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University Microfilms International 300 North Zeeb Road Ann Arbor, Michigan 48106 USA St John's Road, Tyler's Green High Wycombe, Bucks, England HP10 8HR BRECKON, Donald John. 1939PATIENT EDUCATION PROGRAMS IN MICHIGAN NURSING CARE FACILITIES. Michigan State U n iv e rs ity , P h .D ., 1977 Education, adu lt Xerox University Microfilms r Ann Arbor, Michigan 48106 PATIENT EDUCATION PROGRAMS IN MICHIGAN NURSING CARE FACILITIES By Donald John Breckon A DISSERTATION Submitted to Michigan State U n iversity 1n p a r tia l fu lfillm e n t o f the requirements fo r the degree of DOCTOR OF PHILOSOPHY Department o f Adm inistration and Higher Education 1977 ABSTRACT PATIENT EDUCATION PROGRAMS IN MICHIGAN NURSING CARE FACILITIES By Donald John Breckon I t was the purpose o f th is study to describe, in an a n a ly ti­ cal fashion, the status o f p a tie n t education 1n Michigan's 455 nursing care f a c i l i t i e s . Program existence and t h e ir p rin c ip a l components were Id e n t if ie d , and th e ir re la tio n s h ip to In s titu tio n a l type, s iz e , geographical lo c a tio n , and age were determined. The stage o f development o f these programs was assessed and likew ise re la te d to In s titu tio n a l type, s iz e , geographical lo c a tio n , and age. A questionnaire was designed, sent to a ju ry o f exp erts, revised, and then p ilo t tested on adm inistrators o f twelve Michigan nursing care f a c i l i t i e s . I t was then re fin e d , p rin te d , and mailed to the adm inistrators o f a ll the 455 nursing care f a c i l i t i e s In Michigan. A response ra te o f s ix ty -n in e percent was obtained, w ith s ix t y -f iv e percent being usable. The data were then computer ana­ lyzed, and displayed. I t was determined th a t two hundred o f the 294 in s titu tio n s (s ix ty -n in e percent) have an operational p a tie n t education program. I t was most common fo r an In s titu tio n to have a general education Donald John Breckon program (s1xty-one percent d o ), and less common f o r an In s titu tio n to have a health education program ( t h i r t y percent do). In s titu tio n a l size was more freq u e n tly re la te d to the extent and nature o f p a tie n t education than were In s titu tio n a l typ e, loca­ tio n , or age. Large In s titu tio n s were more lik e ly to have opera­ tio n a l programs o f p a tie n t education, more lik e ly to have a p a tie n t education c e n te r, more lik e ly to have a p a tie n t education coordina­ to r , more lik e ly to have a wider range o f o ffe rin g s a v a ila b le , and more lik e ly to have fam ily education a v a ila b le . While the d i f f e r ­ ence between medium-sized and large In s titu tio n s was not always la rg e , the d iffe re n c e between small In s titu tio n s and large In s t it u ­ tions was ty p ic a lly la rg e . The coiranonly held b e lie f th a t small In s titu tio n s have a re s tric te d p a tie n t education program was validated by th is survey. The stage o f program development was measured and re la te d to in s titu tio n a l type, s iz e , age, and lo c a tio n . No s ig n ific a n t fin d ­ ings re su lte d . Seventy-three percent o f the 294 responding In s titu tio n s had a s p e c ific department or coordinator responsible fo r p a tie n t educa­ tio n . S1xty-two percent o f the In s titu tio n s had an area designated as a p a tie n t education cen ter. The general education programs most commonly o ffered a rts and c r a fts , r e a lit y o rie n ta tio n , current events, and music, w ith many other a c t iv it ie s being a v a ila b le . common mode. program. Group In s tru c tio n was the Several outside groups were ty p ic a lly Included In the Donald John Breckon The health education programs most commonly o ffe red were In s tru c tio n about the f a c i l i t y , n u tr itio n , d iabetes, and hearing and visual disorders. In d ivid u al In s tru c tio n was the common mode. Several groups were Involved 1n the program. Combinations o f methods were used to get a p a tie n t Involved in the program. Most commonly used was the p a tie n t conference, f o l ­ lowed by p a tie n t requests, doctor-issued p re s c rip tio n s , and standing orders. Evaluation o f learning was reported 1n s1xty-f1ve percent o f the programs. Program evaluation was reported 1n f1 fty -n 1 n e percent o f the In s titu tio n s . Both p a tie n t health education and general education were considered le g itim a te functions o f nursing care f a c i l i t i e s . Eighty- fiv e percent o f the adm inistrators Indicated they would be w illin g to develop or expand a p a tie n t education program 1 f fre e consultant help were a v a ila b le . DEDICATION This d is s e rta tio n 1s dedicated to Dr. E lizab eth Wheeler Anspach, who more than anyone else 1s responsible fo r n\y being a c o lle g e -le v e l teacher, and th e re fo re a Ph.D. candidate. Her warm, outgoing, student-centered ways continue to be the Ideal toward which I s tr iv e . I count i t a p riv ile g e to fo llo w 1n her footsteps as a public health education fa c u lty member a t Central Michigan U n iv e rs ity . D. J . B. 11 ACKNOWLEDGMENTS The researcher wishes to thank his doctoral committee fo r th e ir e x c e lle n t guidance and support during the development o f th is d is s e rta tio n . These members are Donald Tavano, Russell K le ls , Sheldon Cherney, W illiam Sweetland, and Joseph Dzenowagls, a l l o f the Michigan State U n iv e rs ity fa c u lty . Special thanks are extended to Professor Tavano, who served as Research D ire c to r fo r the p ro j­ e c t, and whose Insig h ts In to planning the research p ro je c t were extremely valu ab le, and to Professor K le is , who provided major e d ito r ia l support 1n a d d itio n to his Input In to the research design. The researcher wishes to acknowledge the continued support and encouragement given by his w ife , Sandra B1ehn Breckon, and expresses appreciation fo r her many hours o f p a tie n t typing on th is p ro je c t. I t must be acknowledged th a t her assistance f a r exceeded th a t ty p ic a l o f ty p is ts , and was more ty p ic a l o f a "research a s s is ta n t." F in a lly , the researcher acknowledges the continued encouragement and in s p ira tio n provided by his fa th e r , R. Joseph Breckon, and his deceased mother, Margaret Wade Breckon, who always encour­ aged him to "get as much education as you can." D.J.B. 111 TABLE OF CONTENTS Page LIST OF T A B L E S .............................................................................................. v1 LIST OF FIGURES............................................................................................... X Chapter I. II. III. IV . PURPOSE AND ORGANIZATION ......................................................... 1 Introduction ........................................................................... Statement o f the Problem .................................................. S ignificance o f the Study ......................... D e fin itio n o f Terms ............................................................... L im it a tio n s ................................................................................. Overview o f the D i s s e r t a t i o n ............................................ 1 3 4 6 10 11 REVIEW OF THE LITERATURE......................................................... 13 ........................................................................... Introduction Evolution o f In s titu tio n a l and Governmental P o l i c y ........................................................................................ The Effectiveness o f P a tien t Education ......................... The Extent o f P a tie n t Education Programming . . . Education fo r the E l d e r l y .................................................. Health Education fo r the E l d e r l y ...................................... Education in Nursing Homes .................................................. S um m ary....................................................................................... 13 13 26 29 33 37 38 41 METHODOLOGY................................................................................. 43 The Evolutionary Stages o f the In v e s tig a tio n . . . Analysis o f the D a t a .............................................................. S u m m ary....................................................................................... 43 50 51 ANALYSIS OF DATA........................................................................... 53 Introduction ........................................................................... D is trib u tio n o f A ll Michigan Nursing Care F a c i l i t i e s ........................................................................... D is trib u tio n o f Respondents ............................................ D is trib u tio n o f P a tie n t Education Programs . . . State o f Development o f P atien t Education P ro g ra m s ................................................. 53 1v 53 56 63 69 Chapter Page P rin cip al Components o f P a tie n t Education P r o g r a m s .................................................................................. 74 Program Coordination ......................................................... 75 Educational Center Designation ........................................ 80 P atien t General Education O fferings ......................... 81 P a tie n t Health Education O fferings .......................... 92 Education fo r the P a tie n t's F a m i l y .......................... 97 P rin cip al P a rtic ip a n ts In Planning and Conduct­ ing P a tie n t Education Programs ................................ 98 In it ia t io n o f P a tie n t Involvement ................................ 112 Evaluation o f Health Education Programs . . . . 115 A d m in istrator's Opinions Concerning P a tie n t E d u c a tio n .........................................................................................117 Sum m ary................................................................................. 126 V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . . . 129 Summary o f P r o c e d u r e s ................................................................129 Summary o f F i n d i n g s ................................................. 132 C o n clu sio n s.........................................................................................142 Discussion o f Findings and Conclusions ......................... 147 R eco m m en d atio n s ............................................................................ 148 Recommendations fo r Further Research ......................... 149 A Concluding Statement ......................................................... 150 A PPEN D IX..................................................................................................................152 BIBLIOGRAPHY .................................................................................................... v 160 LIST OF TABLES Table 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Page The d is trib u tio n o f population, nursing care f a c i l i t y beds, and beds per thousand population among Michigan's eight Health Service Areas .................................. Capacity of responding Michigan nursing care f a c i l i ­ t ie s , by number o f beds and type o f In s titu tio n . 57 . 58 Number and percent o f responding Michigan nursing care f a c i l i t y adm inistrators, by type o f In s titu tio n and Health Service Area .................................................... 59 D is trib u tio n o f Michigan nursing care f a c i l i t y beds represented 1n th is study, byHealth Service Area . 59 Number and percent o f responding Michigan nursing care f a c i l i t i e s , by type and size o f In s titu tio n D is trib u tio n o f responding Michigan nursing care f a c i l i t i e s , by type and age o f In s titu tio n . . . . . . . 61 62 Number and percentage o f nursing care f a c i l i t i e s pro­ viding p atien t education programs, by type o f I n s t i t u t i o n ................................................................................ 65 Number and percentage o f nursing care f a c i l i t i e s pro­ viding p atie n t education programs, by size o f I n s t i t u t i o n ................................................................................ 66 Number and percent o f nursing care f a c i l i t i e s providing p atie n t education programs, by Health Service Area . 68 Number and percent o f nursing care f a c i l i t i e s pro­ viding p atien t education programs, by age of I n s t i t u t i o n ................................................................................ 69 Mean p atien t education development scores displayed by In s titu tio n a l t y p e ............................................................. 71 Mean p atien t education development scores displayed by In s titu tio n a l s i z e ............................................................. 71 Mean p atien t education development scores displayed by Health Service A r e a ............................................................. 73 vl Table 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Page Mean p a tie n t general education development scores displayed by In s titu tio n a l t y p e ............................................ 73 Mean p a tie n t general education development scores displayed by In s titu tio n a l size ............................................ 74 D is trib u tio n o f In s titu tio n s having designated education coordinators, by program and by In s titu tio n a l t y p e ..................................................................... 77 Number and percent o f In s titu tio n s without p a tie n t education coordinators who are planning to designate one, by in s titu tio n a l t y p e ............................... 77 D is trib u tio n o f In s titu tio n s having designated p a tie n t education coordinators, by size o f in s titu tio n . . . 79 Number and percent o f in s titu tio n s w ithout p a tie n t education coordinators who are planning to designate one, by In s titu tio n a l s i z e ................................ 80 D is trib u tio n o f Michigan nursing care f a c i l i t i e s having p a tie n t education centers, by size o f In s titu tio n . . 81 Frequency o f o ffe rin g various topics 1n p a tie n t general education programs, by type o f I n s t i t u t i o n ................................................................................. 83 Methods used 1n selected topic areas o f p a tie n t educa­ tio n 1n the one hundred seventy-eight general education programs 1n Michigan nursing care f a c i l i t i e s ........................................................................................ 84 Range and mean numbers o f general education o ffe rin g s in Michigan nursing care In s titu tio n s , by type o f i n s t i t u t i o n ........................................................................... 90 Range and mean numbers o f general education o ffe rin g s 1n Michigan nursing care In s titu tio n s , by size o f I n s t i t u t i o n ........................................................................... 91 Frequency o f use o f various educational methods In the one hundred seventy-eight general education pro­ grams in Michigan nursing care f a c i l i t i e s . . . . 91 Frequency o f o ffe rin g various topics 1n p a tie n t health education programs, by type o f I n s t i t u t i o n ................................................................................. 94 v11 Table 27. 28. 29. 30. 31. Page Range and mean numbers o f health education o fferin g s 1n Michigan nursing care in s titu tio n s , by type o f I n s t i t u t i o n .......................................................................... 95 Methods used 1n selected topic areas o f p a tie n t educa­ tion 1n the e ig h ty -e ig h t health education programs 1n Michigan nursing care f a c i l i t i e s ............................... 96 Frequency o f use o f various educational methods in the e ig h ty -e ig h t health education programs 1n Michigan nursing care f a c i l i t i e s ....................................................... 97 D is trib u tio n o f educational programs fo r p a tie n ts ' fam ilie s 1n Michigan nursing care In s titu tio n s , by type o f I n s t i t u t i o n .............................................................. 99 D is trib u tio n o f Michigan nursing care In s titu tio n s o ffe rin g programs fo r p a tie n ts ' fa m ilie s , by size o f I n s t i t u t i o n .................................................................... 99 32. Number and source o f personnel involved 1n the 178 p atien t general education programs, by educa­ tio n a l f u n c t i o n .................................................................................102 33. Number and source o f personnel Involved In planning and operating general education programs In Michigan nursing care f a c i l i t i e s , by type o f I n s t i t u t i o n ....................................................... 104 34. Frequency o f Involvement 1n general education programs o f various personnel groups, by educational s ta ff f u n c t i o n s .....................................................................105 35. Range and mean number o f groups Involved in planning and teaching 1n general education programs. . . . 105 Number and source o f personnel Involved 1n the p a tie n t health education programs, by educational function ............................................................. 108 36. 37. Number and type o f personnel Involved In planning and operation o f p a tie n t health education programs 1n Michigan nursing care In s titu tio n s , by type o f I n s t i t u t i o n ........................................................................... 110 38. Involvement 1n health education programs o f various personnel groups, by educationals t a f f functions . v111 . Ill Table 39. 40. 41. Page Range and mean number o f groups involved in planning and teaching in health education programs . . . Frequency o f employment o f each o f four methods to In it ia t e p a tie n t p a rtic ip a tio n 1n health educa­ tion programs, displayed by in s titu tio n a l type . . Ill . Methods and combinations o f methods used to In it ia t e p atie n t p a rtic ip a tio n 1n health education programs, displayed by In s titu tio n a l type ............................................. 113 114 42. Number and percent o f nursing care In s titu tio n s 1n which evaluation o f p atien t learning was done or being planned, by type o f I n s t i t u t i o n ......................................115 43. Number and percent o f nursing care In s titu tio n s 1n which evaluation o f p atie n t health education programs was done or being planned, by type o f I n s t i t u t i o n .................................................................................116 44. Responses o f adm inistrators concerning the legitim acy o f p a tie n t health education as a function o f Michigan nursing care f a c i l i t i e s , by type o f I n s t i t u t i o n .......................................................................................118 45. Responses o f adm inistrators concerning the legitim acy o f p atien t health education as a function o f Michigan nursing care f a c i l i t i e s , by type o f p atie n t education programoperated ...................................... 120 46. Responses of adm inistrators concerning the legitim acy o f p a tie n t general education as a function of Michigan nursing care f a c i l i t i e s , by type o f I n s t i t u t i o n .......................................................................................121 47. Response of adm inistrators concerning the legitim acy o f p atie n t general education as a function o f Michigan nursing care f a c i l i t i e s , by size o f I n s t i t u t i o n ................................................................... 122 Responses o f adm inistrators concerning the legitim acy o f p atie n t general education as a function o f Michigan nursing care f a c i l i t i e s , by type of p atien t education programprovided ..................................... 123 48. 49. 50. Adm inistrator In te re s t 1n developing a p a tie n t educa­ tion program i f fre e consultant help were a v a ila b le . 124 Adm inistrator In te re s t 1n developing a p a tie n t educa­ tion program 1f free consultant help were a v a ila b le . 125 1x LIST OF FIGURES Figure 1. Page Health Service Areas fo r the State o f Michigan . . . 55 CHAPTER I PURPOSE AND ORGANIZATION Introduction The term p a tie n t education 1s a concept th a t t r a d it io n a lly applies to educational programs on health to p ics* and is also called p a tie n t health education. The term is sometimes used in a broader sense to apply to a l l educational programs provided fo r patients in the b e lie f th a t education about non-health topics may be therapeutic. Both p a tie n t health education and other p a tie n t education a c t iv it ie s are the focus o f th is In v e s tig a tio n . P a tien t education has re ce n tly become a major concern among public health educators and other a d u lt educators. While i t existed In many forms p rio r to then, 1t has burst on the consciousness o f many who were previously unaware o f It s existence. This expanded awareness 1s p a rtly due to the increasing concern about reducing the costs o f health care , and p a r tly due to the concern about b e tte r Informed consumers in a l l aspects o f l i f e . I t Is also p art o f a long e x is te n t concern among health care per­ sonnel to prevent as much illn e s s as possible. As a r e s u lt, p a tie n t education programs are developing a l l over the country. Concurrently, these programs are being studied to determine what kind o f programs are emerging. 2 There has also been Increasing concern about the needs o f the aging c itiz e n s 1n the la s t decade. studied, 1 T h eir needs have been a s ta te plan developed fo r Michigan, 2 and many programs developed to help meet some o f the needs Id e n tifie d . Focus has also been centered on th a t segment o f Michigan's aging population liv in g 1n nursing care f a c i l i t i e s . B e tte r stan­ dards fo r f a c i l i t y construction and maintenance, and fo r p a tie n t care have evolved 1n the la s t decade. The concerns fo r p a tie n t care fo r the aging 1n Michigan have resu lted in an a c t iv it y pro­ gramming ru le : "A p a tie n t shall be provided d lverslo n al a c t iv it ie s suited to his needs, c a p a b ilitie s , and In te re s ts as an adjunct to treatment to encourage him to return to s e lf-c a re and normal a c t lv l3 tie s In sofar as po ssib le." This ru le is broad enough to Include health education a c t iv it i e s , general education a c t iv it i e s , and recreation al a c t iv it ie s planned as p a rt o f the p a tie n t's therapy. A major obstacle to expanded p a tie n t education programming has been lack o f fin a n c ia l support fo r educational a c t iv it ie s . While lack o f finances remains a problem 1n nursing care f a c i l i t i e s , the s itu a tio n 1s changing. Third party reimbursement fo r lim ite d p a tie n t health education 1s already occurring. For example, Medicare ^Michigan O ffic e o f Services to the Aging, Michigan's Aging C itizen s: C h a ra c te ris tie s . Opinions, and Service U t iliz a t io n Pat­ terns (Lansing: Michigan O ffic e o f Services to the Aging, 1975), p. 44. 2 Michigan O ffic e o f Services to the Aging, The Michigan Com­ prehensive Plan on Aging (Lansing: Michigan O ffic e o f ^Services to the Aging, 1975), p. 182. 3 Rule 97, Michigan S k ille d and Basic Nursing Home Rules, p. 25. 3 and Medicaid regulations th a t apply to most o f these In s titu tio n s Include some provision fo r reimbursement fo r p a tie n t health educa­ tio n . Government funding programs c u rre n tly being proposed as national health Insurance w ill presumably also apply to nursing care f a c i l i t i e s as w e ll. Concern about p a tie n t health education 1n Michigan's nursing care f a c i l i t i e s 1s developing concurrently w ith th a t o f other sectors o f the health care d e liv e ry system. I t Is apparent th a t social p o licy 1s evolving th a t encour­ ages p a tie n t education. In s titu tio n s are c u rre n tly being given Incentives which favor comprehensive human concerns, ra th e r than the narrower treatment concerns o f the past. This study has been, to a small degree, a case o f social p o licy under study w ith the major focus being on the e ffe c ts o f th a t evolving social p o lic y. Statement o f the Problem I t was the purpose o f th is study to describe, in an a n a ly ti­ cal fashion, the status o f p a tie n t education 1n Michigan's 455 nurs­ ing care f a c i l i t i e s . The p rin c ip a l components o f p a tie n t education programs 1n these f a c i l i t i e s were id e n tifie d , and t h e ir r e la tio n ­ ship to In s titu tio n a l typ e, s iz e , geographical lo catio n and age was determined. The stage o f development o f these programs was assessed and likew ise re la te d to In s titu tio n a l type, s iz e , geographical loca­ tio n , and age. S p e c ific a lly , an attempt has been made to answer the follow ing questions: (1 ) What elements o f organized p a tie n t educa­ tion programs e x is t 1n Michigan's nursing care f a c ilit ie s ? (2 ) Are there p a tie n t education programs In more o f Michigan's nursing 4 homes, medical care f a c i l i t i e s , or hospital long-term care units? (3) Are there more p atie n t education programs 1n la rg e r In s t it u ­ tions, medium-sized, or smaller In s titu tio n s ? Are there more patient education programs 1n some Health Service Areas (HSA's) than 1n others? (5) Are newer nursing care f a c i l i t i e s more apt to have established p a tie n t education programs than older f a c ilit ie s ? (6) Are p atien t education programs more developed in nursing homes, medical care f a c i l i t i e s , or hospital long-term care units? (7) Are p atient education programs more developed 1n la rg e r in s titu tio n s , medium-sized In s titu tio n s , or sm aller in s titu tio n s ? (8) Are p atien t education programs more developed in some HSA's than 1n others? (9) Are p atien t education programs more developed 1n newer nursing care f a c i l i t i e s than In older f a c ilit ie s ? The answers to these questions provide an In d icatio n o f the current level o f an emerging policy th a t favors meeting a l l the needs o f patients rath er than p rim a rily the treatment needs. This 1s not to suggest th a t what 1s current p ractice 1s the ultim ate in programming e ffo r ts . Instead, 1t 1s to assume th a t as policy con­ tinues to. emerge, other as y e t u n id en tified concerns w ill be Incor­ porated. I t Is Important to get a sense o f d ire c tio n , to ascertain where the current level o f programming Is , and where 1t seems to be going. This study, hopefully, has contributed to that goal. Significance o f the Study P atien t education Is as old as the d o cto r-p atien t re la tio n ­ ship, but the significance o f such education 1s ju s t recen tly being 5 recognized and emphasized. Subsequently, p a tie n t education programs are developing 1n many sectors o f the health care system In the United States. Several studies have Investigated or are In v e s ti­ gating the extent o f p a tie n t education programming 1n acute care hospitals both n a tio n a lly and In Michigan. No one has previously studied the extent o f p atie n t education programing 1n Michigan's nursing care f a c i l i t i e s . I t 1s Important fo r un1verslty-based p a tie n t education con­ sultants and other proponents o f p atie n t education to know what kind o f p atient education programs e x is t 1n nursing care f a c i l i t i e s . It 1s Important fo r adm inistrators and boards o f nursing care f a c i l i ­ tie s to know what kinds o f programs e x is t In s is te r In s titu tio n s . I t 1s Important th a t those charged with developing a state plan on aging know what kind o f education the aged residents o f nursing care f a c i l i t i e s are receiving. Indeed, The Michigan Compre­ hensive Plan on Aging points up health education d eficiencies o f the aged both w ithin and without In s titu tio n s , and recomends expansion 4 of educational programming fo r the aged. F in a lly , 1t Is Important th a t those planning fo r the health education o f the public know what health education Is being delivered to this Increasingly s ig n ific a n t segment o f the general public. A Task Force on Health Education o f the Public has been appointed by the State Health Planning Advisory Council. They have reviewed health education program ing In health care In s titu tio n s . They 4 Michigan O ffic e on Services to the Aging, Michigan Compre­ hensive Plan on Aging, p. 182. 6 stated "various In s titu tio n s have proven e ffe c tiv e and e f f i c i e n t . " 5 They went on to s ta te : Associations representing health care In s titu tio n s should encourage and a s s is t t h e ir members to p lan , Implement and evaluate health education a c t iv it ie s 1n the In s titu tio n s and the communities served by these In s titu tio n s . These In s titu tio n s are considered by many to be centers fo r health care 1n the community. Therefore, health care In s titu tio n s have a ro le to p la y , not only w ith in t h e ir f a c i l i t i e s but by reaching outside th e ir w alls to address community needs.® This State Health Planning Advisory Council task force went on to recomnend: I t 1s recommended th a t the Michigan Hospital A ssociation, the Michigan Osteopathic Hospital A ssociation, the Health Care Association o f Michigan, the Michigan N o n -P ro fit Homes Association and the Michigan Association o f County Medical Care F a c ilitie s develop p o lic ie s and procedures fo r plan­ ning, Implementation, and evaluation o f health education 1n health care In s titu tio n s as an In te g ra l p art o f the health care services w ith in the In s titu tio n s and 1n communities.7 This p ro je c t has undertaken a survey o f p a tie n t education in M ichi­ gan's nursing care f a c i l i t i e s , as a prelim in ary step toward the p o lic ie s and procedures c a lle d fo r 1n the recommendation. D e fin itio n o f Terms The term p a tie n t education t r a d it io n a lly applies to educa­ tio n a l programs on health topics provided fo r h o sp italize d p a tie n ts . However, nursing care f a c i l i t i e s freq u e n tly have general education 5 Governor's O ffic e o f Health and Medical A ff a ir s , P re lim i­ nary Recommendations, State Health Planning Advisory Council, Task Force on Health Education o f the Public (Lansing: Governor's O ffic e o f Health and Medical A ff a ir s , 1976), p. 92. 6 Ib 1 d ., pp. 92-93. 7Ib1d. 7 a c tiv itie s a v a ila b le as part o f th e ir dlverslonal therapy programs. These a c t iv itie s are extremely Important i f patients are to continue to be persons, ra th e r than be reduced to objects th a t need resto ra­ tio n . I t 1s Important fo r people to resume or sustain learning a c tiv itie s whether they are patients or not. I t 1s likew ise Impor­ tant that patients engage 1n learning a c t iv it ie s which have In te re s t and meaning to them, whether re la te d to th e ir disorder or not. This continuity o f personhood must be recognized 1n any comprehensive program o f p atien t education. Therefore, fo r the purpose o f this In v es tig a tio n , the follow ing d e fin itio n s are used as working d e fin itio n s : P atient Education Program: An organized program o f educa­ tio nal services to patients which may Include (1 ) o rie n ta tio n to the f a c ilit ie s and services a v a ila b le , (2) explanation o f diagnostic and treatment procedures, (3) access by patien ts to educational leadership, m a te ria ls , or f a c i l i t i e s fo r In d ivid u al or group learning. Patient Health Education: That part o f the p a tie n t educa­ tion program th a t provides educational a c t iv itie s on topics that are d ire c tly intended to Improve p a tie n ts ' understanding o f the diagnostic and treatment procedures, and the nature o f th e ir disorders. P atien t General Education: That p art o f the p a tie n t educa­ tion program th a t provides self-improvement a c t iv itie s to f a c i l i t a t e continuing learning 1n areas not d ir e c tly re la te d to th e ir disorders. 