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Effective Patient Education: Evidence and Common Sense

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The value of patient education cannot be overemphasized. A nurse's ability to teach effectively can optimize patients' knowledge, skills, capabilities for self-care, and ability to make informed choices (Falvo, 2011; London, 2016). Teaching is not a task; it is a practice that requires nurses to engage patients actively to meet individual learning needs. Although challenging in fast-paced healthcare environments, implementing effective and efficient teaching practices is achievable. Practical, evidence-based methods and commonsense teaching tactics for medical-surgical nurses are described.

Patient teaching is a complex process intended to facilitate learning and improve health outcomes (Falvo, 2011; London, 2016). The process includes assessment, planning, implementation, and evaluation. Effective teaching helps patients apply health-related knowledge to their lives. The nurse's role as patient educator is delineated in professional standards (Academy of Medical-Surgical Nurses, 2012; American Nurses Association, 2015). Similar to other clinical practices, patient teaching should be guided by best available evidence.

Effective patient education is not simple, but it is important and has many benefits. A patient-centered, individualized educational approach empowers patients and can impact clinical outcomes (Stewart, 2012). Patient education may lead to enhanced knowledge, quality of life, and self-care; reduced hospital readmissions; and improved medication adherence (Casmir, Williams, Liang, Pitakmongkolkul, & Slyer, 2014; Sandlin, Bennett, Ockerby, & Corradini, 2013; van Driel et al., 2016). Ineffective patient education can cause misunderstandings and place patients at risk for adverse events.

Nurses do not feel prepared to be consistently effective educators and need support to teach patients confidently (Sherman, 2016). Additional challenges related to nurses' patient educator role include lack of a structured approach, inadequate educational preparation in teaching methods, insufficient time, absence of managerial support, lack of teaching materials, interruptions, inadequate privacy, poor interprofessional collaboration, and heavy workloads (Bergh, Karlsson, Persson, & Febe, 2012; Ghorbani, Soleimani, Zeinali, & Davaji, 2014). Teaching patients effectively requires knowledge and skill. Nurses can improve their teaching abilities with practice, education, and mentoring (London, 2016; Sherman, 2016; Svavarsdóttir, Siguroardóttir, & Steinbekk, 2015).

The Practice and Process of Patient Education

The patient education process includes several nonlinear steps (London, 2016). Each step serves a purpose. Nurses can teach efficiently and improve learning outcomes by using these steps.

Learning Needs Assessment

A learning needs assessment (LNA) involves gathering subjective and objective information to...

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This paper is in the following e-collection/theme issue:

Published on 13.4.2020 in Vol 22 , No 4 (2020) : April

Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review

Authors of this article:

• Thomas Timmers 1, 2 , MSc   ; 
• Loes Janssen 3 , PhD   ; 
• Rudolf B Kool 1 , MD, PhD   ; 
• Jan AM Kremer 1 , MD, PhD  

1 IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands

2 Interactive Studios, Rosmalen, Netherlands

3 Máxima Medical Center, Veldhoven, Netherlands

Corresponding Author:

Thomas Timmers, MSc

IQ healthcare

Radboud Institute for Health Sciences

Radboud University Medical Center

Geert Grooteplein Zuid 10

Nijmegen, 6525 GA

Netherlands

Phone: 31 73 644 6069

Email: [email protected]

Background: Patient education is a crucial element within health care. It is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and even better treatment outcomes. Unfortunately, often patients only remember a very limited amount of medical information. An important reason is that most patients are simply not capable of processing large amounts of new medical information in a short time. Apps for smartphones and tablets have the potential to actively educate patients by providing them with timely information through the use of push notifications.

Objective: The objective of this systematic review is to provide an overview of the effects of using smartphone and tablet apps to educate patients with timely education. Within this review, we focused on patients that receive their care in a hospital setting. We assessed the effects of the interventions on outcomes, such as patients’ knowledge about their illness and treatment, adherence to treatment instructions and to medication usage, and satisfaction with the care they received.

Methods: A comprehensive search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science was conducted. Randomized controlled trials (RCTs) published between January 2015 and November 2019 were eligible for inclusion. Two reviewers independently searched and screened articles, assessed study quality and risk of bias, and extracted the data. Due to the heterogeneity of populations, interventions, and outcomes, a meta-analysis was not deemed appropriate. Instead, a narrative synthesis is presented.

Results: A total of 21 RCTs with 4106 participants were included. Compared to usual care, overall effectiveness of the interventions was demonstrated in 69% of the outcomes. Effectiveness increased to 82% when the intervention had a duration shorter than one month and increased to 78% when the intervention provided at least one push notification per week. The interventions showed the highest effects on satisfaction with information, adherence to treatment instructions and to medication usage, clinical outcomes, and knowledge.

Conclusions: This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messages to patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

Introduction

Patient education is a crucial element within health care. Health care professionals provide patients with information about the origins of complaints, treatment options, prognosis, how to prepare for treatment, or how to manage one’s health during the recovery phase. Health care professionals educate their patients because knowledge is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and better outcomes [ 1 , 2 ].

Unfortunately, patients often only remember a limited amount of the medical information they receive. Many different factors contribute to this. Some of these factors are related to the health care professional, such as using jargon or communicating in a passive way. Other factors are related to the patient, such as age, learning style, and stress [ 3 ]. Another important reason is the fact that most patients are simply not capable of processing large amounts of new medical information in a short amount of time [ 4 ].

During the last decade, smartphones, tablets, and apps have become commonplace in our society. These innovations offer many new opportunities within health care, such as optimizing the process of patient education. Apps, for example, allow patients to look at medical information as often as they like, at any place, and at any time. The information is comprehensive and different modes of information delivery and interaction are available. Furthermore, push notifications allow health care providers to actively educate patients with timely information, which, in this review, is defined as providing patients with small pieces of information at the time that these are actually relevant to them.

Although interventions like these appear to have much potential in allowing patients to better understand and to remember medical information, an overview of all available evidence on the effectiveness of these technologies has thus far not been published. The objective of this systematic review is to provide an overview of the effectiveness of educating patients by providing timely information using smartphone and tablet apps. With this systematic review, we focused on patients that receive care in a hospital setting rather than in primary care. We have chosen to do so since projects in primary care have already demonstrated effectiveness of electronic health (eHealth) apps, but these primarily focused on chronically ill patients from a population perspective and on telemonitoring services from an intervention perspective.

In this paper, we assess the effects that these interventions have on outcomes, such as patients’ knowledge about their illness and treatment options, adherence to medication or instructions, and satisfaction with the information or the care they received.

Search Strategy and Data Sources

To identify relevant studies, we used a two-step strategy. First, we conducted a preliminary search in PubMed to identify key articles, relevant keywords, and Medical Subject Headings (MeSH) terms. The second step was to have the search strategy be peer reviewed by an information specialist from the Radboud academic medical center’s medical library. Multimedia Appendix 1 shows the search strategy for the final search. We comprehensively searched the following databases: MEDLINE (Medical Literature Analysis and Retrieval System Online) (Ovid); Embase (Elsevier); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (EBSCO); and Web of Science. Relevant systematic reviews were also assessed for eligible articles. In order to compare the effectiveness of interventions, we preferred to only include randomized controlled trials (RCTs). Since we were unsure about the number and quality of RCTs, our primary search also included cohort and quasi-experimental studies. After assessing the number and quality of RCTs, we decided to only include these in the review. Reporting was done in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [ 5 ].

Based on the results of our preliminary search, we deliberately limited our search to articles published between January 1, 2015, and November 1, 2019, as the interventions described before this period did not meet the eligibility criteria or could no longer be repeated since the technique was outdated or no longer available. We searched for papers in English and looked at reference lists of included studies to optimize our search.

Eligibility Criteria

RCTs were included if they met a number of eligibility criteria: (1) interventions had a focus on patient education through a smartphone or tablet app, used in a hospital setting; (2) interventions had to use push notifications to actively notify patients about newly available information in the app; and (3) the intervention had to be available for multiple days.

We excluded trials that focused solely on the acceptance or feasibility of technology, content or design of the intervention, availability in app stores, telemedicine (ie, remote care), websites or online platforms, or trials that only described the usage of an SMS. Furthermore, articles focusing on data collection, security, behavior or characteristics of patients, and health care professionals were excluded, as were study protocols. Studies were not excluded on the basis of sociodemographic characteristics of patients, such as age, gender, ethnicity, or any other related characteristic.

Data Selection, Extraction, and Management

The search results from different electronic databases were combined within a single Endnote library, version 8.2 (Clarivate Analytics), and duplicates were removed. Two reviewers (TT and LJ) independently screened titles and abstracts to identify studies that potentially met the inclusion criteria. The full text of these articles was retrieved and read. Two review authors (TT and LJ) independently assessed these articles against the eligibility criteria and extracted the data from the included studies using a structured data extraction form. Disagreements were resolved through discussion and, if necessary, a third reviewer (RBK) was consulted. We extracted information about the patient population, outcomes, interventions, controls, results, and outcome measures.

Assessment of Risk of Bias

Two reviewers (TT and LJ) independently assessed the risk of bias of included RCTs using the Cochrane Collaboration’s risk of bias tool [ 6 ]. Judgements concerning the risk of bias for each study were classified as high, some concerns, or low.

Data Synthesis

Included studies were insufficiently homogenous in terms of patient population, outcomes, and type of intervention. The decision not to perform a meta-analysis was made as a consensus by all authors. For any outcome that was investigated in three or more studies, we present a narrative synthesis of results. In order to compare the effects of the different interventions over the different studies, a standardized mean difference (SMD) is reported, including the 95% CI for the effect. SMD is reported only when results are normally distributed and mean and SD are available. The magnitude of the effect is interpreted according to Cohen’s guidelines: small (SMD is 0.2 or lower), medium (SMD is between 0.2 and 0.8), or large (SMD is 0.8 or higher) [ 7 ].

Furthermore, we created a narrative synthesis of overall results per outcome in relation to the duration of the intervention or the frequency with which messages were sent to the patient. Therefore, the duration of the intervention was subdivided into short (<1 month) and long (≥1 month). The frequency of messaging was subdivided into high (>1 message per week) or low (≤1 message per week). The relative effectiveness was calculated by dividing the total number of participants in studies that demonstrated an effect for the outcome by the total number of participants in studies linked to the outcome. Finally, a weighted overall effect was calculated summarizing all outcomes, specified for the duration of the intervention and the frequency of messages.

Our searches yielded a total of 5497 articles from which 2041 unique articles were derived. After screening titles and abstracts, 1970 records were excluded. A total of 71 articles were assessed for eligibility by full-text screening. A total of 50 articles were excluded after full-text reading because of study type (ie, cohort, quasi-experimental, or other) or because the intervention used did not actually deliver timely education. In total, 21 RCTs were included in the review, including 4106 participants (see Figure 1 ). Sample sizes ranged from 34 participants [ 8 ] to 650 participants [ 9 ].

Included Studies: Study Designs and Populations

Nine studies were conducted in Europe [ 10 - 18 ], four studies in North America [ 8 , 19 - 21 ], five studies in Asia [ 9 , 22 - 27 ], and one study in Africa [ 28 ]. In total, 4106 patients participated in the studies. Studies were divided over many different medical departments: gastroenterology [ 9 , 18 , 22 , 24 , 28 ], orthopedics [ 10 , 12 , 13 ], cardiology [ 17 , 20 , 25 , 26 ], oncology [ 21 ], surgery [ 11 , 19 , 23 ], urology [ 16 ], internal medicine [ 27 ], sports medicine [ 14 ], pulmonary disease [ 8 ], and neurology [ 15 ]. Six studies used a social media platform as the medium for the intervention [ 9 , 22 - 24 , 26 , 27 ]. Eight studies used apps that were already commercially available [ 10 , 12 - 14 , 16 , 17 , 19 , 20 ] and five studies used apps that were developed specifically for the study [ 8 , 18 , 21 , 25 , 28 ]. A total of five interventions that were used provided the possibility to interact with a health care provider [ 9 , 22 , 26 - 28 ].

Two studies included detailed information about the content and timing of notifications used in the intervention [ 10 , 17 ] and eight provided some details or images [ 9 , 12 , 13 , 15 , 21 , 22 , 25 , 28 ]. Regarding the phase of the treatment in which the study was conducted, seven studies focused on the period before the start of the treatment [ 9 , 12 , 18 , 21 , 22 , 24 , 28 ], 12 studies focused on the period after the start of the treatment [ 8 , 10 , 11 , 13 - 16 , 19 , 20 , 25 - 27 ], and one focused on both [ 23 ].

