A Study of the Barriers and Facilitators of Patient Education from the Viewpoint of Nursing Students at Jahrom College of Nursing

Objective: Patient education is the process of enhancing patients’ knowledge and skills in order to encourage the required attitude and behaviors for maintaining or improving their health. This study aims to explore the barriers and facilitators of patient education in clinical environments from the viewpoint of nursing students. Materials and Method: 78 senior and junior nursing students at Jahrom University of Medical Sciences formed the participants of this descriptive-cross-sectional study. The participants were selected based on the census method. The questionnaire used to collect data included questions about students’ demography, barriers (10 questions), and facilitators (10 questions) in patient education. Results: The most important barriers to patient education were lack of appropriate educational facilities (4.34±0.99), time limitation (4.31±1.10), and nurses’ inadequate knowledge and skills (4.29±0.59). The most important facilitators were enhancing the knowledge and skills of educator (4.49±0.50), raising the interest of the educator (4.44±0.74), and implementing of the education step-by-step (4.40±0.49). Conclusion: Patient education is an important part of patient care thus nursing teachers should be encouraged to incorporate patient education in the curriculum as part of the introduction of diseases, and stress such issues as evaluation of patients’ health literacy, familiarity with educational tools, and methods of enabling patients.


Introduction:
Patient education is the process of enhancing patients' knowledge and skills in order to encourage the required attitude and behaviors for maintaining or improving their health.Such education includes all the educational activities that are meant for patients-treatment, hygiene, clinical health improvement-and are intended to encourage self-care and reduce mortality andthe side effects of treatments 1 .As one of the major indexes of patient-centered care, patient education affects the effectiveness and quality of care 2 , and can increase patients' satisfaction and adaptation to their diseases and reduce their anxiety 3,4 .One of the concepts related to patient education ishealth literacy.Health literacy is the patient's capacity of obtaining, processing, and understanding basic healthcare information and making proper healthcare decisions accordingly.In other words, health literacy means creating health information and using it to facilitate healthcare-related measures 5 .Nursing teachers refer to the following as important interventions that can be exercised by nursing students to affect patients' health literacy: noticing the patient's language, enhancing the patient's understanding and encouraging the patient to participate in the treatment process 6 .36 percent of the adults in the U.S. have low health literacy, andamong them, the elderly, the minorities, non-English speakers, the undereducated and individuals with a low social or economical status are more likely to suffer from poor health literacy 3 .Patients with poor health literacy are less capable at fully understanding medical instructions, taking preventive measures and controlling their chronic diseases, and, consequently, visit their doctors and are hospitalized more 7,8 .Since the number of people affected by chronic diseases is increasing, it is essential that healthcare personnel have the required knowledge and skills to help patients with poor health literacy.However, according to Edwadson, clinical nurses' performance of patient education is not satisfactoryand they only educate patients informally and on an ad hoc basis and treat it as a less important undertaking 9 .In a study by Deccache at al., few of the patients stated that they had received enough information and counseling with regard to their health conditions 10 .Similarly, Weech's study shows that patients are not satisfied with their education 11 .In order to teach methods of patient education to nursing students, nursing teachers need to design educational strategies based on educational and clinical charters, as well as the results of related research and theories.In other words, the strategies for teaching patient education should be based on evidence as produced by research 5 .Since the best way to analyze a problem is to start from the source, and nursing students, who provide care alongside nurses and teachers, are going to be tomorrow's nurses, it is necessary that their views on patient education be identified and studied.Thus, the present study aims to explore the barriers and facilitators of patient education in clinical environments from the viewpoint of nursing students.

