Overview of Education in Health Care



Overview of Education in Health Care


Susan B. Bastable

Melissa F. Alt







Education in health care today—both patient education and nursing staff/student education—is a topic of utmost interest to nurses in every setting in which they practice. Teaching is an important aspect of the nurse’s professional role (Friberg, Granum, & Bergh, 2012). The current trends in health care are making it essential that clients be prepared to assume responsibility for self-care management. Also, these trends make it imperative that nurses in the workplace be accountable for the delivery of high-quality care. The focus of modern health care is on outcomes that demonstrate the extent to which patients and their significant others have learned essential knowledge and skills for independent care, or to which staff nurses and nursing students have acquired the up-to-date knowledge and skills needed to competently and confidently render care to the consumer in a variety of settings.

According to Friberg and colleagues (2012), patient education is an issue in nursing practice and will continue to be a significant focus in the healthcare environment. Because so many changes are occurring in the healthcare system, nurses are increasingly finding themselves in challenging, constantly changing, and highly complex positions (Gillespie & McFetridge, 2006). Nurses in the role of educators must understand the forces, both historical and present day, that have influenced and continue to influence their responsibilities in practice.

One purpose of this chapter is to shed light on the historical evolution of patient education in health care and the nurse’s role as teacher. Another purpose is to offer a perspective on the current trends in health care that make the teaching of clients a highly visible and required function of nursing care delivery. Also, this chapter addresses the continuing education efforts necessary to ensure ongoing practice competencies of nursing personnel.

In addition, this chapter clarifies the broad purposes, goals, and benefits of the teaching-learning process; focuses on the philosophy of the nurse-client partnership in teaching and learning; compares the education process to the nursing process; identifies barriers to teaching and obstacles to learning; and highlights the status of research in the field of patient education as well as in the education of nursing staff and students. The focus is on the overall role of the nurse in teaching and learning, no matter who the audience of learners might be. Nurses must have a basic prerequisite understanding of the principles and
processes of teaching and learning to carry out their professional practice responsibilities with efficiency and effectiveness.


HISTORICAL FOUNDATIONS FOR PATIENT EDUCATION IN HEALTH CARE

“Patient education has been a part of health care since the first healer gave the first patient advice about treating his (or her) ailments” (May, 1999, p. 3). Although the term patient education was not specifically used, considerable efforts by the earliest healers to inform, encourage, and caution patients to follow appropriate hygienic and therapeutic measures occurred even in prehistoric times (Bartlett, 1986). Because these early healers—physicians, herbalists, midwives, and shamans—did not have a lot of effective diagnostic and treatment interventions, it is likely that education was, in fact, one of the most common interventions (Bartlett, 1986).

From the mid-1800s through the turn of the 20th century, described as the formative period by Bartlett (1986), several key factors influenced the growth of patient education. The emergence of nursing and other health professions, technological developments, the emphasis on the patient-caregiver relationship, the spread of tuberculosis and other communicable diseases, and the growing interest in the welfare of mothers and children all had an impact on patient education (Bartlett, 1986). In nursing, Florence Nightingale emerged as a resolute advocate of the educational responsibilities of district nurses and authored Health Teaching in Towns and Villages, which advocated for school teaching of health rules as well as health teaching in the home (Monterio, 1985). In support of maternal and child health in the United States, the Division of Child Hygiene was established in New York City in 1908 (Bartlett, 1986). Under the auspices of this organization, public health nurses provided instruction to mothers of newborns in the lower East Side on how to keep their infants healthy.

The period from 1930 through 1960 is described as a time of relative quiet for patient education. Patient teaching continued to occur as part of clinical encounters, but it was overshadowed by the increasingly more technological orientation of health care (Bartlett, 1986). The first references in the literature to patient education began to appear in the early 1950s (Falvo, 2004). In 1953, Veterans Administration (VA) hospitals issued a technical bulletin titled Patient Education and the Hospital Program. This bulletin identified the nature and scope of patient education and provided guidance to all hospital services involved in patient education (Veterans Administration, 1953).