Details of the population, type of intervention, outcomes, and mean age of participants are presented in Table 1 . The details of the interventions used, their duration, phase of the treatment, and frequency of notifying patients are presented in Table 2 . An overview of all the measurement instruments used per study to assess these outcomes can be found in Multimedia Appendix 2 .

a QoL: quality of life.

b Age of the children who underwent surgery. In the study, their parents (age not mentioned) used the app and provided the data.

c Study only reports that 75% of the participants were 41 years or older.

a Pre: before the start of the treatment; post: after the start of the treatment.

b eHealth: electronic health.

Risk of Bias of Included Studies

All 21 included studies were assessed for risk of bias in the following domains: selection of the reported result, measurement of the outcome, missing outcome data, deviations from intended interventions, and randomization process. The levels of risk—low, some concerns, or high—per study, per domain are presented in Figure 2 . An overview of the percentage of studies related to the level of risk and domain of bias is presented in Figure 3 .

Characteristics of the included studies are presented per outcome. Per study, the effect of the intervention on the outcome is described as in favor of the intervention group , in favor of the control group , or no effect .

Satisfaction

A total of 12 RCTs [ 10 - 12 , 15 , 17 - 19 , 21 , 22 , 25 , 28 ], in which 2466 patients participated, reported results related to satisfaction. Two main themes emerged from these studies: satisfaction with the information provided [ 10 - 12 , 17 , 19 , 21 , 28 ] and satisfaction with the overall care that was delivered [ 10 - 12 , 18 , 22 , 25 ] (see Table 3 ).

Regarding patients’ satisfaction with the information, an effect in favor of the intervention group was demonstrated in eight out of 10 studies. Interventions included an app that was used to educate patients about the preparation for their colonoscopy [ 28 ], consultation with an orthopedic surgeon [ 12 ], postoperative self-management after knee replacement surgery [ 10 ], breast cancer screening [ 21 ], healthy lifestyle interventions in myocardial infarction patients [ 17 ], and return to normal activities after abdominal surgery [ 11 ]. One study, which focused on enhanced recovery education after colorectal surgery [ 19 ], showed no difference in terms of satisfaction between the intervention and control groups. SMD ranged from medium to large in five studies [ 10 - 12 , 17 , 21 ] and could not be calculated for the two other studies.

Regarding patients’ satisfaction with the overall care they received, an effect in favor of the intervention group was demonstrated in four out of eight studies. These studies measured the patient-perceived level of involvement by the hospital after discharge [ 10 ], satisfactory bowel preparation [ 22 ], satisfaction with anticoagulation therapy [ 25 ], level of patient-centered care in Parkinson disease [ 15 ], and overall experience with the bowel preparation process [ 18 ]. Three other studies showed no differences between groups in patients’ overall satisfaction with care related to abdominal surgery [ 11 ], patients’ satisfaction related to the consultation with their orthopedic surgeon [ 12 ], and patients’ overall satisfaction with the recovery process after pediatric surgery [ 23 ]. SMD ranged from small to large in six studies [ 10 - 12 , 15 , 18 , 22 , 25 ] and could not be calculated for the other study.

a All items were patient reported versus clinician reported.

b Effects were in favor of the intervention group (+) or there were no effects (=). No study had effects in favor of the control group (–).

c SMD: standardized mean difference.

d Outcome only measured in intervention group.

e No SD available (only average and P value).

f Nonnormal distributed data.

A total of 11 RCTs [ 9 , 15 , 17 - 19 , 22 , 24 - 28 ], in which 2573 patients participated, reported results related to adherence. Two main themes emerged from these studies: adherence to treatment instructions [ 9 , 18 , 19 , 22 , 24 , 26 - 28 ] and adherence to medication usage [ 15 , 17 , 25 ] (see Table 4 ).

Regarding patients’ adherence to treatment instructions, an effect in favor of the intervention group was demonstrated in five out of eight studies, focusing on patients’ self-management in diabetes mellitus [ 27 ], hypertension [ 26 ], and adherence to purgative and dietary instructions for bowel preparation before their colonoscopy [ 9 , 22 , 24 ]. No differences between groups were reported in two other studies focusing on preparation for colonoscopy [ 18 , 28 ] and a postoperative recovery program after colorectal surgery [ 19 ]. SMD ranged from small to large in six studies [ 9 , 18 , 24 , 26 - 28 ], was negative in one study [ 19 ], and could not be calculated for the other study.

Regarding patients’ adherence to their medication usage, an effect in favor of the intervention group was demonstrated in all three studies addressing this theme. These studies focused on drug adherence in Parkinson disease [ 15 ], anticoagulation adherence in patients who suffered from atrial fibrillation [ 25 ], or myocardial infarction [ 17 ]. With regard to the latter, patients in the intervention group reported lower missed medication doses. However, the same study also reported that there were no differences between groups in results related to the medication adherence questionnaire that was assessed. SMD ranged from small to medium in two studies [ 15 , 17 ] and could not be calculated for the other study.

a Items were either clinician reported (CR) or patient reported (PR).

d No SD available (only average and P value).

e Nonnormal distributed data.

Quality of Life

Seven RCTs [ 10 , 11 , 15 - 17 , 20 , 25 ], in which 1300 patients participated, reported results related to quality of life (see Table 5 ). An effect in favor of the intervention group was demonstrated in four studies. These studies measured the effect of the intervention on quality of life at four weeks after knee replacement surgery [ 10 ], three months after starting a program for cardiac rehabilitation [ 20 ], three months after starting a program for pelvic floor muscle training [ 16 ], and three months after starting a program for enhanced self-management after atrial fibrillation [ 25 ]. Three studies did not report an effect in the intervention group at the following time points: 6 months after intermediate-grade abdominal surgery [ 11 ], 4 months after starting a self-management program in Parkinson disease [ 15 ], and 6 weeks after starting a support program on lifestyle changes and drug adherence in myocardial infarction patients [ 17 ]. SMD ranged from small to large in five studies [ 10 , 15 , 20 ] and could not be calculated for two studies [ 11 , 25 ].

Clinical Outcomes

A total of 11 RCTs [ 8 , 10 , 11 , 13 - 16 , 20 , 22 , 24 , 28 ], in which 1783 patients participated, reported results related to clinical outcomes. Three main themes emerged from these studies: physical functioning and pain [ 10 , 11 , 13 , 14 ], clinical values [ 20 , 22 , 24 , 28 ], and symptoms [ 8 , 15 , 16 ] (see Table 6 ).

Regarding physical functioning, an effect in favor of the intervention group was demonstrated in three out of four studies, albeit not on all outcomes. These results were related to physical functioning after abdominal surgery [ 11 ] and pain and knee function after knee replacement surgery [ 10 , 13 ]. No differences between groups were reported concerning pain and activities after abdominal surgery [ 11 ] or concerning knee function and physiotherapy assessment tests [ 13 ]. One study related to ankle function after sports-related trauma did not demonstrate a difference between groups either [ 14 ]. SMD was medium in one study [ 10 ] and could not be calculated for the other studies.

Regarding clinical values, an effect in favor of the intervention group was demonstrated in at least one of the outcomes of all four included studies. These effects were related to weight loss during cardiac rehabilitation [ 20 ] and adenoma detection during colonoscopy [ 22 , 24 , 28 ]. No differences between groups were found concerning cholesterol, glucose, and exercise capacity in cardiac rehabilitation [ 20 ]. SMD ranged from small to large in two studies [ 15 , 16 ] and could not be calculated for the other study.

Regarding symptoms, an effect in favor of the intervention group was demonstrated in one out of three studies. These results were related to a decrease in symptom severity after using an intervention to train pelvic floor muscles in women who suffer from stress-related urinary incontinence [ 16 ]. No differences between groups were reported in nonmotor symptoms related to Parkinson disease [ 15 ] and asthma [ 8 ]. SMD ranged from small to large within one study [ 20 ] and could not be calculated for the other studies.

a Items were either patient reported (PR) or clinician reported (CR).

Health Care Economics

Five RCTs [ 10 , 11 , 19 , 23 ], in which 860 patients participated, reported results related to health care economics (see Table 7 ). An effect in favor of the intervention group was demonstrated in three studies, concerning patients’ contact with health care providers after total knee replacement surgery [ 10 ] and after pediatric day-care surgery [ 23 ], as well as after returning to work after abdominal surgery [ 11 ]. The other studies did not report an effect in favor of the intervention group for patients undergoing colorectal or abdominal surgery [ 11 , 19 ] or patients attending a cardiac rehabilitation program [ 20 ]. Regarding 30-day hospital readmissions, an effect in favor of the control group was demonstrated after colorectal surgery [ 19 ]. SMD ranged from small to large in two studies [ 19 , 23 ] and could not be calculated for the other studies.

b Effects were in favor of the intervention group (+), in favor of the control group (–), or there were no effects (=).

d Nonnormal distributed data.

Four RCTs [ 10 , 21 , 25 , 27 ], in which 634 patients participated, reported results related to condition- or treatment-specific knowledge acquisition (see Table 8 ). An effect in favor of the intervention group was demonstrated in all four studies. All studies focused on disseminating disease-specific information, ranging from treatment options for patients with knee complaints due to osteoarthritis [ 12 ] to self-management in atrial fibrillation patients [ 25 ] or diabetes mellitus [ 27 ] and general knowledge about breast cancer and screening options [ 21 ]. SMD ranged from medium to large in three studies [ 12 , 21 , 27 ] and could not be calculated for one study.

b Effects were in favor of the intervention group (+) for all studies, versus effects in favor of the control group (–) or no effects (=).

Narrative Synthesis of Overall Results

Overall results demonstrate an average effectiveness of the intervention of 69% (see Table 9 ). Satisfaction with information, adherence to instructions and medication, clinical outcomes (eg, weight loss or adenoma detection), and knowledge acquisition showed the highest effects (>70%). When taking into account the duration of the intervention, a clear advantage in terms of effect is demonstrated by the interventions that have a duration of less than one month, compared to the interventions that take more than one month: 82% effectiveness versus 69%. A clear difference is noted in the comparison between the frequencies of messaging patients with information as well: an average effectiveness of 78% in the high-frequency group (more than once per week, on average) versus 64% in the low-frequency group (once per week, on average).

a Average effectiveness is the weighted average of the population linked to an outcome and the part of the population with a positive effect on the outcome.

b High frequency is >1 message per week, on average.

c Low frequency is ≤1 message per week, on average.

d N/A: not applicable.

Principal Findings

The objective of this systematic review was to evaluate the effectiveness of educating patients by providing timely information using smartphone and tablet apps. In particular, we focused on patients that had undergone treatment in a hospital. A total of 21 studies were identified, most with some concerns in terms of risk of bias. Included studies showed low levels of homogeneity in terms of populations and outcomes. Overall results demonstrate an average effectiveness of the interventions in 69% of the studies. Satisfaction with information, adherence to instructions and medication, improved clinical values (eg, weight loss or adenoma detection), and knowledge acquisition showed the highest effects (>70%). An overall effect of 82% was observed in studies that lasted less than one month. Studies with a higher frequency of messaging (ie, more than once per week) were associated with an average effect of 78%. These results should not only be considered effective from a single outcome point-of-view, but should be, from a more holistic perspective, considered as important components required for effective patient self-management support as well [ 29 ].

Our results are in line with earlier reviews that focus on the effect of eHealth interventions on multiple outcomes in chronic health conditions [ 30 , 31 ]. A review by Schoeppe et al reported a positive effect in terms of prevention by focusing on lifestyle changes, such as diet, exercise, and sedentary behavior [ 32 ]. The average duration of the interventions in the Schoeppe et al review was 8 weeks, which is longer than the average duration of interventions in our review. However, this is probably due to the fact that the interventions in the Schoeppe et al review focused on behavioral changes related to lifestyle, whereas studies in our review sometimes lasted only 3 or 4 days, in which the aim is not to change one’s lifestyle, but to optimize one’s preparation for a one-time event such as a colonoscopy. The usage of frequent notifications has been recognized to encourage greater exposure to the intervention’s content without deterring engagement [ 33 ].

Even though results seem to indicate that interventions of a short duration with a high frequency of notifications are beneficial to the patient, the low level of homogeneity across these studies makes it impossible to extract an optimal structure, duration, or frequency for messaging patients. Such a challenge has also been reported in a 2018 review on education via strategies and structures [ 34 ]. Unfortunately, only a few studies reported detailed information about the content that was provided to patients, its format (eg, text, photo, or video), and the actual timing of the content delivery. This information could have provided additional insights on what makes interventions successful or not.

