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This is to certify that the dissertation entitled The Nurse's Role as Patient Educator: Bangkok Metropolitan Administration, Thailand presented by Benja Taoklam has been accepted towards fulfillment of the requirements for Ph.D. degree in Education Administration Date 2/0? 5/2/ MS U is an Affirmative Action/Equal Opportunity Institution 0— 12771 PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE | WI | MSU In An Affirmative Action/Equal Opportunity Institution omens-pt THE NURSE'S ROLE AS PATIENT EDUCATOR: BANGKOK HETROPOLITAN ADMINISTRATION, THAILAND BY Benja Tacklan A DISSERTATION Submitted to Michigan state University in partial tultillnent cf the requirements for the degree of DOCTOR OF PHILOSOPHY Departnent of Bducaticnal Administration College of Education 1991 ABSTRACT THE NURSE'S ROLE AS PATIENT EDUCATOR: BANGKOK METROPOLITAN ADMINISTRATION, THAILAND BY Benja Tacklan The major purpose of this study was to provide current information on the nurse's role as patient educator in the health institutions administered by the Bangkok Metropolitan Administration (EMA). Six research. questions focused on whether nurses in practice, nurse administrators, and nurse faculties, have different attitudes, knowledge, and opinions on the role of the nurse as patient educator as well as on the environments of and the barriers to patient education. Suggestions for improvement were also included in the study. 580 professional nurses were drawn randomly from 4 hospitals, 58 health centers, and a nursing college operated by the BMA to complete a researcher-made questionnaire. A The following are the major findings in the study. Attitude. Nurse faculties have a more positive attitude toward patient education than the other groups. However, the attitudes-of all three groups were very positive. Knowledge. Nurse faculties had more clinical knowledge and pedagogic knowledge. Nurses in practice had less knowledge than other groups. Role. The expectation of the three nurse groups was higher than the actual practice in the hospitals and the health centers in all aspects. Nurses performed patient teaching with less evaluation, preparation, and needs assessment. Environment. Three nurse groups viewed support of the environment to patient education differently. The factors that were the least supportive to patient education were facilities and personnel. Barriers. Nurse faculties had the strongest perception of the existence of barriers to patient education. The three nurse groups considered the barrier involving the patients themselves the most important. Suggestions. In order to improve patient education, the three nurse groups suggested a more adequate staff should be provided. The inclusion of patient teaching in nursing care practice can make a real difference. Support in various forms from administrators was important. Providing a standard teaching package also can make effective patient education possible. It is suggested from this study that nursing college should. play' a more important role in. preparing' nursing students with adequate knowledge to become patient educators. The hospitals and the health centers should provide sufficient facilities as well as other form of support. iii TO my great father and mother ACKNOWLEDGEMENT This dissertation was completed with the assistance and support of many people. While I cannot list the names of all those who have been instrumental in helping me complete my doctoral studies, I would like to express my gratitude to many of them. I am particularly indebted to Dr. Kenneth L. Neff, former advisor and chairperson of my Advisory Committee, for his assistance, encouragement, and support during my doctoral program. I would like to express my gratitude to Dr. Louis F. Hekhuis, Advisory Committee Chairperson, for his kindness and support during the project. Special thanks are also expressed to the other Advisory Committee members, Dr. Eldon R. Nonnamaker, Dr. Marvin E. Grandstaff, and Dr. Rhonda Egidio. I would also like to acknowledge the panel of experts who helped validate my research instrument. The members include Dr. Gladys A. Courtney, Dr. Rhonda Egidio, and Mrs. Somboon Paopatana. Their warmth and kindness will always be remembered. Special gratitude is expressed. to Mrs. Somboon Paopatana, a director of Kuakarun College of Nursing, and to the many colleagues who always offered me personal warm support and encouragement. I am indebted.towmy colleagues at the Kuakarun College of Nursing for taking responsibility for my work load during my studies. I want to sincerely' thank. the Bangkok. Metropolitan Administration for granting me a scholarship to support my doctoral program. Deep thanks is expressed to many colleagues for their participation in this study. Without their kind cooperation, the completion of this study would not be possible. I am indebted to Christopher Reznich, my good friend, who reviewed the manuscript thoroughly and made many valuable suggestions. Finally, to my wonderful husband, Wimol Taoklam, I express my sincere thanks for assistance in the statistical procedures and the analysis of data for this study, and for his understanding and inspiration for the duration of my doctoral endeavor. vi TABLE OF CONTENTS Page LI ST OF TABLES O O O O O O O O O O O O O O O O O O O O O CHAPTER 1. INTRODUCTION Background of the Problem . . . . . . . . . 1 Statement of the Problem . . . . . . . . . . 3 Purpose of the Study . . . . . . . . . . -.- 8 Research Questions . . . . . . . . . . . . . 9 Definition of Terms . . . . . . . . . . . . . 10 Delimitations of Study . . . . . . . . . . . 10 summary O O O O O O O O O O O O O O O O O O O 1 1 2. LITERATURE REVIEW Definition of Patient Education . . . . . . . 12 Rationale for Patient Education . . . . . . . 13 Disease Patterns . . . . . . . . . . . . 13 Consumer Dissatisfaction . . . . . . . . 14 Benefit of Patient Education . . . . . . 15 The Goals of Patient Education . . . . . . . 17 Theories and Models Used in Patient Education 19 PRECEDE MOdel O O O O O O O O O O O O O O 19 Self-care Model . . . . . . . . . . . . . 21 Health Belief Model . . . . . . . . . . . 