]oumal of Advanced Nursing, 1993,18, 725-730

Patient education at 25 years; where wehave been and where we are going

Barbara K Redman PhD RN FAANExecutive Director, Amencan Nurses'Association and Amencan Nurses' Foundation,600 Maryland Avenue S W, Suite 100 West, Washington, DC 20024-2571, USA

Accepted for publicahon 21 September 1992

REDMAN B K (1993) Journal of Advanced Nursmg 18 , 725-730

PaKent education at 25 years; where we have been and where we aregoing

In the past 25 years the theory and research base for patient education hasbecome considerably richer Definition of a core of educative functions has nowbeen accomplished for most major disease entities or health problems, andstandards of practice developed for a few In the United States, there is veryinadequate information about the degree to which patient education is delivered,and institutional supports for it seem to have varied with fiscal conditions Thereimbursement system for health care has not explicitly supported patienteducation or the outcomes it could achieve While there has been growth ininstructional approaches, it would be chantable to say that there is a broad andwell-informed view of potential approaches or an organized research anddevelopment function to get these approaches on lme If predictions of patientfocus for business and ethical reasons are realized, a major shift in environmentcould occur, supportive of patient education Clearly, there is little evidence thatpatient education represents a mature technology or that it is delivered atacceptable standards to all those who need it Patient education content m keynursmg textbooks published between 1988 and 1992 is analysed to examine thedegree and character of conceptual penetration

DEVELOPMENT OF PATIENT EDUCATION level of development of these services by nurses m othercountnes Indeed, involvement of nurses in championing

As much as patient education seems a part of our con- patient education services is central to their availabilitysciousness today, it was not alv r̂ays so In the 25 years that across the globethis author has been wntmg about patient education, many Early English leaders saw in the last century the lmport-chcinges have occurred At the same time, development of ance of teachmg families about sanitation, cleanliness andthe held has slowed, and it seems now to lack a clear sense care of the sick, smce much of the care at that time wasof next steps given by the family In the United States, early visitmg

This paper reflects on past developments and on those nurses earned forth the same tradition as they foughtwhich still must come While the scientific foundation of agamst disease and poverty among immigrants But in thepatient education is accepted internationally, development late 1960s and early 1970s, patient education was reborn,of services reflects the values, structures and financing of a especially m nursmg Experts have surmised that the rebirthparticular country's health care system This paper focuses occurred because of a new world emphasis on health,on the expenence of the Umted States, on which the author because development of the field of rehabilitation afterIS most qualified to comment It is hoped, however, that World War II required teachmg, because of an mcrease inanalysis of this expenence will stimulate insights on the long-term illness and disabilities that had to be managed by

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pahents and families, and because of a change in moodtoward authonty including physicians (Brandt 1991)

Whatever the confluence of factors that re-introducedpatient education in health practice, it was part of an oldtradition of all soaetal institutions having an educativefunction Clearly, the family has such a function, as doesreligion and other social institutions The schools might beseen as having a speaalized but clearly not the only edu-cative function m society Among soaal institutions, healthmight be seen as late in developing its educative function,{jerhaps for several reasons The most powerful groups mhealth, namely physiaans and hospitals, did not have sucha tradition Unlike religion, there is no one mstitution thatembodies the health care system, the function takes place indiverse institutions that do not form a true system Inrecent years when the system in the Umted States has beenso dnven by finanaal incentives, it has been difi&cult forphilosophically different 'treatments' to become part ofthat payment system And since all education is political, itinevitably challenged the existing authonty system

Principles

Each soaetal mshtution will develop its educative functionto meet its own goals, that has clearly been the case inhealth where education toward compliance with the medi-cal regimen has been a clear goal And yet, the educativefunction m each soaetal institution should be expected toconform to certain pnnaples, that it

1 supports development of the client, whether indi-vidual, family or community, controlling untowardside-effects of the education to a minimum, and that it

2 balances the client's definition of needs with those ofthe institution for example, in health, this may requireteachmg about personal self-care practices as well asthe more system-onentated goal of compliance, andthat it

3 provides access to its speaal skills by those that need it

Acceptance of such a set of pnnaples does, in itself,provide direction for the field

ACCOMPLISHMENTS IN THE PAST 25YEARS

There have been more than a dozen noteworthy develop-ments m patient education m the past 25 years, they arelisted in no particular order

1 General philosophical statements which mcludedsupport of patient education have now been joined by

the more fully developed theones of Orem, Neuman,Benner and Watson These theones focus on self-care,on the patient's expenoice of the illness and on canngas a moral ideal (Redman 1992)