8 For operational purposes, a p o s itiv e response to question one o f the survey instrument In d ic a tin g a person or department has been designated to coordinate general p a tie n t education Indicated a Beginning Program o f General Education fo r P a tie n ts . A p o s itiv e response to question one, and two or more elements o f both questions three and fou r o f the survey instrument In d ic a tin g th a t people are a c tu a lly conducting educational a c t iv it ie s Indicated an Operational Program o f General Education fo r P a tie n ts , A p o s itiv e response to question fiv e o f the Instrument Indicated a Beginning P a tie n t Health Education Program. A p o s itiv e response to questions f iv e , and to two or more elements o f both seven and e ig h t o f the Instrum ent, Indicated an Operational Program o f P a tie n t Health Education. These d e fin itio n s were considered by the "ju ry o f e xp e rts ," and were judged as appropriate. Nursing Care F a c ili t y : An in s titu tio n th a t provides long­ term professional nursing service. I t may be a nursing home, a o county medical care f a c i l i t y , or hospital long-term care u n it. The major d iffe re n c e between these 1ns1tut1ons and acute care hospitals 1s the length o f stay. Patients 1n these in s titu tio n s may stay several days, weeks or months, u n til they are w ell enough to be d is ­ charged. The length o f stay may be long enough th a t p a tie n ts 1n these In s titu tio n s may be re fe rre d to as resid en ts. S p e c ific a lly not Included 1n th is category are Homes fo r the aged, which provide o D irecto ry o f H o sp itals, Nursing Care F a c ili t i e s , Homes fo r the Aged, Bureau o f Health F a c ilitie s (Lansing: Michigan Department o f Public H ealth, 1974), p. 13. room and board and supervised personal care to e ld e r ly people who generally do not need nursing care. f a c i l i t i e s are aged. Most p atien ts 1n nursing care While there may be an occasional young a d u lt or c h ild e n ro lle d , they are the exception ra th e r than the ru le . Nursing Home: An In s t it u t io n , other than a hospital having as one o f It s functions the rendering o f h ea lin g , cu rin g , o r nurs­ ing care fo r periods o f more than tw enty-four hours to In d iv id u als a ff lic t e d with Illn e s s , in ju r y , In f ir m it y , or abnorm ality. County Medical Care F a c ili t y : Q An In s titu tio n th a t Is county-owned and operated and which provides nursing care. Such f a c i l i t i e s are approved by the State Department o f Social Services and c e r t if ie d by the State Department o f Public Health fo r p a r t ic i­ pation 1n the Medicaid and Interm ediate Care Program s.^ Hospital Long-Term Care U n it: A separate u n it o f a hospi­ t a l which Is designed, equipped and s ta ffe d to provide nursing care fo r In p atie n ts who are s u ffe rin g from chronic disease o r who are convalescing.^ Small In s t it u t io n : An In s titu tio n having a capacity o f f i f t y beds or less. Med1um-S1zed In s t it u t io n : An In s titu tio n having a capacity o f fifty -o n e to two hundred beds. Large In s t it u t io n : hundred beds. An In s titu tio n having more than two 10 Old In s t it u t io n : An In s titu tio n s ta rte d p rio r to 1966. New In s t it u t io n : An in s titu tio n s ta rte d In 1966 up through July o f 1976. Health Service Area: A county or group o f counties desig­ nated by Public Law 93-641, The National Health Planning and Resources Development A ct, to do comprehensive health planning. The state o f Michigan 1s divided in to e ig h t such regions. Development Level Score: A score computed fo r a group o f programs th a t Indicates (1 ) the number o f p a tie n t education topics being o ffered and (2 ) the number o f groups o f s t a f f involved In providing p a tie n t education. These facto rs are combined w ith equal weight to form the development level score. Lim itations The in v e s tig a tio n has been lim ite d to the 455 nursing care f a c i l i t i e s In Michigan th a t appear in the most current lis t in g by the Bureau o f Health F a c ili t i e s , Michigan Department o f Public Health. Acute care hospitals and licensed homes fo r the aged have been s p e c ific a lly excluded. The data accumulated have been lim ite d to s e lf-re p o rts on the questionnaire. Judgment on the q u a lity o f the programs Id e n tifie d 1s out­ side the scope o f th is study. This study has attempted to q u an tify components o f e x is tin g programs, and to provide In s ig h t In to some o f the q u a n tifia b le aspects o f q u a lity . 11 Overview o f the D issertation A ll 455 nursing care f a c i l i t y adm inistrators 1n Michigan have been surveyed. obtained. A response ra te o f s1xty-f1ve percent was The questionnaire used was designed by the researcher, evaluated by a ju ry o f experts, and f ie ld tested on a sample o f Michigan nursing care f a c i l i t y adm inistrators. The resu lts were computer analyzed, to look a t p atie n t education programs In r e la tio n ­ ship to In s titu tio n a l type, s iz e , age, and lo c atio n . elements examined Included: The s p e c ific the number o f In s titu tio n s reporting general education, health education, or a combination o f the two programs; the stage o f development o f such programs; designated p atien t education coordinators and centers; the frequency o f various topics, In s tru c tio n a l methods, personnel groups, personnel functions, methods o f In it ia t in g Involvement of patients and evaluation employed 1n the reported programs; and adm inistrators' judgments as to the legitim acy o f p a tie n t education as a function o f th e ir In s titu tio n s and th e ir in te re s t 1n developing or expanding the function. Chapter I Introduces the to p ic , states the problem, describes It s s ig n ifica n ce , and defines the appropriate terms. The nature and boundaries o f the study are stated. Chapter I I reviews the relevant lit e r a t u r e . The h is to ric a l background o f p atien t education is reviewed to show that social policy Is evolving In both the governmental and p rivate sector th a t favors more p atien t education programming. The background o f educa­ tional programming fo r the aged 1s also reviewed, w ith special atten tio n being given to health education fo r the aged. Studies 12 dealing with the extent o f p a tie n t education programming are also reviewed. Chapter I I I presents the s tra te g ie s used 1n th is p ro je c t. A ttention 1s given to the sources o f data* selectio n o f an In s tru ­ ment, and organization and presentation o f the data. Chapter IV presents the display and analyses o f the data. A ttention 1s focused on the research questions posed 1n Chapter I . The data are displayed and analyzed 1n such ways as to obtain the answers to these questions. Chapter V presents a summary o f procedures, a summary o f re s u lts , conclusions, and recommendations. A discussion section 1s Included th a t Incorporates c e rta in o f the auth o r's views. CHAPTER I I REVIEW OF THE LITERATURE Introduction The p atien t education movement 1s a classic example o f social policy development. I t began with prelim inary p o sitio n -takin g by Interested agencies, and progressed to studies and experiments by voluntary agencies. Such experiments were followed by formal rec­ ommendations, governmental studies, and governmental actio n . This chapter Illu s tr a te s through lite r a tu r e review not only the evolution of a program but also the evolution o f a major social p o lic y . Evolution o f In s titu tio n a l and Governmental Policy P atient education 1s not a new development but rath er 1s as old as the d o cto r-p atien t re la tio n s h ip . Most doctors have long recognized the Importance o f the p atie n t understanding what needs to be done to regain and re ta in his health. While some physicians have emphasized th is more than others, the d o cto r-p atien t re latio n sh ip has always had an educational component. Likewise, the nurse- p atien t relatio n sh ip has always had an educational component. Fre­ quently, the ro le o f the nurse 1n teaching was even g reater than that o f the doctor, Including a t minimum the answering o f a myriad o f questions from p atie n ts . 14 As the knowledge explosion Increased, patients became more sophisticated, and demanded to know more about th e ir problems than before. More explanations and ju s tif ic a t io n were required o f medi­ cal s ta ff than In previous years. Yet physicians had less time to spend with th e ir patients because they now were seeing more patients than before. This widespread "health consciousness" was bringing more people to the doctors' o ffic e s with a greater desire to know. Concurrently, physicians were coming to re a liz e th a t 1t was not enough to merely deal with the acute phase o f an Illn e s s , without stressing follow-up a c t iv itie s o f the p a tie n t th a t would prevent recurrence. Yet the Increased p atie n t load did not re a d ily permit th is needed a tte n tio n 1n many cases. One o f the apparent factors responsible fo r Increasing patient education was the development o f prepaid health care groups such as the Health Insurance Plan o f Greater New York, the Kaiser Permente Plan, and the Group Health Cooperative Program. For a monthly fe e , fam ilies were e n title d to complete medical care, both 1n and out o f the h o sp ital. When such groups were faced with the necessity o f paying the to ta l cost o f medical care, 1t became apparent th a t prevention and Informed s e lf-c a re could be p ro fita b le . Hence, these e a rly groups were among the f i r s t to Implement hospital-based p atien t education programs. References to p atien t education began to appear In the l i t ­ erature 1n the 1950s. Some a rtic le s appeared 1n the publications of 15 Veteran's H ospitals. 1? These hospitals* lik e the prepaid groups mentioned above, were committed to provide to ta l medical care. They thus were more w illin g to reduce long-range p a tie n t care costs through educational e ffo r ts . Other references appeared 1n the publications of the health 13 education profession such as 1n The Health Education Journal, Health Education a t Work, ^ and The In tern a tio n a l Health Education J o u r n a l Yet other references appeared 1n the primary journal fo r a ll public health workers, The American Journal o f Public Health. ^ S t i l l others appeared 1n the publications o f the medical profession such as Journal o f the American Medical Association,^ 7 18 and The B u lle tin o f the History o f Medicine. These attempts a t "spreading the word" among health care professionals were la rg e ly 12 George E. Beauchamp, "P atient Education and the Hospital Program," V.A. Technical B u lle tin (January 1953): 88. ^ A llc e M. Johnson e t a l . , "Health Education In H ospitals," Health Education Journal (October 1952): 175. 14 Luclel E. Brownell, "Progress 1n P atien t Education," Health Education a t Work (May 1975): 4. 15 John Burton,"DoctorMeans Teacher," In tern a tio n a l Journal of Health Education (January 1958): 4. 16George Rosen,"Health Education and Preventive Medicine, New Horizons in Medical Care," American Journal o f Public Health (June 1952): 687. 17H. F. Dowling e t a l . , "Time Spent by In te rn is ts on Adult Health Education and Preventive Medicine," A Journal of the American Medical Association (June 1952): 628. 18 Bruno Gebhard, "H isto rical Relationships Between Scien­ t i f i c and Lay Members fo r Present Day Patient Education," B u lle tin o f the History o f Medicine (January 1958): 32. 16 responsible fo r a growing acceptance o f p a tie n t education as a necessary and In te g ra l p art o f health care. Representatives o f several prepaid health care programs have met annually since the 1950s. The Tenth Annual Group Health In s t i­ tute 1n 1960 was e s p e c ia lly s ig n ific a n t. The proceedings were pub19 11 shed and widely d is trib u te d , fu rth e r spreading the concept. Ross Laboratories, publishers o f a monthly new sletter directed toward hospital a d m in istra to rs , devoted it s e n tir e August 1963 Issue to "Health Education 1n a Hospital S e ttin g ." They con­ cluded the Issue by s ta tin g : The hospital has the opportunity to teach constructive health h ab its. The effectiven ess o f a h o s p ita l's health education e ffo r ts can be measured by the number o f persons 1t succeeds 1n r e h a b ilita tin g to useful liv e s and the num­ ber o f readmissions 1t succeeds in preventing. 20 In 1964, the American Hospital Association held a conference 1n Chicago e n title d "Health Education 1n the H o s p ita l." The pro­ ceedings o f th a t conference were published the fo llo w in g y e a r, and became an Important reference p o in t. 21 The p a rtic ip a n ts agreed th a t: (1 ) The hospital has a re s p o n s ib ility 1n p a tie n t education, ( 2 ) the a b i l i t y o f a hospital to f u l f i l l th is re s p o n s ib ility v a rie s , (3 ) the extent o f the program w ill be determined by s t a f f readiness and a b i l i t y , the population served, and by types o f services 19 Group Health Association o f America, Proceedings. Tenth Annual Group Health In s titu te (Chicago: The A ssociation, 1960), p. 30. 20 Ross Laboratories, "Health Education In a Hospital Set­ tin g ," Currents in Hospital Adm inistration (August 1963): 4. 21 American Hospital A ssociation, Health Education 1n the H o sp ital. Proceedings o f the May 1964 AHA Conference (Chicago: the Association, 1965), p. 74. 17 rendered; (4 ) there needs to be recognition o f the funda­ mental changes an education approach may req u ire o f and bring to the tr a d itio n a l program procedures; (5 ) c a re fu lly planned demonstration programs should be encouraged; ( 6 ) s t a f f must be prepared fo r the new undertaking; (7 ) there 1s a need fo r continued In v e s tig a tio n In to the e ffe c t and meaning o f Illn e s s to the p a tie n t and In to ways fo r meeting the p a tie n t's need fo r Inform ation and assur­ ance. 22 In add itio n to reaching fundamental conclusions about p a tie n t education, the conference recognized th a t the American Hospital Association was the nationwide agency most lik e ly to stim ulate hos­ p ita ls to develop programs o f p a tie n t education. Therefore, the conference recommended th a t the American Hospital Association should: 1. 2. 3. 4. 5. 6. 7. Act as a rep osito ry and clearinghouse o f studies and research 1n health education 1n hospitals . . . . Stim ulate demonstration projects and research, and a s s is t in fin d in g resources to finance these a c t i v i ­ tie s . Id e n tify e x is tin g health education programs 1n hospi­ ta ls and stim ulate more hospitals to I n i t i a t e such programs. Disseminate conference proceedings to In tere s te d p a rtie s . Explore the p o s s ib ilitie s o f s im ila r conferences a t regional and s ta te le v e ls , and to suggest implementa­ tio n o f such conferences. Extend the explorations begun a t the Chicago confer­ ence on the d e fin itio n s and goals o f health education, and on the ro le o f the health educator. Document areas o f n e e d .2 ^ C le a rly , the acceptance o f an advocacy ro le by th is organi­ zation was an Important milestone In the evolution o f p a tie n t edu­ cation progress. I t 1s also s ig n ific a n t th a t th is conference was funded by the M etropolitan L ife Insurance Company. 22Ib 1d ., p. 66. 2 3 I b 1 d ., p. 67. Thus, 18 p rivate Insurance companies entered the scene to Im p lic itly endorse the concept. Yet another major In s t it u t io n , the Russell Sage Foundation, entered the struggle to help p a tie n t education gain acceptance. This o rg an izatio n , long committed to health and social w e lfa re , commissioned the w ritin g and p u b licatio n o f a series o f three mono­ graphs e n title d Newer Dimensions o f P a tie n t Care. Frequent r e fe r ­ ence Is s t i l l being made to these monographs, In d ic a tin g somewhat the Importance o f th is e f f o r t . book form. They were subsequently published 1n 24 In 1966, the American Hospital Association produced a le a f ­ le t e n title d Hospitals As Educational In s titu tio n s . I t was a p o lic y statement approved by the American Hospital Association endorsing p atien t education. The AHA followed 1n 1967 with a statement on the Role and R esponsibility o f the Hospital in Providing C lin ic a l F a c ilit ie s fo r a C ollaborative Educational Program 1n the Health F ie ld . While the c h ief th ru st o f th is p o licy statement was d irected towards r e la tio n ­ ships with medical schools, 1t fu rth e r established the ro le o f the hospital as educator. Another professional society o f f i c i a l l y expressed In te re s t 1n 1968, when the Public Health Education Section o f the American Public Health Association appointed a Cormittee on Educational Tasks a j Esther Brown, Newer Dimensions o f P a tie n t Care (New York: Russell Sage Foundation, 1965), p. 74. 19 1n Chronic Illn e s s . They quickly concluded th a t p atie n t education was an in teg ral p art o f p atie n t care and th a t: Target groups to be considered 1n educational programing Include: (a) the patients and th e ir fa m ilie s , (b) s t a f f members 1n the health care s e ttin g , (c) appropriate groups in the community. The team approach with the physician serving as the team leader and coordinator o ffe rs the most e ffe c tiv e approach to p atien t education. Consideration should be given to an "educational pre­ scription" th a t would be a va ila b le in w ritte n form and would accompany the p atien t as he moved from one f a c i l i t y to another. The committee developed a fiv e -s te p model which Included ( 1) id e n tify the educational needs o f the p atie n t and fa m ily , ( 2) establish educational goals fo r the p a tie n t and fa m ily , (3) select appropriate educational methods, (4 ) carry out the edu26 cational program, and (5) evaluate the p atien t and fam ily education. The elaboration on each step gave s p e c ific "how to do 1t" informa­ tio n . The monograph was the f i r s t "cookbook approach" fo r those who wanted to do p atien t education. F in a lly , there was produced during the 1960s an Important review o f the research to date on p atien t education. 27 The Society of Public Health Education undertook th is task, and thus produced the most comprehensive review of the lite r a tu r e to date. 25 American Public Health Association, A Model fo r Planning Patient Education: An Essential Component o f Health Care (New York: American Public Health Association, 1968), p. 3. 26Ib 1 d ., pp. 9-24. 27 Society fo r Public Health Education, "Review o f Research and Studies Related to P atien t Education," Health Education Monograph (1968): 64. 20 In September, 1971, President Richard Nixon o f f i c i a l l y appointed "The P resident's Committee on Health Education" to study health education across the country and rep ort It s recommendations to him. The committee consisted o f sixteen people who represented very diverse and very special In te re s ts both 1n and out o f the health care f i e l d . The charge to the committee was to: F ir s t, assess what was being done 1n health education throughout the country; second, t r y to fin d a way to evalu­ ate the effectiven ess o f the e f f o r t ; t h ir d , on the basis o f th a t evaluation to recommend i f necessary a new national approach to health education; fo u rth , to devise a strateg y to Implement whatever was recommended.2° The P resident's Committee on Health Education held hearings around the nation about health education, Including but not lim ite d to p a tie n t education. S p e c ific a lly , 1n reference to p a tie n t education: Most o f the physician groups to ld us th a t w ith the possible exception o f p e d ia tric s and o b s te tric s , and gynecological s p e c ia lis ts , most doctors do not have the tim e, In c lin a tio n , In c e n tiv e , or b e lie f 1n health education to do much o f a job 1n p a tie n t education. We found very l i t t l e e ffe c tiv e health education o f p atien ts 1n h o s p ita ls , and y e t we found th a t th is might be one o f the r e a lly teachable moments, when both the p a tie n t and his fam ily are more susceptible to advice . . . . Several studies show what e ffe c tiv e health education might do . . . . readmission rates are substan­ t i a l l y reduced where there 1s e ffe c tiv e health education. . . . Of the 7,000 hospitals 1n the United States we could fin d no more than four th a t were doing what we would con­ sid er an acceptable job o f p a tie n t education. 29 V i c t o r Welngarten, "Report o f the Findings and Recommenda­ tions o f the P resident's Committee on Health Education," Health Education Monographs (1974): 11. 2 9 Ib 1 d ., p. 15. 21 The Committee made It s report 1n 1973 and recommended th at: 1. 2. 3. 4. 5. 6. The government prepayment plans and Insurance companies which pay fo r health care services be w illin g to adjust premium rates to include 1n th e ir services the cost o f health education fo r the patients Involved. The n atio n 's hospitals be strongly encouraged to o ffe r health education programs to patients and fa m ilie s , both on an In p a tie n t and ou tp atien t basis. A major new educational program be undertaken among medical and health professionals and adm in istrato rs, to prepare them psychologically and professionally to accept and respond c re a tiv e ly to Increasingly expressed concerns fo r consumer p a rtic ip a tio n in the design o f health education programs and even o f health care fa c ilitie s . S k ill 1n providing health education be an essential part 1n the tra in in g and continuing education o f a ll health workers. Systematic research and evaluation be a p art o f a ll health education programs w ithin the health care d elive ry system. Various health educational approaches among patients be tested to determine which ones appear to bring about the best results 1n p atien t improvement and 1n reduction o f need fo r health services. 30 This committee gave a new level o f c r e d ib ilit y to health education. I t c e rta in ly gave a "big boost" to p atie n t education. The American Hospital Association followed the developments of the President's Committee on Health Education c lo se ly , and responded to 1 t. In March o f 1973, the AHA appointed a Special Com­ m ittee on Health Education to study the ro le o f hospitals in educat­ ing the consumers 1n matters o f h ealth , and the ro le o f the AHA 1n helping hospitals to achieve th a t o b je c tiv e . S p e c ific a lly , the hospital was charged to : 30 "Summary o f Findings and Recommendations o f the President's Committee on Health Education" (Washington, D .C ., 1973), p. 25. (Mimeographed.) 22 1. 2. 3. 4. 5. 6. 7. Id e n tify the categories o f health education. Make recommendations concerning the exten t o f the AHA's Involvement 1n each category. Id e n tify appropriate goals fo r AHA programs In health education programs. Id e n tify appropriate working re la tio n s h ip s and lia is o n e ffo rts w ith professional groups and associations and agencies Involved 1n health education. C la r ify the legal Im plications Inherent 1n the presence o f or In the absence o f p a tie n t education programs 1n the h o sp itals. Make recommendations concerning the financing o f health education programs 1n which hospitals are Involved. D ra ft a p o lic y statement on the ro le o f the hospitals 1n health education. 31 The policy statement c a lle d fo r was approved 1n May o f 1974 and 1s s ig n ific a n t enough to warrant excerpts. Health education Is an In te g ra l p a rt o f high q u a lity health care. Hospitals and other health care In s titu tio n s , as focal points o f community health care, have an o b lig a tio n to promote, organize, Implement and evaluate health educa­ tio n programs. As a p art o f th is process, hospitals should plan with other health care In s titu tio n s and community agencies to define each o rg an iza tio n 's ro le and responsi­ b i l i t i e s 1n meeting the health education needs o f the populations they serve . . . . Hospitals and other health care in s titu tio n s should recognize the opportunity to exercise a ro le o f leadership in the health education o f three s p e c ific audiences: the p a tie n t and his fa m ily ; personnel, including employees, medical s t a f f , volunteers, and tru stee s ; and the community at la rg e . The major emphasis o f health education 1s health promo­ tio n , which Includes health maintenance, disease and trauma management, and the Improvement o f the health care system and It s u t iliz a t io n . Through health education programs, hospitals and other health care In s titu tio n s can contribute to Important health care goals, such as Improved q u a lity o f p a tie n t care, b e tte r u t iliz a t io n o f o u tp a tie n t f a c i l i t i e s , shorter lengths o f s ta y , and reduced care costs . . . . A s ig n ific a n t corporate commitment, including s t a f f and fin a n c ia l resources, 1s essen tial I f hospitals and other 31 "AHA Appoints Special Committee," Journal o f the American Hospital Association (March 1973): 59. 23 health care In s titu tio n s are to f u l f i l l t h e ir leadership role 1n health education . . . . . . . health education th a t 1s In teg ral to treatment . . . Is a le g itim ate p art o f the cost o f caring fo r the p a tie n t. 32 Another s ig n ific a n t step occurred when the Health Mainten­ ance Organization Act o f 1973 passed by the national Congress required each HMO to "encourage and a c tiv e ly provide fo r Its members' health education, education 1n the appropriate use o f health services, and education in the contribution each member can make to the main33 tenance o f his own h ealth ." Steps are being taken to Implement th is requirement, and patient education programs are being developed 1n HMO's a ll over the country as a re s u lt. Both the President's Committee on Health Education and the American Hospital Association's Special Comnlttee on Health Education indicated that 1t would require s ig n ific a n t fin a n c ia l commitment to do the jo b . Insurance companies had to become Involved 1f the tasks were to be Implemented. P a r tia lly 1n response to the recommendations of these two committees, the Committee on Health Education o f the Health Insurance Benefits Advisory Council Issued a re p o rt. They prefaced th e ir comments by s ta tin g : 32 American Hospital Association, The Role o f Hospitals and Other Health Care In s titu tio n s In Personal and Community Health Education (Chicago: American Hospital Association, 1974), P. 1. ^ H e a lth Maintenance Organization Act o f 1973, T it le X P II. Sec. 1301,“T 9 T. 24 I f health education 1s to achieve It s p o te n tia l and accom­ plish the goals o f the President's Committee . . . i t must establish i t s e l f as an e ffe c tiv e component o f the health care team, with defined goals, c r it e r i a , and methodology fo r evaluation o f progress toward these g o als .34 They went on to s ta te : The general th ru st o f a national health education policy a t th is tim e, should be along two complementary lin es: 1. encouragement, by means o f fin a n c ia l, tec h n ica l, Informa­ tio n a l, p o lit ic a l, moral, or other assistance, o f new pro­ grams and demonstration projects . . . e sp ecially in s e t­ tings where meaningful evaluation can be carried out; and 2 . encouragement by the same means . . . o f tra in in g , evalu­ a tio n , and other a c t iv itie s designed to Improve the q u a lity and quantity o f personnel . . . and programs being o ffe re d . 35 They went on to quote the recommendations o f the President's Commit­ tee, th a t called fo r Insurance companies to "be w illin g to adjust premium rates to Include 1n th e ir payments the cost o f health edu­ cation to the patients Involved," and responded by s ta tin g , "We strongly urge p rivate c a rrie rs to implement these recomnendatlons 36 as soon as possible." On y e t another fro n t, the government Medicare program also moved to provide coverage o f the costs o f p atien t education. The 1974 Medicare Guidelines fo r Reimbursement o f P atien t Education read as follow : While the law does not s p e c ific a lly Id e n tify p atie n t education programs as covered services, reimbursement may be made under Medicare fo r such programs furnished by pro­ viders o f services ( I . e . , h o sp itals, s k ille d nursing f a c i l i t i e s , home health agencies, and o u tp atien t treatment 34 "Report o f the Committee on Health Education to Health Insurance Benefits Council" (New York, 1974). (Mimeographed.) 35Ib 1d . , p. 2 . 3 6 Ib1d. 25 providers) to the extent th a t the programs are ap p ro p riate, In te g ra l parts 1n the re n d itio n o f covered services which are reasonable and necessary fo r the treatm ent o f the in d i­ v id u a l's Illn e s s o r In ju ry . For example, educational a c t iv i­ tie s c a rrie d out by nurses--teach1ng p atien ts to give them­ selves In je c tio n s , fo llo w prescribed d ie ts , adm inister colostomy care, adm inister medical gases, and carry out other In p a tie n t care a c t1v1t 1es--may be reimbursable as a part o f covered ro u tine nursing care. Also, the teaching by an occupational th e ra p is t o f compensatory techniques to Improve a p a tie n t's le ve l o f Independence 1n the a c t iv it ie s of d a lly liv in g may be reimbursable as a p a rt o f covered occupational therapy. S im ila r ly , the In s tru c tio n o f a p atie n t 1n the carrying out o f a maintenance program designed fo r him by a physical th e ra p is t may be reimbursed as a p art o f covered physical therapy. However, where the educational a c t iv it ie s are not closely re la te d to the care and treatm ent o f the p a tie n t, such as programs d irected toward In s tru c tin g p atien ts o r the public generally 1n preventive health care a c t iv it i e s , reim­ bursement cannot be made since the law lim its Medicare pay­ ment to covered care which is reasonable and necessary fo r the treatment o f an Illn e s s or In ju ry . For example, pro­ grams designed to prevent Illn e s s by In s tru c tin g the general public 1n the Importance o f good n u tritio n a l h a b its , exer­ cise regimens, and good hygiene are not reimbursable under the program. Thus, another serment o f society has moved to endorse the concept o f p atien t education. The concept o f p a tie n t education has been evolving fo r a t le as t tw e n ty -fiv e years. I t has been s ig n ific a n tly Influenced thus fa r by the professions, the In s titu tio n s , foundations, p re s id e n tia l committees, and p riv a te and governmental reports and conferences. I t has also been Influenced by s o c ia l, p o l i t i c a l , and economic con­ d itio n s . With the prospects o f a national health Insurance program being Implemented, the prospects o f p a tie n t education look even b e tte r. I t appears to be "an Idea whose time has come." 26 The E ffectiveness o f P a tie n t Education Most o f the lit e r a t u r e to date has d e a lt w ith the needs fo r p atie n t education and the effectiven ess o f programs 1n meeting those needs. I t has been established th a t p atien ts do have needs th a t In d icate educational programming. 1. A ll p atien ts have a need fo r reassurance. requires many adjustments. Illn e s s A p a tie n t's emotional w ell-b ein g demands reassurance th a t a normal l i f e w il l be possible, and what the a n t i­ cipated ra te o f progress toward th a t goal w il l be. 2. Even 1 f p atien ts a r e n 't going to recover f u l l y , or a re n 't going to recover a t a l l , evidence Is mounting th a t they also need to know th a t. made. Adjustments and arrangements may need to be Such adjustments and arrangements need to be based on the best inform ation a v a ila b le . When 1t 1s judged not m edically advis­ able to give such Inform ation to the p a tie n t, the Inform ation should be made a v a ila b le to an appropriate person 1n his b e h a lf. 3. The p a tie n t also has a rig h t to know, 1n add itio n to his need to know. Many court decisions 1n recent years have revolved around the doctrine o f Informed consent. But the scope o f lit ig a t io n 1n th is general area has d e a lt not only w ith Informed consent, but also with the p a tie n t's rig h t o f access to Inform ation 1n his medi­ cal record, and his rig h t to adequate s e lf-c a re procedures upon discharge from the h o s p ita l. This rig h t to know has also been emphasized 1n "A P a tie n t’ s B ill o f Rights" accepted by the American Hospital Association 1n 1972. Five o f the twelve statements deal d ire c tly with the p a tie n t's rig h t to know. 27 4. Patients need f u ll and thorough explanations o f proce­ dures they are to fo llo w , both v erb a lly and in w ritin g . Many patients simply do not follow th e ir doctor's orders. Scott Slmonds summarized the s itu a tio n thus: Studies o f compliance with medical regimens are d i f f i ­ c u lt to compare one with the o th e r, but when you add them a ll up, i t would appear th a t Indeed patients do not comply with a t le a s t on e-h alf to tw o-thirds o f the recommendations made by th e ir physicians. 37 Michael Lesparre likew ise summarizes these studies by s ta t­ ing: "The range o f non-compliance described in the lit e r a t u r e 1s from 15 to 93 percent, a gap th a t ought to make very health profes38 slonal uncomfortable." Much o f the re s p o n s ib ility fo r th is s itu a tio n goes back to a lack o f complete understanding o f what should be done and why. As Lesparre says 1n another a r t ic le : "The hospital environment with its technical environment and professional e x p e rtis e , 1s generally 39 Intim idating to the p a tie n t, and hardly conducive to le arn in g ." Problems th a t contribute to th is phenomenon Include language d if f ic u lt y , c u ltu ra l v a ria tio n s , education le v e ls , and age d if f e r ­ en tia ls between p atien t and provider. Studies in d icate th a t a 37 Scott K. Slmonds, "P atient Education As One C rite rio n fo r Q uality Care," paper presented a t the F ifth Annual In te rd is c ip lin a ry Conference on Health Records, Ann Arbor, Michigan, June 24, 1974, p. 4. ^®M1chael Lesparre, "The P atien t As Health Student," Hospitals (March 1970): 4. 