22 Nursing and Patient Education . . . . . . . . 22 Factors Identified as Interfering with Patient Teaching and the Ways to Improve Patient Education . . . . . . . . . . . 27 Lack of Knowledge and Teaching Preparation . . . . . . . . . . . . . 27 Lack of Communication . . . . . . . . . . 30 Socio-econcmic Factors Influencing Teaching . . . . . . . . . . . . 31 Lack of Administrative Support . . . . . 32 Lack of Documentation . . . . . . 34 Lack of Time, Heavy Work Load, and. Inadequate Staffing . . . . . . . . . 35 summary O O O O O O O O O O O O O O O O O O O 3 5 vii 3. METHODOLOGY Introduction . . . . . The The Data Collection . . . . . . . . . . . Analysis of the Data . . . . . . . . summary O O O O O O O O O O O O O O O Population and th Sample . The Population . . . . . . The Samples . . . . . . . . Instrumentation . . . . . . Questionnaire Construction . Questionnaire Validation . . . Reliability of Piloted Questionnai Description of the Questionnaire e e e e e '1 e e e e e e e 4. ANALYSIS OF DATA Introduction . . . . . . . . . . Questionnaire Return . . . . . . Description of the Samples . . . Reliability of the Questionnaire Results of the Study . . . . . . Attitudes . . . . . . . . . . Knowledge . . . . . . . . . . Global Teaching Knowledge Sub-category Knowledge . . Subject Matter Knowledge Pedagogic Knowledge . . . Role . . . . . . . . . . . . . . Global Role . . . . . . . . . The Global Perception among Groups . . . . . . . The Global Perception within Group . . . . Sub-category Role . . . . . Needs Assessment . . . Teaching Planning .‘. . . Implementation of Teaching Evaluation of Teaching . Expected vs. Actual Role Environment . . . .'. . . . . . Overall Environment . . . Sub-category Environment Barriers . . . . . . . . . Overall-barriers . . . Sub-category Barriers . Suggestions for Improvement Whole Samples . . . . . Sub-group Samples . . . summary O O O O O O O O O O O O O O O O O viii 36 36 36 38 39 39 41 42 44 45 46 47 49 49 51 59 65 66 70 71 73 73 74 75 76 76 79 82 82 85 87 90 92 94 95 95 100 100 102 105 106 107 109 5 . SUMMARY, FINDINGS AND CONCLUSIONS, AND RECOMMENDATIONS Summary of the Study . . . . . . . . . . . . 111 Findings and Conclusions . . . . . . . . . . 114 Recommendations . . . . . . . . . . . . . . . 124 REFERENCES APPENDICES A. Protection of Human Rights B. Questionnaire ix 10. 11. 12. 13. 14. 15. LIST OF TABLES Numbers of Professional Nurses, BMA, Thailand Classified by Types . . . . . . . . . . . . . Comparison of the Population and the Samples Reliability of the Pilot Questionnaire . . . . Comparison of Population, Samples, and Return rate . Distribution Position and Distribution Position and Distribution Position and Distribution Position and Distribution Position and Distribution Position and Distribution Position and Distribution Position and of the Subjects Classified by Their Institutions . . . . . . . . . . of the Subjects Classified by Their Experience in the Present Positions of the Subjects Classified by Their Experience at the Present Workplace of the Subjects Classified by Their Areas of Nursing . . . . . . . . of the Subjects Classified by Their Basic Nursing Education . . . . . of the Subjects Classified by Their Highest Nursing Degrees . . . . . of the Subjects Classified by Their Highest Non-nursing Degree . . . . of the Subjects Classified by Their Ages O O O O O O O O O O O O O O Reliability of the Complete Data Set That Was Used in the Data Analysis . . . . . ANOVA Sources Table and 95% Confidence Interval for Attitude Comparison of Nurses' Attitude Toward the Responsibility for Patient Education . . . . . X Page 37 39 43 50 51 53 55 56 57 58 59 60 67 69 16. 17. 18. 19. 20. 21O 22. 23. 24. 25. 26. 27. 28. 29. ANOVA Sources Table and 95% Confidence Interval for Attitude Toward Patient . . . . . . . . . . . ANOVA Sources Table and 95% Confidence Interval for Global Knowledge of Professional Nurses . . ANOVA Sources table and 95% confidence interval for Subject Matter Knowledge of Professional Nurses O O O O O O O O O O O O O O O O O O O O O ANOVA Sources Table and 95% Confidence Interval for Pedagogic Knowledge of Professional Nurses. . ANOVA Sources Table and 95% Confidence Interval for Expected Global Role in Patient Education . . ANOVA Sources Table and 95% Confidence Interval for the Actual Global in Patient Education as Perceived by the Professional Nurses . . . . . . Statistical Testing of the Differences between the Global Expectation of Professional Nurses and Their Observation on the Actual Implementation of Patient Education . . . . . . ANOVA Sources Table and 95% Confidence Interval for the Expected Need Assessment of Patient Education O O O O O O O O O O O O O O O O O O O O ANOVA Sources Table and 95% Confidence Interval for the Actual Implementation of Need Assessment of Patient Education . . . . . . . . . . . . . . ANOVA Sources Table and 95% Confidence Interval for the Expected Teaching Planning of Patient Education O O O O O O O O O O O O O O O O O O O O ANOVA Sources Table and 95% Confidence Interval for the Actual Teaching Planning of Patient Education . . . . . . . . . . . . . . . . . . . . ANOVA Sources Table and 95% Confidence Interval for the Expected Implementation of Patient Education O O O O O O O O O O O O O O O O O O O O ANOVA Sources Table and 95% Confidence Interval for the Actual Implementation of Patient Education O O O O O O O O O O O O O O O O O O O O ANOVA Sources Table and 95% Confidence Interval for the Expected Evaluation of Patient Education xi 70 72 73 74 78 79 82 84 85 86 87 88 89 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. ANOVA Sources Table and 95% Confidence Interval for the Actual Evaluation of Patient Education Statistical Testing of The Differences between the Expected and the Actual Role of Nurses as Patient Educator in the Four Aspects of Role . ANOVA Sources Table and 95% Confidence Interval for the Overall Environment of Patient Education- ANOVA Sources Table and 95% Confidence Interval for the Environment of Patient Education Involving Facilities ANOVA Sources Table and 95% Confidence Interval for the Environment of Patient Education Involving Organizational Policies . . . . . . . ANOVA