2 Leammg theory has become ncher by the addition ofcogmtive and social learning theory to behaviouralleammg theory which was dominant 25 years ago(Redman 1992) Work reported m a book edited bySkelton & Croyle (1991) bnngs much of this worktogether Lay theones guide all health actions andinclude symptom and a label, consequences of theproblem, its temporal course, attnbutions about causeof the problem, and means by which a cure may beefifected It is clear that educators must work withpatients' lay models, that lay models once formed arehighly resistant but can be changed through feedbacktrainmg, and that both satisfaction and adherence areaffected by congruence between lay and providermodels of lllness/disease

3 The research base on effectiveness of patient educationhas enlarged greatly, so that now there are more than 3 7reviews or meta-analyses of the accumulated researchAlmost v«thout exception, these reviews show patienteducation to be an effective intervention (Redman1992)

4 The early years of this penod brought philosophicalstatements of support by the Amencan Hospital Associ-ation, later years have brought descnption of expliatstandards of practice by groups such as the AmencanDiabetes Association and Oncology Nurses' Associ-ation, and certification of educators by the AmencanAssociation of Diabetes Educators (Redman 1992)

There are some developments that are clearly only partial

5 There is considerable focus on readability of patienteducation matenals but almost no focus on whom theyare effective in teaching Memtt's (1991) researchquestions whether the leammg styles of her smallgroup of patients matched well with leammg bywntten matenals and notes that reading ability doesnot necessanly ensure reading comprehension

6 Management of patient education in systems of healthcare delivery has been carefully conceptualized asrequiring focus not only on teaching individualpatients but also on programmes for groups of hkepatients and on institutional management of groups ofprogrammes and services Although teaching plansand protocols have been developed and patient edu-cation IS incorporated into cntical paths which guidethe sequence of events and timmg of patient progress,there is limited evidence about whether the resources

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Patient education

and structures to support delivery of patient educationare available m many care settings Thus, institutionalresponsibility for delivery of these services appears tobe partial

7 Development of nursmg diagnosis bas provided somebut clearly mcomplete diagnostic categones forexpressing learning needs While the diagnostic cat-egory 'knowledge deficit' is heavily used, it reflects anextremely limited aetiology

8 Development of patient education services has tendedto occur by field of specialization Early developerswere diabetes, prenatal/parenting (and now includinginfant stimulation), cardiovascular, pre- and post-operative, and medicine compliance More recentlydeveloped fields include cancer, mental bealtb andAIDS While there bas been almost no development inimf)ortant fields like genatncs, tbere is a perceptiblecontinuation of development of fields

9 There is some initial work on instruction for illiteratepatients and on appropnate content for differentcultural groups

10 There has been an increase m instructional modalitiessuch as contracting and potential for a virtualexplosion in uses for computers in instruction (Redman1992)

11 Work on creating bealtb behaviour chcinge — usuallyconceptualized as adherence to lifestyle cbangerecommendations — has evolved One reviewer ofthis work notes a focus on the roles of self-efficacy andself-evaluation, the importance of skills training overand above appropnate knowledge and attitudes, theimportance of social support, and recognition ofbamers to performance of the behaviour (Seeker-Walker1990)

These represent considerable, although slow, progress

Mixed results

There are examples of other changes which may havemixed results the merging m US institutions of patienteducation and marketing For example, Kemaghan &Giloth's (1991) study of hospital-based consumer healthmfomiation centres or libranes showed mixed fiinctionsinforming, teachmg and promoting the hospital Themodel began to appear m the 1970s, and by 1987 21% ofhospitals respondmg to an Amencan Hospital Associationhealth promotion survey had organized such libranes ofcentres

Some have boobtores and a very strong marketingemphasis, with screening services and health education and

health promotion programmmg that help consumers makeappropnate links to other hospital services and providersThese entities may be located off site such as m a shoppmgmall or linked electromcally to public libranes They fre-quently are not self-«upportmg and may receive fundsfrom the institution or from physiaan group practices, orcharge a fee for circulation pnvileges

WHAT IS LEFT TO DO?

Very basic developments still remain

1 There is really no adequate descnption of leammg con-ditions under which education for patients takes placeimportant vanables such as time to leam, cognitive ormotivational approaches Perhaps even more import-ant, there is virtually no longitudinal focus on leammgover the course of a chronic disease Ewart (1990) hasrecently descnbed a problem-solvmg model of long-tenn health behaviour change and maintenance, whichrecognizes the necessity of skills m this activity, anddevelopment of the necessary self-ef&cacy and socialreinforcement in order to sustam long-term behaviourchange

2 There is no standard way of descnbing teachmg mter-ventions, and m some literature tbey are not descnbedm any detail at all and certainly not suf&aently toreplicate them

3 It would be useful to conceptualize patient educationservices on a continuum from knowledge developmentto complex behaviour change, matched to the patient'sneeds, instead of seemg only one end of the continuumas legitimate or deliverable m today's health careenvironments