In the 1960s and 1970s, patient education began to be seen as a specific entity where emphasis was placed on educating individual patients rather than providing general public health education. Developments during this time, such as the civil rights movement, the women’s movement, and the consumer and self-help movement, all affected patient education (Bartlett, 1986; Nyswander, 1980; Rosen, 1977). In the early 1960s, voluntary agencies and the U.S. Public Health Service funded several patient and family education projects dealing with congestive heart failure, stroke, cancer, and renal dialysis, and hospitals in a variety of states became involved in various education programs and projects (Public Health Service, 1971).

Concerned that patient education was being provided only occasionally and that patients were not routinely being given information that would allow them to participate in their own health care, the American Public Health Association formed a multidisciplinary Committee on Educational Tasks in Chronic Illness in 1968 that recommended a more formal approach to patient education (Public Health Service, 1971). One of the committee’s seven basic premises was an
educational prescription that would base teaching on individual patient needs and be included as part of the patient’s record. This recommendation represented one of the first times that the documentation of patient education was mentioned (Falvo, 2004). The committee ultimately developed a model that defined the educational processes necessary for patient and family education that could be used with any illness by any member of the healthcare team (Health Services and Mental Health Administration, 1972).

In 1971, two significant events occurred: (1) A publication from the Department of Health, Education, and Welfare titled The Need for Patient Education emphasized a concept of patient education that provided information about disease and treatment as well as teaching patients how to stay healthy, and (2) President Richard Nixon issued a message to Congress using the term health education (Falvo, 2004). Nixon later appointed the President’s Committee on Health Education, which recommended that hospitals offer health education to families of patients (Bartlett, 1986; Weingarten, 1974). Although the terms health education and patient education were used interchangeably, this recommendation had a great impact on the future of patient education because a health education focal point was established in what was then the Department of Education and Welfare (Falvo, 2004). As a result of this committee’s recommendations, the American Hospital Association (AHA) appointed a special committee on Health Education (Falvo, 2004). The AHA committee suggested that it was a responsibility of hospitals as well as other healthcare institutions to provide educational programs for patients and that all health professionals were to be included in patient education. Through these health education programs, hospitals could contribute to important healthcare goals such as improved quality of patient care, reduced healthcare costs, shorter lengths of stay, fewer admissions and readmissions to inpatient facilities, and better utilization of outpatient services (AHA, 1976). Also, the healthcare system began to pay more attention to patient rights and protections involving informed consent (Roter, Stashefsky-Margalit, & Rudd, 2001).

Patient education was a significant part of the AHA’s A Patient’s Bill of Rights, affirmed in 1972 and then formally published in 1973 (AHA, 1973). This document outlines patients’ rights to receive current information about their diagnosis, treatment, and prognosis in understandable terms as well as information that enables them to make informed decisions about their health care. The Patient’s Bill of Rights also guarantees a patient’s right to respectful and considerate care. The adoption of this bill of rights promoted additional growth in the concept of patient education, which came to be seen as a “patient right” as well as an obligation and legal responsibility of health professionals. In addition, patient education was recognized as a condition of quality care and as a factor that could affect the efficiency of the healthcare system (Falvo, 2004). Furthermore, during the 1970s, insurance companies began to deal with issues surrounding patient education, because they saw how patient education could positively influence the costs of health care (Bartlett, 1986).

Further support for and validation of patient education as a right and expectation of quality health care came as a result of the 1976 edition of the Accreditation Manual for Hospitals published by the Joint Commission on Accreditation of Healthcare Organizations, now known as The Joint Commission (Falvo, 2004). This manual broadened the scope of patient education to include both outpatient and inpatient services and specified that criteria for patient education should be established. Patients had to receive information about their medical problem, prognosis, and treatment, and evidence had to be provided that patients understood the information they were given (Joint Commission on Accreditation of Healthcare Organizations, 1976).