Sources Table and 95% Confidence Interval for the Environment of Patient Education Involving Organizational Administration . . . . ANOVA Sources Table and 95% Confidence Interval for the Environment of Patient Education Involving Organizational Personnel . . . . . . ANOVA Sources Table and 95% for the Overall Barriers to ANOVA Sources Table for the Barriers to Health Personnel . ANOVA Sources Table for the Barriers to Patients Themselves ANOVA Sources Table for the Barriers to Environment . . . . and 95% Patient and 95% Patient and 95% Patient xii Confidence Interval Patient Education . Confidence Interval Education Involving Confidence Interval Education Involving Confidence Interval Education Involving 93 95 96 97 98 99 101 103 104 105 CHAPTER I INTRODUCTION Background of the Problem Thailand is a developing country that has been confronting problems of health care. Large numbers of its citizen suffer from disease and illness. The major health problems related to disease include heart disease and chronic disease (Ministry of Public Health, 1987). Malnutrition has been one of the most significant problems of the country. Diarrheal disease and pneumonia are major causes of death in infants. One major reason for illness is lack of basic education and health education. Public health has long been one of the top priority development policies of the nation. In 1986, the government spent about $400 million on public health and public service (Ministry of Public Health, 1987). It is known that an optimum goal of the World Health Organization (WHO) is "Health for All by the Year 2000." In the pursuit of health for all, the World Health Organization specifically called for universal coverage with primary health care to include many essential elements. One of the essential elements is providing education covering the prevention and control of major health problems. Thailand has also been endeavouring to achieve this intention. To solve the health 2 problems of the country, both curing and.prevention.have to be implemented simultaneously. A major key to accomplishing disease prevention is health education. Health education is the responsibility of every member of the professional health team. However, it.is believed that the nurse is one of the best persons to teach the client because she-knows the patient's diagnosis, treatment and prognosis. In addition, among the health professionals, she spends the most time with the patients. Nursing leaders, nursing educators, nursing textbooks and nursing organizations all emphasize the role of the nurse in patient teaching (Winslow, 1976) . Presently, more ‘than 20,000 ‘professional nurses work in different parts of Thailand (Ministry of Public Health, 1987) . It is recognized that these health personnel should also play roles as health consultants and health promoters or health educators to clients both in hospitals and communities. If the application of this idea is made possible in Thailand, it will be tremendously beneficial to public health. Many studies have been done on health promotion and health education in the 0.8., whereas very few studies have been done in Thailand. Before adopting the idea of health education, it is necessary for Thailand to understand the relevant elements of its particular society. Among the various elements, roles of nurses in this matter are very important. 3 Statement of the Problem. It is necessary to investigate the nurse's role as patient educator. A variety of developments over recent years has resulted in a definite increase in the need for patient health teaching and a subsequent increase in the nurses' opportunities to develop this role. There has been an increasing emphasis on the prevention of disease and people are gradually becoming aware that they can and should have more control and responsibility for their own care (Weis, 1988; Fahrenfort, 1990). Patients need, therefore, to be well prepared to care for themselves. Many scholars agree that a role of nurse in patient education is an essential component of patient care (Fahrenfort, 1990; Redman, 1984; Smith, 1984; Hopps, 1983; Winslow, 1976). Roger (1966) believes that the purpose of nursing is to help people achieve their maximum health potential. She feels that nursing's first line of defense is promotion of health and prevention of illness. Even though there is evidence showing that nurses are teaching patients this does not necessarily mean that it is effective. Jenny (1978) states that much of the patient teaching being done:is not achieving its goal. In Pohl's study (1965) of 1,500 nurses, a majority of the respondents were dissatisfied with the quality and quantity of their patient teaching. One-third of the total group reported that they had 4 no preparation for the teaching they were doing. About one- fifth felt they' had. adequate jpreparation. and one-fourth suggested ways to improve the preparation they did have. There are many barriers that seem to interfere with the practice of patient education. One of the obstacles identified is that nursing education fails in some ways to prepare nurses adequately for their role as patient teachers, either during basic training or afterward (Syred, 1981; Schweer and Dayani, 1973; Demak.and.Becker, 1987; Winslow, 1976; Fahrenfort, 1990; Spronk and Warmenhoven, 1983). Much of the literature identifies specific ways in which education is deficient in its preparation of nurses for patient.teaching. There is often.a lack.of knowledge about the content of teaching and this will lead to inadequate patient education (Cohen, 1981; Schweer and Dayani, 1973). Another barrier is the low priority often assigned to patient education by administrative and supervisory personnel. Budget allocations for patient education reflect this low priority (Giloth, 1990; Winslow, 1976). Again, studies suggest that nurses have not learned the necessary skills required to pass on the information. Communication skills are an important aspect of effective patient education. For example, one area of skills is communication of medical information. For most patients, information should be provided in nontechnical terms (Smith, 1987). Studies done by