39 Michael Lesparre, "The Role of the Hospital Organization In P atient Education," Health Education Monographs (Spring 1974): 74. 28 p atien t who 1s s u f f ic ie n t ly fe a rfu l and anxious may become v ir t u a lly 40 unable to function m entally. I t has been established through demonstration projects th a t have been c a re fu lly evaluated th a t p a tie n t education programs can and do meet the needs ju s t o u tlin e d . Fu rth er, I t has been estab­ lished th a t: Substantial reduction in re-adm1ss1on fo r p atien ts w ith congestive h eart f a ilu r e have been found among p atien ts who have p a rtic ip a te d 1n educational programs; reductions In the use o f emergency rooms with asthma p atien ts have been found when they had the opportunity to learn about th e ir s e lf-c a re 1n s p e c ia lly organized groups; reductions 1n bro­ ken appointments and Increased compliance 1n s e lf-c a re have been obtained through a v a rie ty o f educational programs. We have found more cooperation 1n the taking o f laboratory tests when p atien ts are given the opportunity to learn about them. We have found patien ts can be taken o f f admin­ is te re d In je c tio n s and placed on self-adm 1n1stered or oral medication a f t e r they are given an opportunity to hear more about s e lf - c a r e .4 ' Lesparre s ta te s : " I t 1s very lik e ly 1n the long run th a t p atien t education contributes to the most economical use o f health f a c ilit ie s and services. And i t 1s an e x c e lle n t— perhaps the best— 42 means to b e tte r conmunlty re la tio n s ." Lawrence Green concludes his review o f seventy-nine a r tic le s on th is top ic by s ta tin g : 40 George Reader, "The Physician As Teacher," Health Education Monographs (Spring 1974): 34. 41Simonds, p. 6 . 42 Lesparre, "The Role o f Hospital Organization 1n P atien t Care," p. 45. 29 The p o te n tia l b e n e fits f a r outweigh the costs, and the r a tio o f b e n e fits to costs 1s almost c e rta in to be g re a te r than the corresponding ra tio s fo r most medical and s u rg ica l procedures d ire c te d toward the same problems. This 1s not to suggest th a t h ealth education should be 1n d ir e c t compe­ t i t i o n w ith medicine and surgery fo r h ealth care d o lla r s . The two sets o f services must be cast In a complementary framework in which h ea lth education prevents unnecessary medical and su rg ical procedures, whereas medicine and s u r­ gery are an e s s e n tia l back up to unsuccessful h ealth educa­ tio n . Health education is also shown to have undeveloped p o te n tia ls f o r Improving the outcomes o f medicine and su rg ery.43 The Extent o f P a tie n t Education Programming The lit e r a t u r e on the nature and e x te n t o f p a tie n t education which 1s a c tu a lly being conducted 1s much more r e s t r ic t e d . P eters' study e n t it le d "A Survey o f Health Education Programs 1n the United S tates, w ith a Proposed Model fo r a Comprehensive Health Education 44 Program in a H ospital S e ttin g " 1s one such study, and 1s Im portant to th is in v e s tig a tio n because o f the methods she employed. Peters contacted the American H ospital A ssociation and the Resources Devel­ opment D iv isio n o f the United States Department of H ea lth , Education and W elfare fo r a l i s t o f h o s p ita ls w ith h ealth education programs. She also used l i s t s th a t had been published 1n the Journal o f the American H ospital A ssociation from 1967 to 1973, and a 11st o f hos­ p ita ls th a t sent re p re s e n ta tiv e s to a workshop on h o sp ital h ealth 43 Lawrence Green, "Cost Containment and the Economics o f Health Education 1n Medical C are," paper presented a t the American Health Congress, Chicago, August 14, 1974. 44 Susan J. P e te rs , "A Survey o f H ealth Education Programs 1n the United S ta te s , w ith a Proposed Model fo r a Comprehensive Health Education Program 1n a H o sp ital S e ttin g " (Ph.D. d is s e rta tio n , Southern I l l i n o i s U n iv e rs ity , 1974), p. 223. 30 education held 1n Maryland 1n the spring o f 1973. From these lis t s she compiled a sin gle 11st o f 113 hospitals lik e ly to have hospital health education programs, which she then surveyed. Her primary purpose was to describe the nature and extent o f hospital health education programs 1n these selected h o sp itals. More s p e c ific a lly , she wanted to answer the fo llo w in g ten basic questions: (1) Who coordinated the health education programs and what are the educational q u a lific a tio n s fo r these coordinators? (2) Where 1n the hospital s tru c tu re does the health education program belong? (3 ) What types o f health education programs are most com­ mon, and fo r what conditions? quently? (5 ) Are (4 ) What methods are used most f r e ­ educational prescriptions w r itte n , and fo r what? ( 6) Is there a planned evaluation o f the program, and 1 f methods and c r it e r ia are used? ing are provided, and fo r whom? (7 ) What kinds o f In service t r a in ­ ( 8 ) What personnel are most a ctiv e 1n the p a tie n t education programs? cation 1s sponsored? so, what (9 ) What type o f community edu­ (10) What stumbling blocks were encountered 1n program development? Socha's study e n title d "A Survey o f P a tie n t Education Pro45 grams in Michigan Hospitals" was another such study. Even though I t was done on acute care h o s p ita ls , 1t is s ig n ific a n t to th is In vestigatio n because 1t was done 1n Michigan. The presence o f p atient education programs 1n large hospitals 1s an In d ic a tio n o f 45 Marvin P. Socha, "A Survey o f P a tie n t Education Programs in Michigan Hospitals" (M.A. th e s is , Central Michigan U n iv e rs ity , 1975). 31 the stage of development o f p a tie n t education in Michigan. Socha surveyed hospitals 1n Michigan th a t had 200 beds o r more, because of the contention by the American Hospital Association th a t hospi­ ta ls with 200 beds or more are more lik e ly to have a p a tie n t educatio n program. 46 His study attempted to determine how many o f these hospitals had p a tie n t education programs. In a d d itio n , he wanted to fin d out ( 1) which hospital personnel are Involved with p a tie n t education, ( 2 ) which learning resources are being u tiliz e d fo r p atien t education, (3 ) the extent to which p a tie n t education has developed 1n s p e c ific areas o f medicine, and (4 ) what a ttitu d e s and factors have deterred the Implementation o f a p a tie n t education program. His re s u lts p e rtin e n t to th is study Indicated th a t 90% o f these hospitals were Involved 1n p a tie n t education a c t iv it ie s o f some kind. I t must, however, be remembered th a t the data were obtained by s e lf-r e p o r t. Socha categorized these h o s p ita ls , and concluded th a t there were w el1-organized and e ffe c tiv e programs in only 13% o f the hospitals surveyed. There were some d e fin ite p atien t education a c t iv it ie s accomplished 1n 60% o f the hospitals surveyed, w hile another 17% attempted to do p a tie n t education. The remaining 10% did not attem pt to do any p a tie n t education. N eff 47 also surveyed hospitals w ith 200 beds o r more, using a nationwide sample. She also attempted to fin d out who coordinated 46"AHA Research Capsule #7," Hospitals 46 (1972): 102. 47 Martha S. N e ff, "A Survey Concerning the Role o f the Health Educator in Selected Hospitals Throughout the United States" (Ph.D. d is s e rta tio n , Indiana U n iv e rs ity , 1975). 32 the p atien t education program, and what th e ir q u a lific a tio n s were. Then, s p e c ific a lly , she lis te d functions o f p a tie n t educators, and asked the p racticing p atien t educators whether they thought each function was (1 ) very appropriate, (2 ) appropriate, or (3 ) Inappro­ p ria te . She also asked whether the educational a c t iv it y 1s cur­ re n tly a c tiv e ly practiced 1n the hospital p a tie n t education program. Her study 1s s ig n ific a n t to th is In vestig atio n 1n th a t i t provides a p ro file in defining the parameters o f a w ell-organized p atie n t health education program. The American Hospital Association 1sc u rre n tly under con­ tra c t with the Bureau o f Health Educationto survey a l l 5,829 com­ munity hospitals registered with the American Hospital Association. The focus 1s on In p a tie n t educational programs, s p e c ific a lly excluding outpatient or ambulatory care programs. Data are being sought which w ill determine ( 1) the extent th a t p atie n t education 1s Integrated In to the programs and p o lic ie s o f member h o sp itals, ( 2) the differences and s im ila r itie s o f programs among hospitals of various sizes and types, (3 ) p a tie n t education a c t iv itie s 1n hospitals by sta te s , and (4) the outcomes and benefits o f p atie n t 48 education. The AHA study Is by fa r the most comprehensive one under­ taken to date. The report was due to the Bureau o f Health Education 1n the Department o f H ealth, Education and Welfare 1n August, 1976. 48 Personal correspondence, Elizabeth Lee, S ta ff Associate, American Hospital Association, October 15, 1975. 33 The study 1s, however, considerably behind schedule and is not com­ pleted as o f th is w ritin g . Much has been w ritte n ju s tify in g p a tie n t education programs 1n the health care system. Data are being assembled on the response of the hospitals and on the extent of th e ir p a tie n t education pro­ gram ing. The review o f the lite r a tu r e has revealed no attempt to analyze the response of nursing care f a c i l i t i e s to th is movement. Education fo r the E lderly The concept of life lo n g learning or l i f e span education 1s one that has had a s ig n ific a n t Increase 1n it s advocates during the current decade. One o f the Im plications o f th is movement 1s th a t educational programming should occur fo r persons in the la te r years of l i f e . This 1s beginning to happen. Educational In s titu tio n s as well as other community agen­ cies are beginning to get Involved 1n the development and conduct o f educational programming fo r the middle and la te r years o f l i f e . A real In te re s t in providing l i f e span edu­ cation w ithin e xis tin g community In s titu tio n s 1s being fostered in numerous lo catio n s.™ However, there 1s a myth s t i l l prevalent th a t older people cannot le arn , or th a t they a t le a s t s u ffe r a serious decline in mental a b ilit ie s . Yet, as a survey sponsored by the Department o f Health, Education and Welfare Indicated: "Common sense observation should dispel th is notion fo r hundreds o f thousands o f old er adults are learning In programs reported 1n our survey, and m illio n s have learned every Imagined subject in adu lt education programs over the 49 David A. Peterson, "Lifespan Education and Gerontology," The Gerontologist (October 1975): 436. 34 years and decades." 50 This myth has fo rtu n a te ly been challenged by research 1n the past decade. I t 1s tru e th a t when the aged as a group are examined, they perform more slowly than young people. Furthermore, 1t has been established th a t the poorer performance by some may be due to noncognltlve facto rs such as poor m o tivatio n, lack o f confidence, or poor conditions o f le arn in g . 51 Other researchers rep o rt th a t physical facto rs are not a major v a ria b le : "S lig h t decline in various mental a b i l i t i e s , e s p e c ia lly those related to speed are p e rs is te n tly detected, but they are not o f the type or magnitude to have much p ra c tic a l s ig n ific a n c e 1n learning 1n real l i f e s itu a tio n s ." 52 A pparently, what older people need is more time than 1s usually allowed fo r learn in g . The concept o f s e lf - paced learning seems c r it ic a l fo r the aged. The relevance o f the m aterial to be learned is also c r i t i ­ c a l, in th a t i t a ffe c ts m otivation. Some o f the research on le a rn ­ ing tasks have involved meaningless and t r i v i a l tasks which have l i t t l e or no In te re s t fo r o ld er Americans. Being under no compul­ sion to learn they often shun learning such irr e le v a n t tasks. When the relevance is apparent, however, the o ld er le a rn e r is often the best le a rn e r. DeCrow o ffe rs an explanation o f th is : 50 Roger DeCrow, New Learning fo r Older Americans: An Over­ view o f the National E ffo r t (Washington, D .C .: Adult Education Association o f the U .S .A ., 1975). 51 Diana Woodruff and David A. Walsh, "Research 1n Adult Learning: The In d iv id u a l," The G erontologist (October 1975): 425. 5^DeCrow, p. 17. 35 In general, older people have more and b e tte r organized experiences which provides a meaningful context In to which new Information can be assim ilated. They know themselves b etter and more c le a rly perceive what new learning w ill be tru ly useful to them.” In short, "Most older adults liv in g 1n the community can learn what they need and desire to learn i f given su itab le oppor­ tu n ity . " 54 Despite a ll th is , Jack London, w ritin g 1n The Handbook o f Adult Education, suggests that on only a very few occasions have educational opportunities been directed a t real needs and goals of the e ld e rly . He states: While society expresses concern about Improving th e ir physi­ cal and m aterial condition, the aged are seldom provided with the resources they need fo r relevance and a sense o f worth. We tend to place them 1n "playpens" by providing recreation and s im ila r endeavors w hile doing almost nothing to furnish them with the means to keep m entally a le r t . We s trip them o f most o f th e ir meaningful roles on the assump­ tion they are incapable o f carrying them out e ffe c tiv e ly with the ra tio n a liz a tio n that they deserve the rig h t to rest and take i t easy. Recreational a c t iv itie s are not s u f f i­ cien t to maintain mental a b i l i t i e s , id e n tity , and a sense o f significance as a person.55 That this 1s Important 1s Indicated by the 1971 White House Confer­ ence on Aging: They stated: persons o f a ll age groups. "Education 1s a basic rig h t fo r a ll I t 1s continuous and henceforth one of the ways o f enabling older people to have a f u l l and meaningful l i f e , 53I b i d . , p. 17. York: 54Ib 1d . , p. 6 . 55 Robert M. Smith e t a l . , Handbook o f Adult Education (New Macmillan Company, 1970), p. 15. 36 and a means o f helping them develop th e ir p o te n tia l as a resource fo r the betterment o f s o c ie ty ." As a re s u lt o f the a ttitu d e s th a t were developing and which were confirmed 1n the White House s ta te m e n t educational programs fo r the e ld e rly have developed ra p id ly . DeCrow's national study, aimed at the uncovering o f the extent of learning o p portunity, Indicated that about 3,500 d iffe r e n t programs e xis ted . These came from a ll parts o f the educational system and from a v a rie ty o f non-school agencies as w e ll. The study revealed th a t 58% o f these agencies had begun new a c t iv it ie s w ith in the past year ( 1 9 7 4 ) .^ This 1s a pow­ e rfu l in d ic a to r o f the rapid growth in opportunity and 1n the f lu id it y o f the e n tir e s itu a tio n . Peterson Indicates th a t these programs have a p o s itiv e e ffe c t on the e ld e rly 1n a non-cognit1ve dimension. He Indicates that while older persons need education on a great many subjects, what the learner fe e ls 1s often o f more Importance than the data or s k ills the learn er learns: "Loneliness 1s a prime aspect o f aging. I t Induces depression and other forms o f mental illn e s s . The s o c ia b ility and excitement o f learning go fa r to change the d a lly outlook o f older persons." a c tiv ity theo ry." 56 CO Helmstra gives credence to "the The main assumption o f the theory Is th a t an 1971 White House Conference on Aging, Toward a National Policy on Aging (Washington. D.C.: U.S. Government P rin tin g O ffic e , T3>3), p. 6 . 57 DeCrow, p. 58. 58 James A. Peterson, "Frontiers 1n the Education o f the E ld e rly ," Adult Leadership (January 1976): 170. 37 e ld e rly person's morale w ill be high as long as he or she 1s able to stay a c tiv e , even 1 f faced with ro le reductions and changes. This would mean replacing lo s t roles w ith new areas o f In te re s t and a c t iv it ie s . Helmstra concludes: "This suggests th a t there 1s even a greater need fo r continuing education 1n the e ld e rly years than 59 1n the younger y ea rs ." This seems to be supported by a study o f senior c itiz e n s 1n Minnesota, which concluded th a t senior c itiz e n s have a p o sitiv e a ttitu d e toward learning and, In f a c t, enjoy It.® ® Health Education fo r the E ld e rly A decade ago, Is o la te d programs o f health education fo r the e ld e rly flo u ris h e d . The d ire c to r o f one such program wrote: Health programming fo r the aged 1s urgently needed, and the health educator can u t i l i z e e x is tin g d ata , can Influence program p o lic y , can stim ulate in te re s t 1n others to seek fu rth e r knowledge, and can prepare him self fo r e ffe c tiv e action when the opportunity presents I t s e l f . 61 This p o sition Is s t i l l supported by many health educators today. Elwood e s p e c ia lly advocates a strong re la tio n s h ip between go health education and gerontology. He suggests th a t there 1s a great p o te n tia l fo r health education to o ffs e t the problems o f the ®®Roger Helmstra, The Older Adult and Learning (Lincoln: U niversity o f Nebraska Press, 1975), p. 5. ®°Bruce M. Hauer, "A Model o f Continuing Education fo r Older Adults" (Ph.D. d is s e rta tio n , U n ive rs ity o f Minnesota, 1975), p. 188. ®^B. J. Gardiner and I . L. Webber, "Health Education Pro­ gramming fo r the Aged," Health Education Monograph (1964): 3. ®^T. W. Elwood, "Relationship o f Health Education to Gerontology," In te rn a tio n a l Journal o f Health Education (J u ly September 1972): 3. 38 aged, and urges coordinated planning o f more e ffe c tiv e health educa­ tion fo r the aged. Peterson advocates education fo r the e ld e rly and s p e c ific a lly advocates health education. He states: They would lik e to fe e l b e tte r , have more v ig o r, but unless there are those who w il l share w ith them p ra c tic a l methods o f exercise, d ie t , l i f e s ty le , they stumble along. Most o f th e ir great needs are p re cis e ly those th a t a re le va n t ad u lt education program can answer. 63 Also speaking to th is point was DeCrow who urged health edu­ cation o f the aged. National health Insurance, fo r example, however, I t may be financed, w ill be c o s tly , and w ill la y the health care pro­ fessions under tremendous s tr a in . There 1s no way q u ite regardless o f costs, th a t these programs can succeed w ith ­ out massive programs o f tra in in g fo r s e lf care and mutual assistance among the old er population. 64 Helmstra concluded his study o f o ld er people's learning by recom­ mending 1n the th ird o f twenty-two recommendations th a t "health educators fin d means to make learning opportunities more a v a ila b le to the old er person with health problems." 65 Education in Nursing Homes The concept o f education fo r the aged 1n nursing homes Is r e la tiv e ly new. I t must be remembered th a t: The beginnings o f the In s titu tio n s now known as nursing homes are a re s u lt o f the poor house tr a d itio n and p h i­ losophy. Following the enactment o f the Social Security Act o f 1935, Public Assistance funds were made a v a ila b le 63 James A. Peterson, p. 171. ®^DeCrow, p. 16. ®®He1mstra, p. 73. 39 fo r care o f the needy aged In p ro p rie ta ry boarding and nursing homes. Due to these beginnings and the In a b ilit y or possible lack o f desire o f the public sector o f society to provide care fo r nonhospltall zed but 111 aged persons, p riv ate p ro p rie ta ry In s titu tio n s met the need and have become predominant 1n the nursing home f i e l d . 66 From th is meager beginning, the la s t fo r ty years has seen a great deal o f a tte n tio n focused on nursing homes, 1n an attempt to upgrade f a c ilit ie s and programs. Consumer action groups have often advo­ cated expansion o f services. Both fed eral and s ta te regulations curren tly require a c t iv it y programming. Michigan's S k ille d and Basic Nursing Home Rules s p e c ific a lly s ta te : "A p a tie n t shall be provided dlverslonal a c t iv it ie s suited to his needs, c a p a b ilitie s and In te re s ts as an adjunct to treatment to encourage him to resume s e lf care and normal a c t iv it ie s In s o fa r as possible. A governmental pu blicatio n published to help consumers pick a good nursing home states: The most successful program reduces a p a tie n t's is o la tio n --from other p atien ts 1n the home and from l i f e outside the home. For those who can go o ut, a c t iv it ie s should Include trip s to places such as th e a te rs , museums, and parks, and v is its to the homes o f frien d s and fa m ily. Conmunlty In s titu tio n s such as lib r a r ie s should bring th e ir services to the home. People from the community should be encour­ aged to serve as volunteers who work or v i s i t with the p a tie n ts . Each p a tie n t should have an a c t iv it y schedule geared to his In te re s ts and a b i l i t i e s .®6 H. Ross, "Gero Education," Journal o f American G eri­ a tr ic Society (A p ril 1975): 184. **7The Michigan Comprehensive Plan on Aging, p. 171. fiR U.S. Department o f H ealth , Education and W elfare, Nursing Home Care (Washington, D.C.: Government P rin tin g O ffic e ), p. 19. 40 Such educational programming 1s occurring. A check o f the various state nursing home associations and s ta te health departments by s ta ff o f the Department o f H ealth, Education and Welfare revealed "some a c tiv itie s and a great deal o f in te re s t." go The ten Regional Long-Term Care Education Coordinators are Including p a tie n t and family education as an In teg ral part o f p a tie n t care 1n the p atie n t care planning courses funded by the federal government.^® Two such workshops 1n p atien t and fam ily education In long-term care units have been completed. Senator Frank Moss's Subcommittee on Long-Term Care reviewed nursing homes around the country looking fo r good things th a t were happening. One o f the Innovations they recommended fo r widespread dissemination was educational and tra in in g programs th a t were devel­ oping fo r p atie n ts , esp ecially classes 1n r e a lit y o rie n ta tio n and sensory tra in in g , but Including a wide range o f other educational services fo r p a tie n ts .^ The In s titu te o f Gerontology th a t 1s cosponsored by the University o f Michigan and Wayne State U niversity also advocates health education programs fo r the residents o f nursing care f a c i l i ­ ties as part o f M ilie u Therapy. They have reproduced a handbook fo r 69 Personal correspondence, Mr. Stanley Rosenberg, Health Education Consultant, D ivision o f Long-Term Care, USDHEW, March, 1976. U.S. Senate, Subcommittee on Long-Term Care, What Can Be Done 1n Nursing Homes: Positive Aspects inLonq-Term Care (Wash­ ington, D.C.: Government P rin tin g O ffic e , 1975), p. 584. 41 those who f a c ilit a t e such experiences th a t provides d e ta ile d lesson plans fo r classes th a t are conducted d a lly , extending over several weeks. Topics fo r these classes Include understanding medication, d ie t, exercise, v is io n , hearing, dental care, personal hygiene, 72 psychological needs, e tc . Health education fo r e ld e rly persons who are residents o f nursing homes has gained a level o f re s p e c ta b ility I t had not pre­ viously enjoyed. Programs are developing around the natio n . It now remains to maximize the c rea tive Input and to describe and disseminate the good program Ideals th a t evolve, so that they can be re p lic a te d . Summary Patient education programming 1s not new, but rath er 1s In a period o f rapid development. Experiences 1n h o sp itals, government programs, and professional associations have a ll had Impact on th is movement. I t 1s now apparent th a t the governmental units are about to take action which w ill form alize and le g itim iz e p a tie n t educa­ tio n . A Michigan governmental appointed Task Force on Health Edu­ cation o f the Public has called fo r such a study to be done, th a t would be used as the basis fo r po licy development regarding planning, Implementation, and evaluation o f health education In nursing care f a c ilit ie s . 72 This In vestigatio n w ill 1n p art meet th a t need. Frank E. Grant, Catawba Hospital Handbook fo r F a c ilita to rs (Ann Arbor: In s titu te o f Gerontology, 1976), p. 57. 42 Furthermore, th is In v es tig a tio n w ill determine 1 f nursing care f a c i l i t y adm inistrators are aware o f and part o f the developing national trend toward p a tie n t education programming. Program existence w ill r e fle c t 1n part adm inistrator awareness o f the cost effectiveness o f p atien t education. S im ila rly , i t w ill r e fle c t awareness o f the needs o f the e ld e rly to remain m entally a l e r t , to receive s e lf - f u lf illm e n t and social recognition from learning r e le ­ vant m a te ria l, which a l l , 1n tu rn , a ffe c t morale. Most s p e c ific a lly , i t w ill r e fle c t awareness o f the trend toward Increased educational programming 1n Michigan nursing care f a c i l i t i e s . CHAPTER I I I METHODOLOGY The Evolutionary Stages o f the In vestigatio n The purpose o f th is p ro ject was to determine what elements of p atient education programs e x is t 1n Michigan's nursing care f a c ilit ie s . Consideration was given to what factors might Influence the composition o f such programs. I t was determined that the type o f In s titu tio n , the age o f the in s titu tio n , the size of the i n s t i­ tu tio n , and the location o f the in s titu tio n a ll could a ffe c t program. Other factors th a t were considered Include the a ttitu d e s o f the gov­ erning board, the a ttitu d e o f the adm inistrator and other f a c i l i t y s ta ff, and the a ttitu d e s o f the p a tie n ts . These were excluded, as being outside the scope o f th is study, but are recommended fo r f u r ­ ther examination by other researchers. The p ro ject then was lim ite d to determining existence o f patient education programs, s p e c ific elements o f those found to e x is t, and the relationships between these variables and the s iz e , location, age and type o f nursing care f a c i l i t y . I t was decided that a measure should be made o f the stage o f development o f the programs th a t were Id e n tifie d . I n i t i a l l y , an attempt was made to define three stages o f developing as beginning, o p eratio n al, and well developed. However, as attempts were made to d elineate these categories, 1t was re a lize d th a t 1t was d i f f i c u l t , I f not Impossible, 44 to define the categories so as to be m utually exclu sive. Spe­ c if ic a lly * d if f ic u lt y was encountered 1n determining a measure o f a well-developed program th a t might not also be o ften found 1n a beginning program. The th ir d category was accordingly dropped. It was te n ta tiv e ly decided th a t 1f a program had a coordinator whose duties Included doing p a tie n t education, th a t program was judged to be 1n the beginning stages. A program was judged to be operational I f , 1n addition to a coordinator, a t le a s t two other groups were Involved 1n planning o r teaching 1n the program, and 1f a t le a s t two educational o ffe rin g s were a v a ila b le . I t was recognized th a t more programs was not the equivalent of b e tte r programs, and likew ise th a t bigger programs was not neces­ s a rily the equivalent o f b e tte r programs. A fte r much thought and discussion w ith members o f the d is s e rta tio n committee, 1t was decided th a t measurements o f the q u a lity o f the programs observed were outside the realm o f th is study. Such measures would In v o lve , at minimum, some subjective measures by p a rtic ip a n ts , w ith some In ternal and external evaluation measures also Included. Standards fo r comparison would also have to be Id e n tifie d to which the members of the profession would agree. Q u a lita tiv e measures were, th e re fo re , elim inated, and the focus remained on determining program existence and stage o f development. The p ro je c t was discussed w ith the ad m in istrato r o f the Isabella County Medical Care F a c ilit y , Mr. John Verway. He sug­ gested th a t the regional f ie ld representative o f the D ivisio n o f 45 License and Standards o f the Michigan Department o f Public Health would also be a good person to contact to discuss the p ro je ct. Accordingly, the m atter was discussed with Mr. Elwood McCleod. He Indicated th a t 1t would be helpful to also discuss the project with someone from the D ivision o f Long-Term Services of the U.S. Department o f H ealth, Education and W elfare. The m atter was, therefore, discussed with Mr. Stanley Rosenberg, who Indicated a national survey was not fe a s ib le because o f the large differences 1n agencies, and 1n terminology, from state to s ta te . His agency had Investigated such a study and found 1t unfeasible. Thus, the focus returned to Michigan programs In p a tie n t education. A d irecto ry was obtained from the Michigan Department o f Health. I t lis te d 455 nursing care f a c i l i t i e s In Michigan. At th is time, 1t was thought th a t operational programs o f p a tie n t education were scarce, an opinion th a t was shared by the adm in istrato r, the representatives o f the s ta te and federal agencies, and the respec­ tive professional associations. There was some concern th a t 1 f the population were sampled, some Innovative programs could e a s ily be missed. I t was thus determined to study the e n tire population. The problem now was delineated to studying p atie n t educa­ tion programs 1n 455 nursing care f a c i l i t i e s scattered widely throughout Michigan. Personal v is ita tio n s were judged unfeasible. Telephone surveys were ruled out because o f the time required to discuss the program. There was also concern that the Interview er might not be able to reach the most knowledgeable respondent, and that the questions would perhaps be answered by a secretary or 46 recep tion ist. I t was f e l t th a t the adm inistrator was the single most lik e ly person to know what kinds o f p a tie n t education were occurring 1n an In s titu tio n , and th a t 1 f he was n o t, he would know who was 1n such a p o sitio n . Further, adm inistrators were 1n a position to Influence program development. I t was thus established th ata mailed questionnaire to nursing care f a c i l i t y adm inistrators would be the best means o f gathering the desired data. A questionnaire was developed, a fte r c a re fu lly reviewing an Instrument used by the American Hospital Association In a study reviewed In Chapter I I . A request was granted to use or modify any parts of th a t questionnaire. The questionnaire as developed was submitted to a ju ry o f experts to be c ritiq u e d . The ju ry Included an adm inistrator o f a nursing care f a c i l i t y , a university-based p a tie n t education con­ s u lta n t, a practicing p atie n t educator, the current president o f the Society o f Public Health Education, a f ie ld representative o f the Division o f Standards and Licensing o f the Michigan Department o f Public H ealth, a f ie ld representative o f the D ivision of Long-Term Care Services o f the Health Resources Adm inistration o f the Depart­ ment o f Health, Education and W elfare, the executive d ire c to r o f the Michigan N on-Profit Homes Association, and the executive d ire c ­ tor of the Michigan Health Care Association. Their review repre­ sented th e ir personal opinions, and did not r e fle c t any o f f ic ia l agency actio n . Each o f the eight people had experience 1n p a tie n t education or nursing care f a c i l i t y programming, y e t from a s lig h tly d iffe r e n t 47 perspective. F u rth er, i t was judged th a t each had a major In te re s t 1n p a tie n t education 1n nursing care f a c i l i t i e s and should have an opportunity fo r In p u t. Major revisions were suggested a t th is stage and there was unanimous agreement th a t the questionnaire was too long. The ju ry also seemed to agree th a t nursing care f a c i l i t y adm inistrators were u ltra s e n s itiv e regarding requests fo r fin a n c ia l Inform ation, and would discard the questionnaire I f these questions were Included. There were many comments regarding the wording o f s p e c ific questions as w e ll. A fte r c a re fu lly reviewing t h e ir response w ith the d is s e r­ tatio n committee, a decision was made to shorten the questions and to avoid In q u iry about finances, so as to Increase the probable return ra te . The questionnaire was revised accordingly, and shor­ tened from nine pages to fo u r. This was done by more ju d icio u s use o f the space o f each page, by the e lim in a tio n o f some questions, and by the re stru c tu rin g o f others. Two ju ro rs predicted a response rate o f around t h i r t y percent, based on previous experience w ith some ra th e r Informal surveys o f the agencies they represented. The questionnaire was then f ie ld tested on acfcn1n1strators o f twelve nursing care f a c i l i t i e s , taking care to have larg e and small f a c ilit ie s 1n both urban and ural areas represented. Four o f the twelve adm inistrators returned the questionnaire as requested, without any follow -up attem pt, re s u ltin g In a th ir ty - th r e e percent return . The four responses were from two nursing homes and two medical care f a c i l i t i e s . Three o f the responding In s titu tio n s were 48 classed as la rg e , w hile one was sm all. Three were classed as r u r a l, w hile one was urban. A ll four o f the respondents f i l l e d out the questionnaire. There were eig h t marginal comments, a l l o f which were elaborations on answers or a d d itio n a l opinions o f ad m in istrato rs. There were no c riticism s o f the questionnaire and no changes 1n i t were suggested. A cover l e t t e r signed by the In v e s tig a to r as a Central Michigan U n iversity fa c u lty researcher was sent to six o f the twelve adm inistrators. A cover le t t e r signed by the In v e s tig a to r as a Michigan State u n iv e rs ity doctoral student was sent to the other s ix . Three o f the four responses were received from the f i r s t o f these two cover le t t e r s . I t was, th e re fo re , decided to use the le g itim ate fa c u lty t i t l e and u n iv e rs ity le tte rh e a d s ta tio n e ry . The questionnaire was reviewed by Dr. Robert DeBruln. a research consultant In the Computer Services Center a t Central Michigan U n iv e rs ity . The data obtained from the f ie l d te s ts were coded fo r computer p rin to u ts . Minor revisions were made on the basis o f these reviews and pretests. The questionnaire and cover l e t t e r were reviewed one more time by the d is s e rta tio n committee, revised s lig h t ly , and approved fo r d is trib u tio n . On May 26, 1976, the revised questionnaire was mailed to adm inistrators o f a l l 455 nursing care f a c i l i t i e s 1n Michigan, 1n order to provide a complete p r o file or a "census" o f e x is tin g pro­ grams. A stamped return envelope was provided. fo r a copy o f the questionnaire and the l e t t e r . ) (See Appendix There were 160 49 questionnaires returned, fo r an i n i t i a l response ra te o f tw en ty-five percent. On June 8, 1976, a follow-up le t t e r was mailed to the non­ respondents. (See Appendix fo r a copy.) A concluding sentence urged the adm inistrators to c a ll the researcher c o lle c t I f they needed another copy o f the questionnaire. Fourteen adm inistrators did c a ll c o lle c t, and another questionnaire was mailed to each. As a re s u lt o f th is follow-up l e t t e r , seventy-three more question­ naires were returned, making the new to ta l 233, resu ltin g In a new response ra te o f fifty -o n e percent. On June 28, 1976, another follow-up le t t e r was sent to non­ respondents. The le t t e r Included a statement from Mr. Gary Hooyenga, president o f the Michigan Health Care Association, urging member In s titu tio n s to cooperate In th is research p ro je c t. for a copy o f th is l e t t e r . ) (See Appendix Another questionnaire was included this time, as was another stamped return envelope. Eighty-two more ques­ tionnaires were returned, resu ltin g 1n a new to ta l o f 315 and a combined response ra te o f s ix ty -n in e percent. Of the 315 question­ naires returned, 294 or s ix ty -fiv e percent were usable. The remaining twenty-one tric k le d 1n a ft e r the computer analysis had been completed. Members o f the ju ry had predicted a t h ir t y percent response rate. The usable response ra te o f s1xty-f1ve percent Is extremely high 1n comparison to th a t predictio n . 