In the 1980s, national health education programs once again came into vogue as healthcare trends focused on disease prevention and health promotion. This evolution represented a logical response to the cost-containment efforts occurring in health care at that time. The U.S. Department of Health and Human Services’ Healthy People 2000: National Health Promotion and Disease Prevention Objectives, issued in 1990 and building on the U.S. Surgeon General’s Healthy People report of 1979, established important goals for national health promotion and disease prevention in 22 areas (U.S. Department of Health and Human Services [USDHHS] Office of Disease Prevention and Health Promotion, 2000). Establishing educational and community-based programs was one of the priority areas identified in this document. Following on the heels of Healthy People 2000, Healthy People 2010 built on the previous two initiatives and provided an expanded framework for health prevention for the nation (USDHHS, 2000). Specific goals and objectives included the development of effective health education programs to assist individuals to recognize and change risk behaviors, to adopt or maintain healthy practices, and to make appropriate use of available services for health care (USDHHS, 2010). The latest iteration of the Healthy People initiative, Healthy People 2020 is the product of an extensive evaluation process by stakeholders. Its 40 topic areas support four overarching goals: attaining high-quality and longer lives; achieving health equity and eliminating disparities; creating social and physical environments that promote good health for all; and promoting quality of life, healthy development, and behaviors across the entire life span (USDHHS, 2012). Patient education is a fundamental component of these far-reaching national initiatives.

In recognition of the importance of patient education by nurses, The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), established nursing standards for patient education as early as 1993. These standards, known as mandates, describe the type and level of care, treatment, and services that agencies or organizations must provide to receive accreditation. Required accreditation standards have provided the impetus for nursing service managers to emphasize unit-based clinical staff education activities for the improvement of nursing care interventions to achieve expected client outcomes (JCAHO, 2001). Nurses are to achieve positive outcomes of patient care through teaching activities that must be patient centered and family oriented. More recently, TJC expanded its expectations to include an interdisciplinary team approach in the provision of patient education as well as evidence that patients and their significant others participate in care and decision making and understand what they have been taught. This requirement means that all healthcare providers must consider the literacy level, educational background, language skills, and culture of every client during the education process (Cipriano, 2007; Davidhizar & Brownson, 1999; JCAHO, 2001).

In the mid-1990s, the Pew Health Professions Commission (1995), influenced by the dramatic changes surrounding health care, published a broad set of competencies it believed would mark the success of the health professions in the 21st century. Shortly thereafter, the commission released a fourth report as a follow-up on health professional practice in the new millennium (Pew Health Professions Commission, 1998). This report offered recommendations pertinent to the scope and training of all health professional groups, as well as a new set of competencies for the 21st century. Many of the competencies deal with the teaching role of health professionals, including nurses. These competencies for the practice of health care include the need for all health professionals to do the following:



  • Embrace a personal ethic of social responsibility and service


  • Provide evidence-based, clinically competent care



  • Incorporate the multiple determinants of health in clinical care


  • Rigorously practice preventive health care


  • Improve access to health care for those with unmet health needs


  • Practice relationship-centered care with individuals and families


  • Provide culturally sensitive care to a diverse society


  • Use communication and information technology effectively and appropriately


  • Continue to learn and help others learn

In 2006, the Institute for Healthcare Improvement announced the 5 Million Lives campaign. This campaign’s objective was to reduce the 15 million incidents of medical harm that occur in U.S. hospitals each year. Such an ambitious campaign has major implications for teaching patients and their families as well as teaching staff and students the ways they can improve care to reduce injuries, save lives, and decrease costs of health care (Berwick, 2006).

Another recent initiative was the formation of the Sullivan Alliance to recruit and educate health professionals, including nurses, to deliver culturally competent care to the public they serve. Effective health care and health education of patients and their families depend on a sound scienti fic base and cultural awareness in an increasingly diverse society. This organization’s goal is to increase the racial and cultural mix of health professional faculty, students, and staff, who are sensitive to the needs of clients of diverse backgrounds (Sullivan & Bristow, 2007).

Accomplishing the goals and meeting the expectations of these various organizations have necessitated a redirection of education efforts. Since the 1980s, the role of the nurse as educator has undergone a paradigm shift, evolving from what once was a disease-oriented approach to a more prevention-oriented approach. In other words, the focus is on teaching for the promotion and maintenance of health (Roter et al., 2001). Education, which was once done as part of discharge planning at the end of hospitalization, has expanded to become part of a comprehensive plan of care that occurs across the continuum of the healthcare delivery process (Davidhizar & Brownson, 1999).