Redman (1972) and Pohl (1965) report that one of the factors identified as interfering with 5 patient teaching is poor communication between members of the health team. Nurses may not communicate well with each other. Patient teaching should be assigned and should be recorded in the care plan and nurses' notes to enable continuity, and to avoid leaving patient teaching undone because everyone thought someone else was going to do it. However, it was found that little documentation.of patient education exists (Sutherland, 1980). Documentation of nurse participation in patient education is not only a quantity, but also a quality issue. As mentioned before, there has been an increasing emphasis on the prevention of disease and the consumer role has changed from a passive to an active and independent individual. Therefore, the nurse role needs to be expanded with changes in the emphasis of nursing activities. There is some confusion about the role of nurses in patient education. Benedikter (1980) gives evidence from her experience with learning about patient teaching: "I can still remember the terror I felt a few months after I began nursing school, when we would be expected to teach patients about their care as well as give them care. Up to that point my academic life had been spent being taught by teachers. I therefore knew that I was not a teacher, that I was unable to teach. Besides, I had already rejected the teaching profession as a career choice." ( p. 81) 6 Pohl (1965) investigated the teaching activities of the nursing practitioner. The evidence showed that the majority of respondents in the total group felt that teaching is a responsibility of nurses, that they enjoy teaching and wanted to carry out this responsibility. However, having enthusiastic practitioners performing activities should be supported and practice without adequate preparation is obviously not desirable. Another study by Williams (1978) supported a lack of clarity for the role of nurse in patient education. Syred (1980) also stated that the role of health education has been abdicated by hospital nurses. She added that nurses have been poorly prepared for this role. For the purpose of providing a basis for studying a specific nursing role, role development should be explored. Role development was studied within the area of role theory. "Role theory is a science concerned. with the study of behaviors that are characteristic of persons within contexts and with various processes that presumably produce, explain, or are affected by those behaviors" (Biddle 1979, p.4). This definition hinges on four terms which are behavior, person, context, and characteristic. The first term is "behavior." Biddle indicates that roles are behavioral in that actions or performances of the persons are observable. For example, the role of the nurse in patient education is characterized.by the observable behaviors of patient education. The second term is "person." Roles are performed by persons such as patient 7 education is performed by nurses. The next term is context. Roles may also be defined in terms of context. Normally, roles are limited in some way by contextual specification and do not represent the total set of all behaviors. For instance, nurses perform a role as patient educators only at designated times when the teaching is needed. The patient teaching role only describes one role of the nurses. Nurses are supposed to play many other roles such as clinical specialists and managers. The final term of role definition is "characteristic.".Roles consist of those behaviors that are characteristic of a set of persons and a context. To study a role, Biddle suggested three strategies which can be used: observation in real-world contexts, observation in the laboratory, and use of a questionnaire. Although he suggested that the best way to study a role is to observe the characteristic behaviors of persons as they cope with real- world problems and contexts, He also stated "By far the most popular [means] for studying roles to date is to administer a questionnaire and to conduct an interview that asks respondents to describe their own role or those of others." (Biddle 1979, p.82) By this means of study, it is presumed that their descriptive account of role behavior are a fair reflection of those behaviors that have actually occurred. In summary, nurse participation in patient education is a problem of conceptualization, process, product, and documentation. Although patient education was strongly 8 advocated as.a role to be assumed by the nurse, the literature did not support a clear picture of this role as it is currently actualized. There appeared to be confusion of the role and a lack of documentation of the activities related to patient education. Therefore, the understanding of this role, the activities involved in patient education, and the monitoring of the effectiveness of patient education should be studied. Purpose of the study The major purpose of this study is to provide current information on the status of the nurse's role as patient educator in hospitals and health centers under the Bangkok Metropolitan Administration, Thailand. The finding of the study will be a set of guidelines for decision makers to provide health teaching in hospitals and health centers. The information will be useful in planning for providing health education for patients, in providing health education facilities, in formulating policy of health education, and in preparing nurses to be effective health educators. In this study, the major focus will be on examining attitude, knowledge of nurses in patient education, and the role of nurses as patient educators. Environment, facilities, and barriers will be evaluated as well. The information will be collected from three professional nurse groups, namely, 9 nurses in practice, nurse administrators, and nurse faculties. Research Questions In order to achieve the above purpose of the study, the major research questions are the followings. 1. Do the nurses in practice, nurse administrators, and nurse faculties have different attitudes toward patient education? 