4 There is no organized pressure group to focus on direc-tion for development of the field and on assurance ofworkplace conditions that support patient education,even though the legal and regulatory base for thisservice is developmg While the traditional healthprofessions would clearly need to be included inimprovement of the practice and delivery of patienteducation services, some group needs forcefully todefine direction

5 Technology should be much more imaginatively usedThe potential for computers to enhance the teachmg/learmng process is apparently occumng only veryslowly In diabetes education, one of the oldest andbest established fields of patient education, there arecomputer programs to help patients adjust insulindoses and plan meals, to store data such as glucosevalues and provide nutntional analysis of dietary

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components, to test patients' knowledge of diabetes, tooffer self-paced and speaalized lnstruchon for adoles-cents usmg a vanety of formats mcludmg games Yet,monbers of the Amencan Assoaation of Diabetes Edu-cators agree that computers have yet to make a majorcontnbution to the teaching and learning process(Anderson ei al 1992) So, also, two-way video couldbe used m home care to allow providers toobserve patients, provide assurance and motivation,and show them visually how to provide self-care By2010, it IS believed that such technology will be mim-atunzed and portable and linked to home informationsystems and providers (Olson et al 1992)

6 Besides a shift to learning theory that is patient-centred(noted above), some observers beheve that, m the faceof comp>etition, health care mstitutions and prac-titioners will shift their practice and services to meetneeds of the customer It has been noted that modemmediane often behaves as if canng for such humanneeds is beyond its purpose With a growmg burden ofchronic illness, patients and families seek practihonersskilled m addressmg functional loss, pain and anxietyEducational matenals on treatment options and on self-management of chronic disease may be widely avail-able in video stores, with dramatically changed patienthteracy about their conditions and frequency of partici-pation by patients in their treatment Self-admmisteredpam medications in hospitals may be only a start Ifpatients' values about nsks and rewards of treatmentwere more central, new measures would be commonlyused to assess these values and to evaluate treahnent mterms of them (Moloney & Paul 1991) It is noteworthythat each of the clmical practice guidelmes released bythe US Agency for Health Care PoLcy and Researchhas a patient's guide with the goal of assisting patientsto play active roles m choosmg treatment optionsTruly, such a system would require mdividualizedpatient education reaching goals to the patients' satis-faction and mtegrated v«th all care, as opposed to beingan app>endage dehvered when time and resourcesmight allow Focusmg on patient expenences m healthcare would help institutions change staffing levels andservices

7 Consideration of the ethics of patient education shouldundergo rapid evolution Until the late 1960s, healthcare professionals dis{>ensed information to patients ifthe professional felt it would be good for the patient Ifit was thought that information would be harmful orupsetting, it was withheld Now, patients are muchmore likely to be viewed as entitled to the whole truthBartholome (1992) believes health care providers

should see themselves as obligated to maximize thecapacity of the patient to partiapate as a full moralagent, lndudmg understanding the pervasive uncer-tamty and limited predictability of health care mter-ventions Informed consent should be seen as aminimum requirement The real goal is discovery ofwhat fits best the unique expenenced needs and aspi-rations of a particular person, worfang through shareddecision making This involves patient education at itsfinest Attention must also tum to what the new ethicsmean to patient education practice what is an accept-able level of patient outcome from education, how todeal with inadequate reimbursement to deliver minimalpatient education, etc

8 Finally, it should be said that health care systems mmany parts of the world are undergomg reform Dnvenby out-of-control costs of high-tech, specialist-dominated care m an administratively complex system,which leaves many individuals uncovered by insurance,the United States can be said to be in early stages ofdebate over reform Much of organized nursmg m theUmted States has endorsed an agenda which calls forconsumer responsibility for personal health, self-careand lnfonned deasion making m selecting health careservices, and a changed delivery system to support andreinforce such behaviours {Nursing's Agenda 1991)

EXAMINATION OF PATIENT EDUCATIONCONTENT IN NURSING TEXTBOOKS

There are a number of ways to examme the penetration of aconcept mto a field of practice Although scope of prachcestatements in nursing practice acts are now universallysupportive of patient education, there is virtually no descnp-tion of how frequently it is practiced Lack of support forpatient education as a reimbursable element in many sys-tems of care m the US has no doubt dampened its practiceThis author has previously examined catalogues of mastersprogrammes in nursmg and found speaalized courses mpatient education to be very rare This fmdmg is mter-preted to mean that graduate education m nursing has notmade a commitment to prepare for patient education as aspeaahty (Redman & Braun 1991)

For this study, textbooks were selected from the Brandon& Hill (1990) 'Selected list of nursmg books and journals',which had been chosen as representmg contemporarytheones and trends and possessmg sound dmical method-ologies Categones of books from clinical fields werechosen Texts examined were those with publication datesof 1988 or later and selected by Brandon & Hill for mitial

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Patient education

Table 1 Numbers of texts searched and judged to havesubstantial content in pahent educahon, by clinical field