Materials and Methods:
This is a descriptive-cross-sectional study.The study population consisted of the entire senior and junior nursing students (85 students) at the nursing college of Jahrom University of Medical Sciences in 2014.Due to the small size of the population, a census was conducted and 78 questionnaires were completed.First-and second-year students were excluded because they were new in the clinical environments, had not been trained in some wards and were not familiar with problems related to patient education.Inclusion criteria were willingness to participate and being a third-or forth-year student.Once the research project was approved by the Research Department and the Ethics Committee at Jahrom University of Medical Sciences, the dean of the college of nursing was presented with the introduction papers.With the permission of the teacher, at the end of one of the classes, the objectives of the study were explained to the students by the co-researcher who did not have a part in the students' education.Next, the questionnaires were distributed and the students were asked to complete them.
The tool used in the study was the patient education questionnaire designed by Taheri et al. 12 .The questionnaire consists of there parts: demographic information, the barriers (10 items), and the facilitators (10 items).Based on the Likert scale, each item was scored form 5 to 1, with 5 being the most important.The reliability of the questionnaire was verified by the retest method: the barriers and the facilitators had the reliabilities of 0.75and 0.78, respectively.
For ethical considerations, the researcher explained the objectives to the subjects and assured hem that their information would be treated as confidential..Among the educational materials that can be used alongside oral instructions are printed materials, such as books, pamphlets, and newsletters,as well as multimedia products, such as videos, web-pages, and computer programs.Face-toface education, computer-assisted education, telephone-based education, and newsletters can be used to reinforce patient education.For instance, newsletters containing information about the causes and symptoms of diseases, medications, diets and exercise can be sent out to patients weekly or monthly through e-mail 1 .Communication tools of different kinds can enhance patients' understanding of their problems; however, organized, planned, and interactive efforts can increase the efficiency of such education 14 .Time limitation has been referred to as a major barrier to patient education in other studies 15- 17 , which is in accordance with the findings of the present study.According to Dehghani et al., in view of the increase in nurses' workload, the appointing certain nurses for patient education can act as a facilitator 18 .Also, it is necessary that the number of personnel be enough, or one or two nurses be appointed to educate patients and clarify the responsibilities of the medical team with respect to patient education 13 .Inadequate knowledge and skills on the part of nurses is another major barrier to patient education.This finding is in agreement with the results of other similar studies 12,[19][20][21] .Similarly, Aghakhani et al. cite the following as important barriers to patient education: nurses' inadequate knowledge about the importance of patient education, the belief that such education has little influence on the quality of treatment, and nurses' lack of interest in undertaking patient education 22 .Likewise, Namdari finds the educators' insufficient knowledge, skills, and interest to be the main barriers to patient education 23 .VahedianAzimi et al. mention that nurses' inadequate academic knowledge is the direct result of the education they receive at colleges: colleges play an important role in the education of nurses and can facilitate the implementation of patient education in clinical environments 21 .Another significant barrier to patient education is patients' psysical and psychological unreadiness.Due to physical disorders and the resultant anxiety, patients may not be ready for education, or even realize the importance of education in their case 24 .Other studies have similarly referred to psychological disorders and lack of physical preparation on the part of patients as major obstacles to patient education 12,22,[25][26][27][28][29] .It should be noted that at the time of diagnosis, most patients are not prepared for education: being diagnosed with a disease is the beginning of a crisis for most people.The best time for education is when patients are in stable conditions and have begun to adapt to their new lives 1 .In his study, Beagley refers to literacy, culture, language and physiological factors as barriers to presentation of information by care providers, and mentions that nurses must consider the fact that different people have different learning styles and evaluate patients' needs and level of preparation before they start patient education 30 .On the other hand, increasing nurses' knowledge and skills was referred to as the most important facilitator of patient education.Lopon believes that nurses with a better academic knowledge are more successful at patient education 31 .Some nursing teachers believe that having the following skills is essential to patient education: being able to prepare patientsfor healthcare and interaction with care providers, screening patients with poor health literacy, evaluating the educational pamphlets and scripts, making interventions to increase patients' health literacy, and evaluating patients' learning results 32,33 .Also, it is important that patient education influence patients' attitudes and beliefs about learning, education, and their treatment.Decision-makers need to ask themselves the following questions: does the patient have a part in the learning process or is he /she merely a learner who is being treated?Does the interaction between the patient and the nurse concern the patient's needs and beliefs or is it a one-sided communication based on standard tools? 1 .Thus, nursing teachers' familiarity with recent advances in patient education and practical approaches to performing it is essential to nursing students' acquisition of the required knowledge and skills for patient education.Raising interest in educating nurses was found to be another important facilitator.Similarly, Moridi et al. conclude that interesting nurses in patient education and encouraging patients to learn and participate can facilitate such education 34 .At the same time, nurses mention that patient education does not lead to job promotion 22,35 .With regard to nursing education, teachers' disregard for patient education programs and the absence of a systematic program for the evaluation of nursing students' implementation of patient education during their training and trial courses can inhibit the development of patient education.Therefore, teachers' consideration of the educating role of students during their training and managers' consideration and evaluation of the educating role of new nurses at the beginning of their careerscan motivate nurses to educate their patients as best as they can.The results show that a step-by-step implementation of patient education is another factor that can facilitatesuch education.For effective education, first the patient's needs should be identified; then, based on his/her needs, educational background, culture, available facilities, and length of hospitalization, an education plan should be developed, prioritized, implemented and evaluated 36 .Moreover, due to the vastness of the information that has to be communicated and changes in patients' conditions and treatmentsthat may occur over time, most patients are in need of frequent education.Due to the limitation of the study environment to one academic center, the transferability of the results is limited.Therefore, more studies of nursing students and nurses in other hospitals seem necessary.It is also suggested that qualitative studies be conducted to complement the available quantitative research and identify and analyze the issues related to patient education more profoundly.Moreover, teachers' views on the barriers to and facilitators of patient education should be studied.

Conclusion:
Being an important part of healthcare, patient education should be conducted through effective strategies.Nurses who educate patients need to have the required skills for evaluating patients' educational needs and deciding what kind of education to present.Patient education is not simply the transference of information and making patients act according to instructions:ineffective education is wasting both the educator's and the patient's time.The results of the study show that nursing teachers should be encouraged to incorporate patient education in the curriculum as part of the introduction of diseases, and stress such issues as evaluation of patients' health literacy, familiarity with educational tools, and methods of enabling patients.

Table 1 .
Mean, standard deviation and prioritize barriers of patient education from the perspective

Table 2 .
Mean, standard deviation and prioritize facilitators of patient education from the perspective of nurses Data were entered into SPSS version 16.0.Descriptive statistics-e.g.frequency, mean, standard deviation-were used to analyze the data.Level of significance was set at 0.05.