2. Do the nurses in practice, nurse administrators, and nurse faculties have different levels of perception of their knowledge of patient education? 3. Is there any difference between the expected and the actual roles of nurses in patient education as perceived by nurses in practice, nurse administrators, and nurse faculties? 4. Do the environmental factors; facilities, organizational policies, administration, and personnel, as perceived by these three nurse groups, support patient education? 5. What are the barriers to jpatient education, as perceived by the three nurse groups? 6. What are the suggestions of the three nurse groups for patient education improvement? 10 Definition of terms 1. W is defined as a planned learning experience using a combination of methods such as teaching, counseling, and behavior modification techniques which influence patients' knowledge and health behavior. 2. A patient is an individual awaiting or under medical care or treatment, or one who seeks assistance from a health care provider. 3. A patient educatpr is a health professional who provides health education for a patient. 4. A nurse 1;; pracpice refers to a staff nurse who provides nursing care directly to a patient. 5. A npr§e_admipi§p;a§pr refers to a nurse who holds the following positions; Assistant head nurse, or Head nurse, or Supervisor, or Director of a nursing service organization. 6. A.pp;§g_fappl§y refers to a nurse who teaches nursing students in a formal nursing educational program. Delimitations of study The population from which the sample was drawn was limited to ‘the professional nurses who are working for hospitals, health centers, and a nursing college under the Bangkok Metropolitan Administration (BMA) . In this study, therefore, the inferences of the findings will be primarily 11 limited to the hospitals, the health centers, and the college of nursing administered by Bangkok Metropolitan Administration. Summary Illness is one of the most important problems in Thailand that has not been overcome. Patient education becomes an alternative to help solving the problem. The major purpose of this study was to provide the decision makers with information on nurse's current role: as patient educator. The study focussed on health institutions administrated by the BMA. CHAPTER II LITERATURE REVIEI In this chapter, the literature will be reviewed on six major aspects including the definition of patient education, the rationale for patient education, goals of patient education, theories and models used, nursing and patient education, and the factors identified as interfering with patient teaching. Each aspect will be discussed separately. Definition of Patient Education Patient education is one aspect of health education, designed specifically for recipients of preventive, diagnostic, therapeutic or rehabilitation services. It assists an individual to understand his or her disability, to cope with the symptoms, to prevent complications and to make contact with other sources of health information (Jenny, 1978) Smith (1979) defines patient education as intentional, planned, methodical, teaching and information-giving which is not casual or sporadic and which is aimed at helping each individual achieve and maintain an optimum health, free from disease or infirmity. For purposes of professional practice, patient education ought to be defined as learning (change in behavior) brought about by contact with a health care worker or agency. As a 12 13 therapeutic tool teaching is aimed at individuals with normal contact with reality, and its goal is not reconstruction of personality (Redman, 1975). Many authors agree that patient education should be planned, intentional and systematical action which will help the patient to learn (Narrow, 1979; Jenny, 1978; Wilson- Barnett, 1983; Smith, 1979). Rationale for Patient Education Patient education is increasingly being recognized as a component of health care service. Several majors factors such as disease patterns, consumer dissatisfaction, and the benefits of patient. education, have contributed. to this development. Disease Patterns The parallel increase in prevalence of chronic disease and in the age of the population requires people to engage in new patterns of care. In Thailand, the disease pattern has changed gradually from infectious disease to chronic disease such as varieties of heart disease, hypertension, high cholesterol and diabetes. Changing disease patterns need patient education. There has been an increased prevalence of chronic diseases requiring 14 patient self-care. Pohl (1965) states that to deal with chronicity and complicated treatments, a patient must be involved in self-care. Consumer Dissatisfaction Consumer dissatisfaction is a reason for initiating patient. education. Studies, show' that. patients are often dissatisfied with the information they receive in. the hospital. Studies among patients, nurses, and doctors in Dutch hospitals reveal the need for health education. Patients are dissatisfied with the information received and feel that nurses and doctors fail to meet their expectations regarding health education. One of the most frequent complaints of Dutch hospital patients concerns deficient information. The Consumers' Union found that 45% of former patients interviewed complained.of having received no information before admission and 25% considered the information regarding treatment inadequate (Visser, 1984) . A study by Parkin (1976) found that 57% of discharged hospital patients expressed some degree of dissatisfaction with the adequacy of the information which they received during their stay in hospital. Reynolds (1978) found that 69% of patients were dissatisfied with the quality of the information communicated. Linehan interviewed 450 patients about what they wanted to know about their illness before they left the hospital. 