As described by Grueninger (1995), this transition toward wellness entails a progression “from disease-oriented patient education (DOPE) to prevention-oriented patient education (POPE) to ultimately become health-oriented patient education (HOPE)” (p. 53). Instead of the traditional aim of simply imparting information, the emphasis is now on empowering patients to use their potential, abilities, and resources to the fullest (Glanville, 2000). Along with supporting patient empowerment, nurses must be mindful to continue to ensure the protection of “patient voice” and the therapeutic relationship in patient education against the backdrop of ever-increasing productivity expectations and time constraints (Roter et al., 2001).


THE EVOLUTION OF THE TEACHING ROLE OF NURSES

Nursing is unique among the health professions in that patient education has long been considered a major component of standard care given by nurses. Since the mid-1800s, when nursing was first acknowledged as a unique discipline, the responsibility for teaching has been recognized as an important role of nurses as caregivers. The focus of nurses’ teaching efforts is on the care of the sick and promotion of the health of the well public, as well as educating other nurses for professional practice.

Florence Nightingale, the founder of modern nursing, was the ultimate educator. Not only did she develop the first school of nursing, but she also devoted a large portion of her career to teaching nurses, physicians, and health officials about
the importance of proper conditions in hospitals and homes to improve the health of people. Nightingale also emphasized the importance of teaching patients the need for adequate nutrition, fresh air, exercise, and personal hygiene to improve their well-being. By the early 1900s, public health nurses in the United States clearly understood the significance of the role of the nurse as teacher in preventing disease and in maintaining the health of society (Chachkes & Christ, 1996).

For decades, then, patient teaching has been recognized as an independent nursing function. Nurses have always educated others—patients, families, and colleagues. It is from these roots that nurses have expanded their practice to include the broader concepts of health and illness (Glanville, 2000).

As early as 1918, the National League of Nursing Education (NLNE) in the United States (now the National League for Nursing [NLN]) observed the importance of health teaching as a function within the scope of nursing practice. Two decades later, this organization recognized nurses as agents for the promotion of health and the prevention of illness in all settings in which they practiced (NLNE, 1937). By 1950, the NLNE had identified course content in nursing school curricula to prepare nurses to assume the role. Most recently, the NLN (2006) developed the first certified nurse educator (CNE) exam to raise “the visibility and status of the academic nurse educator role as an advanced professional practice discipline with a defined practice setting” (Klestzick, 2005, p. 1).

In similar fashion, the American Nurses Association (ANA, 2010) has for years issued statements on the functions, standards, and qualifications for nursing practice, of which patient teaching is a key element. In addition, the International Council of Nurses (ICN, 2012) has long endorsed the nurse’s role as educator to be an essential component of nursing care delivery.

Today, all state nurse practice acts (NPAs) include teaching within the scope of nursing practice responsibilities. Nurses, by legal mandate of their NPAs, are expected to provide instruction to consumers to assist them to maintain optimal levels of wellness and manage illness. Nursing career ladders often incorporate teaching effectiveness as a measure of excellence in practice (Rifas, Morris, & Grady, 1994). By teaching patients and families as well as other healthcare personnel, nurses can achieve the professional goal of providing cost-effective, safe, and high-quality care.

A variety of other health professions also identify their commitment to patient education in their professional documents (Falvo, 2004). Standards of practice, practice frameworks, accreditation standards, guides to practice, and practice acts of many health professions delineate the educational responsibilities of their members. In addition, professional workshops and continuing education programs routinely address the skills needed for quality patient and staff education. Although speci fic roles vary according to profession, directives related to contemporary patient education clearly echo Bartlett’s (1986) assertion that it “must be viewed as a fundamentally multidisciplinary enterprise” (p. 146).