50 Analysis o f the Data The Univac 1106 Computer a t Central Michigan U n iv e rs ity was used to do the a n a ly s is . The program was w ritte n by Dr. Robert DeBruln and Ms. Joyce Abler using elements o f the S t a tis t ic a l Pack73 age fo r the Social Sciences. and elements o f the Biomedical Com74 puter Programs. S t a tis t ic a l procedures used e xten sively were f r e ­ quency counts, percents, ranges, standard d e v ia tio n s , and measures o f central tendency. was determined. The existence o f p a tie n t education programs Summary data were provided, a f t e r which the pro­ grams were grouped by the Independent variab les o f In s titu tio n a l type, s iz e , lo c a tio n , and age, and then displayed. A program devel­ opment score was computed and likew ise grouped and displayed. The p rin c ip a l components o f p a tie n t education programs were then analyzed. Summary data were provided, a f t e r which the data were grouped according to In s titu tio n a l typ e, s iz e , age, and lo c atio n . An attem pt was made to determine 1 f any o f the follo w ing Items were re la te d to the Independent variab les Id e n tifie d above: existence o f p a tie n t educaton coordinators and centers; the f r e ­ quency o f various to p ic s , In s tru c tio n a l methods, personnel groups, personnel fu n ctio n s, methods o f In it ia t i n g p a tie n t Involvement, and the evaluation methods employed; and ad m in istra to rs ' judgments as to the legitim acy o f p a tie n t education as a function o f t h e ir 73 Norman N1e e t a l . , S t a tis t ic a l Package fo r the S o d a! Sciences, 2d ed. (New York: McGraw-H11l, 1975), p. 675. 74W. J. Dixon, Biomedical Computer Programs (Los Angeles: U niversity o f C a lifo rn ia t’ress, 1975), pp. >297 51 In s titu tio n s , and th e ir In te re s t 1n developing or expanding th is function. S pecific questions to be answered Included the follow ing: (1) What elements o f organized p a tie n t education programs e x is t 1n Michigan's nursing care f a c ilit ie s ? (2) Are there p a tie n t educa- t1on programs 1n more o f Michigan’ s nursing homes, medical care f a c i l i t i e s , or hospital long-term care units? (3) Are there more p atien t education programs 1n la rg e r In s titu tio n s , medium-sized In s titu tio n s , or smaller in s titu tio n s ? (4) Are there more p atie n t education programs In some Health Service Areas than 1n others? (5) Are newer nursing care f a c i l i t i e s more apt to have established p atient education programs than older f a c ilit ie s ? (6) Are p atie n t programs more developed 1n nursing homes, medical care f a c i l i t i e s , or hospital long-term care units? (7) Are p atie n t education pro­ grams more developed 1n la rg er In s titu tio n s , medium-sized In s t it u ­ tions, or smaller In s titu tio n s ? (8) Are p atie n t education programs more developed In some Health Service Areas than 1n others? (9) Are p atie n t education programs more developed 1n newer nursing care f a c i l i t i e s than 1n older f a c ilit ie s ? Summary A questionnaire was designed, sent to a ju ry o f eight experts, and p ilo t tested on adm inistrators o f twelve Michigan nurs­ ing care f a c i l i t i e s . I t was then re fin e d , p rin te d , and mailed to adm inistrators o f a l l 455 nursing care f a c i l i t i e s 1n Michigan. response rate o f s1xty-n1ne percent was A obtained, with s ix ty -fiv e 52 percent being usable. The data were organized and then analyzed by the computer a t Central Michigan U n iv e rs ity , using frequency d is trib u tio n s , percents, ranges, standard deviation s, and measures o f central tendency. The data were then In terp reted so as to answer the research questions. Findings are reported 1n Chapter IV and conclusions are reported 1n Chapter V. CHAPTER IV ANALYSIS OF DATA Introduction This study was undertaken to Id e n tify and analyze p a tie n t education programs as they existed 1n nursing care f a c i l i t i e s 1n Michigan In 1976. The f i r s t task was to locate such programs by area o f the s ta te , and to describe t h e ir d is trib u tio n by typ e, s iz e , bed cap acity, and age o f nursing care f a c i l i t y . Once lo cated , the programs were analyzed to learn about three major fac to rs : (1) exten t o f development; (2 ) p rin c ip a l components, which Included (a) program coo rd in atio n, (b) educational center designation, (c) educational o ffe rin g s fo r p a tie n ts , (d) education fo r the p a tie n t's fa m ily , (e ) p rin c ip a l p a rtic ip a n ts , ( f ) In it ia t i o n o f p atie n t Involvement, (g ) evalu atio n ; and (3 ) whether acknlnlstrators, with consultant h elp, would I n i t i a t e or expand such programs. Analysis o f each o f these facto rs was 1n terms o f lo c a tio n , type, s ize , and age o f f a c i l i t y . D is trib u tio n o f A ll Michigan Nursing Care F a c ilitie s Michigan, 1n 1976, had 455 nursing care f a c i l i t i e s as defined and lis te d by the Bureau o f Health Care A dm inistration o f the Michigan Department o f Public H ealth. c la s s ifie d In to three categories: They are g en erally (1 ) nursing homes, o f which 53 54 there are three hundred n in e ty , (2 ) medical care f a c i l i t i e s , o f which there are th 1 rty-n 1n e , and (3 ) hospital long-term care u n its , of which there are tw e n ty -s ix . Nursing homes can be fu rth e r c la s s i­ fie d as to whether they are p ro p rie ta ry homes operated fo r p r o f i t , or public or p riv a te homes oprated on a n o t - f o r - p r o f it b asis. vast m a jo rity are operated fo r p r o f i t . The Of the three-hundred ninety nursing homes, three-hundred twenty-seven are operated as f o r p r o fit ventures. Michigan 1s divided in to e ig h t Health Service Areas (HSA) (see Figure 1) fo r comprehensive health planning purposes. These are fe d e ra lly created and stress local p a rtic ip a tio n 1n the planning process. Local HSA's prepare plans f o r t h e ir areas. These plans are blended In to a s ta te plan and even tu ally In to a natio n al plan. These health service areas are used as the basis fo r analysis by geographic regions 1n th is study. HSA 1, composed o f seven southeastern Michigan counties and Including the D e tro it m etropolitan a rea , has f if t y - t h r e e percent of Michigan's population and fo r ty -e ig h t percent o f the nursing care f a c i l i t y beds. HSA 4 , composed o f twelve West Michigan coun­ tie s and Including Grand Rapids, Is a d is ta n t second In these respects, w ith ten percent o f the population and th irte e n percent o f the beds. The fewest beds are 1n HSA 7, composed o f eighteen coun­ ties In northern Michigan, and 1n HSA 8 , the e n tire Upper Peninsula. However, because the population 1s so much lower, the beds per thousand population 1s highest 1n the Upper Peninsula, and second highest 1n HSA 7 located In northern lower Michigan. The number o f 55 * M arquette • Sault Ste. M a rie it l ta 1 ««an» Traverse City Saginaw M G W tC A k t* •G ra n d Rapids Kalamaxoo* • F lin t D etro it Figure 1 . —Health Service Areas fo r the State o f Michigan. 56 beds per thousand population fo r the e n tir e s ta te o f Michigan 1s 5 .1 4 , w ith a range 1n the HSA's from 3.51 1n the Shiawassee, Genesee, Lapeer area to 10.15 In the Upper Peninsula. The highest rates are 1n the norther HSA's with lowest population d en s ity, w hile the low­ est beds per thousand rates are In the m etropolitan areas o f south­ ern Michigan. The d is trib u tio n o f nursing care f a c i l i t y beds, general population, and beds per thousand among these HSA's are d is ­ played 1n Table 1. D is trib u tio n o f Respondents As d e ta ile d 1n Chapter I I I , a statewide survey was under­ taken. Questionnaires were mailed to adm inistrators o f a l l 455 o f the s ta te 's nursing care f a c i l i t i e s . were returned and usable. A to ta l o f 294 questionnaires Thus s1xty-f1ve percent o f a l l f a c i l i t i e s are represented 1n the a n alysis. The response ra te was g reatest among adm inistrators o f medi­ cal care f a c i l i t i e s (n in e ty p e rc e n t), followed by adm inistrators o f nursing homes operated on a n o t - f o r - p r o f it basis (e ig h ty -th re e p ercen t), and adm inistrators o f hospital long-term care units (six ty-tw o p ercen t). Among the large number o f adm inistrators who operated nursing homes fo r p r o f i t , the response ra te was f if t y - e ig h t percent. This below average response ra te was concentrated 1n two areas, HSA 1 In southeastern Michigan where the response ra te was fo r ty -s ix percent, and HSA 3 1n southwestern Michigan where the response ra te was f i f t y - s i x percent. Except fo r s lig h t under­ representation o f the large number o f f o r - p r o f it nursing homes 1n TABLE 1 .—The distribution of population, nursing care f a c ilit y beds, and beds per thousand population among Michigan's eight Health Service Areas. Nursing Care Beds Population Nursing Home For P ro fit Not for P ro fit Medical Care F a c ility Hospital Long-Term Care Unit Total 1,197 23,219 4.65 2,809 4.11 Beds per Thousand HSA 1 4,990,994 18,541 3,199 282 HSA 2 683,415 1,726 307 776 HSA 3 769,617 2,841 362 474 672 4,349 5.65 HSA 4 1,017,143 4,452 802 523 945 6,722 6.61 HSA 5 608,929 1,823 — 313 — 2,136 3.51 HSA 6 736,253 2,049 624 673 815 4,161 5.65 HSA 7 265,770 911 — 599 508 2,013 7.59 HSA 8 263,886 1,245 171 736 518 2^607 10.15 Total 9,336,007 33,588 5,465 4,376 4,650 48,079 5.14 SOURCE: Population Projections of the Counties of Michigan by Age and Sex for Each Year 1970-1980, Bureau of Program and Budget, Executive O ffice, State of Michigan, December 1972, p. 16. 58 these two areas and the small number o f hospital long-term care u n its , approximately th ree-fo u rth s o f all nursing care f a c i l i t i e s In a l l areas o f Michigan are represented 1n the study. These data are displayed 1n Tables 2 and 3. Respondents from HSA 1 represent the la rg e s t number o f beds (1 2 ,8 7 5 ), and the la rg e s t number o f In s titu tio n s (n in e ty -e ig h t). T heir In s titu tio n s also have the la rg es t mean bed s ize (1 3 1 ). HSA 4, which includes the twelve counties around Grand Rapids, has nearly twice as many beds (5,3 9 8) represented as the next closest HSA, and f i f t y percent more In s titu tio n s ( f i f t y - f o u r ) . HSA's c lu s te rin g near th ird place. There are several HSA 7 1n northern Michigan has the fewest beds represented 1n the study (9 9 6 ). I t also has the fewest number o f In s titu tio n s represented ( f i f t e e n ) , and the sm all­ est mean number o f beds ( s ix t y - s ix ) . Table 4 displays these data. TABLE 2 . — Capacity o f responding Michigan nursing care f a c i l i t i e s , by number o f beds and type o f In s tit u tio n . Number o f Beds Number In s t. Mean Std. Dev. 19,502 102.10 58.06 12-325 191 Nursing homes not fo r p r o f it 5,520 106.15 92.19 5-473 52 Medical care fa c ilitie s 3,958 113.09 55.70 36-206 35 Hospital long­ term care units 1,422 88.86 132.06 17-524 16 E ntire population 30,402 103.40 70.31 5-524 294 Nursing homes fo r p r o f it Range 59 TABLE 3 .- - -Number and percent of responding Michigan nursing care f a c i l i t y adm inistrators, by type o f In s titu tio n and Health Service Area. Nursing Home Not fo r P r o fit N % For Prof 11 N % HSA 1 HSA 2 70 14 46.0 70.0 24 4 HSA 3 18 56.2 HSA 4 33 HSA 5 HSA 6 Medical Care F a c ility Hospital Long-Term Care Unit Total N % N % N % 80.0 2 100 2 50.0 98 52.1 80.0 4 80.0 - 22 73.3 4 80.0 4 80.0 2 50.0 28 60.8 75.0 11 78.6 5 100 5 100 54 79.4 16 84.0 — — 2 100 - 18 85.7 63.0 72.7 7 100 7 100 2 40.0 35 71.4 HSA 7 19 8 mm — 5 83.3 2 40.0 15 68.1 HSA 8 13 68.4 2 100 6 85.7 3 100 24 77.4 191 58.4 52 82.5 35 89.7 16 61.5 294 64.6 Total * TABLE 4 . - -D is trib u tio n o f Michigan nursing care f a c i l i t y beds repre­ sented In th is study, by Health Service Area. Total Number o f Beds Mean Std. Dev Range Total Number In s t. HSA 1 12,875 131.38 85.43 5-473 98 HSA 2 2,167 98.50 47.93 HSA 3 2,338 86.59 43.81 24-194 12-196 22 27 HSA 4 5,398 75.67 27-524 54 HSA 5 1,925 99.96 106.94 58.22 26-230 18 HSA 6 HSA 7 2,898 996 80.50 66.40 44.61 43.69 25-206 36 HSA 8 1,805 75.21 42.16 25-181 29-197 15 24 30,402 103.41 70.31 5-524 294 Total 60 Approximately two-th1rds o f the responding In s titu tio n s are In the medium-sized class having from fifty -o n e to 200 beds. Approximately one-fourth o f the In s titu tio n s are 1n the sm all-sized group, with f i f t y beds or less. Only one 1n twelve are In larg e­ sized in s titu tio n s o f more than 200 beds. While one-fourth o f the In s titu tio n s are sm all, only eight percent o f the to ta l beds represented are 1n sm all-sized In s titu tio n s . S1xty-e1ght percent o f the In s titu tio n s are medium-sized, and a s im ila r s ix ty -n in e percent o f the to ta l beds represented are 1n medium-sized In s titu tio n s . However, while e ig h t percent o f the In s titu tio n s are la rg e , these tw enty-six In s titu tio n s have twentythree percent o f the beds represented 1n th is study. A very large percentage (eighty-one percent) o f the hospital long-term care units are sm all, pro p ortio n ally more than any o f the other three types o f In s titu tio n s . Marginal notations on three o f the sixteen questionnaires Indicated th a t hospital long-term care units are being phased out. F o r-p ro f1t nursing homes and n o t-fo r -p r o fit nursing homes have a s tr ik in g ly s im ila r d is trib u tio n 1n size groups, w ith both types having about o n e-f1 fth o f th e ir In s titu tio n s In the sm all-slze group, about seventy percent in the medlum-size group and about nine percent 1n the la rg e -s lze group. Responding medical care f a c i l i t i e s are more commonly between fifty -o n e and two-hundred beds (seventyseven percen t), with both fewer large In s titu tio n s and fewer small In s titu tio n s than other types o f f a c i l i t i e s . data. Table 5 displays these 61 TABLE 5 . — Number and percent o f responding Michigan nursing care f a c i l i t i e s , by type and s ize o f In s t it u t io n . Nursing Home Small In s titu tio n s Not fo r P r o fit Med. Care F a c ll. Hospital Long-Term Care U n it 40 20.9 11 21.2 5 14.3 13 81.3 69 23.5 135 70.7 36 69.2 27 77.1 1 6 .3 199 67.7 % 16 8 .4 5 9.6 3 8 .6 2 12.5 26 8 .8 N % 191 65.0 52 17.7 35 11.9 16 5 .4 294 100 N % N Medium-sized In s titu tio n s % Large In s titu tio n s Total For P r o fit N Total The respondents are evenly divided In to the newer and the older groups. A newer In s titu tio n was defined as one th a t s ta rte d 1n the past ten years, through J u ly , 1976. Forty percent o f the responding In s titu tio n s are c la s s ifie d as o ld e r, I . e . , more than ten years o ld , w hile f o r t y - f iv e percent are newer. Age o f in s t it u ­ tio n was not reported by f if t e e n percent o f the respondents. Table 6 displays how the four types o f In s titu tio n s are d is trib u te d by age. Approximately h a lf the beds (14,666) 1n the responding I n s t i ­ tutions are 1n In s titu tio n s reported as o ld e r, meaning more than ten years o ld . Another 10,492 beds are 1n In s titu tio n s reported as newer, those less than ten years o ld . Age was not reported fo r the remaining 1ns1tut1ons whose to ta l bed capacity 1s 5,244. 62 TABLE 6 . — D is trib u tio n o f responding Michigan nursing care f a c i l i t i e s , by type and age o f In s titu tio n . Nursing Home Older In s titu tio n s Newer In s titu tio n s No In d icatio n Total N % N % N % N % Med. Care Facil Hospital Long-Term Care Unit Total For P r o fit Not fo r P r o fit 73 38.2 21 40.4 17 48.6 7 43.8 118 40.1 96 50.3 15 28.8 13 37.1 8 50.0 132 44.9 22 11.5 16 30.8 5 14.3 1 6 .3 44 15.0 191 65.0 52 17.7 35 11.9 16 5.4 294 100 In sumnary o f th is section. s1xty-f1ve percent o f the 455 adm inistrators o f the state returned a usable questionnaire. Admin­ is tra to rs o f medical care f a c i l i t i e s were considerably above average 1n response, as were adm inistrators o f nursing homes operated on a n o t-fo r -p r o fit basis. Administrators o f hospital long-term care units were near the average. Administrators o f nursing homes opera­ ted on a profit-m aking basis co n stitu te the la rg es t group, and had a below average response ra te . The return was e s p e c ia lly low 1n the southeastern and southwestern areas o f the s ta te , where approximately h a lf the adm inistrators returned the completed questionnaire. Approximately two-th1rds o f the In s titu tio n s represented are between f i f t y and 199 beds 1n s iz e , nearly one-fourth o f the repre­ sented In s titu tio n s have less than f i f t y beds, and approximately 63 nine percent o f the respondents have more than 200 beds. The responding In s titu tio n s are f a i r l y evenly divided In to those o f ten or less years o f age and those o f more than ten years o f age. Nearly two-th1rds o f the p a tie n t beds represented 1n the study are In fo r -p r o f1 t nursing homes, w hile the other th ird are d is trib u te d 1n n o t - f o r - p r o f it nursing homes, medical care f a c i l i t i e s , and hospital long-term care u n its . More than a th ir d o f the I n s t i ­ tutions and beds represented are 1n HSA 1. S lig h tly less than h a lf the beds are 1n In s titu tio n s less than ten years o ld . D is trib u tio n o f P a tie n t Education Programs One o f the basic o bjectives o f th is In v e s tig a tio n was to determine how many o f Michigan nursing care f a c i l i t i e s are presently operating programs o f p a tie n t education and what 1s the general char­ acter o f those operating programs. A program was defined to be operational 1 f the follow ing three conditions were met: (1 ) a coor­ dinator was appointed, (2 ) two or more educational a c tiv ite s were o ffe red , and (3) two or more d iffe r e n t categories o f s t a f f members were Involved. The educational programs were c la s s ifie d as p a tie n t general education, p a tie n t health education, o r both. I f e ith e r a general education or a health education program were o p e ra tio n a l, a p atien t education program was said to be in existence. I t was found th a t 200 o f the 294 nursing care f a c i l i t i e s (s1xty-n1ne percent) had operational programs. These programs were then categorized by In s titu tio n a l type to ascertain 1 f p a tie n t education programs were more lik e ly to e x is t 1n the two types o f 64 nursing homes, medical care f a c i l i t i e s , or hospital long-term care u nits. Analysis was made In an e a r lie r section o f the to ta l number o f nursing care f a c i l i t y beds In Michigan, and o f the number o f beds represented in th is study. sequent analyses. These data provide the context fo r sub­ No attempt was made to analyze the number o f beds 1n In s titu tio n s with operational programs o f p a tie n t education. The u n it o f analysis used In the follow ing sections o f th is report 1s the In s titu tio n . A p atie n t education program was defined fo r th is study as consisting o f e ith e r a general education program or a health educa­ tion program. The percentage o f In s titu tio n s w ith e ith e r program in existence was examined f i r s t . F o r-p ro f1t nursing homes and medical care f a c i l i t i e s were found to have an almost Id e n tic a l percentage o f operational pro­ grams, a t seventy-two and seventy-one percent, re sp e ctiv ely. Not- f o r -p r o f it nursing homes were a d is ta n t th ird a t f if t y - e ig h t percent, whereas hospital long-term care units had operational programs In h a lf the In s titu tio n s . These data are displayed 1n Table 7. Another way o f looking a t the d is trib u tio n o f programs 1n Table 7 Is to examine the d is trib u tio n o f p a tie n t general education programs separate from p a tie n t health education programs. In s tit u ­ tions with these s p e c ific programs were categorized to permit com­ parison. There were 178 operational general education programs 1n the 294 responding In s titu tio n s (s1xty-one percent). S1xty-f1ve percent o f the f o r - p r o f it nursing homes had general education pro­ grams, w hile s ix ty percent o f the medical care f a c i l i t i e s , 65 TABLE 7 . - - Number and percentage o f nursing care f a c i l i t i e s providing p a tie n t education programs, by type o f in s tit u tio n . Nursing Home For P r o fit Operational general education program N Operational health education program N E ith e r program in existence N % % % Not fo r P r o fit Med. Care Facll Hospital Long-Term Care U n it Total N=35 N=16 N=294 N-191 N=52 125 65.4 25 48.1 21 60.0 7 43.8 178 60.5 59 30.9 10 19.2 16 45.7 3 18.8 88 29.9 137 71.7 30 57.7 25 71.4 8 50.0 200 68.0 fo r ty -e ig h t percent o f the n o t - f o r - p r o f it nursing homes, and f o r ty four percent o f the ho sp ital long-term care u n its had such programs. E1ghty-e1ght ( t h ir t y percent) o f the 294 responding In s t it u ­ tions reported operational p a tie n t health education programs. F o rty -s ix percent o f the medical care f a c i l i t i e s had operational health education programs, w hile th irty -o n e percent o f the f o r p r o fit nursing homes had such programs. N o t-fo r -p r o fit nursing homes and hospital long-term care u nits were considerably behind, with nineteen percent o f the two types o f In s titu tio n s o ffe rin g p atie n t health education programs. P a tie n t education programs were then categorized by I n s t i ­ tu tio n a l size to te s t the accuracy o f the popular b e lie f th a t large In s titu tio n s have more programs than medium-sized or small In s t it u ­ tio n s . A g re ater percentage o f the la rg e r In s titu tio n s did have 66 patient education programs (e ig h ty -e ig h t percent) than did the medium-sized in s titu tio n s (seventy-four percent) or the sm aller In s titu tio n s (fo rty -tw o percent). eral education programs. This was esp e cia lly tru e fo r gen­ Health education programs, however, are most common in medium-sized In s titu tio n s . A p a r tia l explanation fo r this phenomenon 1s the fa c t th a t f1fty-n1ne o f the e ig h ty -e ig h t health education programs are 1n fo r-p ro f1 t nursing homes. Table 5 e a r lie r revealed th a t seventy-one percent o f such f a c i l i t i e s are in the medium-sized category. The 200 programs are displayed by in s t i­ tutio nal size In Table 8. The d is trib u tio n o f p atie n t education programs by HSA Is also o f In te re s t 1n view o f the planning roles o f HSA's. The per­ centage o f In s titu tio n s with operational p atien t education programs ranged from fo rty -e ig h t percent 1n HSA 3 to eighty percent 1n HSA 7, with s ix ty -e ig h t percent o f a ll responding In s titu tio n s having TABLE 8 . —Number and percentage o f nursing care f a c i l i t i e s providing p atien t education programs, by size o f In s titu tio n . Operational general education program N % N Small Medium Large Total N=69 N=199 N*26 N=294 23 33.3 134 67.3 21 80.8 178 60.5 Operational health education program % 14 20.3 66 33.2 8 30.8 88 29.9 E ither program in existence N % 29 42.0 148 74.3 23 88.4 200 68.0 67 programs. The two HSA's with the largest number of In s titu tio n s o ffe rin g programs are HSA 1 and HSA 4. They both reported opera­ tional programs 1n seventy-four percent of the In s titu tio n s , well above the average fo r Michigan. The proportions o f In s titu tio n s o ffe rin g general education programs range from a low o f t h ir ty - s ix percent 1n HSA 6 to a high o f seventy-three percent 1n HSA 7, with an average o f s1xty-one percent fo r a l l HSA's. Operational health education programs occurred In as few as nineteen percent o f the 1nstutut1ons in HSA 4, as high as fo rty percent in HSA 7, and an average o f t h ir t y percent fo r a l l HSA's. These data are displayed 1n Table 9. An attempt was also made to te s t the hypothesis that newer In s titu tio n s were more lik e ly to have operational p atie n t education programs than older In s titu tio n s . Accordingly, the 200 programs were aggregated by age, with those started in the la s t ten years being c la s s ifie d as newer in s titu tio n s . Of the newer in s titu tio n s seventy-two percent had p atie n t education programs, while s1xty-six percent of the older In s tit u ­ tions had programs. The proportion fo r p a tie n t health education was almost Id e n tic a l, w ith t h ir t y percent of both the new and older In s titu tio n s o ffe rin g health education. There are both a la rg e r number o f In s titu tio n s and a large percentage o f In s titu tio n s that have p a tie n t general education programs In the newer group. These data are displayed In Table 10. In summary o f th is section. I t should be pointed out that only s ix ty -s ix In s titu tio n s or twenty-two percent have both general TABLE 9 .—Number and percent of nursing care fa c ilitie s providing patient education programs, by Health Service Area. HSA 1 HSA 2 HSA 3 HSA 4 HSA 5 HSA 6 HSA 7 HSA 8 Total N=98 N-22 N-27 N=54 N=18 Ns36 N-l 5 Ns24 N*294 Operational general education program N 67 % 68.4 14 63.6 11 40.7 39 72.2 12 66.7 13 36.1 11 73.3 11 45.8 178 60.5 Operational health education program N 8 36.4 7 25.9 10 18.5 . 7 38.9 10 27.8 6 40.0 9 37.5 88 29.9 Either program in existence N 15 68.1 13 48.1 40 74.0 13 72.2 21 58.3 12 80.0 13 54.1 200 68.0 31 % 31.6 73 % 74.4 69 TABLE 1 0 .—Number and percent o f nursing care f a c i l i t i e s providing p a tie n t education programs, by age o f In s tit u tio n . Older In s t. Newer In s t. No Data ,o ta i N=118 N=132 N=44 N=294 Operational general education program N % 69 58.4 87 65.9 22 50.0 178 60.5 Operational education N % 35 29.7 39 29.5 14 31.8 88 29.9 N 78 66.1 95 71.9 27 61.3 200 68.0 health program E ith e r program 1n existence % education and health education programs o p e ra tio n a l. I t 1s most common fo r an In s titu tio n to have a general education program (s1xty-one percent d o ), and less common fo r an i n s t i t u t i o n to have a health education program a v a ila b le ( t h ir t y percent do). Two hun­ dred o f the 294 In s titu tio n s (s ix ty -n in e percent) had one or the other or both categories o f programs a v a ila b le . State o f Development o f P a tie n t Education Programs Another o f the basic o b jectives o f th is study was to d e te r­ mine the stage o f development o f p a tie n t education programs. Spe­ c i f i c a l l y , 1 t was o f In te re s t to fin d i f p a tie n t education programs were more developed 1n some types o f In s titu tio n s than o th ers, In older or newer In s titu tio n s , 1n la rg e , medium, o r sm all-sized I n s t i ­ tu tio n s , or 1n some HSA's more than 1n others. 70 I t was I n i t i a l l y thought th a t a good In d ic a to r o f develop­ ment would be the number o f I n s t it u t i o n s w ith a beginning program compared to the number o f In s titu tio n s with operational programs. However, 1 t was discovered th a t there are very few programs In the beginning stages. Most In s titu tio n s have e ith e r a f u l ly operational program or none a t a l l . I t was, th e re fo re , decided to devise a more discrim in atin g "p a tie n t education development stage score" which would permit comparison o f the development stage o f the operational programs. A fte r much d e lib e ra tio n and discussion, 1t was decided th a t the best p a tie n t education devlopment score would consist o f a combination o f the number o f general education o ffe rin g s and health education o ffe rin g s , with the number o f groups o f s t a f f Involved 1n general education and health education. These sets o f data were each standardized on a te n -p o in t s c a le , and then combined w ith equal weight to form a p a tie n t education development score. The f i r s t step was to examine p a tie n t education program development stage by In s titu tio n a l type. F o r -p r o fit nursing homes were found to have a very s lig h tly higher development score with a mean score o f 4 .1 6 , and a range o f .21 to 7 .09 . Medical care f a c i l i ­ tie s were almost as high, w ith a mean score o f 4.07 and a range o f .52 to 6 .6 6 . N o t-fo r -p r o fit nursing homes were r e la tiv e ly close w ith a mean score o f 3 .8 6 , with hospital long-term care units being almost Id e n tic a l a t 3 .71 . There appeared to be almost no d iffe re n c e 1n program development stage among the fou r types o f In s titu tio n s . These data are displayed In Table 11. TABLE 1 1 .- - Mean p a tie n t education development scores displayed by In s titu tio n a l type. Number Mean P atien t Educ. Devel. Score Standard Deviation Range 137 4.16 1.66 0 .2 1 -7 .0 9 Nursing homes not fo r p r o fit 30 3.86 1.90 0 .2 1 -7 .2 5 Medical care fa c ilitie s 25 4.07 1.68 0 .5 2 -6 .6 6 8 3.71 1.73 1.46-7.16 Nursing homes fo r p r o fit Hospital long-term care units When programs were aggregated according to s iz e , la rg e -s i zed In s titu tio n s did have a somewhat higher mean program development score o f 4 .3 7 , with medium and sm all-sized In s titu tio n s being close behind a t an almost Id e n tic a l mean score o f 4 .0 . 1s displayed This Inform ation In Table 12. TABLE 1 2 .