15 They wanted more explanation about what was wrong with them and what was done to them and why; more information about medicine, diet, and activities; more explanation of nursing procedure; more discharge information, especially the approximate date of discharge. A study by Abdellah and Levine (1966) found that many patients were dissatisfied with the quality of the information they received from doctors and nurses and to illustrate this they quoted a patient, "I have confidence in my nurses and doctors, but they just won't take the time to explain my illness or treatment." Benefit of Patient Education A number of studies were related to the benefits of patient education. Lineman and Van Aernam (1971) pointed out that the ability of patients to breath deeply and cough postoperatively was significantly improved by the structured preoperative teaching method, and the length of their hospitalizations was reduced by the implementation of this method. A study by Meyers (1964) found that less tension and fewer misconceptions are created when the patients are given specific information with which they can structure the experience. It is known that hospitalization is a stress-producing event which happens to many people at some point in their 16 lives. Apart from the physical stress of illness itself, hospitalization leads to many changes in daily living and activities which may result in psychological stress. Volicer and Burns (1977) found that many items of specific hospital stress related to lack of information about diagnoses, treatments, when things could be expected to happen, and so on. These sources of stress can be reduced through education. Again, one of the most difficult problems in clinic management is the vicious cycle of patient dissatisfaction leading to broken appointments, and the consequent over- scheduling of appointments, increased waiting time, and further patient dissatisfaction. Patient dissatisfaction can be reduced by health education. Health education can contribute to patient satisfaction through helping patients understand the importance of an appointment, the reasons for waiting time, and the procedures of the clinic. Among the objectives and the benefits of health education, Green states that high. priority should. be placed. on reducing broken appointments, because most other benefits-administrative and medical-depend on it. It is crucial to continuity of care (Green, 1976). Some other benefits of patient education are the following. A literature review by Wilson-Barnett & Osborn (1983) found that patients dc gain from and appreciate more information. This many result in iless anxiety, more participation and an increased feeling of control over their 17 lives. In summary, patient teaching is necessary to improve self-care, to improving patient compliance, to achieve the best cost-benefits, to encourage a consumer role, to reduce broken appointments, to reduce stress, and to reduce morbidity and mortality. The Goals of Patient Education The primary goals of patient education are to inform the patient of unhealthful behaviors predisposing individuals to their present.state of ill health, to facilitate the patient's adaption to the sequence of the present disease process, and to help individuals attain their maximum health potential (Stanton, 1985). According to Orem, the fundamental aim of the education is toward maximizing patient autonomy and increasing health- care. She added that patient education occurs at two levels: education in general, and education in specific to each patient's needs (Orem, 1988). Narrow (1979) divided the goals of patient teaching into three major categories: teaching to promote health, teaching to prevent illness, and teaching to cope with illness. Redman noted that: "Teaching plays a part in the general goal of nursing to help patients strengthen themselves through strengthening role performance." (Redman, 1984, p.5). 18 Redman (1988) further stated that major objectives of teaching are often classified by phase of health care. She described three phases in which patients need education. The first phase deals with maintenance of health and the prevention of disease. During this phase of patient education topics include: health care services or resources available, growth and development, nutrition and hygiene, safety, and first aid. The second phase is related to the needs of patients when they have a health problem and are required to seek assistance. The education will be focused on the disease or illness process and the need for care and treatment, and the hospital or clinic environment. The third phase encompasses the education necessary to assist patients to leave the health care system. The patient teaching in this phase should emphasize the need to understand care at home such as medication and diet, activity, continuing rehabilitation, and prevention of recurrence or complications. Redman, therefore, described the goal of health education in three situations in which an individual might need patient education: in the maintenance of health and prevention of disease, in preparing to leave the health care system, and ‘preparing to do self-care at home. Attaining the goal of optimum health for everyone depends on the cooperation of all of the members of society. It is not enough to teach only people who are ill; health education must be made available to as many people as possible, so that they 19 will be able to take care of themselves and family members as well (Pohl, 1981). Theories and Models Used in Patient Education There are :many theories and. models used in health teaching. There are three models that are related directly to patient teaching. The models that will be discussed include the PRECEDE model, the Self-care model, and the Health Benefit model. PRECEDE Model The PRECEDE model is a health education planning model which was developed by Lawrence Green and Colleagues. PRECEDE is stand for Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation. The model can be used to evaluate and plan health education for a single patient and for the health of a community. The model consists of four steps; epidemiological and social diagnosis, behavioral diagnosis, education diagnosis, and administrative diagnosis. 1) Epidemiological and social diagnosis refers to analysis and.understanding'of the nature, the usual cause, the effects and the duration of the disease. In addition, the social and economic status of patient or community are very important. Actually, a goal of the national development is to 20 improve personal quality of life. The quality of life is due to health problems and non-health factors. Non-health factors refer to the social and economic situation of the society. 