Clinical field

Cancer nursingCardiovascular nursingCommunity health nursingCnhcal care nursingEmergency nursingGenatnc nursingMatemal-child nursmgMedical-surgical nursingNeurological nursingPaediatnc nursingPsychiatnc nursmgRespiratory nursingUrological nursing

Number ofbookssearched

2224I33214511

Number ofsubstantialcontent

202300310I011

purchase for those starting a library Books which con-tained only protocols and were not texts were elimmatedSince the number of books meeting these cntena wasoccasionally small, the judgements flowing from thisexamination should be seen as preliminary To fmd contenton patient education, each book's mdex was searched forthe terms 'education', 'health education', 'patient edu-cation', 'learning' and 'teachmg', and the table of contentsand actual contents of the book were also searched Fieldsand number of books searched and judged to have substan-tial content (more than a few paragraphs) may be seen mTable 1

3 For those with any substantial content, the teachmg-leaming process was a central organizmg theme Othercommon content included learning theory, motivationand readiness, and teachmg approaches somehmesmcluding teaching matenals

4 For many texts with substantial coverage of patienteducation, the content is frequently general and couldalmost be mterchangeable across fields of practice Afew provided, m addition, teachmg plans for contentspecific to that speciahty

5 Use of nursmg diagnosis for pahent education wasrare, and when it was used focused on diagnoses ofnon-compliance and knowledge defiat In maternity afuller range of diagnoses was used and mcluded alter-ation in family process, potential impaired homemamtenance management, anxiety and effective familycoping

CONCLUSION

One could conclude from this prelimmary examinationthat, 25 years cifter its rebirth, patient education is onlypartially integrated into the structure of the US nursingprofession's basic teaching matenals its texts Whilespecialized books m pahent educahon can be used, onewould exfject texts m areas of nursmg commonly taught inthe basic cumculum and in nursmg speaalihes to build onbasic understanding to develop a set of competenaesspeafic to that speciality

When patient educahon was rebom 25 years ago fromits anaent roots in the profession, it was welcomed Whileconsiderable progress has been made in the mtervenmgyecirs, incorporation of this funchon central to thephilosophy of nursing shll requires work

Findings

Review of these 31 texts showed the followmg

1 About 45% had substanhal content in teaching2 Maternity nursing texts displayed by far the best

developed model of pahent education There is a welldeveloped 'cumculum' both prenatally and post-partally including copmg with labour, infant care,siblmg and grandparent preparation Texts in cancernursing have focused on coping with disease process,m respiratory nursmg on motivational states m thesepahents and on breathing retraining, and in medical-surgical nursing on pre- and post-operahve teachingNone of the five psychiatnc nursmg texts exanunedhad any substantial content on pahent educahon

Author's note

The opinions expressed are solely those of the author anddo not necessanly reflect those or the Amencan Nurses'Association of the Amencan Nurses' Foundation

References

Anderson R M , Donnelly M B & Hess G E (1992) An assess-ment of computer use, knowledge, and attitudes of diabeteseducators The Diabetes Educator 18, 40-46

Bartholome W G (1992) A revolution in understanding howethics has transformed health care deasion making QualityReview Bulletin 18,6-11

Brandon A N & Hill D R (1990) Selected list of nursmg booksand journals Nursing Outlook 38, 86-95

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Brandt A M (1991) Emerging themes in tbe history of medicine Olson R, Jones M G & Bezold C (1992) Zlst Century LeammgThe Mtllbimk Quarterly 69,199-214 and Hmlth Care m the Home Inshtute for Altemative Futures,

Ewart CK (1990) A soaal problem-solving approach to Alexandria, Virginiabehavior cbange in coronary beart disease In The Handbook of Redman B K (1992) The Process of Patient Education 7tb edn C VHealth Behavior Change (Sbumaker S, Scbron E B & Ockene Mosby, St Louis, MissounJ K eds) Spnnger, New York pp 153-190 Redman B K & Braun R (1991) Courses m pahent education in

Kemagban SG & Gilotb B (1991) Consumer Health Infor- masiers progTams m nursmg Journal of Nursmg Education 30,mation Managing Hosptal-Based Centers Amencan Hospital 42-43Assoaation, Chicago Seeker-Walker R H (1990) Commentary In The Handbook of

Memtt S L (1991) Leammg style preferences of coronary artery Health Behavior Change (Sbumaker S, Scbron E B & Odcenedisease patients Cardiovascular Nursmg 27, 7—11 ] K eds), Spnnger, New York, pp 216-218

Moloney T W & Paul B (1991) Tbe consumer movement takes Skelton J A & Croyle R T (eds) (1991) Mental Representation mhold in medical care Health Affairs 10,168-179 Health and Illness Spnnger-Verlag, New York

Nursing's Agenda for Health Care Reform (I99I) Amencan Nurses'Assoaation, Washington, DC

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