—Mean p a tie n t education development scores displayed by In s titu tio n a l s ize . Mean P atien t Educ. Devel. Score Standard Deviation Range 29 3.96 1.65 0.21 -6.9 7 148 4.06 1.69 1.25-7.16 23 4.37 1.80 0 .2 1 -7 .9 8 Number Small In s titu tio n Med1um-s1zed In s titu tio n Large In s titu tio n 72 When program scores were grouped according to HSA's, 1 t was In te re s tin g to note th a t HSA 8 1n the Upper Peninsula had the g reatest degree o f development. The mean p a tie n t education devel­ opment scores In the e ig h t HSA's ranged from a high o f 4.84 to a low o f 3 .4 0 . These data are displayed in Table 13. V ir t u a lly no d iffe re n c e was detected when p a tie n t education development scores were compared 1n older and new in s titu tio n s . The mean scores were n early id e n tic a l, both rounding o f f a t 4 .0 . In re tro s p e c t, none o f the Independent variab les seemed to make any d iffe re n c e 1n the stage o f development o f p a tie n t educa­ tio n programs. This was also tru e when a separate development score was computed fo r p a tie n t health education. There were no s ig n ific a n t v a ria tio n s when grouped by type, s iz e , age, o r lo c a tio n . However, th is was not tru e when a separate program development score was computed fo r p a tie n t general education. Type and size o f in s titu tio n appear to be re la te d to p a tie n t general education development scores, w hile age and locatio n appear not to be. Hos­ p ita l long-term care u n its and medical care f a c i l i t i e s had low mean scores a t 3.27 and 3 .4 7 , re s p e c tiv e ly , with n o t - f o r - p r o f it nursing homes having the highest mean development score a t 4 .2 8 . Data on In s titu tio n a l type are displayed 1n Table 14. Large In s titu tio n s had a higher general education develop­ ment mean score (4 .6 4 ) than did medium-sized in s t it u t i o n s (3 .9 4 ) and small In s titu tio n s ( 3 .7 6 ). Table 15 (page 7 4 ). These data are displayed 1n 73 TABLE 1 3 .—Mean p a tie n t education development scores displayed by Health Service Area. Number Mean P a tie n t Educ. Devel. Score Standard Deviation Range HSA 1 73 4.17 1.74 0 .2 1 -7 .2 5 HSA 2 15 4.73 1.51 0 .2 1 -6 .3 5 HSA 3 13 4.23 1.51 0 .2 1 -6 .0 0 HSA 4 40 3.64 1.69 0 .2 1 -7 .9 8 HSA 5 13 4.07 1.73 0 .2 1 -6 .9 9 HSA 6 21 3.40 1.34 0 .2 1 -5 .0 7 HSA 7 12 3.67 1.37 0 .8 0 -5 .7 6 HSA 8 13 4.84 1.48 0 .2 1 -6 .8 3 TABLE 1 4 .—Mean p a tie n t general education development scores d is ­ played by In s titu tio n a l type. Mean General Educ. Devel. Score Standard D eviation Range 125 4 .08 1.15 0 .4 2 -8 .5 4 Nursing homes not fo r p r o f it 25 4.28 1.08 0 .4 2 -6 .4 6 Medical care f a c ilitie s 21 3.47 .90 0 .3 1 -5 .4 2 7 3.27 .46 0 .6 3 -6 .2 5 Number Nursing homes fo r p r o f it Hospital long-term care u nits 74 TABLE 1 5 .—Mean p a tie n t general education development scores d is ­ played by in s titu tio n a l s ize . Number Mean General Educ. Devel. Scores Standard Deviation Range 23 3.76 1.27 0 .4 2 -6 .0 4 134 3.94 1.05 0 .3 1 -8 .5 4 21 4.64 1. 22 2 .5 0 -6 .2 5 Small in s titu tio n Medium-sized in s titu tio n Large in s titu tio n In summary o f th is section* nothing much has been estab­ lished about the re la tio n s h ip o f p atien t education program develop­ ment stage to in s titu tio n a l type* size* age, or lo c atio n . When development scores were computed fo r health education programs, no s ig n ific a n t relationships were found. When development scores fo r general education were computed separately, type and size were very modestly re la te d fa c to rs . Nursing homes and la rg e r In s titu tio n s more frequently reported general education programs than did medi­ cal care f a c i l i t i e s , hospital long-term care units or medium or small f a c i l i t i e s . P rincipal Components o f P atien t Education Programs One o f the basic objectives o f th is study was to determine what elements o f p a tie n t education e x is t In Michigan nursing care fa c ilitie s . Several major components were Id e n tifie d and w ill be described In th is section. 75 Program Coordination The f i r s t Issue In vestigated in each o f the 294 in s titu tio n s was whether or not the in s titu tio n had a s p e c ific department or coordinator th a t was responsible fo r general education programs o ffe red . There were 214 In s titu tio n s , or seventy-three percent, that responded p o s itiv e ly . This was an in te re s tin g fin d in g . On the one hand the number o f program coordinators was la rg e r than the number o f operational programs (178) as defined; on the other hand, since s ta te licensure rules demand Md1vers1ona1 a c t iv it ie s ," the twenty-seven percent th a t reported no such designated coordinator was surprising. E ith e r general education o f p atien ts was not considered part o f th is program o f dlverslonal a c t iv it y , or else such a c t iv i­ tie s were coordinated by s t a f f members with other p rin c ip a l duties and without designation as coordinators. E igh ty-six percent ( t h ir t y o f th 1 rty -f1 v e ) o f the medical care f a c i l i t i e s had coordinators fo r general education, w hile only f i f t y percent o f the sixteen hospital long-term care units had such positions. Nursing homes were in between these two extremes. Seventy-five percent o f the one hundred ninety-one fo r -p ro f1 t nursing homes and s1xty-two percent o f the f if t y - t w o n o t- fo r - p r o fit nursing homes had coordinators. Those 214 In s titu tio n s th a t did have coordinators responsi­ ble fo r general education ty p ic a lly assigned th is duty to a d iv isio n or department called the P atien t A c tiv itie s (n in e ty -e ig h t) or Dlverslonal Therapy (s ix ty -fo u r ) Department. Seven mentioned a social service d ire c to r, while s ix allowed an external agency such 76 as the community school program, the Interm ediate school d i s t r i c t , o r the mental h ealth a c t iv it ie s center to coordinate th e ir general education programs. There were 106 In s titu tio n s (th 1 rty -s 1 x percent) th a t In d i­ cated th a t they had coordinators o f p a tie n t health education, eighteen more than had a f u l ly operational program. Medical care f a c i l i t i e s were above the mean (th 1 rty -s 1 x p e rc e n t), having such coordinators 1n h a lf o f t h e ir In s titu tio n s . Thirty-seven percent o f f o r - p r o f it nursing homes had coordinators w hile twenty-nine percent o f n o t - f o r - p r o f it nursing homes and nineteen percent o f hospital long-term care u n its had coordinators fo r p a tie n t health education. In t h i r t y o f the 294 in s titu tio n s (ten percent) there were designated coordinators who coordinated both general and health education programs. Looked a t d if f e r e n t ly , t h i r t y o f the 214 gen­ e ral education coordinators (fourteen percent) also coordinated health education, or t h i r t y o f the 106 health education coordinators (tw en ty-eig h t percent) also coordinated general education. These data are displayed 1n Table 16. Four o f the e ig h t hospitals w ithout general education coordi­ nators were rep o rted ly planning to designate one, as were a th ird o f the fo r -p r o f1 t nursing homes, f ift e e n percent o f the n o t- fo r - p r o fit nursing homes and twenty percent o f the medical care f a c i l i t i e s who did not have coordinators fo r general education. A much sm aller pro­ portion o f the In s titu tio n s planned to add p a tie n t health education coordinators, however. Only about ten percent (twenty o f 188) o f 77 TABLE 1 6 .—D is trib u tio n o f In s titu tio n s having designated education coordinators, by program and by In s titu tio n a l type. Nursing Home For P r o fit Have general education coordinator N Have health education coordinator N Same person coordi­ nates both programs N % % % Not fo r P r o fit Med. Care Facll Hospital Long-Term Care U nit Total N=35 N=16 N-294 N*191 N=52 144 75.4 32 61.5 30 85.7 8 50.0 214 72.8 70 36.6 15 28.8 18 51.4 3 18.7 106 36.0 21 11.0 4 7.7 4 11.4 1 6.2 30 10.2 TABLE 1 7 .--Number and percent o f in s titu tio n s without p a tie n t educa­ tio n coordinators who are planning to designate one, by In s titu tio n a l type. Nursing Home For P r o fit No general education coordinator Planning fo r a gen­ eral education coordinator No health education coordinator Planning fo r a health education coordi­ nator Not fo r P r o fit Med. Care F a c ll. Hospital Long-Term Care U nit Total N 47 20 5 8 80 N % 15 31.9 3 15.0 1 20.0 4 50.0 23 28.8 N 121 37 17 13 188 N 14 11.6 4 10.8 0 0 2 15.4 20 10.6 % 78 nursing care f a c i l i t i e s were planning to add such a s t a f f designa­ tio n . These data are displayed 1n Table 17 (page 76). There was no s ig n ific a n t difference 1n the frequency o f education departments or coordinators among In s titu tio n s by region or age. size. There was, however, when In s titu tio n s were examined by The larg er In s titu tio n s , as might be expected, provided departments or coodlnators o f education with much g reater frequency. Only fo r ty -fo u r percent o f the s ix ty -n in e small In s titu tio n s employed such a coordinator fo r p atien t general education, while eighty percent o f the one hundred n1nety-n1ne medium-size In s t it u ­ tions and ninety-two percent o f the tw enty-six large in s titu tio n s did so. Small In s titu tio n s were s u b s ta n tia lly below the average o f a ll nursing care f a c i l i t i e s (seventy-three percent) 1n providing coordinators o f p a tie n t general education. Only a fourth o f the small In s titu tio n s had coordinators o f health education. This was well below the average fo r a ll nursing care f a c i l i t i e s ( t h ir t y - s ix percent). Med1um-s1ze and large In s t i­ tutions were nearly Id e n tic a l with almost fo rty percent providing coordinators fo r such programs. In fiv e o f the tw enty-six large In s titu tio n s cen t), the same person coordinated both programs. (nineteen per­ In twenty-two o f the 199 med1um-s1ze In s titu tio n s (eleven percent) there were single directors fo r both general and health eduatlon. the s ix ty -n in e small In s titu tio n s In only three o f (fo u r percent) was th is tru e . These data are displayed 1n Table 18. 79 TABLE 1 8 .—D is trib u tio n o f In s titu tio n s having designated p a tie n t education coordinators, by s ize o f In s tit u tio n . Have general education coordinator N % Have health education coordinator N Same person coordinates both programs N % % Smal 1 Med1urn Large N=26 Total N=69 N=199 30 43.5 160 80.4 24 92.3 214 72.8 17 24.6 79 39.7 10 38.5 106 36.0 3 4 .3 22 11.1 5 19.2 30 10.2 N*294 Med1um-s1zed In s titu tio n s w ithout general education coor­ dinators often In d icated they were planning to designate such coor­ d inators. This was tru e 1n f if t e e n o f the th1rty-n1ne In s titu tio n s . Among small in s titu tio n s w ithout general education coordinators, eight o f th ir ty -n in e (twenty-one percent) reported planning to designate them. N eith e r o f the two large In s titu tio n s in d icated any Immediate plans to designate one. Size was not a s ig n ific a n t v a ria b le when plans to designate a health education coordinator were examined. Eleven percent o f a l l nursing care f a c i l i t i e s w ithout such a coordinator were planning to add them. average. A ll three size groups were s tr ik in g ly close to th a t These data are displayed 1n Table 19. In summary o f th is s ec tio n , there were coordinators o f gen­ e ral education In 214 In s titu tio n s and coordinators o f h ealth educa­ tio n In 106 In s titu tio n s . The same persons coordinated both 80 TABLE 1 9.—Number and percent o f In s titu tio n s without p a tie n t educa­ tio n coordinators who are planning to designate one, by In s titu tio n a l s ize . Small N=69 Medium N=199 Large N=26 Total N=294 No general education coordinator N 39 39 2 80 Planning fo r a general education coordinator N 8 20.5 15 38.4 0 0 .0 23 28.8 No health education coordinator N 52 120 16 188 Planning fo r a health education coordinator N 5 9.6 13 10.8 2 12.5 20 10.6 % % programs 1n t h ir t y In s titu tio n s . Stated d if fe r e n t ly , approximately twice as many In s titu tio n s had coordinators o f general education as had coordinators o f health education. Twenty-three o f eig h ty, nearly a t h ir d , o f the In s titu tio n s without general education coor­ dinators were planning to create such positio n s, w hile twenty of one hundred e ig h ty -e ig h t, ju s t over one-tenth, o f the In s titu tio n s without health education coordinators were planning to create such a position. Educational Center Designation Another Issue Investigated was whether or not the f a c i l i t i e s had space designated as educational centers fo r p atie n ts . S ix ty - two percent o f the 294 in s titu tio n s , according to respondents, had centers. Another nine percent were In the planning stages. No 81 s ig n ific a n t d ifferen ces were revealed when looking a t the data by age, region, or type. Again, however, s ize o f In s titu tio n was a s ig n ific a n tly re la te d fa c to r. While t h ir ty -th r e e percent o f the small In s titu tio n s had p a tie n t education cen ters, seventy percent o f the medium-sized i n s t i ­ tution s and seventy-seven percent o f the la rg e r In s titu tio n s had such centers. Another nine percent o f a l l In s titu tio n s were plan­ ning to provide centers. These data are displayed 1n Table 20. P a tien t General Education O fferings The next concern o f the study was to determine what general education topics were covered and the method 1n which they were pre­ sented. Respondents were s p e c ific a lly asked about lit e r a t u r e , a rts and c r a f t s , music, c re a tiv e w r itin g , th e a te r, r e a lit y o rie n ta tio n , and current events. (See qu estion n aire, Appendix.) An open-ended TABLE 2 0 .— D is trib u tio n o f Michigan nursing care f a c i l i t i e s p a tie n t education centers, by s ize o f in s tit u tio n . N Small Medium Large Total N=69 N=199 N=26 N-294 Have center % 23 33.3 139 69.8 20 76.9 182 61.9 No center N % 37 53.6 40 20.1 3 11.5 80 27.2 N 15 7.5 2 7.7 25 8 .5 5 2 .5 1 3 .8 7 2 .4 Planning stage % 8 11.6 No report N % 1 1.4 82 question encouraged respondents to "please 11st others." H o rtic u l­ tu re , physical fitn e s s , re lig io u s In s tru c tio n , film s , and high school completion or GED classes were lis te d . S1xty-one percent or 178 o f the 294 In s titu tio n s o ffered some form or combination o f general education. These operational programs were then examined to determine the frequency o f education o ffe rin g s . The topics most commonly offered 1n order o f frequency were a rts and c r a fts , lit e r a t u r e , r e a lit y o rie n ta tio n , current events, and music. Table 21 presents comparative data on the f r e ­ quency o f a ll such o ffe rin g s . The topics have been arranged 1n descending order, according to the frequency o f th e ir occurrence. Some conments on the fiv e most conmonly lis te d general edu­ cation topics are appropriate. Again, these Include arts and c ra fts , lit e r a t u r e , r e a lit y o rie n ta tio n , current events, and music. Arts and c ra fts were offered by n in e ty -e ig h t percent o f the In s titu tio n s , and were a v a ila b le to patients as part o f the d lv e r­ slonal therapy program. Such In stru ctio n was provided 1n every Instance except fo r three o f the f o r - p r o f it nursing homes. Group In stru ction was provided by n1nety-s1x percent of the in s titu tio n s while Individual in stru ctio n was also provided by seventy-four per­ cent o f the f a c i l i t i e s . Very l i t t l e s e lf-in s tru c tio n a l media or printed m aterial was reportedly used. Data on methods used appear 1n Table 22. L ite ra tu re was offered by e1ghty-two percent o f the I n s t i ­ tutions but 1n only fifty -s e v e n percent o f hospital long-term care units. The most common method used was simply the providing o f 83 TABLE 21.--Frequency o f o ffe rin g various topics 1n p a tie n t general education programs, by type o f In s titu tio n . Nursing Home For P r o fit Not fo r P r o fit Med. Care F a c ll. Nunber having no program1 N= 66 N=27 N=14 N°9 N*116 Number having opera­ tional program N*125 N=25 N=21 N=7 N*178 122 97.6 25 100 21 100 7 100 175 98.3 103 82.4 20 80.0 18 85.7 4 57.1 145 81.5 105 94.0 18 72.0 15 71.4 6 85.7 144 80.9 98 78.4 22 88.0 15 71.4 5 71.4 140 78.7 93 74.4 21 84.0 15 71.4 5 71.4 134 75.3 20 16.0 7 28.0 6 28.6 0 0 33 18.5 Arts and c ra fts L ite ra tu re R eality o rie n ta tio n Current events N % N % N % N % N Hospital Long-Term Care Unit Total Music % Creative w ritin g % Theater % 20 16.0 5 20.0 4 19.0 1 14.3 30 16.9 Religious In stru ctio n N % 18 14.4 3 12.0 0 0 0 0 21 11.8 N 11 8 .8 4 16.0 2 9.5 0 0 17 9 .6 7 5.6 2 8 .0 0 0 0 0 9 5.1 N N Physical fitn ess % High school completion % N 84 TABLE 2 2 .—Methods used 1n selected topic areas o f p a tie n t education In the one hundred seventy-eight general education pro­ grams 1n Michigan nursing care f a c i l i t i e s . Arts and c ra fts L iterature R eality o rie n ta tio n Current events Music Creative w ritin g Theatre Group In s tru c . In d iv id . In s tru c . S e lf In s tru c . Printed M aterial 170 95.5 132 74.2 39 21.9 36 20.2 78 43.8 58 32.6 50 28.1 109 61.2 % 121 68.0 106 59.6 19 10.7 34 19.1 N % 116 65.2 62 30.8 31 17.4 68 38.2 N % 122 68.5 35 19.7 21 11.8 14 7.9 N * 12 6.7 22 12.4 9 5.1 7 3.9 N 28 15.7 3 1.7 3 1.7 0 0 21 11.8 8 4.5 3 1.7 7 3.9 % 17 9.6 10 5.6 3 1.7 3 1.7 N * 9 5.1 3 1.7 3 1.7 5 2 .8 N % N % N % N % Physical fitn e s s N 85 printed m aterial fo r optional use o f p atien ts (s ix ty -o n e p ercen t). Subscriptions to several magazines and newspapers were common. Reading p rin ted m aterial may be edu catio n al, and 1s an easy way to make education a v a ila b le to the p a tie n ts . A number o f In s titu tio n s have worked out re la tio n s h ip s w ith local lib r a r ie s to ro ta te a supply o f books. No data were gathered w ith respect to u tH z a tlo n o f such reading m a te ria ls . (The Incidence o f th is re la tio n s h ip w il l be spelled out 1n a la t e r section o f th is a n a ly s is .) Group in s tru c ­ tion was provided 1n lit e r a t u r e by fo r ty -fo u r percent o f the I n s t i ­ tu tio n s . These Included but were not lim ite d to book reviews by both p atients and non-pat1ents. S e lf-In s tru c tio n a l media was pro­ vided by tw enty-eight percent o f the In s titu tio n s . Examples given were records, tape recorded lit e r a t u r e , and film ed versions o f books. Some In s titu tio n s provided a lib r a r y o f large p r in t books and books 1n B r a ille . Others provided reading programs f o r the )Hnd and n e a r-b lin d . One In s titu tio n provided reading Improvement classes. R e a lity o rie n ta tio n was provided by eighty-one percent o f the In s titu tio n s , most freq u en tly in fo r -p r o f1 t nursing homes and hospital long-term care u n its . R e a lity o rie n ta tio n 1s a series o f a c t iv it ie s designed to maintain or re e s ta b lis h a p a tie n t's con­ ta c t with r e a lit y . A lo t has been said about th is 1n the jo u rn als and conferences f o r nursing care f a c i l i t y s t a f f . Some o f the basic elements are making p atien ts aware o f what day and date I t 1s, what events have been planned fo r patien ts and how they can p a rtic ip a te 1n them. The Importance o f d a lly grooming, and the Importance o f 86 eating a varied d ie t are also Included. Regular reading o f a news­ paper 1s encouraged, as 1s lis te n in g to or watching the newscasts. Individual In s tru c tio n 1n th is area was lis te d 1n s ix ty percent o f the In s titu tio n s . Getting p atien ts out o f t h e ir rooms and In to group a c t iv i­ tie s was stressed. Group In s tru c tio n was lis te d 1n s ix ty -e ig h t percent o f the In s titu tio n s . Birthday p a rtie s were h eld , as were bingo, bowling, cards, popcorn, and p atio p a rtie s . Periodic trip s were made to nearby shopping centers or other places o f In te r e s t. On other occasions tr ip s were made to restaurants to "eat o u t." Occasional home v is it s were likew ise encouraged. P a tie n t In v o lve ­ ment 1n planning and conducting these a c t iv it ie s was stressed. Resident councils existed 1n some In s titu tio n s . R e a lity o rie n ta tio n was obviously an Important p a rt o f the d a lly ro utine o f the s t a f f . C e rta in ly , I t f a l l s w ith in the scope of education, and 1s a good example o f f i t t i n g educational programs to the needs o f the learners. Current events was also mentioned by seventy-nine percent o f the In s titu tio n s , with group In s tru c tio n being the most common method used. Inasmuch as the questionnaire was d is trib u te d in May and June o f the bicentennial year 1976, 1t 1s not surprising th a t numerous classes were reported on n a tio n a l, s ta te , and local h is ­ to ric a l to p ics. "Oral histo ry" o f lo cal communities was comnon. Films were likew ise shown on h is to ric a l topics and other Items o f current In te re s t. 87 Another series o f sessions mentioned s p e c ific a lly was "Know Your Candidates" nights, to both prepare and encourage the patients to vote. Weekly discussion groups were held In some In s titu tio n s on topics o f current In te re s t. Printed m aterial was the second most common means o f pro­ viding education about current events, and as mentioned above, Involves provision o f newspapers and magazines. Individual In s tru c ­ tion was mentioned by th irty -o n e percent o f the respondents. I t was presumed that his Involved s t a f f In te ra c tio n with patients about the events o f the outside world but th a t 1t was also stressed as p art o f the more formal aspects of r e a lit y therapy, occurring as p art o f the d a lly routine o f Interpersonal convnunlcation. Music was likew ise Important 1n nursing care f a c i l i t i e s and was provided 1n seventy-five percent o f the in s titu tio n s , varying l i t t l e among types o f In s tru c tio n . Group in s tru c tio n was provided by s ixty -n in e percent o f the in s titu tio n s . were music appreciation classes. Most commonly mentioned Group musical a c t iv itie s with an educational component Included "s1ng-alongs," "rhythm bands," and the more formal "choirs." Concerts were held fo r patients by these groups and by outside groups as w e ll. Individual In s tru c tio n was availab le 1n twenty percent o f the In s titu tio n s . S e lf-In s tru c tio n a l media were used 1n twelve percent o f the f a c i l i t i e s . S p e c ific a lly mentioned were record and tape lib r a r ie s . The remainder o f the topics were offered by less than twenty percent o f the In s titu tio n s . comment. Four o f these topics warrant some 88 Creative w ritin g sessions were held In nineteen percent o f the In s titu tio n s . Twenty o f these th ir ty -th r e e programs were 1n fo r-p ro f1 t nursing homes, which represented sixteen percent o f such in s titu tio n s . While the actual numbers o f programs were sm aller, both the n o t-fo r -p r o fit nursing homes and the medical care f a c i l i ­ tie s had such a c t iv it ie s . In some places they Involved w ritin g short s to rie s , plays, and poetry. other patients In v ite d . Formal readings were held, with In others, patients prepared a weekly or monthly newspaper or n ew sletter. This required th a t they be involved with other patients and s ta ff In order to know what news to rep ort. Study o f re lig io n was provided fo r 1n eighteen (fourteen percent) fo r-p ro f1 t and three (twelve percent) n o t- fo r - p r o fit nurs­ ing homes. I t was not provided 1n any of the medical care f a c i l i ­ tie s or hospital long-term care u n its . Physical fitn e s s was not lis te d on the o rig in a l l i s t , but was a "w rite -in " by ten percent o f the In s titu tio n s , esp ecially 1n n o t-fo r -p r o fit nursing homes. Physical fitn e ss classes were held reg ularly 1n some in s titu tio n s , and were called by such names as "Gerlgymnastlcs" and " g e ria tric exercises." a c tiv ity often w ritte n 1n was dancing. Another closely related C e rta in ly , part o f the advantage o f dancing fo r e ld e rly people 1s 1n the movement and resu ltant Increased function o f many parts o f the body. F in a lly , high school completion courses or GED tuto rin g were offered 1n fiv e percent o f the In s titu tio n s . The nine In s t i­ tutions having such programs were a l l nursing homes. Classes 1n h isto ry, sociology, English, speech, mathematics, botany, and 89 typing were o ffe red . These were usually offered by e ith e r the local community school programs or the local Interm ediate school d is tr ic t s . While the numbers o ffe rin g such courses w eren't la rg e, the e xp eri­ ence o f those who did so had been p o s itiv e . Comments were made lik e "we've been turned on to adu lt education here, and I t ' s fantas­ t ic ." Two other In s titu tio n s expressed in te re s t 1n th is area but reported th a t they had not been given the necessary help or encour­ agement from the local community school programs. One nursing care f a c i l i t y adm inistrator said , "They are not In terested in us." Another said , "They have to have fifte e n students to o ffe r a class here, and we usually c a n 't make that minimum." Not a ll nursing care ad m in istra to r's , however, were so favorably In c lin e d . One stated, "When patients are in th e ir 80s, what kind o f education would do any one any good?" Nonetheless, high school completion programs did e xis t In fiv e percent o f the In s titu tio n s . Yet another way o f looking a t th is Issue is to compare the mean numbers o f general education o fferin g s by in s titu tio n a l type. When th is was done 1t was apparent th a t only minor type related d i f ­ ferences existed. The two types o f nursing homes provided s lig h tly more general education opportunities showing means o f nine offerings each. The medical care f a c i l i t i e s and hospital long-term care units both had means o f eig ht o fferin g s each. Table 23 compares these aggregate scores. There was a wide range 1n numbers o f o fferings w ith in each of the four types, however. Some o f the fo r-p ro f1 t nursing homes provided as many as tw enty-eight d iffe re n t educational o ffe rin g s , 90 TABLE 2 3 .— Range and mean numbers o f general education o fferin g s In Michigan nursing care In s titu tio n s , by type o f In s t it u ­ tio n . Mean Std. Dev. Range For-prof1t nursing homes 9.43 4.96 3-28 N o t-fo r-p ro fit nursing homes 9.48 5.58 2-20 Medical care f a c i l i t i e s 7.86 3.95 3-20 Hospital long-term care units 7.86 4.34 3-14 whereas in every category some in s titu tio n s o ffered only th re e , and one o f the n o t-fo r -p r o fit nursing homes reported only two. Region 5, in which F lin t is located, had a high average number o f o fferin g s (eleven) as did Region 2 1n which Lansing Is located (eleven ). There was nothing s ig n ific a n t to be reported when the number of offerings were examined by In s titu tio n a l age or lo c atio n . Again, however, the number o f o fferings was correlated with in s titu tio n a l size. Though the range in numbers o f o fferin g s was wide fo r a ll three categories, and widest fo r large in s titu tio n s , patients 1n larger in s titu tio n s generally found more o fferings a v a ila b le to them (mean, 1 0 .9 5 ). U nfortunately, 1n a ll size categories, even among those reporting programs, some In s titu tio n s provided sharply lim ite d choices. Other In s titu tio n s 1n each size category o ffered much more choice. Table 24 presents these data. In general, group In stru ctio n was used most freq u ently as the method o f teaching. The mean score o f 4.03 Indicates th a t I t was used as a teaching method in an average o f four o f the o ffering s 91 TABLE 2 4 .--Range and mean numbers o f general education o ffe rin g s In Michigan nursing care In s titu tio n s , by s iz e o f In s t it u ­ tio n . Mean Std. Dev. Range Small in s titu tio n 8.91 5.62 3-21 Medium-sized In s titu tio n 8.96 4.55 2-21 10.95 6.16 4-28 Large In s titu tio n 1n the responding In s titu tio n s . In d ivid u al In s tru c tio n (mean = 2.50) 1s also used more often than e ith e r p rin ted m aterial (mean * 1.61) or s e lf-in s tr u c tio n a l m aterial (mean * 1 .0 3 ). Classes and Individual in s tru c tio n were c le a r ly the most popular methods o f teaching 1n general education programs. These data are displayed in Table 25. TABLE 2 5 .— Frequency o f use o f various educational methods 1n the one hundred seventy-eight general education programs In Michigan nursing care f a c i l i t i e s . Group In s tru c . Reported frequency o f use Mean number o f uses per In s titu tio n In d iv id . In s tru c . S e lf In s tru c . Printed M aterial 71Q 713 446 184 287 4.03 2.50 1.03 1.61 92 In summary o f th is sectio n , 1 t was determined th a t the 178 In s titu tio n s w ith operational general education programs ty p ic a lly offered e ig h t o r nine general education a c t iv it ie s but they ranged from as few as two to as high as tw enty-eight such o ffe rin g s per In s titu tio n s . Those most commonly o ffered were a rts and c r a fts , lit e r a t u r e , r e a lit y o rie n ta tio n , curren t events, and music. Group In s tru c tio n was used most w ith In d iv id u al In s tru c tio n , p rin ted m a te ria l, and s e lf-in s tru c tio n a l media follow ing 1n th a t o rder. P atien t Health Education O fferings E ig h ty -e ig h t o f the 294 in s titu tio n s ( t h i r t y percent) have operational programs o f p a tie n t health education. These operational programs were examined to determine the frequency o f educational o ffe rin g s and the methods 1n which they were presented. Topics lis te d include cancer, death and dying, diabetes, hearing or visual disorders, heart disease or hypertension, n u tr itio n , o rie n ta tio n to the f a c i l i t y , orthopedic disorders, and re s p ira to ry disorders. Per­ s o n a lity changes, discharge planning, dental hygiene, and colostomy care were occasional w r ite -in responses. When the topics were examined according to the frequency o f occurrence, they tended to f a l l In to two groups. The group o f topics covered most often Include o rie n ta tio n to the f a c i l i t y , n u tr itio n , and diabetes. This group o f topics was covered 1n e ig h ty -th re e to n in e ty -fo u r percent o f the programs. There was some overlap with the n u tritio n Item and the diabetes Item , Inasmuch as d ie t regulation 1s an Important p art o f diabetes education. 93 However, n u tritio n also 1s a fa c to r 1n cardiovascular disease, and may be c r it ic a l 1n normal functioning o f the e ld e rly . Hospital long-term care units were considerably below average In th e ir p ro vi­ sion o f education about th e ir f a c i l i t y , n u tr itio n , and diabetes. The second group o f topics included hearing and visual d is ­ orders (s ix ty -e ig h t p ercen t), death and dying and orthopedic d is ­ orders (both a t s ix ty percent) with the major k i l l e r s , heart disease (fifty -s e v e n percen t), re sp irato ry disorders ( f if t y - t w o per­ cent) and cancer (fo r ty -e ig h t p ercen t), being o ffered in about h a lf the In s titu tio n s . Again, hospital long-term care units were below average In a ll the categories except fo r education about heart disease and re sp irato ry disease. Table 26 presents comparative data on the frequencies o f such o ffe rin g s . The topics have been arranged In descending order, according to the frequencies o f th e ir occurrence. Nothing s ig n ific a n t was apparent when the mean number o f health educational o fferin g s was examined by In s titu tio n a l s iz e , age or lo c atio n . I t was, however, useful to look a t the mean number o f health education o fferin g s by In s titu tio n a l type. Hospital long­ term care units had the highest average number o f o ffe rin g s . Even though some In s titu tio n s o ffered as few as fo u r, others o ffered as many as twenty-two fie ld s o f In s tru c tio n w ith the mean being eleven. F o r-p ro fit nursing homes had a comparable mean a t ten o ffe rin g s, but a wider range. Some o f these In s titu tio n s offered as few as two educational a c t iv itie s w hile others o ffered as many as t h ir t y - s ix . N o t-fo r -p r o fit nursing homes and medical care 94 TABLE 2 6 .— Frequency o f o ffe rin g various topics 1n p atie n t health edu cation programs, by type o f In s titu tio n . Nursing Home For P r o fit Not fo r P r o fit Care F a d l. Hosp1ta, Long-Term Care Unit Number having no program N=132 N=42 N*19 N=13 N=206 Number having opera­ tio nal programs N= 59 N=10 N=16 N= 3 N= 88 58 98.3 8 80.0 15 93.8 2 66.7 83 94.3 51 86.4 9 90.0 15 93.8 2 66.7 77 87.5 50 84.7 9 90.0 12 75.0 2 66.7 73 83.0 O rientation to fa c ility N u tritio n Diabetes N % N % N % N ^ Total Hearing or visual disorders % 39 66.1 9 90.0 11 68.8 1 33.3 60 68.2 Death and dying N % 37 62.7 7 70.0 7 43.8 1 33.3 52 59.1 N % 34 57.6 6 60.0 11 68.8 1 33.3 52 59.1 Heart disease hypertension N % 33 55.9 7 70.0 8 50.0 2 66.7 50 56.8 Respiratory disorders N 29 49.2 5 50.0 10 62.5 2 66.7 46 52.3 30 50.8 4 40.0 7 43.8 1 33.3 42 47.7 Orthopedic disorders Cancer % N % 95 f a c ilit ie s had s im ila r means of nine o ffe rin g s . These data are d is ­ played In Table 27. TABLE 2 7 .