Our results demonstrate the emerging character of this field of research: the 21 included studies were conducted in 10 different medical departments, covering 15 different types of treatments. Four medical specialties—cardiology, orthopedics, surgery, and gastroenterology—have had more than three studies included. Only interventions related to colonoscopy and knee replacement were studied more than once. The results regarding the number of studies that we excluded from this review also demonstrate that many studies still focus on feasibility, acceptance of technology, and the design and content of apps, rather than on the actual effect of this type of intervention.

Strengths and Limitations

To our knowledge, this review is the first to assess the effectiveness of educating patients in preparation of, during, or after their treatment in the hospital using an app for smartphones or tablets. This review adopted a detailed and comprehensive search strategy, followed by robust screening, data extraction, and risk-of-bias assessment, adhering to the PRISMA guidelines. A total of 21 studies were found eligible for inclusion, seven of them having a low risk level of bias and 14 of them having a level of bias with some concerns according to Cochrane’s risk of bias assessment. The relatively large sample sizes allowed us to calculate SMDs and therewith enabled us to compare study outcomes. The observed high level of heterogeneity in terms of outcomes, population, and intervention characteristics, such as interaction models, commercial and noncommercial products, or social media platforms, made it inappropriate to perform a meta-analysis for any outcome.

In this review, we focused on the timely delivery of educational information to overcome patient-perceived information overload. The duration of the interventions within these studies ranged from 3 days to 6 months. In our opinion, this range is another indicator that this type of research is still at an early stage, in which the focus of the trial is really on the intervention itself instead of its long-term effects.

Implications for Practice

The results of our review demonstrate the effective application of smartphone and tablet apps to educate patients with timely information. The effects are visible within various outcomes and across various medical specialties. Medical practices could benefit from these effects by combining two already-existing resources: patient education materials and smartphones and tablets. Patient education is already available on hospital websites, brochures, and through the oral advice of health care professionals. Additionally, more and more patients, as well as their surrounding caretakers, possess a smartphone or tablet. By adding the concept of timing to existing educational materials, one could improve the likelihood that patients receive the right information at the right time. By using the push notification mechanism on smart devices, patients can also be actively made aware of newly available information related to their treatment. Medical practices may choose to either build an app themselves or use already-available commercial products or platforms, social media or otherwise. After the initial development of an app, little or no further adjustments to existing workflows are needed for successful implementation, which is regarded as a crucial factor for successful eHealth implementation [ 35 ]. Of course, some patients may require support during the initial downloading or configuring of the app, but when this effort is compared to the possible benefits in terms of improved outcomes, satisfaction, and health care consumption as described in this review, these efforts appear worthwhile.

Future Research

Delivering timely education to patients through an app for smartphones or tablets has the potential to contribute to the emerging field of patient education research, which may lead to a positive effect on numerous outcomes. Given the novelty of this area of research, more studies need to be performed in order to demonstrate the generalizability of the concept, as well as its long-term effects. In this review, we chose to include only RCTs, since this study design is currently considered to be the gold standard research design to assess the effectiveness of interventions. Yet, we believe it is legitimate to question whether this is the only appropriate study design, as eHealth innovations and research projects could be characterized by what we would like to refer to as “moving objects” and “moving targets.” By moving objects, we refer to the interventions themselves, as these may easily be adapted to the real-time needs of patients and health care providers by their inventors. By moving targets, we refer to outcomes that might not have been defined in the original research protocol but arose from the data and insights that were gathered during the study. Changing the intervention itself or adding outcomes during the course of a study is, however, often considered not done , as it could quickly lead to a high risk of bias and a lower overall quality of the research. As a consequence, many interventions might not be studied at all, because from a supplier’s or producer’s perspective, it feels unnatural not to be able to respond to these real-world demands “just because a study design won’t allow you to.” This challenge was also reported by two recent studies focusing on eHealth interventions in general [ 36 ] and, more specifically, in the field of psychiatry [ 37 ].

We suggest that other study designs, such as pragmatic RCTs, action research, or even real-world data, are considered to be eligible to demonstrate the effectiveness of these interventions. These designs more closely mimic a routine clinical setting from a health care provider’s perspective (ie, no double blinding or placebo-controlled setting) and allow the interventions to be altered by the supplier during the course of the study if needed. This could lower some of the existing barriers and may convince more stakeholders to participate in eHealth research.

Conclusions

This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messaging patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

Acknowledgments

The authors would like to thank Elmie Peters, medical librarian at Radboud University Medical Center (Radboudumc), for her input in shaping and optimizing the search strategy. Furthermore, the authors would like to thank Samuel Credgington for language editing.

Authors' Contributions

All authors were involved in the design of the protocol, development of the search strategy, and selection of data sources. TT and LJ independently screened articles and assessed the risk of bias of the included studies. TT drafted the manuscript. LJ, RBK, and JAMK critically revised the manuscript. All authors read and approved the final manuscript.

Conflicts of Interest

None declared.

MEDLINE (Medical Literature Analysis and Retrieval System Online) search strategy.

Overview of outcomes per study and instruments used to assess them.

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Abbreviations

Edited by G Eysenbach; submitted 08.12.19; peer-reviewed by L Whitehead, D Reukers, MC Chang, G Dermody, C Mullens; comments to author 15.01.20; revised version received 21.02.20; accepted 22.03.20; published 13.04.20

©Thomas Timmers, Loes Janssen, Rudolf B Kool, Jan AM Kremer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 13.04.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

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Article Contents

Lay summary, introduction, materials and methods, author contributions, supplementary material, conflict of interest statement, data availability.

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A systematic review of the effectiveness of patient education through patient portals

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Adam M Johnson, Andrew S Brimhall, Erica T Johnson, Jennifer Hodgson, Katharine Didericksen, Joseph Pye, G J Corey Harmon, Kerry B Sewell, A systematic review of the effectiveness of patient education through patient portals, JAMIA Open , Volume 6, Issue 1, April 2023, ooac085, https://doi.org/10.1093/jamiaopen/ooac085

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The objective of this study was to systematically review all literature studying the effect of patient education on patient engagement through patient portals.

Patient portals provide patients access to health records, lab results, medication refills, educational materials, secure messaging, appointment scheduling, and telehealth visits, allowing patients to take a more active role in their health care decisions and management. A debate remains around whether these additional aids actually improve patient engagement and increase their ability to manage their own health conditions. This systematic review looks specifically at the effect of educational materials included in patient portals.

In accordance with PRISMA guidelines, the literature search was mapped across 5 databases (PubMed, CINAHL, Scopus, PsychINFO, Embase), and implemented on June 2, 2020.

Fifty-two studies were included in the review. Forty-six (88.5%) reported rates of patient utilization of educational resources in the patient portal. Thirty (57.9%) shared patients’ perceptions of the usefulness of the education materials. Twenty-one (40.4%) reported changes in health outcomes following educational interventions through the patient portal. This review found that efforts are indeed being made to raise awareness of educational resources in patient portals, that patients are increasingly utilizing these resources, that patients are finding them useful, and that they are improving health outcomes.

It seems that patient portals are becoming a powerful tool for patient education and engagement, and show promise as a means of achieving the quadruple aim of healthcare. Moving forward, research should establish more uniform methods of measurement in order to strengthen the literature surrounding the effectiveness of patient education through patient portals.

Patient portals provide patients access to health records, lab results, medication refills, educational materials, secure messaging, appointment scheduling, and telehealth visits, allowing patients to take a more active role in their health care decisions and management. This article systematically reviewed all literature regarding patient education through patient portals to determine its effectiveness in improving patient engagement and ability to manage their health conditions. The results found that efforts are being made to raise awareness of educational resources in patient portals, that patients are increasingly utilizing these resources, that patients are finding them useful, and that they are improving health outcomes. It seems that patient portals are becoming a powerful tool for patient engagement and show promise as a means of improving patients’ health. Continued efforts need to be made to raise awareness of patient educational resources in patient portals so that patients utilize these resources to increase their knowledge, skills, and confidence for managing their own health and health care.

Since the Institute of Medicine (IOM) established new aims for an improved healthcare system, efforts have been made to make healthcare safe, effective, patient-centered, timely, efficient, and equitable. 1 Patient engagement has been shown to help achieve the quadruple aim of healthcare, which is to: (1) improve patient outcomes, (2) improve patient experience, (3) reduce costs, and (4) improve the providers’ experience in their work. 2 , Patient education is an effective way to increase patient engagement in their own health. 3 Healthcare providers and organizations believe that using education to increase patient engagement will improve patients’ knowledge, skill, and confidence in managing their own health and health care. 3 , 4

Current research shows that patients are interested in and want education and information about their health and how to manage it. 5 , 6 They are increasingly turning to online sources for information about their conditions, especially when they feel providers fail to answer their questions. 7–9 While the internet can be helpful 10 , 11 sources such as YouTube, Wikipedia, Google, and social media platforms are unfiltered information sources and sometimes contain information that is either less accurate or inaccurate. 7 , 12 , 13 This has problematic implications particularly for patients with lower health literacy, with research indicating they have a harder time distinguishing between reputable and unreputable sources. 14

To address patients’ needs for health information and mitigate issues associated with poor quality information in many internet sites, healthcare providers, organizations and electronic health record (EHR) vendors created apps or digital resources to provide reputable education and tools to help patients manage their health. 15 Some of these apps are standalone resources, while some called patient portals or personal health records (PHRs), are directly tethered or connected to the EHRs of providers and organizations. 15 These tethered patient portals provide patients access to their health records, secure messaging, appointment scheduling, lab results, medication refills, educational materials, and telehealth visits, increasing patients’ ability to take an active role in their health care decisions and management. 15 Healthcare providers can leverage patient portals to meet the rising demand for health education and information by providing reputable resources to patients online in a controlled and tailored manner. 7 , 8 , 11 Currently, educational resources included in patient portals often include reading materials, videos, and links to reputable websites that are approved or created by the organization producing the patient portal. 15

Previous reviews have studied patient portals generally, reviewing all the literature produced in recent years regarding their effect on patient empowerment, 16 , 17 safety and quality of care, 18 and utilization. 19–22 In a meta-analysis, Neves et al 18 found that patient portal use was associated with improved health outcomes for patients, as well as increased safety and quality of care. Alternatively, Ammenwerth et al 16 , 17 found that patient portals had little to no effect on patient empowerment and health outcomes. Despite attempts to expand patient portals, patient use and adoption of these resources has been relatively low. 19 To date, the percentage of patients who are registered to use their patient portal is typically less than 50% of the total patient population, and the number of patients who use it routinely is even lower. 23 There appears to be a discrepancy between the resources provided and patients’ use of these resources. Zhao et al reviewed all literature surrounding barriers and facilitators of utilization and found that demographic factors such as age, race, and socioeconomic status can limit patients’ ability to access or use patient portals. 19 , 24 A common barrier to accessibility is providing resources at a literacy level that the average patient can understand. 19 For example, Chaet et al 20 in their review, raised concern over the lack of patient portals that have resources in Spanish for Spanish speaking patients. Grossman et al 21 reviewed all interventions used to increase utilization, and Beal et al 22 reviewed the different ways researchers have used to track utilization. Current methods for increasing and measuring utilization have been widely varied and almost unique to the organization or research conducting the study, so there have been calls to analyze and standardize which practices are the most effective on both fronts in order to unify the field in a more common practice. 21 , 22

While all these contributions have been valuable, no systematic reviews have been done to date to summarize the research regarding the use of patient education through patient portals. Just as with other aspects of patient portals, providers need to know about the effectiveness of education resources provided through patient portals, what factors determine patient use, and how to increase their effectiveness in the future. The objective of this study was to systematically review all literature studying the effectiveness of patient education through patient portals on patient engagement and ability to manage their health conditions.

Research question

What is the effectiveness of educational resources within patient portals?

Are patients aware of the educational resources within the patient portal?

Are patients utilizing the educational resources?

Do the patients find the content useful?

Does use of patient education information in patient portals increase patients’ understanding of their own health conditions and improve their self-management or health outcomes?

The terms PHR and patient portal have become nearly synonymous in the research, 15 so while both terms were included in our review’s search terms, we refer to these resources as patient portals throughout this review. The systematic review protocol and data underlying this article are available online via the Open Science Framework ( https://osf.io/uey5c/?view_only=b3a792a77ab64fc8a5e5a39cec0cdfbd ).