In addition to providing patient education, professional nurses are responsible for educating their colleagues. Another role of today’s nurse educator is one of training the trainer—that is, preparing nursing staff through continuing education, in-service programs, and staff development to maintain and improve their clinical skills and teaching abilities. Nurses must be prepared to effectively perform teaching services that meet the needs of many individuals and groups in different circumstances across a variety of practice settings. The key to the success of our profession is for nurses to teach other nurses. We are the primary educators of our fellow colleagues and other healthcare staff personnel (Donner, Levonian, & Slutsky, 2005). In addition, the demand for educators of nursing students is at an all-time high.

Another very important role of the nurse as educator is serving as a clinical instructor for
students in the practice setting. Many staff nurses function as clinical preceptors and mentors to ensure that nursing students meet their expected learning outcomes. However, evidence indicates that nurses in the clinical and academic settings feel inadequate as preceptors and mentors as a result of poor preparation for their role as teachers. This challenge of relating theory learned in the classroom setting to the practice environment requires nurses not only to keep up-to-date with clinical skills and innovations in practice, but also to possess knowledge and skills related to the principles of teaching and learning. Knowing the practice field is not the same thing as knowing how to teach the field. The role of the clinical educator is a dynamic one that requires the teacher to actively engage students to become competent and caring professionals (Gillespie & McFetridge, 2006).


SOCIAL, ECONOMIC, AND POLITICAL TRENDS AFFECTING HEALTH CARE

In addition to the professional and legal standards various organizations and agencies have put forth, many social, economic, and political trends nationwide that affect the public’s health have focused attention on the role of the nurse as teacher and the importance of client and staff education. The following are some of the significant forces influencing nursing practice in particular and healthcare practice in general (Ainsley & Brown, 2009; Berwick, 2006; Birchenall, 2000; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Cipriano, 2007; DeSilets, 1995; Glanville, 2000; Lea, Skirton, Read, & Williams, 2011; USDHHS, 2000; Zikmund-Fisher, Sarr, Fagerlin, & Ubel, 2006):



  • The federal government, as discussed earlier, published Healthy People 2020, a document that set forth national health goals and objectives for the next decade. Achieving these national priorities would dramatically cut the costs of health care, prevent the premature onset of disease and disability, and help all Americans lead healthier and more productive lives. Nurses, as the largest group of health professionals, play an important role in making a real difference by teaching clients to attain and maintain healthy lifestyles.


  • The growth of managed care has resulted in shifts in reimbursement for healthcare services. Greater emphasis is placed on outcome measures, many of which can be achieved primarily through the health education of clients.


  • Health providers are recognizing the economic and social values of reaching out to communities, schools, and workplaces to provide education for disease prevention and health promotion.


  • Politicians and healthcare administrators alike recognize the importance of health education to accomplish the economic goal of reducing the high costs of health services. Political emphasis is on productivity, competitiveness in the marketplace, and cost-containment measures to restrain health service expenses.


  • Health professionals are becoming increasingly concerned about malpractice claims and disciplinary action for incompetence. Continuing education, either by legislative mandate or as a requirement of the employing institution, has come to the forefront in response to the challenge of ensuring the competency of practitioners. It is a means to transmit new knowledge and skills as well as to reinforce or refresh previously acquired knowledge and abilities for the continuing growth of staff.


  • Nurses continue to define their professional role, body of knowledge, scope of practice, and expertise, with
    client education as central to the practice of nursing.


  • Consumers are demanding increased knowledge and skills about how to care for themselves and how to prevent disease. As people are becoming more aware of their needs and desire a greater understanding of treatments and goals, the demand for health information is expected to intensify. The quest for consumer rights and responsibilities, which began in the 1990s, continues into the 21st century.


  • Demographic trends, particularly the aging of the population, require nurses to emphasize self-reliance and maintenance of a healthy status over an extended life span. As the percentage of the U.S. population older than age 65 years climbs dramatically in the next 20 to 30 years, the healthcare needs of the baby-boom generation of the post-World War II era will increase as this vast cohort deals with degenerative illnesses and other effects of the aging process.

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Sep 9, 2016 | Posted by in NURSING | Comments Off on Overview of Education in Health Care
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