—Range and mean numbers o f health education o fferin g s 1n Michigan nursing care In s titu tio n s * by type of In s t it u ­ tio n . Mean Std. Dev. Range F o r-p ro fit nursing homes 9.69 6.20 2-36 N o t-fo r-p ro fit nursing homes 8.90 5.02 3-21 Medical care f a c i l i t i e s 8.62 4.35 2-17 10.67 9.87 4-22 Hospital long-term care units Individual In stru ctio n was by fa r the most widely used method in a ll topic areas* with group In stru ctio n being the second most common method. The use o f printed m aterial was a close th ir d , with s e lf-in s tru c tio n a l m aterials being a d is ta n t fo u rth . This sequence was true 1n a l l topical areas except education about cancer. There* individual In stru ctio n was most corrvnon, but the use o f printed m aterial occurred more frequently than did group In stru c­ tio n . Table 28 presents some Illu s tr a te d data on th is concern. When the comparative frequencies o f the use o f the four methods o f In stru ctio n were computed, 1t was determined that the most common method used was In d ividual In s tru c tio n . The mean score of 4 .8 Indicated th a t I t was used as a teaching method 1n an average o f fiv e offerin g s 1n the responding In s titu tio n s . Group in stru ction was the second most common method* used on an average o f two 96 TABLE 2 8 .--Methods used 1n selected topic areas o f p a tie n t education In the e ig h ty -e ig h t health education programs 1n Michigan nursing care f a c i l i t i e s . Group In stru c. O rientation to fa c ility N u tritio n N S e lf In stru c. Printed M aterial 34 38.6 75 85.2 13 14.8 25 28.4 39 44.3 61 69.3 11 12.5 24 27.3 26 29.5 59 67.0 7 8.0 25 28.4 % 23 26.1 45 51.1 4 4.5 16 18.2 N % 25 28.4 33 37.5 3 3.4 18 20.5 N 11 12.5 43 48.9 3 3.4 10 11.4 17 19.3 39 44.3 5 5.7 15 17.0 10 11.4 37 42.0 2 2 .3 9 10.2 12 13.6 30 34.0 3 3.4 18 20.5 % N % N Diabetes % Hearing or visual disorders N Death and dying In d iv id . In stru c. Orthopedic disorders % Heart disease hypertension % Respiratory diseases % Cancer % N N N offerings per In s titu tio n (mean * 2 .2 3 ). Printed m aterial ranked th ird (mean * 1 .7 2 ), while s e lf-in s tru c tio n a l media was a d is ta n t fourth (mean * .5 4 ). These data are displayed 1n Table 29. In sunvnary o f th is section, the e ig h ty -e ig h t In s titu tio n s with operational health education programs o ffered o rie n ta tio n to the f a c i l i t y , n u tr itio n , and diabetes In e1ghty-f1ve to n in e ty -fo u r percent o f the In s titu tio n s . Education was offered about hearing 97 TABLE 2 9 .--Frequency o f use o f various educational methods 1n the e ig h ty -e ig h t health education programs in Michigan nursing care f a c i l i t i e s . Group In s tru c . ReS?r , ^ frequency o f use 197 Average number o f uses per In s titu tio n In d iv id . In s tru c . S e lf In s tru c . Printed M aterial 423 48 151 „ . Qn 223 4 *80 c* 54 1.72 and visual d iso rd ers, death and dying, orthopedic disorders, heart disease, re s p ira to ry disorders and cancer 1n h a lf to tw o -th ird s o f the In s titu tio n s . The mean number o f educational o ffe rin g s per In s titu tio n ranged from nine 1n n o t - f o r - p r o f it nursing homes and medical care f a c i l i t i e s to eleven 1n hospital long-term care u n its . In a ll fo u r types o f In s titu tio n s , the range o f educational o ff e r ­ ings varied from a low o f two to a high o f th 1 rty -s 1 x . The most common method used was In d iv id u al In s tru c tio n with group in s tru c tio n and p rin ted m aterial being also commonly used w h ile s e lf-in s tr u c tio n a l media ranked a d is ta n t fo u rth . Education fo r the P a tie n t's Family An attempt was made to analyze the 294 In s titu tio n s 1n terms of programs provided fo r the p a tie n ts ' fa m ilie s . these 294 In s titu tio n s o ffe red such a program. About a th ir d o f S lig h tly more than h a lf o f the sixteen hospital long-term care units ( f i f t y - s i x percent) provided education fo r the fa m ily , w hile th irty -o n e percent o f both the 191 fo r -p r o f1 t nursing homes and the th 1 rty -f1 v e medical care 98 f a c i l i t i e s o ffered such programs. The f if t y - t w o n o t - f o r - p r o f it nursing homes were a d is ta n t fo u rth , w ith only seventeen percent o f them o ffe rin g such programs. These data are displayed 1n Table 30. No s ig n ific a n t findings were apparent when these data were analyzed by In s titu tio n a l age or lo c a tio n . In s titu tio n a l s iz e , however, did appear to be s ig n ific a n tly re la te d . Family education was provided 1n twenty-one percent o f the small In s titu tio n s , In th irty -o n e percent o f the medium-sized In s titu tio n s , and 1n h a lf o f the large In s titu tio n s . T h irty o f the 164 In s titu tio n s (eighteen percent) reporting no fam ily education programs Indicated they were planning such programs. These data are displayed 1n Table 31. Most respondents did not give examples o f what program o ffe rin g s were provided, but the most common example among the few th a t were c ite d was discharge planning. Most o fte n , discharge plan­ ning was geared to the In d iv id u al p a tie n t and fa m ily , and included p a tie n t d a lly care, r e h a b ilita tio n exercises, d ie t , and medication. Some In s titu tio n s d e a lt with the mental and emotional aspects o f having a sick or dying person In the fa m ily 's home. Others d e a lt with the fin a n c ia l demands, and with the kinds o f assistance th a t could be a n tic ip ate d from social service agencies. P rin cipal P artic ip an ts 1n Planning and Conducting P a tie n t Education Programs The next major concern was to discover what kinds o f per­ sonnel were represented 1n planning, group teaching, o r In d iv id u al In s tru c tio n o f p a tie n ts . S p e c ific a lly lis te d were f a c i l i t y s t a f f 99 TABLE 3 0 .—D is trib u tio n o f educational programs fo r p a tie n ts ' fam ilies 1n Michigan nursing care In s titu tio n s , by type o f In s t i­ tu tio n . Nursing Home Family education provided No fam ily education Med. Care F a c il. Hospital Long-Term Care U nit Total For P r o fit Not fo r P r o fit N-191 N=52 N=35 N-16 N=294 N % 60 31.4 9 17.3 11 31 .4 9 56.3 89 30.3 N 103 53.9 37 71.2 20 57 .1 4 25.0 164 55.8 4 7 .7 3 8 .6 2 12.5 30 10.2 2 3 .8 1 2 .9 1 6 .3 11 3.7 % In planning stages N % 21 11.0 No report N % 7 3.7 TABLE 3 1 .—D is trib u tio n o f iMichigan nursing care In s titu tio n s o ffe rin g programs fo r p a tie n ts ' fa m ilie s , by size o f in s titu tio n . Small Medium Large Total N=69 N=199 N=26 N=294 14 21.3 62 31.2 13 50.0 89 30.3 % 46 66.7 107 53.8 11 42.3 164 55.8 In planning stages N % 7 10.1 22 11.1 1 3 .8 30 10.2 No report N % 2 2.9 8 4 .0 1 3 .8 11 3.7 Family education provided N No fam ily education N % TOO such as educational s p e c ia lis ts or nurses, p a tie n ts , local school personnel, college personnel, educational te le v is io n personnel, and lib ra ry or museum personnel. As might be expected, f a c i l i t y s t a f f were most widely represented, being Involved 1n n1nety-s1x percent o f the programs. They p artic ip a te d about equally 1n planning (eig h ty percen t), group teaching (eighty p ercen t), and 1n Ind ivid u al In s tru c tio n (seventyseven percent) o f a l l programs. Patients were the next most widely Involved 1n planning and conducting programs. 1n seventy-one percent o f the programs. They were Included They p a rtic ip a te d 1n plan­ ning In fifty -o n e percent o f the programs, 1n group teaching s itu ­ ations In th ir ty -fo u r percent o f the programs, and In Individual Instruction 1n t h ir t y percent o f the programs. Local school personnel were Involved 1n one way or another 1n f if t y - f o u r percent o f the programs. In e1ghty-one programs (fo rty -s ix percent) they p a rtic ip a te d In group teaching, but they participated In planning in only th irty -o n e percent o f the programs. Apparently, community school personnel were asked to do s p e c ific tasks, but were not widely Included 1n broad-based planning o f programs. As mentioned 1n an e a r lie r section, local lib r a ry and museum personnel were Involved 1n fo rty-tw o percent o f the programs. In te re s tin g ly , they served as planning consultants 1n tw enty-eight percent o f the In s titu tio n s , which approximated the frequency o f such p a rtic ip a tio n by local school personnel. They were Involved In group Instru ctio n 1n twenty-two percent o f the programs. 101 There was considerably less frequent Involvement o f local college personnel. The s t a f f o f local colleges made contributions 1n tw enty-eight percent o f the In s titu tio n s . m arily by making group presentations. They contributed p r i­ Some comments were made by respondents to the e ffe c t th a t they had tr ie d to get help from local colleges, but found l i t t l e evidence o f w illingness to help. Volunteer groups were w ritte n In as being Involved In f i f ­ teen percent o f the programs, with volunteers from re lig io u s groups w ritten 1n by fiv e percent o f the respondents. Volunteers came from local schools and colleges, men's and women's clubs, scouting groups, 4-H groups, and as mentioned above, re lig io u s groups. They p a r t ic i­ pated 1n planning, group teaching, and In d ivid u al In stru ctio n with approximately equal frequency. I t 1s In te re s tin g th a t educational te le v is io n personnel were not more widely Involved. With only fiv e in s titu tio n s (th ree per­ cent) using th is medium, i t 1s apparent th is resource remains r e la ­ tiv e ly untouched. Data on personnel Involvement appear 1n Table 32. No s ig n ific a n t Insights emerged when th is Issue was examined by In s titu tio n a l age, s iz e , or lo c a tio n . However, when s t a f f Involvement was examined by In s titu tio n a l type, several s trik in g Items emerged. Local school personnel were Involved In f i f t y - f o u r percent o f the In s titu tio n s . Approximately s ix ty percent o f the two la rg es t groups o f In s titu tio n s , nursing homes, Involved them. However, only one hospital long-term care u n it Involved local school personnel, and only a th ird o f the medical care f a c i l i t i e s Included such s t a f f . S im ila r, though not as s tr ik in g , differences appeared 102 TABLE 3 2 .--Number and source o f personnel Involved 1n the 178 p a tie n t general education programs, by educational fu n ctio n . d i anninn rianm ng Group Teach1ng P F a c ility s t a f f N % 143 8Q>3 142 79>Q p a tie H an n ts tc ra N % 91 5K1 60 33>7 In d iv id u al In s tru c tio n 137 77>Q Total N=178 171 96>1 53 2g>Q 126 7Q>8 Local school personnel N % 55 3Q g 81 45 5 2Q51? 96 53.9 Library o r museum personnel N % 49 27.5 39 21.9 33 18.5 74 41.6 rCollege „ , , « personnel N % 27 15>2 41 23>Q 27 15>2 49 2?>5 Individual volunteers N % 15 8 .4 23 12.9 18 10.1 27 15.2 6 3 .4 8 4 .5 7 3 .9 9 5.1 2 1.1 2 1.1 1 0 .6 5 2 .8 Religious group representative Educational TV s ta tio n personnel N % N % 103 regarding Involvement o f college personnel. These data are d is­ played In Table 33. When one looks a t the comparative frequency o f Involvement by various personnel groups 1n the three s t a f f functions lis te d , I t can be observed th a t more groups were Involved in group teaching (mean = 2 .22 ) and planning (mean = 2.17) than 1n in d ivid u al In s tru c ­ tion (mean = 1 .8 3 ). I t Is In te re s tin g to note th a t the mode 1n each of the three cases 1s two, In d icatin g th a t two groups or points o f view were ty p ic a lly represented 1n planning and conducting educa­ tional programs. These data are displayed 1n Table 34 (page 105). An aggregate score was computed fo r each In s titu tio n , taking to ta l number o f groups involved and the number o f the three functions 1n which each was Involved. For example, eig ht groups were lis te d with three possible functions fo r each one. I f an in s titu tio n Included a ll eig h t groups 1n a ll three functions i t would have had an aggregate score o f tw enty-four. aggregate score computed was seventeen. The highest The two types o f nursing homes both had mean scores th a t were somewhat higher and maximum scores th a t were much higher than the other two types o f nursing fa c ilitie s . The widest choice o f o fferin g s and methods was reported by a fo r -p ro f1 t nursing home 1n HSA 4 , In the Grand Rapids area. No s ig n ific a n t Insights resulted when the Issue was examined by age, s iz e , or HSA. In s titu tio n a l type. 105). The widest range o f aggregate scores was by These data are presented 1n Table 35 (page 104 TABLE 3 3 .— Number and source o f personnel Involved 1n planning and operating general education programs In Michigan nursing care f a c i l i t i e s , by type o f In s titu tio n . Nursing Home F a c ility s ta ff Patients Local school personnel Library or museum personnel College personnel Individual volunteers Religious group representatives Educational TV station personnel ^ Care F a c il. Hospital Long-Term Care U nit Total For P r o fit Not fo r P r o fit N=125 N=25 N=21 N=7 N=178 121 96.8 25 100 19 90.5 6 85.7 171 96.1 92 73.6 15 60.0 14 66.7 5 71.4 126 70.8 72 57.6 15 60.0 8 38.1 1 14.3 96 53.9 51 40.8 15 60.0 6 28.6 2 28.6 74 41.6 % 34 27.2 10 40.0 4 19.0 1 14.3 49 27.5 N 21 4 0 2 27 % 16.8 16.0 0 28.6 15.2 N 9 7.2 0 0 0 0 0 0 9 5.1 3 2.4 0 0 1 4 .8 1 14.3 5 2 .8 N % N % N % N % N % N % 105 TABLE 3 4 .— Frequency o f Involvement 1n general education programs o f various personnel groups, by educational s t a f f functions. 0, ann4„„ Planning Group Teaching In d iv id u al In s tru c tio n Reported frequency o f Involvement 388 396 327 Mean number o f groups per In s titu tio n 2.17 2.22 1.83 TABLE 3 5 .— Range and mean number o f groups Involved 1n planning and teaching 1n general education programs. Mean Std. Dev Range F o r-p ro fit nursing homes 6.54 3.27 2-17 N o t-fo r -p r o fit nursing homes 6.64 3.07 2-13 Medical care f a c i l i t i e s 4.52 1.89 2- 9 Hospital long-term care units 4.71 2.21 2- 8 In q u iry was also made to discover what kinds o f s t a f f were Involved 1n planning, group teaching or in d iv id u al In s tru c tio n 1n the health education program. Nursing s t a f f , d ie tic ia n s , acfcnlnls- tra to rs , and th e ra p ists were a l l commonly Involved. Nursing s ta ffs were the most widely Involved 1n educating p a tie n ts , v e rify in g what 1s commonly perceived. 1n eighty-seven o f the e ig h ty -e ig h t programs. They were Involved They did In d iv id u al In s tru c tio n 1n e ig h ty -th re e percent o f the programs, were involved 1n planning 1n seventy-one percent, and did group in s tru c tio n in fifty -s e v e n percent o f the programs. 106 D ie titia n s were Involved 1n eig hty-n in e percent o f the pro­ grams, again p rim a rily In Ind ivid u al In s tru c tio n (s ix ty -e ig h t per­ cent) and planning (s ix ty -fo u r percent). Administrators were Involved 1n e ig h ty -th re e percent o f the health education programs. As might be expected, adm inistrators In a ll types o f In s titu tio n s played more o f a ro le 1n planning educa­ tional programs (s ix ty -e ig h t percent) than 1n In d ivid u al In s tru c ­ tion (fo r ty -s ix percent) or 1n group teaching (twenty-seven percent). A s lig h tly la rg e r percentage o f the programs had nurses involved 1n planning (seventy-one percent) than adm inistrators (s ix ty -e ig h t percent). The fourth most widely Involved group was the th e ra p is ts , the most common o f which were occupational, physical, re s p ira to ry , and speech th e ra p is ts . the programs. They were involved 1n e1ghty-two percent o f Again, a common perception was v e r ifie d by th is study 1n th a t they did Ind ivid u al In stru ctio n 1n seventy-three percent o f the programs. teaching. They also were heavily Involved 1n planning and group They performed these functions In a la rg e r percent o f hospital long-term care units (sixty-seven percent) and medical care f a c i l i t i e s ( f i f t y - s i x percent) than 1n fo r-p ro f1 t nursing homes (fo r ty -s ix percent) or n o t-fo r -p r o fit nursing homes ( t h ir t y per­ cent). This presumably was a re s u lt o f th e ir more frequent employ­ ment by hospitals and h o s p ita l-lik e medical care f a c i l i t i e s than 1n nursing homes. Whether or not they were Involved In th is capacity was presumably a function o f th e ir a v a ila b ilit y more than o f th e ir job description. 107 Physicians were Involved 1n health education programming In seventy-six percent o f the programs. They were Involved 1n the planning process 1n s ix ty -th re e percent and In In d ivid u al In s tru c ­ tion 1n fo rty -th re e percent o f the programs. They were Involved in group In s tru c tio n 1n only seventeen percent o f the In s titu tio n s . Apparently, the "team approach" w ith the physician a member o f the team th a t plans and sometimes conducts the learning experience 1s being applied 1n these nursing care f a c i l i t i e s . Some comments are appropriate regarding the ro le o f educa­ tion s t a f f . The s ta tis tic s Indicate they were Involved 1n only forty-seven percent o f the In s titu tio n s . function o f la b e lin g . Presumably, th is was a Many o f the In s titu tio n s assigned educational tasks to other s t a f f members, who were not labeled p rim a rily as edu­ cation s t a f f . Education s ta ff were reported to be Involved In planning 1n th ir ty -e ig h t percent, 1n group teaching 1n th 1rty-s1x percent, and 1n in d ividual in stru ctio n In th irty -tw o percent o f the programs. This apparently low level o f Involvement presumably re fle c ts the concept th a t the p atie n t educator should be p rim a rily a coordinator leaving the actual planning and teaching up to others. S ta ff from public health departments and voluntary health agencies were the le a s t frequently Involved o f the nine groups lis te d . The data on the frequency o f Involvement o f various groups of personnel are displayed 1n Table 36. The personnel groups have been arranged 1n descending order according to the frequency o f th e ir p a rtic ip a tio n . 108 TABLE 3 6 .—Number and source o f personnel Involved 1n the p a tie n t h ealth education programs, by educational fu n c tio n . Nursing s t a f f D ie titia n s Administrators Therapists Physicians Social workers Clergy Education s t a f f Health agency s t a f f d i a n n -in n M anning Group Teach1ng 62 70.5 50 56.8 73 8 3.0 87 98.9 56 63.6 29 33.0 60 68.2 78 88.6 60 68.2 24 27.3 40 45.5 73 83.0 51 58.0 41 46.6 64 72.7 72 8 1 .8 55 62.5 15 17.0 38 43.2 67 76.1 45 51.1 32 36.4 56 63.6 67 76.1 31 35.2 40 45.5 46 52.3 61 69.3 % 33 37.5 32 36.4 28 31.8 42 47.7 N % 27 30.7 16 18.2 21 23.9 40 45.5 N % N % N % N % N % N % N % N In d iv id u al in s tru c tio n Total N*88 109 Nothing s ig n ific a n t was revealed when these data were examined by In s titu tio n a l age, s iz e , o r HSA. However, when exam­ ined by In s titu tio n a l type, one Item o f In te re s t was revealed. Hospital long-term care units were c o n s is te n tly below average In the numbers and types o f personnel Involved In p a tie n t health edu­ cation programs as w ell as 1n actual numbers o f In s titu tio n s . Only three such In s titu tio n s had health education programs, and only one o f these reported Involvement o f any s t a f f except nurses 1n those programs. Medical care f a c i l i t i e s were u su ally s lig h tly above the averages fo r a l l In s titu tio n s In the range o f personnel Involved. This presumably r e fle c ts the g re ater Incidence o f health education programs 1n such f a c i l i t i e s . These data are displayed 1n Table 37. When one looks a t the comparative frequency o f the in volve­ ment o f the three s t a f f groups lis t e d , 1t can be observed th a t the groups were most often Involved 1n In d iv id u a l In s tru c tio n and plan­ ning. The In s titu tio n s Involved a mean o f 4.84 groups 1n in d ivid u al In s tru c tio n , a mean o f 4.77 groups in planning, and a mean o f 3.17 groups 1n group teaching. Again, however, the modal scores reveal th a t e ig h t groups were ty p ic a lly Involved In planning, fiv e groups were Involved 1n In d iv id u al In s tru c tio n , w hile four groups were Involved In group In s tru c tio n . These data are displayed In Table 38 (page 111) . An aggregate group Involvement score was computed fo r each In s titu tio n having a health education program. The highest aggre­ gate score computed was tw e n ty -s ix , meaning several groups were Involved 1n one or more o f the three functions lis t e d . Nothing 110 TABLE 3 7 .—Number and type o f personnel Involved 1n planning and operation o f p atie n t health education programs In Michigan nursing care In s titu tio n s , by type o f In s titu tio n . Nursing Home Nursing s t a f f D ie titia n Administrators Therapists N % N % N % N % N Med. Care F a c ll, Hospital Long-Term Care Unit N=3 Total For P rof1t Not fo r P r o fit N=59 N=10 N=16 58 98.3 10 100 16 100 3 100 87 98.9 55 93.2 8 80.0 14 87.5 1 33.3 78 88.6 52 88.1 6 60.0 14 87.5 1 33.3 73 83.0 47 79.7 6 60.0 16 100 3 100 72 81.8 7 70.0 13 81.3 1 33.3 67 76.1 N**88 Physicians % 46 78.0 Social workers N * 45 76.3 6 60.0 15 93.8 1 33.3 67 76.1 N 39 66.1 7 70.0 14 87.5 1 33.3 61 69.3 29 49.2 5 50.0 7 43.8 1 33.3 42 47.7 27 45.8 5 50.0 7 43.8 1 33.3 40 45.5 Clergy Education s ta ff Health agency s ta ff % N % N % Ill TABLE 3 8 .— Involvement 1n health education programs o f various per­ sonnel groups, by educational s t a f f functions. 9 Reported frequency o f use Average number o f uses Group Teaching In d ivid u al In s tru c tio n 420 279 426 4.77 3.17 4.84 s ig n ific a n t was revealed when the Issue was examined by In s t it u ­ tio n a l age, s iz e , or lo c a tio n . The widest d is p a rity was when the aggregate scores were grouped by In s titu tio n a l type. F o r-p ro f1 t nursing homes and medical care f a c i l i t i e s had Id e n tic a l mean scores o f th ir te e n , w hile hospital long-term care units were lowest (mean = 1 0 .3 3 ). The range fo r a ll groups was extensive (ran g e■ 2 -2 6 ). These data are displayed 1n Table 39. In summarizing th is section 1t 1s apparent th a t representa­ tives o f several groups were ty p ic a lly Involved 1n some aspect o f the general education programs. The groups most lik e ly to be TABLE 3 9 .— Range and mean number o f groups Involved 1n planning and teaching 1n health education programs. Mean Std. Dev. Range F or-p ro f1t nursing homes 13.07 5.54 2-26 N o t-fo r -p r o fit nursing homes 10.90 7.48 4-26 Medical care f a c i l i t i e s 13.37 4 .3 8 6-22 Hospital long-term care units 10.33 11.15 2-23 112 Involved were f a c i l i t y s t a f f , p a tie n ts , local school personnel, and lib ra ry or museum personnel, with a v a rie ty o f other groups being Involved occasionally. They were Involved w ith approximate equal frequency 1n planning, group teaching, and In d ivid u al In s tru c tio n . Representatives o f several groups were also Involved in some facets of health education programs. Nursing s t a f f , d ie tic ia n s , ackn1n1s- tra to rs , th e ra p is ts , physicians, social workers, and clergy were involved 1n more than tw o-thirds of the programs. They were Involved most commonly 1n Individual In s tru c tio n and planning, though they were also often Involved in group teaching. In it ia tio n o f P atien t Involvement E1ghty-e1ght or t h ir t y percent o f the 294 In s titu tio n s reported th a t they provide p atie n t health education programs. These Included only three o f the sixteen hospital long-term care u n its , sixteen o f the t h ir t y - f iv e medical care f a c i l i t i e s , ten o f f i f t y two n o t-fo r -p r o fit and f1fty-n1ne o f the 191 fo r -p ro f1 t nursing homes. There were four methods fo r In it ia t in g p a tie n t Involvement 1n p atient education: p atien t conferences, p a tie n t requests, phy­ sician p rescrip tio n s, and standing orders. The p atie n t conference was the most commonly employed method fo r in it ia t in g p atien t health education, reported 1n eig h tytwo or nin ety-th ree percent o f the programs. the only method used. I t was ra r e ly , however, Patient requests might have In it ia te d health education programs In f if t y - n in e or sixty-seven percent o f the cases. In only one In s titu tio n , a fo r-p ro f1 t nursing home, was 1t reported as the only method. Doctor-Issued prescriptions were another means 113 of In it ia t in g health education In forty-seven or f if t h - t h r e e percent o f the In s titu tio n s ; but 1n only one in s titu tio n , a n o t-fo r -p r o fit nursing home, was 1t the only means. Standing orders were employed In th ir ty -e ig h t or fo rty -th re e percent o f the In s titu tio n s , but 1n only two fo r-p ro f1 t nursing homes and one medical care f a c i l i t y was 1t the only means. A combination o f methods was reportedly employed fo r I n i t i ­ ating p a tie n t health education 1n most In s titu tio n s . Twenty reported using a ll four methods; tw en ty-five reported three; tw enty-eight reported two; and only fifte e n reported a single method fo r I n i t i ­ ating them. These data are displayed 1n Tables 40 and 41. Analysis of the data revealed no apparently s ig n ific a n t differences 1n means o f In it ia t in g p atien t Involvement 1n health education programs by s ize , age, or location o f In s titu tio n . TABLE 4 0 .— Frequency o f employment o f each o f four methods to In i t i a t e p atien t p a rtic ip a tio n 1n health education programs, d is­ played by in s titu tio n a l type. Nursing Home Patient care conference Patient requests Educational prescription Standing orders Med. Care Fac1l. Hospital Long-Term Care Unit N*3 Total For P r o fit Not fo r P r o fit N=59 N=10 N=16 55 33.2 9 90.0 15 93.7 3 100 82 93.1 43 72.8 6 60.0 10 62.5 0 0 59 67.0 % 36 61.0 5 50.0 6 37.5 0 0 47 53.4 N % 23 38.9 5 50.0 8 50.0 2 66.6 38 43.1 N % N % N N*88 114 TABLE 4 1 .—Methods and combinations o f methods used to In it ia t e p a tie n t p a rtic ip a tio n 1n health education programs, displayed by In s titu tio n a l type. Nursing Home For P r o fit N*59 Patient conference only Patient request only Conference and request Education prescrip­ tion only N*88 3 18.8 1 33.3 10 11.4 N 1 1.7 0 0 0 0 0 0 1 1.1 12 20.3 1 10.0 1 6.3 0 0 14 15.9 0 0 1 10.0 0 0 0 0 1 1.1 7 11.9 0 0 0 0 0 0 7 8 .0 1 1.7 0 0 0 0 0 0 1 1.1 11 18.6 1 10.0 4 25.0 0 0 16 18.2 2 3.4 0 0 1 6 .3 0 0 3 3.4 1 1.7 1 10.0 2 12.5 2 66.6 6 6 .8 3 5.0 1 10.0 3 18.0 0 0 7 8 .0 2 2 .3 0 0 0 0 0 0 2 2.3 15 17.0 3 3.4 2 2.3 0 0 20 22.7 % N % N % N % % N % N % Standing orders, and conference N Standing orders, con­ ference and request N A ll four methods N=3 2 20.0 Prescription and request Standing orders, conference and prescription N=16 Total 4 6.8 N Standing orders only Hospital Long-Term Care Unit N % Prescription and conference Conference, request, and prescription Not fo r P r o fit N=10 Med. Care F a c ll. % % N % N % 115 Evaluation o f Health Education Program? Considerable evaluation o f p a tie n t learning was being done 1n health education programs, as was Indicated by p o s itiv e responses to the question by fifty -s e v e n ( s ix t y - f iv e percent) o f the e ig h ty eig ht respondents, w ith an a d d itio n a l ten (eleven percent) planning to do eva lu atio n . Evaluation o f p a tie n t learning was apparently considered Important and was being done. I t was done 1n approxi­ mately tw o-th ird s o f the fo r -p r o f1 t nursing homes, the medical care f a c i l i t i e s , and the h o sp ital-lo n g term care units and 1n fiv e of the ten n o t - f o r - p r o f it nursing homes. In Table 42. These data are displayed No s ig n ific a n t Insig h ts were gained by analyzing the data by In s titu tio n a l s iz e , age, or lo c a tio n . TABLE 4 2 .—Number and percent o f nursing care In s titu tio n s In which evaluation o f p a tie n t learning was done or being planned, by type o f in s tit u tio n . Nursing Home r_ ~ Wrt+ P r o f it P r o fit Do evaluate Do not evaluate Planning to evaluate No data N % N % N % N % Med Care F a c il* Hospital Long-Term Care U nit Total N=59 N=10 N=16 N=3 N=88 39 66.1 5 50.0 11 6 8 .8 2 66.7 57 64.8 11 18.6 3 30.0 4 25.0 1 33.3 19 21.6 9 15.3 0 0 1 6 .3 0 0 10 11.4 0 0 2 2 .3 0 0 0 0 2 2 .3 116 S u rp risin g ly, fifty -tw o o f the e ig h ty -e ig h t In s titu tio n s (f1fty-n 1ne percent) reported th a t they did evaluations o f th e ir to ta l health education programs, w ith another fourteen percent reporting th a t they planned to do 1 t. Program evaluation was s lig h tly more prevalent 1n fo r-p ro f1 t nursing homes than 1n other In s titu tio n a l types. This prevalence 1s lik e ly to Increase as another seventeen percent o f the f o r - p r o f it nursing homes were plan­ ning to do program evaluation. Program evaluation has been stressed 1n the health education f ie ld fo r the past several years. Nursing care f a c i l i t i e s seem to be 1n step with the re s t o f the agencies In this regard. Table 43 presents add itio n al data on th is Issue. No s ig n ific a n t Insights were gained by examining the data by In s t it u ­ tional s iz e , age, or lo c atio n . TABLE 4 3 .—Number and percent o f nursing care In s titu tio n s 1n which evaluation o f p atien t health education programs was done or being planned, by type o f In s titu tio n . Nursing Hone eft*. N Do evaluate % Do not evaluate % Planning to evaluate No data N N % N % „ed Care Hospital Long-Term Total p S flt P r o fit N=59 N=10 N=16 N*3 N=88 36 61.0 5 50.0 9 56.3 2 66.6 52 59.1 10 16.9 3 30.0 5 31.3 1 33.3 19 21.6 10 16.9 0 0 2 12.5 0 0 12 13.6 3 5.0 2 2 .3 0 0 0 0 5 5.7 117 In summarizing th is section, p atie n t health education pro­ grams existed In less than a th ird o f the In s titu tio n s . These operational programs offered a v a rie ty o f a c t iv it ie s , most commonly through Individual In s tru c tio n or group In s tru c tio n . There was substantial involvement o f f a c i l i t y s ta ff and le ss , though s t i l l s ig n ific a n t, Involvement o f outside resource people. A combination o f methods was used to get patients started 1n the programs, but the most common method was the p atie n t conference. Physicians were Involved through educational prescriptions In nearly h a lf o f these programs, and through standing orders in more than one-third o f them. F in a lly , there was evaluation o f Individual p atien t learning and o f to ta l programs In a m ajo rity o f the programs. Administrators* Opinions Concerning P atien t Education" Another o bjective o f th is study was to s o lic it the opinions of adm inistrators regarding the legitim acy o f p atien t health educa­ tion and p a tie n t general education as functions o f nursing care fa c ilitie s . Administrators were asked to respond to statements Indicating that health education and general education are l e g i t i ­ mate functions o f nursing care f a c i l i t i e s . They were asked to check the response most clo sely expressing th e ir own judgment, selecting from strongly agree, agree, n e u tra l, disagree, and strongly disagree. P atien t health education was considered a le g itim a te func­ tion o f nursing care In s titu tio n s by three-fourths (75.8%) of the adm inistrators. F o rty -eig h t percent agreed and tw enty-eight percent 118 strongly agreed th a t 1t 1s. I t can be observed when looking a t Table 44 th a t th is 1s consistent across the fo u r types o f In s t it u ­ tions w ith e s p e c ia lly strong support expressed by the small group o f hospital long-term care u n it adm inistrators and the large group o f fo r-p ro f1 t nursing home ad m in istrato rs. Looking a t the same ques­ tio n from the other end o f the spectrum, only fo u r percent o f the adm inistrators expressed judgment th a t p a tie n t health education is not a le g itim a te fu n c tio n . Out o f 294 a d m in istra to rs , only twelve expressed disagreement, one expressing strong disagreement, w ith the statement. C le a rly , there was l i t t l e disagreement among TABLE 4 4 .— Responses o f adm inistrators concerning the legitim acy o f p a tie n t health education as a function o f Michigan nursing care f a c i l i t i e s , by type o f In s tit u tio n . Nursing Home Med. Care Facil Hospital Long-Term Care Unit Total For P r o fit Not fo r P r o f it N=191 N=52 N=35 N=16 N=294 Strongly agree N % 57 29.8 13 25.0 7 20.0 6 37.5 83 28.2 Agree N % 91 47.6 21 40.4 20 57.1 8 50.0 140 4 7 .6 Neutral % 26 13.6 6 11.5 4 11.4 0 0 36 12.2 Disagree N % 5 2 .6 3 5 .8 2 5.7 1 6 .3 11 3 .7 Strongly disagree N % 1 0 .5 0 0 0 0 0 0 1 0 .3 No response N % 11 5 .8 9 17.3 2 5.7 1 6 .3 23 7 .8 N 119 administrators th a t nursing care In s titu tio n s can and should do patient health education. No s ig n ific a n t Insights were gained by analyzing the data by In s titu tio n a l s iz e , age, or lo c atio n . Another way o f examining the data 1s to look a t responses when adm inistrators are grouped according to the programs offered In th e ir In s titu tio n s . As might be a n tic ip a te d , those adm inistrators who had p atien t health education programs more freq u ently expressed judgments th a t I t Is a le g itim ate function than did those who did not have such programs. More s ig n ific a n tly , w hile there was a mild d iffe re n c e , s ix ty -th re e percent o f those without e ith e r program agreed or strongly agreed that such programs are le g itim ate func­ tions, and only seven percent disagreed. Of course, 1t 1s also In te re s tin g , and perhaps s ig n ific a n t, th a t fourteen percent were neutral and sixteen percent "passed." I t appears th a t while there was perhaps t h ir t y percent apathy there was only seven percent oppo­ s itio n and s ix ty -th re e percent endorsement fo r the p rin c ip le o f p atient health education. The data seem to reveal that adm inistra­ tors who had p atien t health education programs d iffe re d from others p rim arily 1n strength o f agreement. These data are displayed In Table 45. P atien t general education was also considered a le g itim ate function o f nursing care f a c i l i t i e s . Only nine percent o f the f a c i l i t y adm inistrators were opposed to the concept, w hile twothirds (66.3%) endorsed 1 t. Forty percent o f the respondents agreed, and twenty-seven percent strongly agreed th a t I t 1s a 120 TABLE 4 5 .