2) Behavioral diagnosis. The health problem may be caused by non-behavioral factors or ‘behavioral problems. This diagnosis requires an identification of what behaviors cause and contribute to the health problem. These behaviors will be ranked and chosen to be addressed as an objective of health education. 3) Educational diagnosis consists of three variables; predisposing factors, enabling factors, and reinforcing factors. Predisposing factors include the patient's knowledge, attitudes, values, and perceptions about their illness and their therapy. Enabling factors include the availability of resources, accessibility of services, and the skills that the patient possesses. Education diagnosis also includes reinforcing factors. These factors include the attitude and behavior of health practitioners, peers, family, and employers. 4) Administrative diagnosis refers to understanding of the size, location, financial structure, goals and objectives of an organization, and the feasibility of the health education to be conducted. The PRECEDE model is a useful framework for health education planning. 21 Self-care Model During the 19608 a group of nurses developed a theory of nursing based on the self-care concept. Self-care nursing is a specific approach to clinical practice that places primary emphasis on the client's ability to attain and maintain health. A primary outcome of effective self-care nursing is that clients are able to perform their own self-care without (or with only minimal) contact with health services on a long term basis (Hill & Smith, 1990). Orem is the person most commonly associated with the integration of self-care into nursing practice. According to the self-care nursing theory, Orem identifies helping people learn self-care skills to recover from illness as a major nursing priority. In her model, nurses play a role as health educators and consultants for clients. Education is the primary means employed to correct self-care deficits or problems in providing for one's own health needs. Orem identified five methods of helping: (1) acting for or doing for another; (2) guiding another; (3) supporting another (physically or psychologically); (4) providing an environment that promotes personal development in relation to becoming able to meet present or future demands for action; and (5) teaching another (Orem, 1985) . These methods are applicable in a variety of situations. The nurses may help the clients by using any or all of these methods to provide assistance with self-care. 22 Health Belief Model The Health Belief model was developed by M. H. Becker in the early 19503 and is probably the most complete theory regarding readiness to take health action. Becker says that people are not likely to take health action unless (1) they believe that they are susceptible to the disease in question, (2) they perceive the severity of the‘disease and illness, (3) they are aware of certain actions that can be taken and believe that these actions may reduce their likelihood of contracting the disease or reduce the severity of it, and (4) they believe that the threat to them of taking the action is not as great as the threat of the disease itself (Redman, 1988). A major model addition to the model has been the concept of motivation. It is evident that the nurse could teach on a daily basis, but if the patient is not motivated to learn or change behavior, little will be accomplished (Jackson & Johnson, 1988). nursing and Patient Education Currently, the teaching role of nurses is supported by a long and distinguished history of helping others learn. Nurses have a proven history of contributing to the goal of patient and community teaching. It was Florence Nightingale who set 23 the supreme example in her analysis of the nurse's role in diagnosing the patients' health status and affecting their health potential. She contributes the positive health of the world to the area of sanitation. Nightingale's nurses tried to help their patients understand that poor hygiene and the lack of sanitation lead to infection and illness. The idea of disease prevention through teaching was an important part of Nightingale's philosophy. After the Crimean war (1853) her nurses shifted their teaching focus to maternal and child health in the belief that improving infant hygiene would reduce the high infant mortality rate. The public health nursing movement was synonymous with patient and family teaching (Rorden, 1987). In the United States the early 19003 saw an increasing awareness of nurses' need for educational preparation in addition to apprenticeship training for their roles in patient care and teaching. The health profession grew in size in the United States, currently numbering almost three million nurses and licensed vocational nurses. Generally, employed nurses are responsible for and accountable to the patient and family for nursing’ care that includes (patient. and family ‘teaching. Patient education has been an integral component of nursing since the role of nurse was created. In addition, the increasing importance of patient education functions has been clarified in the policies of professional organizations regarding preparation of nurses and the competencies expected 24 of nurses. The words "health teaching" are included as one of the major functions of the registered nurse. In the almost 1500 approved nursing preparation programs, nursing students are likely taught something about teaching patients (Simonds & Kanters, 1990). In Thailand, information and education for health play a vital role in promoting participation and self reliance as an essential basis for the National Primary Health Care program in order to attain "Health for all by the year 2000 and quality of life of the people within the nation." The Health Education division is under the direct administration of the Office of the Permanent. Secretary; The iHealth Education Division is responsible for implementation of information and education for health. The internal