Search strategy and screening

One author (GJCH), who is an information specialist/librarian, iteratively designed the search strategy using recommended controlled vocabulary and keywords for patient education and patient portals (see Table 1 ), in collaboration with 2 other authors (AMJ and KBS). The search was initially mapped in PubMed using MeSH terms and syntax and subsequently mapped to controlled vocabulary and syntax for the other identified databases (CINAHL, Scopus, PsychINFO, Embase). PubMed and Embase are standard databases for systematic reviews. The other 3 cover additional journals not indexed by PubMed and Embase but also focus on specific subject areas that were relevant to the research question. No limitations were placed on the search (ie, date, peer review, geography, or language). The date of the original search was June 2, 2020 All studies produced by the initial search were loaded into Endnote X9 (Clarivate Analytics, USA) for manual deduplication. After deduplication, the studies were loaded into Covidence ( www.covidence.org ), which identified additional duplicates missed during initial deduplication.

Reproducible search terms for PubMed

Two reviewers (AMJ and ETJ) independently screened all titles and abstracts against inclusion and exclusion criteria (see Table 2 ). Conflicts were resolved by discussion until consensus was reached. Articles that passed the initial screening were included in a second round of screening, where studies underwent duplicate full-text review by 2 authors (AMJ and ETJ) to determine their inclusion to the final review. Any discrepancies between the reviewers were resolved by discussion.

Criteria for inclusion and exclusion

Data extraction and synthesis

The PRISMA guideline for reporting systematic reviews was followed while conducting this study ( https://prisma-statement.org/PRISMAStatement/Checklist ). Data extraction was done using Covidence and Microsoft Excel. Extracted data elements included: author(s) last name(s), year of publication, country and language of publication, patient portal used, population size and characteristics, sampling method, study design, outcomes, and findings. Data extraction was performed by the primary investigator (AMJ) and confirmed by another author (ETJ). Data were synthesized using narrative synthesis methods. 25 One author (AMJ) synthesized findings and one author (ASB) checked the results and provided recommendations for any needed changes.

Risk of bias and interrater reliability

Although risk of bias assessment is recommended for systematic reviews, study methods varied considerably among included studies. Since of risk of bias assessment instruments are created for specific study designs (see the variety of checklists here: https://casp-uk.net/casp-tools-checklists/ ), providing a unified risk of bias assessment using just 1 or even 2 risk of bias tools was not possible. Interrater reliability analysis using the Kappa statistic was performed to determine consistency among the screeners. Interrater reliability for the title and abstract screening was found to be Kappa = 0.275, and title abstract screening for the full text review was found to be Kappa = 0.499. These measurements are considered to be fair and moderate, respectively. 26

The initial search retrieved 17,807 records across the 5 identified databases (PubMed—5347, CINAHL—3018, Scopus—2152, PsycInfo—3383, Embase—3018). Following manual (EndNote) and machine-driven deduplication (Covidence), 12,062 unique articles remained for title and abstract screening. Following title and abstract screening, 180 articles were retained for full text review. Fifty-two articles were retained for full inclusion in this review. The PRISMA flow diagram ( Figure 1 ) provides a record of the article selection process for the review.

PRISMA flowchart of the inclusion/exclusion process.

Due to the large number of studies included ( n  = 52), a master table with information from all studies is included as Supplementary Material . Only a minority of studies included demographic information on participants, so a synthesis of that data was not included in this review. Results are organized by the research questions, with smaller tables describing the articles relevant to each of the 4 subquestions guiding the review. Of the studies included, 36 (69.2%) were based on US healthcare systems and 16 (30.8%) were based on other countries. Forty-four of the patient portal systems (84.6%) were utilized in outpatient settings, while 9 (17.4%) were for inpatient treatment (one was utilized in both, and so double counted). Forty-three (82.7%) provided education for the patient, 8 provided education for both the patient and the caregiver (15.2%), and one targeted only the caregivers (2%). The populations targeted in the included studies varied across several health conditions (ie, diabetes, cancer, pregnancy, etc.). Another important finding was that 40 of the studies (77%) were published between 2013 and 2020, with only one published before 2000, 27 reflecting that patient portals are still a relatively new resource being developed.

Question 1—are patients aware of the educational resources within the patient portals?

The primary factor determining whether an article was included was its use of patient education within the patient portal. As a result, all 52 studies had some educational features as a portion of their patient portal and each made attempts to inform their patients about its availability (see Figure 2 ). Of these studies, 15 (28.8%) had content pushing features, meaning that the patient portal automatically linked patients with relevant educational resources based on their medical information, such as diagnoses. 28–42 While these studies confirm that patients were notified of the educational resources available, especially those who were enrolled in the 15 studies relying on push notifications, it does not necessarily provide insight into the awareness of the typical patient who is not enrolled in an ongoing study measuring the use of patient portals.

Number of included articles relevant to each of the 4 research questions. Results are sectioned according to research question. “Applicable” represents the number of articles included in the review, which relate to each of the 4 questions. N/A indicates the number of included articles which did not include results relevant to each question.

Question 2—are patients utilizing the educational resources?

While all included patient portal studies had educational resources and made patients aware of them, utilization of these resources remained low. Of the 52 studies included in the review, 46 (88.5%) reported on patient’s utilization of the educational resources (see Figure 2 ). This data was obtained in a variety of ways, including: (1) survey data relying on patient self-report ( n  = 16; 30.8%); (2) required utilization for pilot studies ( n  = 11; 21.2%), (3) qualitative statements simply saying that resources were used ( n  = 10; 19.2%); and (4) metadata audits of patient portal systems and how often resources were clicked on or accessed ( n  = 9; 17.3%).

The most common form of data collection (survey data) revealed that, according to patients’ self-report, utilization rates varied from as low as 20% 43 to 95% 42 with an overall average of 47% across 12 studies (see Table 3 ). 27 , 30 , 32 , 36 , 41–48

Rates of utilization

Note : Parentheses show the number of patients who reported utilizing the patient portal education over the total sample size. The total number of patients who utilized patient portal education in these studies was 871/1839 (47%).

This finding excludes the 11 studies whose utilization rates were 100% because participants were required to use it as part of the study. 39 , 49–56 The variability in utilization rates seems to be associated with sample size, as studies with smaller samples typically experienced higher utilization rates. There also appears to be some discrepancy between desire for resources and the actual rate at which participants use them. Patients reported wanting educational resources included in the patient portal between 84% 5 , 6 and 89% 57 of the time, and planned on using them “very often.” 58 It is also worth noting that 78% of caregivers also indicated that they wanted educational resources. 5 Although many participants reported wanting educational resources, and felt they would use them frequently, the data indicates that expressed desire for patient portal-based educational resources does not equate with an equally high level of use of those resources.

Metadata audits of the patient portal software reported the number of times educational resources were accessed over varying amounts of time 23 , 31 , 59–65 but the nondescript nature of the audit made it hard to interpret how frequently educational resources were utilized by individual patients. However, one of the studies specifically reported that patients who accessed educational resources through the patient portal made up only 42% of registered patient portal users, and 10% of the entire patient population of that site. 23

Question 3—do the patients find the content useful?

Only 30 of the 52 studies included in the review included some aspect that measured patients’ perception of the usefulness of educational content (see Figure 2 ). Based on the review of those articles, it appears that patients find educational resources in patient portals to be extremely useful. Like utilization rates, these reports were received using a variety of methods, including: (1) surveying the study sample to see what percentage of participants perceived education resources as useful ( n  = 13, 43%), (2) qualitative statements simply stating that patients thought content was useful ( n  = 9, 30%), (3) having participants report level of usefulness using Likert scale measurements ( n  = 6, 20%), and (4) utilizing validated measures of usefulness ( n  = 2, 7%).

Of the 4 different styles of measurement, the 2 most informative were the survey studies reporting perceived usefulness by the percentage of participants and those which relied on Likert scales to quantify the degree of usefulness, both of which showed that patients thought the educational resources within the patient portal were very useful (see Table 4 ). 5 , 27 , 29 , 30 , 39 , 42 , 45 , 46 , 48–51 , 53 , 54 , 57 , 58 , 66–68 Two studies used the Net Promoter Score 44 and the System Usability Scale 65 to measure patient’s perceptions of usefulness, and both reported that patients found educational resources included in the patient to be very useful. While this only makes up 7% of the included studies measuring perceptions of usefulness, they are noteworthy because they represent a shift in the field to more standardized methods of measurement. The remaining 9 simply stated that patients thought the resources were useful, often with quotations from qualitative studies. 40 , 43 , 55 , 59 , 61 , 63 , 69–71

Patient’s report of education resources’ usefulness

Note : Parentheses show the number of patients reporting patient portal education as useful over the total sample size. The total number of patients who said patient portal education was useful across these studies was 540/689 (78%).

Likert scale shows the average score of patient reports of usefulness of the patient portal education resources. A score above the midpoint of the scale (ie, <3/5, <4/7, <5/9) indicates patients reporting that the education was useful.

Question 4—does use of patient education information in patient portals increase patients’ understanding of their own health conditions and improve their self-management or health outcomes?

The use of patient education resources provided through the patient portal had a positive effect on patient outcomes. Of the 52 articles included in the review, 21 (40.4%) reported on the association between patient portals and patient self-management and health outcomes (see Figure 2 ). While each of these included studies used patient portals that featured patient education resources among other tools, they did not differentiate the individual contribution of education on patient outcomes, reporting results instead as the effects of the whole intervention. Patient outcomes were measured in 3 ways, including: (1) improvement in self-management of health conditions ( n  = 12, 57%), (2) changes in patient lab values ( n  = 5, 24%), and (3) adoption of desired health behaviors ( n  = 4, 19%).

The most common measure of patient outcomes, self-management of health, was determined in 2 different ways; quantitative measures that scored improvement ( n  = 6) and qualitative reports from patients ( n  = 6). The 6 studies that used quantitative outcomes found that use of educational resources in the patient portal were associated with significant increases in: (1) patient activation 45 ; (2) knowledge of conditions 33 , 56 ; (3) self-management 42 ; (4) adoption of desired health behaviors 33 ; (5) decision making 55 ; and (6) decreased anxiety. 68 The patients in the qualitative self-report studies indicated they felt that education through the patient portal: (1) increased their knowledge of their health 30 , 46 , 48 , 61 , 63 ; (2) increased their confidence in their ability to take care of themselves or those in their care 30 , 40 , 46 , 61 , 63 ; (3) improved safety during and after hospitalization 46 , 48 ; (4) improved decision making and ability to communicate with healthcare providers 46 ; and (5) decreased anxiety around treatment and prognosis. 40 , 48 It should be noted that 3 studies also found improvements that, while positive, were nonsignificant in areas of self-efficacy, 68 , 72 adherence, 72 knowledge, 4 and health behaviors such as physical exercise. 45

As for improvements in health behaviors and lab values, 4 studies reported significant improvements in patients adopting positive health behaviors such as receipt of vaccination, 32 use of effective contraception, 37 medication compliance, 33 and decision to undergo a preventative screening procedure. 50 Changes in patient lab values (ie, HgA1c) following use of educational resources were positive, though not always significantly so. Two studies associated significant improvements 66 , 70 in intervention groups who were given educational resources, while 3 found improvements that were not significantly better than control groups. 4 , 36 , 44 In each of these cases, nonsignificant results still showed slight positive changes and were often presented alongside significant findings in other aspects of patient health, so it seems that use of educational resources in the patient portal is generally associated with improvements in patient outcomes.

This review sought to evaluate the effectiveness of educational resources within patient portal systems by determining availability and patients’ awareness of resources, their utilization and perceived usefulness of those resources, and the effect of those resources on patient outcomes. In response to the first 2 research questions of this study, many providers and healthcare organizations have developed or are utilizing patient portals to provide more accurate and reliable sources of information in response to patients’ increased interest in their own healthcare, and are making efforts to increase patient awareness of these resources. 5 , 6 The main discussion point, however, is how to increase utilization of educational resources through patient portals in the general population. In response to the second two research questions of this study, educational resources provided through patient portals useful (see Table 4 ), and when used, they had a significant impact on patient outcomes. 32 , 33 , 37 , 50 , 66 , 70 The methods used to measure usefulness and patient outcomes varied widely, and creating more uniform methods of measurement will be the focus of discussion.

