written materials, demonstration, play, telephone counseling, and practical training. To assess educational needs, the nurses used a combination of different methods. They observed the child and parents, and verified their observation by reviewing hospital documents, interviewing patients, and receiving information from other sources .Delparte et al. (2014), used a mixed method study, which consist of: (1) Environmental scan by using identification of content educational materials. The results of the environmental scan were then used to generate a preliminary list of handouts for stakeholder feedback. (2) By using semi-quantitative study, a search for potential handout and finally come up with One hundred and fifty-six potential handouts were identified; 83 deemed high priority. (3) qualitative study dengan open-ended questions solicited general feedback from staff and patients, including pro-s and con-s on launched handouts .By using a mixed method study, the aforementioned two articles are able to customize more and `play around' to suit their need in delivering a better patient education. They were using media such as telephone, handouts/written materials, and open-ended questions to get feedbacks from the healthcare professionals itself, and primarily from the patient, for evaluating their method of patient education.
• ObservationalAccording to a single study which was using observational method, by Crawford et al. (2016) on interactional consequences of `empowering discourse' in intercultural patient education, found that discourse analysis is limited by reliance on interpretive analytic procedures to deduce speakers' intent and listeners' interpretation; however this is mitigated through ethnographic techniques of participant observation, field notes and discussions with the participants to validate observations. Audio-recordings also enabled repeated listening of the interactions to check interpretation of the transcript. Empowering behavior builds trusting nurse-patient relationships which underpins good patient education .Through this study, seems a single observational method a good method to deliver a patient education, in means of bulling a trusting nurse-patient relationship by empowering behavior. Though seems not as maximum as the other methods mentioned earlier. This observational method is suitable for tele-patient education which can be recorded and listened-to repeatedly for interpretation check.In addition to various methods of patient education obtained out of the studies resumed as a systematic review earlier, by the Indonesian Standard of Hospital Accreditation (2011), an effective patient education method will have to consider patient and family's value and norms, which allows adequate interaction between patient and family, and the healthcare providers, in order to develop the learning process .
An effective communication of patient education must provide knowledge, skills and increased self-awareness so patients or their family members can use the power to act in their own self-interest , self-efficiency and participation in decision-making , to then gradually build their own self-management, not to forget the patient and family's value and norms, which allows adequate interaction between patient and family, and the healthcare providers, in order to develop the learning process .
Various methods on communicating an effective patient education, yet evaluation has to made, to objectively assess the effectiveness in patient education. In order to do so, variables have to be determined, both from the healthcare providers as the educator's point of view, along with patient as the care receiver's point of view. This method with determination of variables in continuous evaluation, is also known as qualitative method of patient education.
The qualitative method alone is already a great way of delivering patient education, though it would be better if combined with usage of other media and materials, such as written materials (e.g., handouts and banner, etc.), telephone counseling, even internet will be quite useful.
Broadening patient access to and delivery of patient education could lead to improved levels of satisfaction with the information that patients in this facility received. In addition, educational efforts that are directed at increasing patient's understanding about their disease have benefits for patients, their families, providers, and society [2,5].
Society in general is increasingly developing toward equality, participation and citizen rights. Consequently, it is important to take this development into account in health care and patient education as well, because long term success will be achieved only by supporting the patient's self-management as a consequence of the co-operation, support and facilitation of healthcare professionals .