--Responses o f adm inistrators concerning the legitim acy o f p a tie n t health education as a function o f Michigan nurs­ ing care f a c i l i t i e s , by type o f p a tie n t education program operated. Strongly agree psn esp. Those With N either program Those With Only Health Education Those With Only Gen. Education Those With Both N=294 N=94 N=22 N=112 N=66 83 28.2 16 17.0 12 54.5 20 17.9 35 53.0 140 47.6 43 45.7 5 22.7 66 58.9 26 39.4 36 12.2 13 13.8 4 18.2 16 14.3 3 4 .5 11 3.7 7 7.4 0 0 4 3.6 0 0 % 1 0.3 0 0 0 0 1 0.9 0 0 N % 23 7.8 15 16.0 1 4.5 5 4 .5 2 3.0 N % N Agree % N Neutral % Disagree Strongly disagree No data N % N legitim ate function. Again, th is support was f a i r l y consistent across In s titu tio n a l types. These data are displayed 1n Table 46. Nothing s ig n ific a n t was revealed when these data were exam­ ined by In s titu tio n a l age or lo catio n . However, when looked a t by s ize , considerably stronger support came from large In s titu tio n s . F ifty -fo u r percent o f the adm inistrators o f large In s titu tio n s strongly agreed and another twenty-seven percent agreed th a t general education programing should be a function o f nursing care f a c i l i ­ tie s . Med1um-s1zed In s titu tio n s were near the average, w hile administrators o f small In s titu tio n s were much less lik e ly to see such programing as le g itim a te . I t Is s ig n ific a n t to note th a t 121 TABLE 4 6 . - - Responses o f adm inistrators concerning the leg itim acy o f p a tie n t general education as a function o f Michigan nursing care f a c i l i t i e s , by type o f in s t it u t io n . Nursing Home N Strongly agree % N Agree % N Neutral % N D1sagree % N Strongly disagree % N No data % Med. Care F a c ll. Hospital Long-Term Care U n it Total For P r o fit Not fo r P r o fit N=191 N=52 N=35 N=16 N*294 54 28.3 11 21.2 8 22.9 5 31.3 78 26.5 75 39.3 23 44.2 15 42.9 4 25.0 117 39.8 29 15.2 10 19.2 6 17.1 4 25.0 49 16.7 17 8 .9 2 3.8 3 8 .6 2 12.5 24 8 .2 1 0 .5 0 0 0 0 0 0 1 0 .3 15 7.9 6 11.5 3 8 .6 1 6 .3 25 8 .5 while support was less strong among adm inistrators o f small In s t it u ­ tio n s , i t was s t i l l present in h a lf the cases. These data are d is ­ played In Table 47. Again, the p re d ictab le occurred. Those w ith both programs, or with general education programs, more freq u e n tly expressed judg­ ments th a t general education Is a le g itim a te function o f nursing care f a c i l i t i e s . More than th ree -fo u rth s o f such adm inistrators expressed e ith e r agreement o r strong agreement. disagreed. Only s ix percent 122 TABLE 4 7 .--Response o f adm inistrators concerning the legitim acy o f p a tie n t general education as a function o f Michigan nursing care f a c i l i t i e s , by s ize o f In s tit u tio n . Strongly agree N % N Small Medium Large Total N=69 N=199 N=26 N-294 10 14.5 54 27.1 14 53.8 78 26.5 25 36.2 85 42.7 7 26.9 117 39.8 Agree % Neutral % 17 24.6 29 14.6 3 11.5 49 16.7 Disagree N % 9 13.0 14 7 .0 1 3 .8 24 8 .2 Strongly disagree N * 0 0 1 0 .5 0 0 1 0 .3 N 8 11.6 16 8 .0 1 3 .8 25 8 .5 N No data % Again, 1t is s ig n ific a n t to note th a t fo rty -o n e percent o f the adm inistrators o f in s titu tio n s without a p a tie n t education program o f any kind e ith e r agreed or strongly agreed th a t such programming 1s appropriate. T h irty percent were neutral on the Issue, and only th irte e n percent o f such adm inistrators disagreed. These data are displayed 1n Table 48. The adm inistrators were asked I f they would be In te re s te d In developing a p a tie n t education program a t t h e ir f a c i l i t y I f fre e consultant help were a v a ila b le . The overwhelming m a jo rity (e ig h ty - fiv e percent) indicated th a t they would. Only e ig h t percent In d i­ cated th a t they would n ot, although another seven percent did not 123 TABLE 4 8 .--Responses o f adm inistrators concerning the legitim acy o f p a tie n t general education as a function o f Michigan nurs­ ing care f a c i l i t i e s , by type o f p a tie n t education program provided. Strongly agree A ll Resp. Those With N either Program Those With Only Health Education Those With Only Gen. Education N=294 N=94 N=22 N*112 N=66 78 26.5 8 8 .5 6 27.3 33 29.5 31 41.0 117 39.8 31 33.0 8 36.4 55 49.1 23 34.8 49 16.1 28 29.8 4 18.2 11 9 .8 6 9.1 % 24 8 .2 11 11.5 3 13.6 7 6.3 3 4 .5 N % 1 0 .3 1 1.1 0 0 0 0 0 0 N 25 8 .5 15 16.0 1 4 .5 6 5.4 3 4 .5 N % N Agree % N Neutral % Disagree Strongly disagree No data N % respond to the question. Those With Both Q u alifying statements were w ritte n In occasionally In d ic a tin g th a t the respondent was a s t a f f member ra th e r than the ad m in istrato r and could not a n tic ip a te what the ad m in istra to r's opinion might be. In te re s t 1n consultant assistance fo r In it ia t i n g programs was q u ite consistent 1n the four types o f In s titu tio n s , as displayed 1n Table 49. Nothing s ig n ific a n t was revealed when these data were exam­ ined by In s titu tio n a l s iz e , age, or lo c a tio n . When the responses were examined according to program existen ce, several In te re s tin g Items emerged. I t was evident th a t the m a jo rity o f adm in istrato rs, Including nearly th ree -fo u rth s (71.3%) o f those who had no program, 124 TABLE 4 9 .--A d m in is trato r In te re s t 1n developing a p a tie n t education program 1 f fre e consultant help were a v a ila b le . Nursing Home N Yes % N No % N No data % For P r o f it Not fo r P r o f it Med. Care F a c ll. Hospital Long-Term Care U nit Total N=191 N=52 N=35 N=16 N-294 169 88.5 37 71.2 31 88.6 12 75.0 249 8 4.7 10 5.2 8 15.4 3 8 .6 3 18.8 24 8 .2 12 6 .3 7 13.5 1 2 .9 1 6.3 21 7.1 would u t i l i z e consultant assistance to e s ta b lis h or expand p a tie n t education programs. Only e ig h t percent o f a ll adm inistrators and sixteen percent o f those w ith no programs Indicated they would not do so. These data are displayed 1n Table 50. A few adm inistrators were apparently re lu c ta n t to commit themselves to such programs. tim e. A few believed i t to be a waste of Comments such as the follow ing were w ritte n 1n: The average age 1n th is f a c i l i t y 1s 75 and any educa­ tio n program would be a waste o f tim e. Patients do not understand and are not in te re s te d . We are a t le a s t ten years too la te fo r my people. I question the m otivation o f a p a tie n t to learn some­ thing never sought before becoming a p a tie n t. Other comments centered on the fin a n c ia l aspects o f provid­ ing the service: 125 TABLE 5 0 .—A dm inistrator In te re s t 1n developing a p a tie n t education program 1 f fre e consultant help were a v a ila b le . N Yes % N No % No data N % A ll Resp. Those With N eith er Program Those With Only Health Education Those With Only Gen. Education N=294 N-94 N=22 N=112 N=66 249 84.7 67 71.3 18 81.8 103 92.0 61 92.4 24 8 .2 15 16.0 2 9.1 4 3 .6 3 4 .5 21 7.1 12 12.8 2 9.1 5 4.5 2 3.0 Those With Both We are not In tere s te d 1n doing more than we are when no one 1s In tere s te d 1n the p a tie n t enough to even underwrite present costs. I strongly disagree th a t tax money should be spent to enlarge the re s p o n s ib ilitie s o f nursing homes when the s ta te 1s u n w illin g and/or unable to reimburse nursing homes fo r ever-expanding requirements. We simply do not have the funds. We would love the Idea 1 f the s t a f f werepaid fo r by someone. The State o f Michigan does not. Only I f the s ta te pays the f u l l cost. Many In s titu tio n s have programs, however, and had found ways of financing them. Comnents were made such as the follo w in g : We are r e a lly In to education and have discovered some absolutely fas cin a tin g things about I t . That comnent came from a small nursing home th a t o ffe rs classes 1n English, mathematics, h is to ry , music, and B ib lic a l studies, plus the tr a d itio n a l a rts and c ra fts and r e a lit y o rie n ta ­ tio n . Another adm in istrato r said: 126 We have been try in g to set up some form o f educational programs, but d o n 't know how to s ta r t or where to get help. We need HELP, we want HELP. In summarizing th is sectio n , 1 t should be noted th a t there was considerable support fo r the leg itim acy o f both h ealth education and general education programming fo r p a tie n ts . Three-fourths o f the adm inistrators endorsed p a tie n t health education programming while tw o -th ird s o f them endorsed p a tie n t general education. Four percent e ith e r disagreed o r strongly disagreed th a t health education was a le g itim a te function o f nursing care f a c i l i t i e s , w hile nine percent expressed s im ila r judgment about p a tie n t general education. Further, e ig h ty -fiv e percent o f the responding adm inistrators in d i­ cated they were In terested 1n developing or expanding a program 1n p a tie n t education a t t h e ir in s titu tio n 1 f fre e consultant help were a v a ila b le . Summary More than two-th1rds o f the In s titu tio n s were found to have one or the other or both forms o f education programs a v a ila b le fo r p a tie n ts . I t was more corranon fo r an in s titu tio n to have a general education program (n e a rly tw o -th ird s d id ) than a health education program (les s than one-th1rd d id ), and even less common fo r an i n s t i ­ tu tio n to have both programs avaiable ( o n e -fifth d id ). Coordinators were a v a ila b le 1n about th ree -fo u rth s o f the In s titu tio n s , and they ty p ic a lly coordinated both kinds o f programs when both were pro­ vided. Educational centers were a v a ila b le 1n about tw o -th ird s o f the In s titu tio n s . 127 General education o ffe rin g s th a t were most common Included a rts and c r a f t s , lit e r a t u r e , r e a lit y o rie n ta tio n , current events, and music. The health education o ffe rin g s most ty p ic a lly were o rie n ­ ta tio n to the f a c i l i t y , n u tr itio n , d iabetes, and hearing and visual disorders. There were many other In te re s tin g o ffe rin g s a v a ila b le In both groups. Group In s tru c tio n was used most freq u e n tly 1n general edu­ cation , w hile In d iv id u al In s tru c tio n was used most freq u e n tly 1n health education. Reliance s o le ly upon p rin ted m aterial was very rare and s im ila r re lia n c e upon s e lf-in s tr u c tio n a l m aterial was even more rare 1n both kinds o f programs. F a c ilit y s t a f f , p a tie n ts , and local school personnel were most commonly Involved 1n providing general education programs, w ith many others being Involved o ccasionally. Nurses, d ie t it ia n s , admin­ is tr a to r s , th e ra p is ts , physicians, and social workers were a l l com­ monly Involved 1n the health education Educational programs were most care conferences and by p a tie n t requests. programs. commonly in it ia t e d by p a tie n t Educational prescriptions and standing orders were commonly used In about h a lf o f the i n s t i ­ tu tio n s. P a tie n t learning was tu tio n s . Program evaluation evaluated 1n tw o -th ird s o f the I n s t i ­ occurred 1n almost th a t many In s t it u ­ tio n s . Adm inistrators expressed agreement th a t both health educa­ tio n and general education are le g itim a te functions o f nursing care 128 fa c ilitie s . Less than ten percent disagreed. E1ghty-f1ve percent expressed a w illingness to develop or expand a program 1n p atie n t education 1 f fre e consultant help were a v a ila b le . CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary o f Procedures I t has been the purpose o f th is study to describe 1n an ana­ ly tic a l fashion the status o f p a tie n t education 1n Michigan's nurs­ ing care f a c i l i t i e s . An attempt was made to id e n tify the prin cipal components o f p atien t education programs In these f a c i l i t i e s and re la te them to In s titu tio n a l type, s iz e , geographical location and age. The stage o f development o f these programs has been assessed and likew ise re la te d to In s titu tio n a l type, s iz e , geographical loca­ tio n , and age. A review o f the lit e r a t u r e revealed th a t p a tie n t education programs have been In existence fo r approximately tw e n ty -fiv e years, and that such programming 1s supported In o f f ic ia l statements by representatives o f many health agencies. They have recently become more prominent fo r a v a rie ty of reasons including the very great growth 1n the nursing care enterprise and a series o f studies th a t have shown p atie n t education to be cost e ffe c tiv e . Educational pro­ graming fo r the e ld e rly has likew ise become more common 1n the recent past, as research reveals th a t e ld e rly people can le a rn , want to le a rn , and are learning . The lite r a tu r e suggested th a t health education programming fo r the e ld e rly 1s o f more recent vintage, and that such programming 1n nursing homes 1s s t i l l 1n It s Infancy. 130 A questionnaire was designed and sent to a ju ry o f experts fo r Inpu t, a ft e r which i t was revised and f ie l d tested. In May o f 1976, 1t was sent to a ll 455 nursing care f a c i l i t i e s In Michigan. Two follow-up le tte r s were sent a t appropriate In te rv a ls . A usable response ra te o f s ix ty -fiv e percent was obtained which was called exceptionally good fo r studies o f th a t population, by members o f the ju ry o f experts. The responses were analyzed to determine the proportions o f the various types, regions, s izes, and ages o f In s tl' tutlons they represented. Administrators o f medical care f a c i l i t i e s were considerably above average In response, as were adm inistrators o f nursing homes operated on a n o t-fo r -p r o fit basis. Administrators o f hospital long-term care units were near the average. Administrators o f fo r-p ro f1 t nursing homes constituted the larg est group, both 1n number o f responses and the to ta l number o f In s titu tio n s , but they had a below average response ra te . The return was lowest 1n two Health Service Areas, HSA 1 1n southeastern Michigan and HSA 3 in southwestern Michigan, where approximately h a lf the adm inistrators returned the completed questionnaire. Approximately tw o-thirds o f the In s titu tio n s represented were between fifty -o n e and 199 beds 1n s iz e , nearly one-fourth o f the represented In s titu tio n s had less than f i f t y beds, and approxi­ mately nine percent of the respondents had more than 200 beds. The responding In s titu tio n s were f a i r l y evenly divided In to those of ten or less years o f age and those o f more than ten years o f age. 131 Nearly tw o-thirds o f the p a tie n t beds represented 1n the study were 1n fo r-p ro f1 t nursing homes, w hile n o t-fo r -p r o fit nursing homes, medical care f a c i l i t i e s , and hospital long-term care units were a d is ta n t second, th ir d , and fourth 1n th a t order. More than a th ird o f the In s titu tio n s and beds represented were 1n HSA 1. Approximately h a lf the beds were 1n In s titu tio n s less than ten years old. About two-th1rds o f the beds represented were 1n in s titu tio n s with f i f t y to 199 beds. The re su lta n t data from the 294 usable questionnaires were analyzed by the computer a t Central Michigan U n ive rs ity. from S ta tis tic a l Packages fo r the Soda! Sciences 76 A program and another from Biomedical Computer Programs7** were adapted by Or. Robert DeBruIn and Ms. Joyce Abler fo r use on Central Michigan U n ive rs ity's Unlvac 1106 Computer. S ta tis tic a l procedures used extensively were f r e ­ quency counts, percents, ranges, standard d eviation s, and measures of central tendency. was determined. The existence of p atien t education programs Summary data were provided, a f t e r which the pro­ grams were grouped by the Independent variables o f in s titu tio n a l type, s iz e , lo c a tio n , and age, and then displayed. A program devel­ opment score was computed and likew ise grouped and displayed. The principal components o f the p a tie n t education programs were then analyzed. Summary data were provided, a fte r which the data were grouped according to the Independent variables Id e n tifie d above. 75N1e, p. 429. 7601xon, p. 729. 132 In a l l cases, an attem pt was made to determine i f the existence o f any o f the dependent variab les were re la te d to the Independent v ariab le s. S p e cific facto rs analyzed were: existence o f p a tie n t edu­ cation coordinators and cen ters, the frequency o f various to p ic s , methods o f In s tru c tio n , personnel groups and t h e ir fun ction s, methods o f In it ia t in g p a tie n t Involvement and evaluation methods employed; and ad m in istrato rs' judgments as to the leg itim acy o f p a tie n t education as a function o f th e ir in s titu tio n s and th e ir In te re s t in developing or expanding th is fu n ctio n . Summary o f Findings I t was determined th a t two hundred o f the 294 In s titu tio n s (s1xty-n1ne percent) had an operational p a tie n t education program o f some type a v a ila b le . I t was most common fo r an In s titu tio n to have a general education program (s ix ty -o n e percent d id ), and less com­ mon fo r an In s titu tio n to have a health education program a v a ila b le ( t h ir t y percent d id ). F o r-p ro f1 t nursing homes and medical care f a c i l i t i e s were more lik e ly to have p a tie n t education programs o f e ith e r the general education or health education type (seventy-two percent d id ) than were n o t - f o r - p r o f it nursing homes ( f i f t y - e i g h t percent) o r hospital long-term care u nits ( f i f t y percent). Size was an Important v a ria b le . E1ghty-e1ght percent o f the large 1ns1tut1ons had such programs, compared to seventy-four per­ cent o f the medium-sized In s titu tio n s and f if t y - t w o percent o f the sm aller In s titu tio n s . 133 There was also much variance by lo c atio n . HSA 7 1n northern lower Michigan reported the highest Incidence o f In s titu tio n s having such programs (e ig h ty -e ig h t p ercen t), w hile HSA 3 1n southwestern Michigan, Including Kalamazoo, reported the lowest Incidence o f such programs (fo rty -e ig h t percent). HSA 1 In southeastern Michigan, Including D e tro it, and HSA 4 1n west central Michigan, Including Grand Rapids, are the two HSA's with the larg est number o f nursing care f a c i l i t i e s . They both reported operational programs In seventy-four percent o f the In s titu tio n s , well above the average fo r Michigan. There was less variance by age o f In s itu tio n . Seventy-two percent o f the In s titu tio n s th a t were ten years old or less had such programs. There were both a la rg e r number o f In s titu tio n s and a larg er percentage o f In s titu tio n s th a t had p a tie n t education programs 1n the newer group. There were 178 operational general p a tie n t education programs In the 294 responding In s titu tio n s (s1xty-one percent). F o r-p ro fit nursing homes more frequently provided general p a tie n t education than did the other types o f in s titu tio n s . them reported such programs. S 1 x ty -fiv e percent of Medical care f a c i l i t i e s were s lig h tly below average, a t s ix ty percent. N o t-fo r -p r o fit nursing homes were su b stan tially below average (fo rty -e ig h t p ercen t), as were hospital long-term care units (fo rty -fo u r percent). A la rg e r percentage o f the large In s titu tio n s (eighty-one percent) had programs a v a ila b le , than did medium-sized In s titu tio n s (sixty-seven percent) o r small In s titu tio n s (th ir ty -th r e e percent). Such programs o f general 134 education were most frequent 1n HSA 7 1n northern Michigan and HSA 4, the Grand Rapids area (both a t more than seventy-two per­ c en t), and le as t frequent 1n HSA 4 , the Kalamazoo area (fo rty-o n e percent), and HSA 8, the Upper Peninsula (fo r ty -s ix percent). Gen­ eral education programs were also s lig h tly more common 1n newer In s titu tio n s ( f if t y - n in e percent) than 1n older In s titu tio n s ( f i f t y percent). E ighty-eight ( t h ir t y percent) o f the In s titu tio n s reported operational programs o f p a tie n t health education. F o rty -s ix percent of the medical care f a c i l i t i e s had operational programs, w hile notf o r - p r o f it nursing homes and hospital long-term care units were considerably less lik e ly to have such programs a v a ila b le to patients (nineteen percent do). Health education programs were most frequent 1n medium-sized In s titu tio n s (th ir ty -th r e e percent) as compared to large In s titu tio n s (th irty -o n e percent) and small In s titu tio n s (twenty percent). They were again most frequent in HSA 7 (fo r ty percent) and le a s t frequent 1n HSA 3 (tw en ty-six percent). They were equally prevalent In newer and older In s titu tio n s . An education program development score was computed, which consisted o f a combination o f the number o f general education o ffe rin g s , the number o f health education o ffe rin g s , the number of groups o f s t a f f Involved 1n the general education programs, and the number o f s t a f f Involved in the health education programs. This score was found not to be re la te d s ig n ific a n tly to any o f the Inde­ pendent v a ria b le s , type, s iz e , age or location o f f a c i l i t i e s . was also true when a development score was computed fo r p a tie n t This 135 health education separate from p a tie n t general education. There were no s ig n ific a n t differences when grouped by In s titu tio n a l type, s ize , lo c a tio n , or age. However, when a development score was com­ puted fo r p a tie n t general education alone, type and size o f In s t i­ tu tio n were moderately re la te d variab le s. The two types o f nursing homes were somewhat higher than other In s titu tio n a l types though the differences were not larg e. A somewhat higher development score was computed fo r large In s titu tio n s than fo r medium-sized or small in s titu tio n s , though again the differences were not la rg e. Nothing conclusive was established about the re la tio n s h ip o f p a tie n t educa­ tion development stage to type, s iz e , location or age o f In s titu tio n s . I t was determined that most o f the 294 responding In s t it u ­ tions (seventy-three percent) had designated s p e c ific departments or coordinators to be responsible fo r general education. Medical care f a c ilit ie s more frequently reported such designations (e1ghty-s1x percent) than did f o r - p r o f it nursing homes (se ve n ty -fiv e p ercen t), n o t-fo r -p r o fit nursing homes (s1xty-two percent) or hospital long­ term care units ( f i f t y percent). There were 106 o f the 294 respond­ ents (th 1 rty -s1 x percent) who had coordinators o f p a tie n t health education. Medical care f a c i l i t i e s again more freq u ently reported such coordinators ( f i f t y percent) than did fo r-p ro f1 t nursing homes (th irty -s e v e n p ercen t), n o t-fo r -p r o fit nursing homes (twenty-nine percent), and hospital long-term care units (nineteen percent). t h ir t y of the 294 In s titu tio n s , the same person coordinated both programs. In 136 There was no s ig n ific a n t d iffe re n c e 1n the frequency o f designated coordinators when the data were grouped by In s titu tio n a l location or age. re la te d . However, s ize o f In s titu tio n did seem to be Medium-sized (eig h ty percent) and larg e In s titu tio n s (ninety-tw o percent) were above the In s titu tio n a l average o f seventy three percent, w hile small In s titu tio n s reported general education coordinators e x is t In fo r ty -fo u r percent o f the In s titu tio n s . This was s im ila rly tru e when the existence o f health education coordina­ tors was examined. Med1um-s1zed and large In s titu tio n s , a t t h i r t y - nine percent, were above the in s titu tio n a l average o f t h ir t y - s ix percent, w hile the s1x ty -n 1ne small In s titu tio n s reported such coordinators 1n only tw e n ty -fiv e percent o f the cases. Most o f the 294 In s titu tio n s (s1xty-tw o percent) had estab­ lished p a tie n t education centers, w hile another nine percent were planning them. No s ig n ific a n t variance was revealed when th is Item was examined by In s titu tio n a l type, age, or region. size was a highly re la te d fa c to r. Again, however, While th ir ty - th r e e percent o f the small In s titu tio n s had p a tie n t education cen ters, seventy per­ cent o f the medium-sized In s titu tio n s and seventy-seven percent o f the la rg e r In s titu tio n s had such centers. Topics most freq u en tly o ffe red 1n the 178 general education programs were a rts and c ra fts (n in e ty -e ig h t p e rc e n t), lit e r a t u r e (eighty-tw o p e rc e n t), r e a l it y o rie n ta tio n (e 1ghty-one p e rc e n t), current events (seventy-nine p e rc e n t), music (s e v e n ty -fiv e p e rc e n t), c rea tive w ritin g (nineteen p e rc e n t), th e a te r (seventeen p e rc e n t). 137 re lig io u s In s tru c tio n (tw elve p e rc e n t), physical fitn e s s (ten per­ c e n t), and high school completion courses ( f iv e p ercen t). The two types o f nursing homes reported an Id e n tic a l mean number o f nine o ffe rin g s per in s tit u tio n . The medical care f a c i l i ­ tie s and ho sp ital long-term care u n its both o ffe red a mean o f eig ht o ffe rin g s . Large In s titu tio n s had a mean o f eleven o ffe rin g s , com­ pared to nine 1n the small and medium-sized in s titu tio n s . There 1s in a ll groups a wide range 1n the number o f o ffe rin g s , w ith some programs providing as few as two o ffe rin g s , and others as many as tw en ty-eig ht. Group In s tru c tio n was the most freq u e n tly used mode o f in s tru c tio n 1n general education programs. It s mean score o f 4.03 Indicated I t was used 1n an average o f four o f the e ig h t to eleven o fferin g s 1n the 178 general education programs. In d iv id u al In s tru c ­ tio n was used less often (mean = 2 .5 0 ), as was p rin ted m aterial (mean - 1 .6 1 ), o r s e lf-in s tr u c tio n a l m aterial (mean - 1 .0 3 ). Classes and In d iv id u al In s tru c tio n were c le a rly the most popular method o f teaching In general education programs. Topics most freq u e n tly o ffe red in the e ig h t-e ig h t programs o f p a tie n t health education Included o rie n ta tio n to the f a c i l i t y (n in e ty -fo u r p erce n t), n u tritio n (e ig h t-e ig h t p e rc e n t), diabetes (e ig h ty -fo u r p e rc e n t), hearing o r visual disorders (s 1x ty -n 1ne per­ c e n t), death and dying (s ix ty p erce n t), orthopedic disorders (s ix ty p ercen t), heart disease (fifty -s e v e n p e rc e n t), re s p ira to ry disease ( f if t y - t w o p erce n t), and cancer (fo r ty -e ig h t p ercen t). 138 Hospital long-term care units reported the highest mean number o f o fferin g s (e le v e n ), with f o r - p r o f it nursing homes reporting ten , and n o t-fo r -p r o fit nursing homes and medical care f a c ilit ie s reporting nine such o ffe rin g s . No s ig n ific a n t variance was revealed where these data were grouped by in s ltu tio n a l s iz e , age, or lo c atio n . Again, a wide range 1n the number o f o fferin g s existed In a l l groups, with some reporting as few as two and others as many as th 1r t y - s 1x. Individual In stru ctio n (mean = 4 .8 ) was reported to be more than twice as common as group in stru ction (mean * 2.23) or printed m aterial (mean = 1.72) as the dominant mode of In s tru c tio n 1n the nine to eleven o fferin g s o f p atien t health education top ics. S e lf- In stru ction al media was reported much less often (mean ■ .5 4 ). E1ghty-n1ne o f the 294 ( t h ir t y percent) responding In s t it u ­ tions reported the a v a ila b ilit y o f educational a c t iv itie s fo r p atie n ts ' fam ilies or fam ily members. I t was a v a ila b le In f i f t y - s i x percent o f the hospital long-term care u n its , th irty -o n e percent o f both the f o r - p r o f it nursing homes and medical care f a c i l i t i e s , and seventeen percent o f the n o t-fo r -p r o fit nursing homes. No s ig n if i­ cant Information was revealed when these data were grouped by In s t i­ tu tio n al age or lo catio n . S ize, however, was a s ig n ific a n t v a ria b le . Small In s titu tio n s provided fam ily education in only twenty-one per­ cent o f the cases, compared to th irty -o n e percent o f the medium­ sized In s titu tio n s , and f i f t y percent of the la rg e r in s titu tio n s . T h irty o f the 164 in s titu tio n s (eighteen percent) reporting no fam ily education program Indicated such programs were 1n the planning 139 stages. Most respondents did not provide examples o f what was o ffe red , but the most common example th a t was c ite d was discharge planning. Groups most frequently Involved 1n general education pro­ grams were f a c i l i t y s t a f f (n1n ety-s 1x percent), patients (seventy percent), local school personnel ( f if t y - f o u r p ercen t), lib r a r y or museum personnel (fo rty-tw o percent), college personnel (tw entyeight percen t), Individual volunteers ( fifte e n p ercen t), re lig io u s group representatives ( fiv e percent), and educational te le v is io n station personnel (three percent). More groups were Involved 1n group teaching (mean * 2.22) and planning (mean ■ 2.17) than 1n Individual In s tru c tio n (mean * 1 .8 3 ). These differences were not larg e; the computed means a ll round o f f to two. A mean number o f seven o f these groups were Involved 1n the two types o f nursing homes, while a mean o f fiv e such groups were Involved 1n hospital long-term care units and medical care f a c i l i ­ tie s . There were no s ig n ific a n t differences revealed when these means were grouped by in s titu tio n a l s iz e , age, or lo c atio n . As many as seventeen groups were Involved 1n some programs. Groups o f s t a f f most frequently Involved 1n the health edu­ cation programs were nursing s t a f f (ninety-nine p ercen t), d ie titia n s (e 1ghty-n1ne p ercen t), adm inistrators (e ig h ty -fo u r p ercen t), thera­ pists (e 1ghty-two p ercen t), physicians (seventy-six percent), social workers (seventy-six percent), clergy (seventy p ercen t), 140 education s t a f f (fo r ty -e ig h t p e rc e n t), and health agency s t a f f ( fo r t y - s ix p ercen t). More groups were Involved 1n In d iv id u al In s tru c tio n (mean * 4 .84 ) and 1n planning (mean a 4 .7 7 ) than 1n group teaching (mean ■ 3 .1 7 ). Again, these differences were not la rg e . The e ig h ty -e ig h t health education programs were fu rth e r examined to determine how p a tie n t education was In it ia t e d . The p a tie n t conference was the most commonly employed method, reported 1n n in e ty -th re e percent o f the programs. P a tie n t requests some­ times In it ia t e d programs 1n sixty-seven percent o f the In s titu tio n s . Doctor-Issued p rescriptions were among the I n it ia t i n g options 1n f if t y - t h r e e percent o f the In s titu tio n s , w hile standing orders were used 1n fo rty -th re e percent o f the In s titu tio n s . Combinations o f methods o f In it ia t io n were reported 1n most In s titu tio n s . Twenty o f the e ig h ty -e ig h t In s titu tio n s reported using a l l four methods, tw e n ty -fiv e reported using th re e , tw enty-eight reported two, and only f if t e e n reported use o f only a sin g le method. Evaluation o f p a tie n t learning was reported 1n s ix t y -f iv e percent o f the health education programs, with an a d d itio n a l eleven percent planning to do e valu atio n . Program evaluation occurred 1n f if t y - n in e percent o f the In s titu tio n s , with another fourteen per­ cent planning to do so. No s ig n ific a n t v a ria tio n s were revealed when the data were grouped by In s titu tio n a l typ e, s iz e , age, or lo c a tio n . P a tie n t health education was considered a le g itim a te func­ tio n o f nursing care f a c i l i t i e s by seventy-six percent o f the 141 adm inistrators, who e ith e r agreed (fo rty -e ig h t p ercen t), or strongly agreed (tw enty-eight percent), as to It s legitim acy. Out o f the 294 adm inistrators, eleven disagreed, and one strongly disagreed. Thirteen percent were n e u tra l, while sixteen percent did not respond to the question. S ix ty -th re e percent o f the adm inistrators without a p a tie n t eduatlon program e ith e r agreed or strongly agreed that such programs are le g itim ate functions o f nursing care f a c i l i t i e s . P atien t general education was also considered a le g itim a te function o f nursing care f a c i l i t i e s by the