Questions 1 and 2

While this review indicates that patient education through patient portals improves patient experiences and patient outcomes, utilization of educational resources is low (see Table 3 ) 23 even after patients are made aware of them. These findings highlight a common finding in effectiveness research. Utilization rates of educational resources are potentially inflated because attempts to study patient portals require that participants are enrolled in studies where they are being asked, as part of the study, to use the resources. This was especially true in pilot studies where utilization rates were 100% because participants were required to use them. However, in studies which simply measured rates of use (ie, metadata studies) utilization rates of both patient portals and educational resources are relatively low. These findings present an interesting dilemma for professionals in this field that needs to be addressed. It may be that patients from the general population are still not aware of these features and therefore they remain underutilized. Strategies for increasing use by the average patient need to be developed. A couple of strategies that seem to make a difference, based on this review, is including additional resources, like patient navigators, or automating connection of patients with relevant resources. Considering that this technology is still relatively new, there is hope that patient utilization will increase as patients become more aware of its availability. Like many new technologies, utilization rates might continue to be low for the average American until a tipping point occurs that shifts use from early adopters (those who are either technologically savvy or heavily invested in their health) to part of the mainstream culture. Efforts to raise this awareness will be essential if patient portals are ever going to realize the full potential these educational resources have to increase patient health. Also, it is important to recognize that, given the rapid pace of technological advances, new technologies will continue to expand and develop, thus, requiring research to evolve with it.

Questions 3 and 4

Current research suggests that patients found educational resources provided through patient portals useful (see Table 4 ), and when used, they had a significant impact on patient outcomes. 32 , 33 , 37 , 50 , 66 , 70 While this review focuses on patient perceptions, it is also worth noting that Fricton et al 5 found that 70% of caregivers thought it was useful too. Given that caregiver engagement can have enormous impacts on patient outcomes, this finding is notable. 73 The variability of methods of measurement for utilization, usefulness, and impact of patient education included in this review may be due to the fact that research regarding patient education through patient portal systems is still in its infancy. Most of the articles included in the review (77%) were published between 2013 and 2020, because patient portals themselves are a relatively new technology. Up to this point, most research has focused on development, design, implementation, and beta testing new systems and resources, and so have used a wide variety of methods and measures of effectiveness. While these studies have added to the existing literature the fact that they are measuring different variables makes it hard to establish a consistent message regarding utilization rates and effectiveness. One benefit of a systematic review is it provides a comprehensive summary of the literature that exists around a specific topic and highlights some of the potential gaps. One finding this review highlights is that patients who are using the educational resources found in patient portals are finding them helpful. How helpful is hard to determine because researchers have typically used a variety of different methods to measure both utilization and effectiveness. Different measurements make it difficult to develop a cohesive argument regarding the effectiveness of these resources. Future research in this area should include a Delphi study to establish the best method of standardized measurement to help strengthen the argument surrounding patient portals and their effectiveness, as survey data does not seem to reliably measure use in the general poplulation 23 and measures such as the Net Promoter Score 44 do not specifically measure utilization or outcomes, but rather satisfaction. Until a specific study is done to provide a more definitive recommendation for standardize measurement of patient portal utilization, it seems that system audits of actual use, as used in the study done by Ancker et al 23 provide the most accurate measure of utilization, and that Likert scales seem to be the most uniform way to measure perceived usefulness.

Limitations

This systematic review screened and included a large quantity of literature regarding broad topics of patient engagement, patient education, and health records, which may have contributed to the moderate interrater reliability and may limit the reproducibility of this study. While it had several strengths there is an important limitation to consider. The majority of articles that match our criteria are from the United States (69.2%). There are several possible explanations for this outcome. First, all of the authors on this project are from the United States and therefore may be more familiar searching systems based on literature published predominantly in the United States. Second, the search was limited to patient portals that were tethered. Other countries may have studies related to patient education that operate differently enough to not meet the inclusion criteria for this review (ie, Australia’s patient-owned record, which is not tethered to an organization). Lastly, it is also possible that most of the articles were from the United States because the regulatory and reimbursement-based mechanisms noted above create an environment in which some healthcare systems provide patient portals that do not support the addition of features beyond access to the patient’s medical record.

Implications for future research

Now that patient portals are more common, future researchers studying the effect of education through patient portals should seek to use more uniform methods of measurement so that results can be easily compared between studies and systems. We are already witnessing the beginning of this trend, with some studies using validated measures of effectiveness rather than just participant self-report. 44 , 65 What’s more, after beta testing educational resources in patient portals with small sample populations, studies should move to observe rates of utilization in the general population so that we can observe their impact in everyday contexts, rather than in controlled settings. 23

In response to the issue of low utilization, future research should study the effect of interventions (ie, pushing education or patient navigators) on patient portal patient education utilization. Providers and organizations can raise awareness and utilization by programing patient portals to push, or connect, relevant education to patients. Relying on push notifications may help providers avoid the existing problem that is happening where a library of educational resources lies dormant while patients are seeking unreliable sources to answer many of their health care questions because they do not know where else to look. 74 , 75 Personalized or patient-relevant education can be pushed to patients based on diagnosis, 28 , 29 , 35 , 38 lifespan stage, 30 , 76 prevention for at-risk populations, 32 , 37 or any other personal health information. 31 , 42 This can be done by providers, sometimes known as patient navigators, 36 but can also be automated to reduce costs. 39–41 It may be beneficial for future research to focus more on specific strategies that help increase utilization rates.

A word of caution. One of the problems often discussed about patient portals are barriers to adoption. 24 , 77 Disparities have been found in patient use of patient portals and educational resources by age, race, and socioeconomic status. 24 While patient portals present a low risk of harm to patients if misused, researchers should consider the risk of widening health disparities by providing yet another tool to privileged populations, 78 and thus widening what has been dubbed “the digital divide” 24 between privileged and underprivileged populations. Simple interventions such as providing visual summaries of personal health information, such as charts or picture descriptions, 79 have been found to help neutralize disparities in health literacy. 77 Future researchers need to be cognizant of issues of privilege and oppression that may be accentuated by interventions with patient education through patient portals and other rising technology in healthcare.

This review found that efforts are being made to raise awareness of educational resources in patient portals, that patients are increasingly utilizing these resources, that patients are finding them useful, and that they are improving health outcomes. It seems that patient portals are becoming a powerful tool for patient engagement and show promise as a means of achieving the quadruple aim of healthcare. 2 Continued efforts need to be made to raise awareness of patient educational resources in patient portals so that patients utilize these resources to increase their knowledge, skills, and confidence for managing their own health and health care. 3

All authors contributed to the study conception and design. Search terms and databases were selected by AMJ, GJCH, and KBS, searches were run and results uploaded to Covidence by GJCH. The screening of abstracts and full text review was carried out by AMJ and ETJ. AMJ extracted and organized the data, which was then confirmed by ETJ. AMJ and ASB drafted the manuscript. JH, KD, and JP served as committee members on AMJ’s dissertation committee, and reviewed and helped edit the manuscript as part of that role.

Supplementary material is available at JAMIA Open online.

None declared.

The data underlying this article are available in the Dryad Digital Repository.

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Research Article

Teach-back: A systematic review of implementation and impacts

Contributed equally to this work with: Jason Talevski, Alison Beauchamp

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Medicine–Western Health, The University of Melbourne, VIC, Australia, Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, VIC, Australia

Roles Conceptualization, Investigation, Methodology, Writing – review & editing

¶ ‡ These authors also contributed equally to this work.

Affiliations Ballarat Health Services, VIC, Australia, Department of Rural Health, School of Medicine, Deakin University, VIC, Australia

Roles Investigation, Methodology, Writing – review & editing

Affiliations School of Nursing and Midwifery, Deakin University, VIC, Australia, Centre for Quality and Patient Safety Research—Western Health Partnership, VIC, Australia, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Affiliation Ballarat Health Services, VIC, Australia

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Medicine–Western Health, The University of Melbourne, VIC, Australia, Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, VIC, Australia, School of Rural Health, Monash University, VIC, Australia

• Jason Talevski, 
• Anna Wong Shee, 
• Bodil Rasmussen, 
• Georgie Kemp, 
• Alison Beauchamp

• Published: April 14, 2020
• https://doi.org/10.1371/journal.pone.0231350
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Patients often have difficulty comprehending or recalling information given to them by their healthcare providers. Use of ‘teach-back’ has been shown to improve patients’ knowledge and self-care abilities, however there is little guidance for healthcare services seeking to embed teach-back in their setting. This review aims to synthesize evidence about the translation of teach-back into practice including mode of delivery, use of implementation strategies and effectiveness. We searched Ovid Medline, CINAHL, Embase and The Cochrane Central Register of Controlled Trials for studies reporting the use of teach-back as an educational intervention, published up to July 2019. Two reviewers independently extracted study data and assessed methodologic quality. Implementation strategies were extracted into distinct categories established in the Implementation Expert Recommendations for Implementing Change (ERIC) project. Overall, 20 studies of moderate quality were included in this review (four rated high, nine rated moderate, seven rated weak). Studies were heterogeneous in terms of setting, population and outcomes. In most studies (n = 15), teach-back was delivered as part of a simple and structured educational approach. Implementation strategies were infrequently reported (n = 10 studies). The most used implementation strategies were training and education of stakeholders (n = 8), support for clinicians (n = 6) and use of audits and provider feedback (n = 4). Use of teach-back proved effective in 19 of the 20 studies, ranging from learning-related outcomes (e.g. knowledge recall and retention) to objective health-related outcomes (e.g. hospital re-admissions, quality of life). Teach-back was found to be effective across a wide range of settings, populations and outcome measures. While its mode of delivery is well-defined, strategies to support its translation into practice are not often described. Use of implementation strategies such as training and education of stakeholders and supporting clinicians during implementation may improve the uptake and sustainability of teach-back and achieve positive outcomes.

Citation: Talevski J, Wong Shee A, Rasmussen B, Kemp G, Beauchamp A (2020) Teach-back: A systematic review of implementation and impacts. PLoS ONE 15(4): e0231350. https://doi.org/10.1371/journal.pone.0231350

Editor: Tim Mathes, Universitat Witten/Herdecke, GERMANY

Received: January 14, 2020; Accepted: March 20, 2020; Published: April 14, 2020

Copyright: © 2020 Talevski et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: JT is supported by an Australian National Health and Medical Research Council (NHMRC) Postgraduate Scholarship (1151089) and AB is supported by a MRFF NHMRC TRIP Fellowship (1150745). This work was funded in part by the Nurses Board of Victoria Legacy Limited (NBVLL) and the views expressed in this article do not represent those of the NBVLL.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The healthcare system places a significant burden on patients to participate in their own care such as shared decision-making, providing informed consent or adhering to therapeutic regimens [ 1 , 2 ]. Self-management of health is becoming increasingly complicated, leading to the need for strategies that support patients to not only understand complex health information, but also to apply this information in everyday life [ 3 ]. The ability to understand and use health information is a core component of health literacy, a concept which is consistently associated with health outcomes [ 4 ] and identified by the World Health Organization as key to achieving the Sustainable Development Goals [ 5 ].

There is a well-recognized communication gap in health care, with several studies identifying that healthcare providers may overestimate their own ability to communicate [ 6 – 8 ]. One survey-based study reported that 75% of surgeons believed they communicated well with their patients, but only 21% of their patients reported satisfactory communication [ 8 ]. Another qualitative study reported that 77% of doctors believed their patients were aware of their diagnosis, although only 57% of patients could correctly recall this [ 9 ]. These communication gaps can lead to adverse outcomes including compromised safety and increased economic burden [ 10 , 11 ]. A frequently observed barrier to patient understanding is the continued use of medical terminology by doctors [ 12 – 14 ], with one systematic review reporting that patients want clearer explanations about their condition as they frequently misunderstand terms used in medical consultations [ 14 ]. Another major challenge in healthcare communication is patients’ ability to recall the information provided to them. Recall is considered an important mediator for treatment adherence and improved health outcomes [ 11 , 15 ]. Studies have shown that less than half the information provided about medication and diet is accurately recalled by patients [ 15 , 16 ], and can be even more challenging for people with low levels of education [ 3 ]. Interventions to improve communication at the patient-clinician interface are warranted; with one approach being the use of education and recall communication strategies such as ‘teach-back’ [ 17 ].