health service system, information and education for health have been integrated into hospitals and health centers (Ministry of Public Health, 1985). Although there are few studies and little documentation related to nursing and patient education, almost all job descriptions for professional nurses in Thailand include "health teaching" as one of the major functions of professional nurse both in hospitals and in the community. Professional nurses are responsible, along with other members of the health care team, for providing health education designed to meet the perceived learning needs of the clients served and promoting their self-care. Although the 25 nurse is not consistently held accountable for providing effective consumer health education, a number of factors such as economic and societal changes and disease pattern changes have exerted pressure on health professionals to provide this service consistently and find ways to improve consumer health education. Literature supports the nurse's role as a provider of health education within the health care system. Jackson and Johnson (1988) noted that the nurse is the primary source of patient teaching. There are many reasons such as the nurse's knowledge, opportunities for patient teaching, and the nature of the patient-nurse relationship. Many physicians indicate that their patients will confide their learning needs to the nurse before talking with them. Knowledge, skill, and caring encourage nurses to take on the role of patient educators. Tone (1983) suggests that ‘the 'underlying' principle ‘when considering who should take responsibility for appropriate health education is that it should be done by those who have closest contact with an individual. The nurse has more opportunity for patient teaching than any other health team ‘member because she spends more time with.the patient and is in a position to be able to assess patient needs and their readiness to learn.(Narrow 1979; Smith 1979; Winslow 1976). In Sutherland's study (1980), 41.5% of the registered nurses stated that 20% to 50% of the nursing care they gave to patients involved health teaching. 26 Related to consumer attitudes toward the role of nurses in health teaching, the results of a study conducted by the American Hospital Association (1975) revealed that the nursing profession was already the leader in patient education in hospitals across the country. The result of this extension study further indicated that nurses were the most likely personnel to be found on patient education policy-setting committees (93.7%), followed by physicians (71.8%) and administrators (57%) (Chaisson, 1980). According to a survey of 2,680 hospitals conducted by the American Hospital Association (1977), the registered nurses were the staff members most frequently involved in patient education. Furthermore, Brekon (1976) indicated that the role of the nurse in teaching was greater than that of the physician, including answering questions. Close (1987) pointed out that, based on the results of Caffarella's study, other health professionals largely agree that nurses should play a substantial part in patients' education. The study reveals that 69% of the physicians and allied health workers judged that nurses should have a primary. responsibility for conducting patient education and almost 75% of the nurse themselves felt they should play this role. Visser's (1984) report about the actual patient-education behavior of nurses stated that, based on the results of Cassee's study, an average of 89% of nurses declared always supplying information about nursing activities such as 27 preparation for treatment, diet. Medication information is provided in all or many cases by 59% of the nurses. Factors Identified as Interfering with Patient Teaching and the Ways to Improve Patient Education Although it is known that nurses performed patient teaching, many factors seem to be obstacles and interfere with the practice of patient teaching. Some of them have been stated in Chapter 1. The following additional factors will be discussed in more detail. In each aspect, the barriers will be discussed along with the ways to improve. Lack of Knowledge and Teaching Preparation Much of the literature revealed that lack of knowledge and teaching preparation is one of the major obstacles to patient education. If the nurses are not confident in what they have to teach the patients, they will not do it (Schweer & Dayani, 1973; Pohl, 1965; Redman, 1972; Cohen, 1981). In an early study by Streeter (1953) , 19 medical and surgical nurses were interviewed to identify factors inhibiting effective patient education. Five were concerned with feeling inadequate in the teaching role. They declared the factors directly related to the teaching role: a lack of knowledge of content, inability to use audiovisual material 28 and equipment, lack of knowledge of various methods and teaching skills, and not seeing health teaching as a responsibility of the nurses. In later studies, Pohl (1965) and.‘Williams (1978), supported a lack of clarity for the role of the nurse as patient educator and lack of adequate preparation for this role. Again, Sutherland (1980) assessed the status of patient education in a hospital. All 131 nurses indicated they did patient teaching. When the respondents were asked why they would refer a patient's question to someone else to answer, 41% stated that they might feel unqualified to answer the patient's question. While 65% felt. they ‘were adequately prepared to teach, 90% indicated they would like more continuing education related to patient teaching. There is some indication that poor assessment is an obstacle to patient education. Incomplete assessment could lead to inappropriate teaching. One of the main reasons why patient teaching fails is that the nurse's own education has not equipped her with the necessary assessment skill (Close, 1987). A lack of 'teaching’ skills and. a lack. of skill in utilizing them is another barrier. The typical nurse has not had courses in principles and methods of teaching (Schweer & Dyani, 1973). Weis (1988) suggested that the nursing staff should be 29 required.to have several years of