adm inistrators; only nine percent were opposed to the concept, while s1x ty -s 1x percent endorsed 1 t. Again, 1t 1s s ig n ific a n t to note th a t forty-one per­ cent o f the adm inistrators without a p atie n t education program o f any kind e ith e r agreed or strongly agreed th a t such programming is appro­ p ria te . Only th irte e n percent disagreed, w hile t h ir t y percent were neutral and sixteen percent did not respond to the question. When asked 1 f they would be interested 1n developing or expanding a p a tie n t education program 1f free consultant help were a v a ila b le , the overwhelming m ajo rity (e ig h ty -fiv e percent) o f responding adm inistrators Indicated th a t they would. Only eig ht percent Indicated they would n ot, although another seven percent did not respond to the question. Nothing s ig n ific a n t was revealed when these data were examined by In s titu tio n a l type, s iz e , age, or lo catio n . However, th is was not true when the data were grouped according to program existence. The m ajo rity o f the adm inistrators, Including seventy-one percent o f those who have no program now, would u t i l i z e consultant assistance to establish o r expand p atie n t 142 education programs. Only e ig h t percent o f a l l adm inistrators and sixteen percent o f those w ith no programs In d icated they would not do so. Conclusions There were more p a tie n t education programs in existence than a n tic ip a te d . There were operational programs 1n approximately two- th ird s o f the In s titu tio n s . General education programs were twice as common as health education programs. While health education was r e la tiv e ly new and undeveloped 1n th is population, the concept o f p a tie n t education was not. Adm inistrators were supportive o f the concept o f p a tie n t health education, presumably due 1n p a rt to pre­ vious experience w ith p a tie n t general education. The e ffo r ts a t assessing the development stage o f p a tie n t education programs 1n th is study were In e ffe c tiv e . The attempt to determine which programs were operational and which programs were 1n the beginning stages did not produce useful In form atio n , since very few In s titu tio n s were in the beginning stages. The more sophisticated e f f o r t to compute a p a tie n t education development score was likew ise not productive as no s ig n ific a n t d ifferen ces were revealed. I t 1s s t i l l assumed th a t there are measurable d ifferen ces In the development stage o f p a tie n t education programs, but th a t appropriate Indices o f these differences were not measured 1n th is In v e s tig a tio n . In s titu tio n a l s ize was more freq u e n tly re la te d than were In s titu tio n a l type, lo c a tio n , or age to the extent and nature o f 143 p a tie n t education. Large In s titu tio n s were more lik e ly to have operational programs o f p a tie n t education, more lik e ly to have p atie n t education cen ters, more lik e ly to have coordinators o f p atie n t education, more lik e ly to have wider ranges o f educational o fferin g s a v a ila b le . While the d ifferen ces between medium-sized and large In s titu tio n s were not always g re a t, the d ifferen ces between small In s titu tio n s and large In s titu tio n s were ty p ic a lly la rg e. The commonly held b e lie f th a t small In s titu tio n s have re s tric te d p a tie n t education programs was v alid a ted by th is survey. In s titu tio n a l type was the next most s ig n ific a n t v a ria b le . F o r-p ro f1t nursing homes and medical care f a c i l i t i e s more freq u ently provided p a tie n t education o f some type than did n o t - f o r - p r o f it nursing homes and hospital long-term care u n its . F o r-p ro f1 t nursing homes were most lik e ly to provide general education, second most lik e ly to provide p a tie n t health education, second most lik e ly to have designated p a tie n t education coordinators, had the highest mean number o f o ffe rin g s 1n both general education and health educa­ tio n , and were second most lik e ly o f the four In s titu tio n a l types to provide fam ily education. These In s titu tio n s comprise the la rg e s t group o f nursing care f a c i l i t i e s and the leading type o f in s titu tio n 1n the various categories o f p a tie n t education measured 1n th is survey. Medical care f a c i l i t i e s were tie d w ith f o r - p r o f it nursing homes In being most lik e ly to provide p a tie n t education, were sec­ ond 1n providing general education, and were considerably above average 1n providing general education, and were considerably above 144 average In providing health education. have p a tie n t education coordinators. compared, even They were most lik e ly to When mean o ffe rin g s were though they ranked th ird w ith a mean score o f eig ht general education o ffe rin g s , they ranked only s lig h tly below the two types o f nursing homes w ith th e ir mean o ffe rin g o f nine each. They were ranked fourth 1n health education o ffe rin g s , with a mean o f nine but the d iffe re n c e between f i r s t and fourth was again not larg e. N o t-fo r -p r o fit nursing homes g en erally ranked th ir d among the fo u r types o f In s titu tio n s 1n the extent and nature o f p a tie n t education programs provided. They were below average 1n a v a ila ­ b i l i t y o f programs, designation o f coordinators, mean number o f health education o ffe rin g s , and a v a ila b ilit y o f fam ily education. They had a higher than average mean number o f general education o ffe rin g s . Hospital long-term care units reported the highest mean number o f health education o ffe rin g s . In most o f the categories o f th is In v e s tig a tio n , however, they ranked la s t among the fo u r I n s t i ­ tu tio n a l types. There are only sixteen such In s titu tio n s . Their p a tie n t education programs understandably emphasize health education. In s titu tio n a l age was also a s ig n ific a n t v a ria b le 1n some aspects o f th is study. There were both a la rg e r number o f In s t it u ­ tions and a la rg e r percent o f In s titu tio n s th a t had p a tie n t educa­ tio n programs among those established In the la s t ten years than among older In s titu tio n s . While age appeared to be a fa c to r 1n 145 determining the existence o f a program, I t appeared not to be a fa c ­ to r In determining the c h a ra c te ris tic s o f programs. In s titu tio n a l lo catio n was not g en erally a s ig n ific a n t v a r i­ a b le, though wide v a ria tio n s existed from HSA to HSA. HSA 7 In northern lower Michigan was co n sisten tly most lik e ly to o ff e r p a tie n t education, w hile HSA 3 1n southwestern Michigan, Including Kalamazoo, was co n sisten tly le a s t l ik e ly . HSA 1 in southeastern Michigan, Including D e tr o it, and HSA 4 in west central Michigan, Including Grand Rapids, have the la rg es t number o f In s titu tio n s , and both are above average 1n the provision o f p a tie n t education. The mean numbers o f educational o ffe rin g s 1n the two types o f p a tie n t education programs were s im ila r. Mean numbers o f health education o ffe rin g s were also remarkably close. In general education programs, group In s tru c tio n was the most frequent method o f In s tru c tio n , followed 1n order by in d ivid u al In s tru c tio n , printed m a te ria l, and s e lf-in s tr u c tio n a l media. Classes and other group a c t iv it ie s were c le a rly the most common means o f In s tru c tio n 1n general education programs. This sequence was not tru e o f the health education programs. Individual In s tru c tio n was the most commonly used method, followed by group In s tru c tio n and printed m a te ria l. S e lf-In s tru c tio n a l media were seldom used 1n health education programs. One-to-one In s tru c tio n was c le a rly the most common method used 1n health edu­ cation programs. Family education was not commonly a va la b le. I t was more freq u en tly a v a ila b le In large In s titu tio n s than 1n medium-si zed or 146 small ones. A s ig n ific a n t number o f in s titu tio n s without such pro­ grams were planning to I n i t i a t e them. Health education programs tended to Involve a la rg e r number of groups In th e ir planning and operations than did general educa­ tion programs. However, the differences were not larg e. Health education programs most freq u ently used p atien t care conferences to In it ia t e p atie n t Involvement 1n p a tie n t education programs. Patient requests, doctor-issued p rescrip tio n s, and stand­ ing orders were a ll commonly used as w e ll. In s titu tio n s most often used a combination o f the above mentioned methods to get a p atien t Into a program. Evaluation o f p a tie n t learning was usually done, as was program evaluation. Administrators appeared to be 1n tune with the trend toward more evaluation 1n health education. Perhaps the most s trik in g o f a ll conclusions was th a t admin­ is tra to rs were ready to develop or expand such programs I f consult­ ant help were a v a ila b le . A large m ajo rity o f the 294 responding adm inistrators indicated th a t they would be interested 1n developing or expanding a p atien t education program 1f fre e consultant help were a v a ila b le . P atien t general or health education programs existed In about two-th1rds o f the In s titu tio n s . Y et, 1n a d d itio n , there was registered a strong amount o f support fo r the Idea o f expanding such programming, esp ecially to Include health education. P atien t edu­ cation 1n Michigan nursing care f a c i l i t i e s appears to be an Idea whose time has come. 147 Discussion o f Findings and Conclusions P a tie n t education 1n a nursing care f a c i l i t y must o f neces­ s ity be defined so as to Include both general education and health education. I t 1s a r b itr a r y and counter-productive to lim it the term to health education. While th a t may be tr a d itio n a l and appropriate fo r acute care In s titu tio n s , I t Is c le a rly unacceptable 1n the nursing care s e ttin g . The longer term o f residency combined w ith the fa c t th a t many residents have learned to liv e w ith t h e ir condi­ tion make both kinds o f education b e n e fic ia l. may be varied in nature. a t the p a tie n t. Educational a c t iv it ie s They may also be d irected a t the s t a f f or However, those a c t iv it ie s prepared fo r d ire c t p a tie n t Involvement must be labeled as p a tie n t education, regardless o f the content. F u rth er, the p a tie n t involvement and re s u lta n t e ff e c t on mind and morale may be a t le a s t as therapeutic as the Inform ation transm itted. The p a tie n t must continue to fin d something to look forward to 1n l i f e which can, when achieved, produce s e lf - f u lf illm e n t and recognition by others. E ith e r general education or health educa­ tio n meets these conditions. Having so defined p a tie n t education, th is In v e s tig a tio n revealed more organized programs than a n tic ip a te d . S lig h tly more than tw o-th1rds o f the In s titu tio n s have programs o f one type or the o th er. This fa c t produced fee lin g s o f pleasant surprise 1n the In v e s tig a to r u n til the other side o f the s itu a tio n came In to focus. Nearly a th ird o f the In s titu tio n s do not have programs o f any type. 148 More than a th ird do not have general education programs and more than th ree -fo u rth s do not have health education programs. P a r tic u la r ly d is tre s sin g 1s the fa c t th a t p rin ted m aterial 1s not comnonly used 1n e ith e r type o f program. abound. Such m aterials Many pamphlets are prepared and d is trib u te d fre e o f charge, e s p e c ia lly by voluntary health agencies. F u rth e r, they can be lo c a lly developed to meet s p e c ific needs, and Inexpensively prepared. A great re s e rv o ir o f p o te n tia l education remains untapped. Likew ise, 1 t 1s d is tre s sin g to th is In v e s tig a to r to discover th a t l i t t l e use 1s made o f p ro fe s s io n a lly tra in e d educators. Those c u rre n tly employed as educational s p e c ia lis ts 1n community agencies are seldom c a lle d upon fo r Input 1n program planning. Much exper­ tis e 1s going untapped. I t 1s also d istu rb in g to note th a t l i t t l e te le v is io n is occurring. use o f educational The p o s s ib ilitie s o f closed c ir c u it t e le ­ vision have been explored 1n public school and u n iv e rs ity s e ttin g s . I t 1s being adapted to p a tie n t health education In acute care hos­ p ita ls w ith much lo c a lly prepared and commercially prepared m aterial being a v a ila b le . I t y e t remains fo r some c re a tiv e people to adapt the media to p a tie n t education 1n nursing care f a c i l i t y s e ttin g s . Recommendations A dm inistrators appear ready to develop o r expand p a tie n t education program ing. They appear receptive to consultant help. Yet where should they turn? Where Is there expert s t a f f w ith ade­ quate time and budget to provide the needed help? Where can 149 adm inistrators fin d train e d s t a f f a v a ila b le to develop o r expand programs? s ta ff? Where can 1nserv1ce tra in in g be obtained fo r the e x is tin g How w ill the s t a f f tra in in g and development o f programs be financed? C e rta in ly , the fo llo w in g questions ought to be addressed: (1 ) What should be the ro le o f the Michigan Department o f Public Health? (2 ) What should be the ro le o f the Michigan Department o f Social Services? ment o f Education? (3 ) What should be the ro le o f the Michigan Depart­ (4 ) What should be the ro le o f the re le va n t pro­ fessional associations? (5 ) What should be the ro le o f the HSA’ s? Whether or not these questions are answered q u ickly and adequately w ill help determine the fu tu re o f p a tie n t education 1n Michigan nursing care f a c i l i t i e s . Recommendations fo r Further Research This study, or an Improved but s im ila r version o f I t , should be repeated 1n three to fiv e years. The d ire c tio n o f change and the ra te o f change w il l then come more c le a r ly In to focus. As mentioned e a r lie r w ith in th is re p o rt, the concept o f pro­ gram development stage needs re fin in g . Other c h a ra c te ris tic s o f program m atu rity need to be Id e n tifie d and te s te d . The dimension o f p a tie n t education program q u a lity remains untested. An In v e s tig a tio n o f variab les th a t a ff e c t program q u a lity 1s 1n o rder. Among those th a t should be examined are (1 ) the a t t i ­ tudes o f the adm in istrato r and the s t a f f toward p a tie n t education, ( 2 ) the a ttitu d e s o f the board o f d ire cto rs o f the f a c i l i t y , 150 (3 ) the community mores regarding education, (4 ) budget, (5 ) ade­ quacy o f f a c i l i t i e s , ( 6 ) p a tie n t enrollm ent tren d s, (7 ) In s t it u ­ tio n a l membership 1n professional associations, ( 8 ) general In s titu tio n a l coumltment to excellence, (9 ) selectio n and tra in in g o f s t a f f , and ( 10) time and tim ing o f In s tru c tio n . Strong evaluation models o f p a tie n t education need to be developed and applied to nursing care f a c i l i t i e s . While th is study counted how many adm inistrators attempted to do program evalu­ a tio n , no attempt was made to determine the adequacy o f such evalu­ a tio n . What con stitu tes adequate program evalu atio n y e t remains a nebulous question. What such an evaluation would show when done on the programs Id e n tifie d 1n th is study 1s unpredictable, y e t an Important next step. Special emphasis needs to be given to compar­ ing the effectiven ess o f Inexpensive programs to expensive programs. Even fu r th e r , the required In te n s ity o f a program necessary to pro­ duce a desired e ffe c t demands to be In v es tig a ted . But perhaps the most basic research should be done f i r s t , with an In v e s tig a tio n o f the re al needs o f the residents o f Michigan nursing care f a c i l i t i e s , and a determ ination 1f p a tie n t education programs a c tu a lly r e la te to the developmental needs o f people approaching s e n ilit y or death. A Concluding Statement This In v e s tig a tio n was not Intended to be a d e f in it iv e study o f the population, but ra th e r an exp lo ra to ry , d es c rip tive In v e s tig a ­ tio n . While much has been learned, as usual, more questions have 151 been raised. Both more programming and more research y e t need to occur. I t 1s the hope o f th is researcher th a t th is In vestigatio n has or w ill raise the consciousness o f some people 1n positions o f Influence so th a t u ltim a te ly e ld e rly patients w ill fin d more meaning in the fin a l months o f th e ir liv e s . tion 1s term inated. With th is hope, th is Investiga­ APPENDIX 153 May 26, 1976 CENTRAL MICHIGAN UNIVERSITY Dear Adm inistrator: Organized programs o f p atien t and fam ily education are beginning to develop in nursing care f a c i l i t i e s a l l over the coun­ try . This has occurred In response to the P a tie n t's B ill of Rights, the Issue o f Informed consent, and the p o ten tial fo r reimbursement of costs from federal funds. Have you thought about doing more 1n patient education 1n your In s titu tio n ? Have you wondered what your fellow adm inistrators are doing about this? To obtain the answers to these questions, and to determine the extent o f p atie n t education, we have begun a study o f such pro­ grams 1n the nursing care f a c i l i t i e s o f Michigan. Enclosed 1s a questionnaire th a t has been c ritiq u e d by representatives o f the Michigan Non P r o fit Home Association, the Michigan Health Care Association, and six other agencies. The questionnaire has also been f ie ld tested In Michigan nursing care f a c i l i t i e s . We now need your assistance. Please take fiv e to ten minutes now to f i l l In the enclosed questionnaire. Your Individual responses w ill be kept c o n fid e n tia l. The survey results w ill be sent to each adm inistrator who completes the questionnaire. A ll responses should be returned by June 4, 1976. A stamped, self-addressed envelope 1s enclosed fo r your convenience. Thank you In advance fo r your Important contribution to th is p ro je ct. S incerely, Donald J. Breckon Associate Professor Health Education Dept. MOUNT PLEASANT. MICHIGAN 48059 June 8 . 1976 CENTRAL MICHIGAN UNIVERSITY Dear Adm inistrator: On May 26, a questionnaire was sent to you asking about edu­ cational programs you have a v a ila b le fo r p a tie n ts . Approximately 150 of your fe llo w adm inistrators responded. Your response 1s y e t needed to present a complete p ictu re o f the presence or absence of p atient education 1n Michigan. You can be assured th a t your In d ividual response w ill be treated with c o n fid e n tia lity . A ll reporting w ill be done by cate­ gories only. 1 re a liz e how busy you a re , and that you haven't got to the questionnaire y e t. Please be assured th a t your response Is valuable to th is study, regardless o f whether or not you o ffe r any p atien t education. Please take the ten minutes now to f i l l 1n the question­ n aire. Ten minutes o f your time today w ill re s u lt 1n you receiving the most current report a v a ila b le on p a tie n t education programs 1n Michigan nursing care f a c i l i t i e s . Please respond by June 16. I f you need another question­ n a ire , please c a ll c o lle c t 517-773-7151. Sincerely, Donald J. Breckon Associate Professor Health Education Department MOUNT PLEASANT, MICHIGAN 48859 June 2 8 , 1976 CENTRAL MICHIGAN UNIVERSITY Dear A dm inistrator: You may re c a ll th a t on May 26 I sent you a questionnaire asking about any educational a c t iv it ie s you have a v a ila b le fo r p a tie n ts , e ith e r on an In d iv id u a liz e d or group basis. To d ate, I have received 218 completed questionnaires, f o r a 48% response. A response ra te o f 60% 1s d esirab le to e s ta b lis h the v a lid it y o f th is study. W111 you reconsider and take ten minutes to f i l l out the questionnaire. I have discussed th is p ro je c t w ith Gary Hooyenga, President o f the Michigan Health Care A ssociation, and w ith t h e ir executive s t a f f . They have endorsed the study, and urge your cooperation. Remember, 1t 1s ju s t as Important to th is study to get a questionnaire w ith a l l "No" answers as one w ith a l l "Yes" answers. Please d o n 't h e s tla te to f i l l 1 t out merely because your educational program Is lim ite d or nonexistent. You can be assured th a t your in d iv id u a l response w il l be treated w ith c o n fid e n tia lity . A ll reporting w il l be done by cate­ gories only. I w il l send the survey re s u lts to a l l who complete the ques­ tio n n a ire . You, to o , w il l know what your fe llo w adm inistrators are doing 1n th is area. I need ten minutes o f your time today to successfully com­ p le te th is study. Please a ss is t me 1n th is important m atter. Please respond by July 2 , 1976. S in c e re ly , Donald J . Breckon Associate Professor Health Education Dept. MOUNT PLEASANT, MICHIGAN 48859 156 A SURVEY OF PATIENT EDUCATION PROGRAMS FOR THE AGED IN MICHIGAN NURSING CARE FACILITIES Part One: Id e n tify in g Data Name o f Fac1l1ty_ Telephone_ Street and number_ Z1p_ C ity and state ___ County Type o f F a c ility (check one): Profit-m aking nursing home _Non-prof1t nursing home Medical care f a c i l i t y _Hosp1tal long-term care u n it Number o f beds Year f a c i l i t y opened. Name o f respondent. Part Two: T it le General Educational Program fo r Patients Note: For th is section, please consider any general educational pro­ grams offered to patients 1n your in s titu tio n a l dlversional therapy program, such as music, c r a fts , or any educational a c t iv it y that does not d ire c tly cover a health to p ic . 1. Does your f a c i l i t y have a sp ecific department or coordinator th a t 1s responsible fo r general education programs offered? I f yes, Id e n tify the department___ Yes No In "planning stages 2. Does your f a c i l i t y have a space designated as an educational cen­ te r fo r patients? Yes No In "planning stages 3. Please In d icate which o f the follow ing topics are provided fo r patients and check the columns that describe them. Please 11st others. Group In - Individual stru ctlo n In stru ction L ite ra tu re Arts and c ra fts Music Creative w ritin g Theater R ea lity o rie n ta tio n Current events S e lf-In s tru c tlo n a l Media Printed M aterial 157 4. Please In d icate which o f the follow ing people are Involved 1n your general education program fo r p atie n ts . Check as many columns as appropriate. Please 11st o thers. Planning Group Teaching Individual In s tru c tio n F a c ility s t a f f _______________________ ___ ___ Patients ___ ___ ___ Local school personnel ___ ___ ___ College personnel ___ ___ ___ Educational TV personnel ___ ___ ___ H b ru ary or museum personnel ___ ___ ___ Part Three: Health Education Programs fo r Patients Note: For th is section, the focus o f your answers should be on p atjen t health education programs, rath er than general educational a c t iv itie s ! For example, think o f educational a c t iv itie s provided fo r patients and fam ilie s th a t deal with s p e c ific health problems such as diabetes, colostomy care, e tc . 5. 6. Does your f a c i l i t y have a s p e c ific department or coordinator th a t 1s responsible fo r p atien t health education programs offered? I f yes, 1s th is the same department or coordinator th a t 1s responsible fo r p atie n t general education? Do you provide any educational pro grams fo r fam ilies o f patients? I f so, in what areas? Yes No _Yes No Yes No In planning stages In planning stages 158 7. Please In d ic a te which o f the follo w in g topics are covered 1n your p a tie n t education programs. Check as many columns as ap p ro priate. Please l i s t o th e rs . Group In - In d iv id u al s tru c tio n In s tru c tio n S e lf-In s tr u c tlo n a l Media P rinted M aterial Cancer__________________ ___ ___ ___ ___ Death and dying_________ ___ ___ ___ ___ Diabetes________________ ___ ___ ___ ___ Hearing or visual disorders---------------------- ----- ----- ----- ----- Heart disease, hypertension ----- ----- ----- ----- N u tritio n _______________ ___ ___ ___ ___ O rientation to fa c ility ----- ----- ----- ----- Orthopedic disorders ___ ___ ___ ___ Respiratory disorders ___ ___ ___ ___ 8 . Which o f the follow ing persons help plan or teach p atie n ts and fa m ilie s 1n your health education program? fCheck as many columns as ap p ro p riate. ) Please 11st o th e rs . Planning Group Teaching In d ivid u al In s tru c tio n Physicians ___ ___ ___ Nursing s t a f f ___ ___ ___ D ie titia n s ___ ___ ___ Social workers_______________________ ___ ___ ___ Adm inistrators ___ ___ ___ Occupational, ph ysical, re s p ira ­ to ry , or speech th erap ists_________ ___ ___ ___ Clergy ___ ___ Education s t a f f S ta ff from health department o r voluntary health agency ___ 159 9. How 1s the health education program In it ia t e d fo r Individual patients? ( Check as many as appropriate. ) Please l i s t others. Standing orders Educational prescription byphysician P atient request Discussed during p atien t care conference 10. Does your f a c i l i t y evaluate the learning of Individual patients? Yes No In plann1ng stages 11. Does your f a c i l i t y evaluate It s to ta l educational program? Yes No In plann1ng stages Part Four: Adm inistrator Opinions on Education of Patients Note: Please In d icate your views on p atien t education programs by checking the response th a t most c le a rly represents your opinion. 12. Health education o f patients and/or th e ir fam ilies Is a le g itim a te func­ tion o f nursing care f a c i l i t i e s . _Strongly agree Agree Neutral Disagree Strongly disagree 13. General educational programming Is a le g itim ate function o f nursing care fa c 1l 1tie s . Strongly agree Agree Neutral Disagree Strongly disagree 14. I f consultant help were a v lla b le a t no charge* would you be Interested 1n developing a p a tie n t education program 1n your f a c ilit y ? Yes No Thank you fo r your assistance. Please return the questionnaire promptly 1n the enclosed envelope. Feel fre e to add any additional Information you think appropriate on the bottom or back o f th is sheet. Donald J. Breckon Health Education Dept. Central Mich. U niversity Mt. Pleasant* MI 48858 BIBLIOGRAPHY BIBLIOGRAPHY "AHA Appoints Special Committee." Journal o f the American Hospital Association (March 1973): 59. "AHA Research Capsule #7." Hospitals 46 (1972): 102. Beauchamp, George E. "P atient Education and the Hospital Program." V.A. Technical B u lle tin . Washington: V.A. A dm inistration, ----------------------------------------- Brown, Esther. Newer Dimensions o f P atien t Care. s e ll Sage Foundation, 1965. New York: Brownell, Luclel E. "Progress 1n P atien t Education." Education a t Work (May 1957). Rus­ Health Burton, John. "Doctor Means Teacher." In tern a tio n a l Journal o f Health Education (January 1958): 4-12. DeCrow, Roger. New Learning fo r Older Americans: An Overview o f the National E ffortT Washington: Adult Education Associ­ ation o f the U .S .A ., 1974. D irectory o f H ospitals, Nursing Care F a c ilit ie s , Homes fo r the Aged. Lansing: Michigan Department o f Public H ealth, Bureau o f Health F a c ilit ie s , 1976. Dowling, H. F. e t a l . "Time Spent by In te rn is ts on Adult Health Education and Preventive Medicine." A Journal of the American Medical Association (June 1952): 628 Elwood, T. W. "Relationship o f Health Education to Gerontology." In tern atio n al Journal o f Health Education (Julv-S ept. 1972): Gardiner, B. J . , and Webber, I . L. "Health Education Programming fo r the Aged." Health Education Monograph (1964): 3. Gebhard, Bruno. "H is to rica l Relationships Between S c ie n tific and Lay Members fo r Present Day P atien t Education." B u lle tin o f the History o f Medicine (January 1958). Grant, Frank E. Catawba Hospital Handbook fo r F a c ilita to r s . Arbor: The In s titu te o f Gerontology, 1976. 161 Ann 162 Green, Lawrence. "Cost Containment and the Economics o f Health Edu­ cation 1n Medical Care." Paper presented a t the American Health Congress, Chicago, August 14, 1974. Hauer, Bruce M. "A Model o f Continuing Education fo r Older A d u lts ." Ph.D. d is s e rta tio n , U n ive rs ity o f Minnesota, 1975. "Health Education 1n a Hospital S e ttin g ." Currents In Hospital A dm in istratio n . Columbus: Ross Laboratories, August 1963. "Health Education 1n the H o s p ita l." Proceedings o f the May 4 -6 , 1964, A.H.A. Conference, Chicago, 1965. Health Maintenance Organization Act o f 1973. T i t l e X P II. Sec. 1301. ------------------------------------------- Helmstra, Roger. The Older Adult and Learning. s ity o f Nebraska, 1975. Lincoln: Johnson, A lic e M. e t a l . "Health Education 1n H o s p ita ls ." Education Journal (October 1952): 175-85. Univer­ Health Lee, E liza b e th . S ta ff Associate, American Hospital Association. Personal correspondence, October, 1975. Lesparre, M ichael. "The P a tie n t As Health Student." (March 1970): 4. Hospitals ________ . "The Role o f the Hospital Organization 1n P a tie n t Educa­ tio n ." Health Education Monographs (Spring 1974): 44. Michigan's Aging C itize n s : C h a ra c te ris tic s , Opinions, and Service U t i1iz a tio n P attern s. Lansing, Michigan: O ffic e o f Services to the Aging, 1975. Michigan Comprehensive Plan on Aging. Services to the Aging, 19757 Lansing, Michigan: O ffic e o f A Model fo r Planning P a tien t Education: An Essential Compound o f Health Care7 New York: American Public Health A ssociation. T M -------------- N e ff, Martha S. "A Survey Concerning the Role o f the Health Educa­ to r 1n Selected Hospitals Throughout the United S ta te s ." Ph.D. d is s e rta tio n , Department o f Health and S a fety, Indiana U n ive rs ity. N le , Norman, e t a l . S t a tis t ic a l Package fo r the Social Sciences. New York: M cGraw-Hill, 1975. 163 Peters, Susan J. "A Survey o f Health Education Programs In the United S tates, w ith a Proposed Model fo r a Comprehensive Health Education Program 1n a Hospital S e ttin g ." Ph.D. study, Department o f Health Education, Southern Ill in o is U n iv e rs ity , August, 1974. Peterson, David A. "L ife Span Education and Gerontology." Gerontologist (October 1975): 436. The Peterson, James A. "Frontiers 1n the Education o f the E ld e rly ." Adult Leadership (January 1976): 170. Prelim inary Recommendations. State Health Planning Advisory Council, Task Force on Health Education ol* the P u b lic. Lansing: O ffice o f Health and Medical A ffa ir s , January, 1976. Reader, George. "The Physician As Teacher." graphs (Spring 1974): 34. Health Education Mono­ "Report o f Committee on Health Education to Health Insurance Bene­ f i t s Council." New York, 1974. (Mimeographed.) "Review o f Research and Studies Related to P a tien t Education." Health Education Monograph 26 (1968): 64. The Role o f Hospitals and Other Health Care In s titu tio n s In Personal and Community Health Education. Policy Statement, American Hospital Association, 1974. Rosen, George. "Health Education and Preventive Medicine, New Horizons in Medical Care." American Journal o f Public Health (June 1952): 687-93. Rosenberg, Stanley. Health Education Consultant, D ivision o f LongTerm Care, Department o f Health Education and W elfare. Personal correspondence. March, 1976. Ross, C. H. "Gero Education." Journal o f American G e ria tric Society (A p ril 1975): 184-89. Shapiro, Irv in g . The Patient and Control o f Q uality in Medical Care. Proceedings Tenth Annual Group Health In s tit u te , Group Health Association o f America, Chicago, 1960. Slmonds, Scott K. "P atient Education As One C rite rio n fo r Q uality Care." Paper presented a t the F ifth Annual In te r d is c i­ p lin a ry Conference on Health Records, Ann Arbor, Michigan, June 24, 1974. 164 Smith, Robert M ., e t a l. Handbook o f Adult Education. Macmillan Company, 1970. New York: Socha, Marvin P. "A Survey o f P atien t Education Programs 1n M ichi­ gan H ospitals." M.A. th e s is , Central Michigan U n ive rs ity, May, 1975. "Sunmary o f Findings and Recommendations o f the President's Commit­ tee on Health Education." Washington, O .C ., 1973. (Mimeographed.) Task Force on P atien t Education fo r the President's Committee on Health Education. "The Concept o f Planned Hospital Based P atien t Education Programs." Health Education Monographs (Spring 1974). Turablan, Kate L. A Manual fo r W riters o f Term Papers, Theses, and D is se rtatio n s . Chicago: The U niversity o f Chicago f*ress, 1973. U.S. Department o f H ealth, Education and W elfare. Nursing Home Care. Washington, D.C.: Government P rin tin g O ffic e . U.S. Senate. Subcommittee on Long-Term Care. What Can Be Done in Nursing Homes: Positive Aspects 1n Long-Term t a r e . Washington, D .C.: Government P rin tin g O ffic e , 1975. Welngarten, "Report o f the Findings and Recommenatlons o f the P resi­ dent's Committee on Health Education." Health Education Monographs (1974): 11-19. White House Conference on Aging. Toward a National Policy on Aging. Vol. I I . Washington, D .C .: Government P rin tin g O ffTce, 1973. Woodruff, Diana, and Walsh, David A. "Research 1n Adult Learning: The In d iv id u a l." The Gerontologist (October 1975): 425.