Teach-back involves asking patients to explain in their own words what a health provider has just told them. Any misunderstandings are then clarified by the health provider and understanding is checked again. This process continues until the patient can correctly recall the information that was given. Use of teach-back has been shown to improve knowledge, skills and self-care abilities in patients with chronic disease [ 18 – 25 ]. Teach-back is recommended as a health literacy-based communication approach in several policy documents and position statements, including the Australian Commission on Safety and Quality [ 17 ], the American Heart Association [ 26 ] and the American Diabetes Association [ 27 ]. Despite these recommendations and the simplicity of its use, teach-back is not consistently utilized [ 28 – 30 ]. This may, in part, be related to organizational or interpersonal barriers including lack of time, limited support by senior staff, or low self-efficacy to use teach-back [ 29 , 31 ]. Furthermore, there is little guidance for healthcare services seeking to embed teach-back in their setting in a sustainable way. To promote the translation of teach-back into routine practice, it is important to identify strategies that may address any contextual and interpersonal barriers that support the uptake of this evidence-based intervention.

This narrative review aims to synthesize the latest evidence about the translation of teach-back within healthcare settings including: 1) how teach-back is delivered in different settings; 2) what strategies are used to support the implementation and uptake of teach-back; and 3) the effectiveness of teach-back across different healthcare settings and populations. As shown in Fig 1 , these components form the ‘zone of translation’ within the translational research process [ 32 ], thus providing a conceptual basis for our research questions.

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https://doi.org/10.1371/journal.pone.0231350.g001

Material and methods

A systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [ 33 ].

Search strategy

An electronic search using Ovid Medline, CINAHL, Embase and The Cochrane Central Register of Controlled Trials was performed for published literature from inception to 11 July 2019. A sensitive search strategy was developed using the following search terms: “Teach-Back Communication” or “Teach-back” or “Show-me” or “Closing the loop” or “Closing the cycle” or “Ask-tell-ask” or “Repeat back” or “Verbal exchange” or “Patient-provider communication”. Reference lists from eligible studies, systematic reviews and grey literature were also reviewed for further relevant studies.

Study selection

One author screened the titles and abstracts of potentially relevant studies against the eligibility criteria. Of potentially relevant studies identified from this initial screening, full length articles were attained and assessed independently by two authors. If there were discrepancies from the first two independent reviews, the authors discussed the conflicting results until consensus was reached. Reasons for exclusion at this stage were recorded and detailed in Fig 2 .

https://doi.org/10.1371/journal.pone.0231350.g002

Eligibility criteria

Study design and participants..

Studies were included if they were conducted as a randomized controlled trial (RCT), non-randomized trial, quasi-experimental study, case-control study, analytic cohort study or before and after study that implemented a teach-back intervention. This review included participants of all ages who were patients, clients or consumers with any health condition.

Teach-back intervention.

Eligible studies included at least one group that participated in a teach-back intervention. A teach-back intervention was defined as ‘a structured education approach in which something is explained, the recipient’s understanding is checked by explaining back to the educator what they have just been told or demonstrating what they have been shown, any misunderstandings are then clarified, and understanding is checked again’. For the purposes of this review, structured education approaches were defined as those that were not complex in nature (i.e. not comprised of multiple, interacting components which were expected to lead to the primary outcome through several different pathways) [ 34 ]. Given that previous reviews have evaluated teach-back in conjunction with additional strategies (e.g. discharge care bundles, motivational interviewing) [ 18 , 19 ], studies that delivered a teach-back intervention in combination with other comprehensive strategies were excluded from this review; unless the sole effect of teach-back could be extracted separately.

Quality assessment

All studies were assessed for methodological quality by two independent reviewers using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies [ 35 ]. This tool was developed for use in RCTs, controlled clinical trials, case-control and observational study designs and includes eight domains of quality assessment: selection bias (were participants representative of the target population); study design; confounders (controlled for in the analysis); blinding (outcome assessors/participants); data collection methods (use of valid tools); withdrawals and dropouts; intervention integrity (consistency of the intervention); and analysis (use of appropriate statistical methods). The final two domains are not included in the overall methodological quality score. The EPHPP tool leads to an overall methodological rating score of strong, moderate or weak, and has been evaluated for content and initial construct validity and inter-rater reliability [ 35 ]. If consensus could not be reached by the two independent reviewers, a third reviewer was called upon to complete an independent quality assessment.

Data synthesis

Data from included studies were independently extracted by two authors. The following information was extracted from each study: lead author, publication year, country of study, study design, participant characteristics (% female, mean age, health condition), intervention description, outcome data (outcome measures and effect size), mode of delivery and implementation strategies. Implementation strategies were extracted into distinct categories established in the Implementation Expert Recommendations for Implementing Change (ERIC) project [ 36 , 37 ]. In the ERIC project, a panel of experts in the field of implementation science and clinical practice compiled a list of 73 implementation strategies and grouped them into 9 categories, with the intention of guiding implementation research and clinical practice ( S1 Table ). The extracted data were evaluated against the ERIC framework to determine how teach-back has been previously implemented within healthcare settings. Data synthesis was primarily done by the first author and checked for consistency by the corresponding author.

Literature search

The electronic search identified 2,738 studies for screening of eligibility after duplicate studies were removed. Of these, 2,563 studies were excluded based on title and abstract and full text was obtained for the remaining 175 studies. Based on the authors’ decisions, 20 studies met the eligibility criteria and were included in this review ( Fig 2 ).

Study characteristics

Of the 20 studies, there were nine RCTs, two controlled clinical trials, four pre-post studies, one before and after study, three prospective cohort studies and one cross-sectional study. Most studies were from the USA (n = 10) or Iran (n = 7); with one study each from Australia, China and India. Studies were conducted across hospitals (n = 8), emergency departments (EDs; n = 3), outpatient clinics (n = 4), primary care practices (n = 2), community health centers (n = 1) and nursing homes (n = 1). There was a broad range of participant characteristics across studies. One study included children aged 6–13 years old; two studies focused on older adults aged ≥60 years; one study included young adults aged 20–30 years; two studies included people aged 30–55 years; and 15 studies included all adults aged ≥18 years. Studies included people with chronic conditions such as heart disease (n = 2), chronic obstructive pulmonary disease (n = 2), Type II Diabetes (n = 4), breast cancer (n = 1) and asthma (n = 2); post-surgical inpatients (n = 2); and people discharged from the ED (n = 2). Eleven studies included a higher percentage of females. Patient characteristics are summarized in Table 1 .

https://doi.org/10.1371/journal.pone.0231350.t001

Methodological quality

The methodological quality of included studies varied (Tables 1 and S2 ). Four studies were rated as high quality, nine as moderate quality and seven as weak. Common methodologic limitations identified across studies included omission of reporting if outcome assessors were blinded to intervention/exposure study of participants, participants being blinded to the research questions and whether individuals selected to participate in the study were likely to be representative of the target population.

Delivery of teach-back

Teach-back interventions were delivered by either healthcare personnel, including nurses (n = 9), primary care providers (n = 2) and pharmacists (n = 1); or by research staff (n = 8). Fifteen studies [ 38 , 39 , 41 , 43 , 45 – 51 , 53 – 55 , 57 ] used teach-back as part of a structured educational approach. This teach-back enhanced education ranged from brief sessions to more complex training. Nine studies [ 38 , 41 , 43 , 46 , 48 , 49 , 51 , 53 , 54 ] comprised more than one education session over the study period (range 2–11); brochures or written information were given in five studies [ 39 , 42 , 47 , 53 , 57 ] to aid the teach-back process; and demonstration of a technique was used in two studies [ 47 , 55 ]. There were four studies in which teach-back was delivered as a less structured approach; two of these focused on training clinicians to use teach-back as part of their routine care [ 31 , 40 ], and two studies [ 44 , 56 ] trained nursing staff to use teach-back when providing discharge instructions in the ED ( Table 2 ).

https://doi.org/10.1371/journal.pone.0231350.t002

Implementation strategies

Implementation strategies were infrequently reported within studies. Of the 20 included studies, only 10 [ 39 , 40 , 44 , 48 , 51 – 54 , 56 , 57 ] reported sufficient information regarding implementation of teach-back. Of the remaining 10 studies, three [ 42 , 45 , 50 ] did not report any details related to implementation and seven [ 38 , 41 , 43 , 46 , 47 , 49 , 55 ] delivered teach-back via research staff, meaning that implementation strategies were not relevant in clinical practice, but for research purposes only ( Table 2 ).

Train and educate stakeholders.

Providing training and education to staff who were employing teach-back was the most used implementation strategy (n = 8 studies) [ 39 , 40 , 44 , 48 , 52 , 54 , 56 , 57 ]. Education and training programs differed but generally focused on four main concepts: 1) identifying the needs of the patient; 2) establishing the preferred learning style of the patient; 3) choosing the appropriate resources; and 4) demonstration of how to use teach-back during a patient interaction. Seven studies [ 39 , 44 , 48 , 52 , 54 , 56 , 57 ] provided a one-time education/training program in teach-back, and one study [ 40 ] provided three 1-hour interactive training sessions in health literacy and use of teach-back. One study [ 54 ] utilized an online education module, five studies [ 44 , 48 , 52 , 56 , 57 ] implemented a group education session, three studies [ 40 , 44 , 56 ] provided interactive role-playing scenarios and one study provided written education materials [ 39 ].

Use of evaluative and iterative strategies.

Four studies [ 39 , 51 , 52 , 54 ] reported the use of evaluative and iterative strategies. Two of the studies [ 52 , 54 ] developed a quality monitoring system to ensure teach-back was being undertaken appropriately, with one of these [ 54 ] also providing continued auditing of the teach-back standard. One study [ 39 ] implemented a weekly email update to inform nurses delivering teach-back on their progress and improvements, and one study [ 51 ] developed a needs assessment checklist to inform a targeted education approach for each patient.

Provide interactive assistance.

Providing interactive or technical assistance were reported in two studies [ 44 , 54 ]. This included techniques such as documentation and tracking of the use of teach-back encounters via patient electronic medical records (EMRs).

Adapt and tailor to context.

No studies reported an interpersonal focus by tailoring or adapting the teach-back intervention to the specific patient population.

Develop stakeholder interrelationships.

Developing stakeholder relationships, an important process for sustainability, was reported in only two studies [ 39 , 54 ]. One of these studies [ 54 ] designated teach-back champions on each ward to guide and motivate nurses in the use of teach-back. These champions were provided with an additional 2-hour ‘‘train-the-trainer” workshop. The other study [ 39 ] organized implementation team meetings between nurses (administers of teach-back) and a newly convened patient perception team (made up of managers, bedside nurses, and individuals who had been treated at the hospital) to achieve nursing feedback and support for the intervention.

Support for clinicians.

Ongoing support for clinicians implementing teach-back was reported in six studies [ 39 , 40 , 52 , 54 , 56 , 57 ] and mainly focused on developing clinical reminders for teach-back use. This included use of prompts such as posters and flyers on the wards [ 39 , 40 , 56 , 57 ], reminder cards [ 56 ], notes on white boards in patients’ rooms [ 54 ] and electronic prompting processes such as reminder emails or videos [ 39 , 52 , 57 ].

Engage consumers.

Only one study [ 48 ] engaged patients in the development of an implementation plan for the delivery of teach-back. This study solicited feedback from recipients through interviews on the teach-back process to inform the delivery of the intervention moving forward.

Changes in infrastructure.

Three studies [ 44 , 54 , 57 ] employed a change in infrastructure, primarily through the EMR system. This included adding teach-back prompts to the EMR [ 40 , 54 ] and making patient education materials and documentation of teach-back available within the EMR [ 57 ].

Utilize financial strategies.

Utilizing financial strategies was one of the least utilized implementation strategies, applied in only one study [ 48 ]. This study organized a prize-winning knowledge contest among patients each month as an incentive to reinforce the educational effect of teach-back and stimulate interest in patients to participate.

Outcome measures and effectiveness of teach-back

Although there was variability among studies in relation to study populations, settings and outcomes, 19 studies (95%) reported positive findings for primary outcome measures. The outcomes measured fell into three distinct categories: 1) knowledge, skills and attitudes (disease knowledge, comprehension and retention, patient satisfaction); 2) behavior change (self-care practices, medication adherence); and 3) objective health-related outcomes (hospital re-admissions, quality of life). Three studies [ 44 , 48 , 52 ] measured health literacy, however only one study measured health literacy change as an outcome [ 48 ]. In this RCT of older people (aged ≥60 years), health literacy scores–measured by the Chinese Citizen Health Literacy Questionnaire–significantly increased in the teach-back group compared to the control group (110.1 vs 74.9; p = 0.001) [ 48 ]. The three studies that involved patients discharged from ED [ 44 , 56 , 57 ] reported increased knowledge of post-discharge procedures after teach-back compared to standard discharge instructions. Most studies were conducted among participants with chronic conditions (n = 12). Studies that included participants with Type II diabetes reported significant improvements in medication adherence [ 42 , 53 ], diet changes [ 53 ] and foot self-care [ 49 ] following teach-back compared to usual care control groups. The two studies in heart failure patients measured hospital re-admissions, with both studies reporting a minor reduction in re-admission rates [ 45 , 54 ]. Demonstration of proper inhaler technique using teach-back in people with chronic obstructive pulmonary disease lead to significant improvements in inhaler technique in two studies [ 47 , 55 ]. One study in children with asthma found that teach-back was associated with increased patient-centered communication (OR = 4.97; 95% CI: 4.47–5.53) and increased engagement of parents during pediatric clinical encounters [ 40 ]. Other outcomes showing improvements following teach-back included happiness in breast cancer patients [ 38 ], quality of life in post-partum women [ 43 ], anxiety in women awaiting caesarean surgery [ 50 ] and patient satisfaction in participants using a maternal and child health call center [ 52 ]. Most outcomes were measured immediately post-intervention (n = 11); studies with follow-up ranged from 2 weeks to 1 year. Outcome measures and key findings are summarized in Table 1 .

To our knowledge, this is the first systematic review appraising the translation of teach-back into clinical practice. We found that implementation of teach-back is not well described in the literature. The most frequently utilized implementation strategies were training and education of stakeholders (e.g. educational materials, training modules) and reminding clinicians to implement the intervention (e.g. clinical reminders/prompts). Findings from this review can inform healthcare services and providers about key strategies to optimize the routine uptake and sustainability of this effective health literacy-based communication technique.

Delivery and feasibility

Teach-back was most commonly delivered as part of a structured, but simple educational approach, with this ‘teach-back enhanced education’ being reported as effective across a wide range of settings, populations and outcome measures. Settings included hospitals, outpatient clinics, the ED, and community health centers. Many health interventions are designed for a specific setting and are generally not implemented in a different setting to that which it was intended for [ 58 ]. Findings from this review reflect the broad application of teach-back enhanced education across multiple settings, including the ED. Delivering health interventions or programs in the ED is challenging given the high-pace and perplexing nature of this setting. Previous studies have shown that ED clinicians rarely confirm comprehension of instructions with their patients and that patient comprehension of ED discharge instructions is poor [ 59 , 60 ]. Three studies in this review were undertaken in the ED setting [ 44 , 56 , 57 ] and reported increased knowledge of post-discharge procedures, higher levels of diagnosis knowledge and improved recall of follow-up instructions compared to standard discharge care. These results highlight the success of teach-back in reinforcing ED discharge instructions and should be considered by ED clinicians as a key component when providing patients with information.

Implementation and integration

The most used implementation strategy in the included studies was training and educating the healthcare providers who were delivering teach-back. Education sessions were often structured and focused on the importance of tailoring teach-back to patient needs, reflecting best-practice communication techniques [ 61 ]. However, while education is essential to introduce a new intervention it is well-established that training alone is not sufficient to effect ongoing change and uptake into standard clinical practice [ 62 ]. Successful implementation requires a multifaceted approach that is guided by an implementation plan or framework, and incorporates an identified need for improvement, collaboration between stakeholders and health services, flexibility in responding to feedback, using data to drive practice change, and a culture receptive to change [ 63 ]. Among the studies in this review, only one reported using almost all implementation strategies in the ERIC framework [ 54 ]. The authors took a staged approach to implementation, initially establishing a multidisciplinary working group. This group developed a structured teach-back protocol; clinicians were trained in identification of the key learner for each patient and educated in use of teach-back through an online learning module; teach-back prompts and feedback were provided within the patient EMR; and teach-back champions were trained and assigned to individual wards. This detailed and systematic implementation plan resulted in significant improvements in patients’ understanding of their disease, improved compliance among nurses regarding the use of teach-back in educating patients, and a sustained drop in readmission rates for patients with heart failure one-year post-implementation.

The lack of involvement from consumers in the implementation of teach-back was surprising, given the consumer-focus of teach-back and the current global interest in the involvement of consumers in the design and implementation of healthcare interventions. Three studies [ 51 , 53 , 54 ] mentioned assessing the patients’ understanding before providing teach-back in order to tailor the intervention to fit the individual’s learning needs, however this is part of standard teach-back practice.

In terms of process evaluation, no studies in this review assessed implementation fidelity. This concept refers to the extent to which an intervention has been implemented in practice as it was intended to [ 64 ]. Implementation fidelity has been frequently recommended as an essential component of undertaking intervention trials [ 65 ], yet was not examined in any of the studies included in this review. Therefore, a key message from our review is that there is a need to improve reporting of implementation fidelity within intervention trials assessing the teach-back method. This would allow researchers and clinicians to identify the association between successful implementation and improved outcomes and promote the integration of teach-back into routine practice.

Effectiveness and replicability

The overwhelming effectiveness of teach-back reported in 95% of studies, and across such a broad range of patient groups and outcomes, supports the use of teach-back enhanced education in clinical practice. Additionally, the studies were of moderate quality which limits the degree of caution for interpreting this conclusion. Systematic reviews of studies examining educational interventions (without teach-back) have shown inconclusive or even negative findings [ 66 , 67 ]. Most studies in this review delivered teach-back as part of a simple educational program and compared outcomes against participants receiving ‘general education’. This demonstrates that teach-back is a valuable addition to patient education in health care settings. However, most learning-related outcomes were measured immediately post-intervention; therefore, research demonstrating that teach-back has long-term effects on patient knowledge and recall is warranted. Further, outcomes such as patient knowledge, recall of information and medication adherence are feasible outcome measures within healthcare settings. Providing feedback to clinicians through demonstration of positive outcomes may be one useful strategy to build support for continued use of teach-back.

Finally, comprehending medical diagnoses and treatments requires a level of intermediate or proficient health literacy. It is well established that patients with low health literacy have less ability to understand and recall health information [ 68 , 69 ], although few studies examined the effectiveness of teach-back to improve comprehension and recall across patients with differing literacy levels. Three studies in this review [ 44 , 48 , 52 ] measured health literacy in participants, although only Liu et al . measured health literacy change as an outcome. In this RCT of older people (aged ≥60 years), health literacy scores significantly increased in the teach-back group compared to the control group [ 48 ]. A second RCT reported that teach-back significantly improved comprehension of post-ED care (i.e. medications, self-care, and follow-up instructions) among patients with limited health literacy, compared to standard ED discharge instructions [ 44 ]. Similarly, Morony et al . reported improved knowledge of healthcare services among people with inadequate health literacy following a nurse-delivered teach-back teleconsultation [ 52 ]. Health providers are the most trusted source of health information for people [ 70 ], and therefore have a responsibility to deliver information to their patients that is clear, understandable and practical [ 71 ]. This is especially true for those with limited literacy skills, who are more likely to solely rely on their clinician for health information [ 72 ]. Teach-back may be a feasible, practical and cost-effective intervention to address this health literacy-based communication gap in health care.

Strengths and limitations

The strengths of this review include our rigorous methodology and comprehensive search strategy. We have confidence that we identified all published studies that met our inclusion criteria as we used various synonyms of “teach-back” in our search strategy. Furthermore, we excluded studies that delivered a teach-back intervention in combination with other comprehensive strategies so we could examine the sole effect of teach-back. This differed from all previous reviews on the teach-back method [ 18 , 19 ]. Limitations of our review should also be considered. Searches were limited to published studies, subjecting this review to the possibility of publication bias. Only half of the included studies provided a detailed description of implementation–three studies provided no information on implementation and teach-back was delivered by research staff in seven studies (implementation strategies not relevant in clinical practice)–which limited the main aim of this review. Additionally, given the heterogeneity of outcome measures, it was not possible to conduct a meta-analysis. It would be useful to understand the link between implementation and health outcomes; however, this was not possible due to the lack of detail regarding implementation and heterogeneity of implementation strategies in the included studies.

Conclusions

Teach-back is effective across a wide range of settings, populations and outcome measures, although implementation techniques are not well described. Use of recognized implementation strategies such as training and education of stakeholders (e.g. educational materials, training modules) and supporting clinicians to apply the intervention (e.g. clinical reminders/prompts) may support the uptake and sustainability of teach-back. In clinical practice, teach-back provides a low-cost and effective technique that can be used to enhance structured, simple education to achieve positive outcomes in communication at the patient-clinician interface. Further research examining the long-term benefits and barriers to translation of teach-back is recommended.

Supporting information

S1 table. implementation categories from the expert recommendations for implementing change (eric) project.

https://doi.org/10.1371/journal.pone.0231350.s001

S2 Table. Quality assessment results using the Effective Public Health Practice Project (EPHPP) tool

https://doi.org/10.1371/journal.pone.0231350.s002

S1 Checklist. PRISMA guidelines

https://doi.org/10.1371/journal.pone.0231350.s003

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• Research article
• Open access
• Published: 15 April 2020

Hospital falls prevention with patient education: a scoping review

• Hazel Heng 1 ,
• Dana Jazayeri 1 ,
• Louise Shaw 1 ,
• Debra Kiegaldie 2 ,
• Anne-Marie Hill 3 &
• Meg E. Morris 4  

BMC Geriatrics volume  20 , Article number:  140 ( 2020 ) Cite this article

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Metrics details

Hospital falls remain a frequent and debilitating problem worldwide. Most hospital falls prevention strategies have targeted clinician education, environmental modifications, assistive devices, hospital systems and medication reviews. The role that patients can play in preventing falls whilst in hospital has received less attention. This critical review scopes patient falls education interventions for hospitals. The quality of the educational designs under-pinning patient falls education programmes was also evaluated. The outcomes of patient-centred falls prevention programs were considered for a range of hospital settings and diagnoses.

The Arksey and O’Malley (2005) framework for scoping reviews was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Eight databases, including grey literature, were searched from January 2008 until February 2020. Two reviewers independently screened the articles and data were extracted and summarised thematically. The quality of falls prevention education programs for patients was also appraised using a modified quality metric tool.

Forty-three articles were included in the final analysis. The interventions included: (i) direct face-to-face patient education about falls risks and mitigation; (ii) educational tools; (iii) patient-focussed consumer materials such as pamphlets, brochures and handouts; and (iv) hospital systems, policies and procedures to assist patients to prevent falls. The included studies assessed falls or education related outcomes before and after patient falls prevention education. Few studies reported incorporating education design principles or educational theories. When reported, most educational programs were of low to moderate quality from an educational design perspective.

Conclusions

There is emerging evidence that hospital falls prevention interventions that incorporate patient education can reduce falls and associated injuries such as bruising, lacerations or fractures. The design, mode of delivery and quality of educational design influence outcomes. Well-designed education programs can improve knowledge and self-perception of risk, empowering patients to reduce their risk of falling whilst in hospital.

Peer Review reports

Falls in hospitals remain an ongoing concern, despite world-wide recognition of this persistent problem [ 1 ]. Rates vary widely across hospitals globally and typically range from 3 to 11 falls per 1000 bed days [ 2 , 3 , 4 ]. Around 25% of hospital falls are injurious, and result in fractures, soft-tissue injuries and fear of falling [ 5 , 6 , 7 ]. As reported in the National Institute for Health and Care Excellence (NICE) guidelines [ 8 ], hospitalised older adults are at risk of falling due to factors such as ill health, co-morbidities, anaesthetics, pain, medications, polypharmacy and muscle weakness, yet many patients do not realise their risk [ 9 , 10 , 11 , 12 ]. Patient education is one strategy to address this gap by increasing engagement in falls prevention programs [ 6 , 13 ]. Alongside clinician education, medication management, multi-disciplinary reviews, environmental modifications, assistive devices, and hospital systems and policies, education assists patients to self-manage their own falls risk [ 6 , 14 , 15 , 16 , 17 ].

Patient education is important because there can be a mismatch between perceived and actual falls risk whilst in hospital [ 10 , 11 , 12 ]. Hospital falls risks have been historically assessed using tools such as the Falls Risk Assessment Tool (FRAT) [ 18 ], St Thomas’s Risk Assessment Tool (STRATIFY) [ 19 ] and the Hendrich II Fall Risk Model [ 20 ]. Some of these assign a falls risk score to each patient [ 18 , 19 , 20 ]. Clinicians can also use their clinical judgement and application of research evidence on a case-to-case basis to determine falls risk. Carefully considered, evidence-based decision making can assist the selection of individualised falls prevention interventions [ 21 ]. Unfortunately, some patients appear to engage in risk taking behaviours that increase their falls risk [ 22 ] such as not pressing the call bell when needing to walk to the toilet [ 23 ], or not waiting for nurses to arrive before attempting to mobilise, when they are unsafe to walk without supervision [ 12 ]. Particularly for people with poor balance, cognitive impairment or gait disorders, there is an increased falls risk whilst in hospital [ 12 ]. Up to 80% of falls occur when patients are not observed [ 24 ]. Some patients initiate risky decisions about mobility based on their own judgements, without always seeking help from nurses or other health professionals [ 25 ]. Others report feeling secure by virtue of being in a hospital environment, even though they are actually at high risk of falling [ 11 , 22 , 26 ]. Although risk taking is not always problematic, it becomes dangerous when excessive, poorly considered or not in a supported environment [ 22 ].

Patient education aims to increase a person’s awareness of their own falls risk and to provide them with strategies to mitigate falls whilst hospitalised [ 27 ]. There are varying levels of evidence for different methods of patient falls prevention education, such as handouts [ 28 , 29 ], videotapes [ 30 , 31 ], posters [ 32 , 33 ], falls risk communication alerts and assistive devices (such as sensors, wristbands and bed alarms) [ 33 , 34 ], and face-to-face discussions about safe footwear and other interventions [ 35 , 36 ]. Whilst education is an aspect of most hospital falls prevention programs, few studies have evaluated the outcomes or design of educational components, based on educational theory [ 14 ]. A systematic review by Lee et al. [ 37 ] reported preliminary evidence for the benefits of delivering hospital patient education informed by educational theory and the principles of health behaviour change. Recent investigations add further weight to the idea that falls mitigation interventions that incorporate evidence-based design are successful at reducing falls [ 38 , 39 , 40 , 41 , 42 ].

For these reasons, we conducted a scoping review to identify gaps in current research by summarising and evaluating different sources of evidence from systematic reviews, narrative literature reviews, clinical trials and grey literature [ 41 , 42 ]. Given the potential for patient education to mitigate hospital falls, this scoping review aimed to (i) conduct an up to date search of hospital falls prevention interventions pertaining to patient education; (ii) appraise the design of hospital patient education programs and; (iii) identify and critique variables, tools and measures used to quantify changes in falls and associated outcomes.

Protocol and registration

The protocol for this scoping review incorporates frameworks developed by Arksey and O’Malley [ 42 ], the Joanna Briggs Institute [ 43 ] and the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) [ 44 ]. The methods were described in detail in a published protocol [ 45 ].

Research question

The broad research question was "What are the findings of current literature regarding patient falls prevention education in hospitals?" [ 45 ] The specific questions were: (i) what was the content of the patient education program? (ii) what mode of delivery was used? (iii) was the design informed by educational principles or evidence-based behaviour change models? (iv) what were the main outcomes?

Identifying relevant studies

Eligibility criteria.

Studies were included if they investigated hospital falls prevention interventions that utilised patient education. Educational interventions designed for the families of cognitively impaired hospitalised patients were also included. Educational interventions that were delivered in the emergency department with the intent of only reducing falls post-discharge were excluded. Also excluded were investigations outside of the hospital setting or in paediatric populations. Non-empirical reports were excluded. Any studies that were directed towards clinician education alone were excluded. All study designs were included, such as quantitative, qualitative and mixed-methods designs, to ensure that the full breadth of literature was captured. Only English language studies were included.

An initial limited search of PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted to identify key words and index terms. A qualified librarian established a search strategy consisting of key words and index terms, together with medical subject headings (MeSH) related to falls prevention and patient education in hospitals. This search strategy was conducted across Allied and Complementary Medicine Database (AMED), PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), PsychINFO, CINAHL and Education Resources Information Center (ERIC) for articles published from January 2008 to February 2020. Trove and ProQuest Theses and Dissertations Global were searched for grey literature. Finally, reference lists of selected articles for full text review were hand searched. An example search strategy is in Additional file  1 .

Study selection

The results from the searches were uploaded into Covidence® (a web platform for systematic reviews) and duplicates were identified and removed. The title and abstracts of articles were screened by two independent reviewers (HH, LS). The same reviewers obtained and assessed the full text of identified papers. Any discrepancies were discussed and resolved through consensus.

Data charting

A data extraction chart was developed to identify the key characteristics of each study as well as relevant information regarding the characteristics of patient falls education. Two reviewers independently charted the data and resolved inconsistencies through discussion with a third researcher. The variables included authors, publication year, country of origin, aims, settings falls prevention methods, patient characteristics, education program characteristics, measurement tools and reported outcomes.

The quality of the patient falls education program for each study was assessed by an independent researcher (HH) using a quality metric (Additional file  2 ). Any uncertainties were discussed with a second independent research who also reviewed the articles, until consensus was reached (DJ). We adapted the tool created by Kiegaldie and Farlie [ 46 ] which assesses the quality of education programs in falls prevention research for health professionals. The modified metric excludes clinician education specific items and identifies components of the education program such as the aim and setting, characteristics of the learner and teacher, learning activities and evaluation of the program. The scoring system assigned one point to each ‘yes’ response and no points to each response that was ‘no’ or ‘not stated’. A total of 0–6 points was considered to represent low quality, 7–12 points to represent moderate quality and 13–17 to indicate high quality.

Collating, summarising and reporting the results

The data extracted were summarised using thematic analysis [ 45 ]. The studies were grouped by their design, characteristics of education interventions and outcomes. When a systematic review was identified, the studies reported in that review were screened and added if they met the inclusion criteria and were not already incorporated into the search yield. As documented in our protocol paper [ 45 ], systematic reviews were included to summarise the highest level of evidence in current literature, in addition to narrative reviews, clinical research trials and grey literature.

Study characteristics

The search of the databases yielded a total of 9340 citations. The flow of studies is presented as a PRISMA flow chart (Additional file  3 ). Following full text review, 73 records were excluded. Five systematic and three non-systematic reviews were identified, and their references searched, providing an additional five articles to be included. A total of 43 articles were finally included in the current review (Additional file  4 ). They were from the USA, Australia, Israel, Singapore, China, Japan, Switzerland, the Netherlands and Canada. The highest proportion of studies was from the USA ( n  = 24).

Of the included articles, five were systematic reviews (Table  1 ) [ 14 , 37 , 47 , 48 , 49 ], three were targeted literature reviews [ 6 , 50 , 51 ], 10 were randomised controlled trials (RCTs) (Table  2 ) [ 30 , 31 , 32 , 34 , 38 , 52 , 53 , 55 , 57 ], three were qualitative studies [ 58 , 59 , 60 ], and three were unpublished theses [ 61 , 62 , 63 ]. The remaining studies were quasi-experimental trials ( n  = 18). Several of these utilised the same overall data set yet reported different outcomes. Haines et al. [ 64 ] examined economic evaluations of falls prevention programs following an RCT [ 30 ]. Three qualitative studies reported staff [ 58 ], educator [ 59 ] and participant perspectives [ 60 ] following an intervention carried out in an earlier study [ 38 ]. For the purposes of this scoping review, investigations such as these were analysed together.

Most of the trials were in an acute hospital setting ( n  = 22). Seven were conducted in sub-acute settings [ 36 , 38 , 52 , 58 , 59 , 60 , 65 ] and six included both acute and sub-acute hospital wards [ 30 , 53 , 55 , 64 , 66 , 67 ]. Six studies reported including cognitively impaired patients [ 30 , 36 , 38 , 52 , 53 , 65 ]. Only Haines et al. and Hill et al. conducted sub-group analyses of cognitively impaired patients [ 30 , 38 ].

Less than half of the studies trialled patient education as a single intervention ( n  = 11) [ 28 , 29 , 30 , 31 , 35 , 38 , 55 , 56 , 61 , 62 , 63 ]. The remaining investigations reported multi-factorial falls prevention programs that included a patient education component. Broadly, the falls education interventions could be categorised as (i) direct education of the patient about falls mitigation via face-to-face discussions that could include the use of videotapes [ 28 , 29 , 30 , 31 , 33 , 34 , 35 , 36 , 38 , 52 , 53 , 55 , 58 , 61 , 62 , 63 , 64 , 66 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ]; (ii) educational tools such as posters on walls to prevent falls [ 32 , 33 , 67 , 69 , 76 ]; (iii) consumer materials such as pamphlets and written guides for patients and families [ 28 , 29 , 30 , 31 , 32 , 33 , 35 , 38 , 54 , 55 , 56 , 57 , 58 , 61 , 62 , 64 , 65 , 68 , 70 , 71 , 72 , 74 , 75 , 76 ]; and (iv) hospital falls prevention systems, policies or procedures that included an element of patient education [ 32 , 33 , 36 , 54 ].

Content of patient falls education programs

Most hospital patient education programs focused on providing information to individuals about falls risks, and how to prevent falling (Additional file  5 ). Some only reported educating patients about risk whilst in hospital [ 29 , 33 ]. Others reported educating patients more generally about falls prevention strategies at home, in the community and whilst in hospital [ 36 , 67 , 72 , 76 ]. These instructions varied between studies. Several delivered individualised patient education based on risk factors that were identified through risk assessments [ 32 , 34 , 53 , 54 , 63 , 73 , 74 ]. Examples included using the call bell when needing to transfer, waiting for the nurses to arrive to assist with mobility, encouragement to use appropriate footwear and instructions about using appropriate assistive devices to walk [ 32 , 34 , 53 , 54 , 63 , 73 , 74 ]. Two studies incorporated goal setting within patient education [ 30 , 38 ]. Another two reported engaging the patient to identify their own falls risk [ 30 , 33 ]. Some reports did not provide enough description of the content of the education program to enable replication of exact elements [ 30 , 52 , 57 , 69 , 70 , 75 ].

Education delivery mode

A range of modes of patient falls education were used, with some investigators implementing combinations of approaches (Additional file 5 ). The most prevalent mode was face-to-face education, where either hospital clinicians or research staff delivered falls education directly to the patient [ 34 , 35 , 36 , 53 , 66 , 73 ]. Others used videotapes [ 62 ], handouts [ 32 , 54 , 57 , 65 ] or fall prevention posters [ 67 ] as single modalities. Some combined face to face discussions with handouts [ 28 , 29 , 56 , 68 , 71 , 74 , 75 ], videotapes [ 61 , 63 ], posters [ 69 , 72 ], or a combination of videotapes and handouts [ 30 , 31 , 38 ]. Yet others combined handouts with videotaped education [ 55 , 70 ], posters [ 76 ], or with posters and videotapes [ 33 ].

Educational design principles and models

The majority of articles in this review did not provide any information on educational design, theoretical models or guiding principles on which programs were based (Additional file 5 ) [ 28 , 31 , 33 , 34 , 35 , 36 , 52 , 53 , 57 , 61 , 63 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. Three reported the content of the education program to be designed with reference to the Health Belief Model [ 30 , 38 , 55 ]. The Health Belief Model poses that health behaviour change occurs when an individual’s perception of threats, barriers, benefits and self-efficacy are acknowledged and managed [ 77 ]. Three studies designed falls education programs with consideration of adult learning principles [ 29 , 33 , 38 ], which posits that adults learn best when they have high self-esteem, are active in knowledge gain, receive appropriate feedback and have low levels of anxiety [ 78 ]. Others reported taking into consideration the level of consumer literacy [ 32 , 54 ], theoretical principles of educational design and communication [ 55 ], or principles of patient engagement when designing the falls education program [ 62 ]. Three investigations used the teach-back method to assess what the patient learned. Based on this assessment they targeted gaps in knowledge [ 35 , 61 , 73 ]. Another study engaged patients with motivational interviewing to encourage behaviour change to prevent falls [ 56 ]. Such educational design principles reflected the recommendations of the Prevention of Falls Network Europe (ProFaNE) guidelines, which advocate increasing awareness of falls risk, positive self-identity, and self-management [ 79 ].

Education and fall outcomes

Education-specific outcomes.

Educational outcomes were reported in six trials [ 29 , 31 , 54 , 55 , 56 , 63 ]. Cerilo et al. [ 63 ], Dykes et al. [ 54 ], Hill et al. [ 55 ] and Kuhlenschmidt et al. [ 31 ] assessed patient self-perceived ratings of their falls risk. Cerilo et al. used the Falls Risk Awareness Questionnaire (FRAQ) which is yet to report validity and reliability [ 80 ]. Hill et al. and Kuhlenschmidt et al. both developed questionnaires to evaluate knowledge, motivation and satisfaction [ 31 , 55 ]. Kuhlenschmidt et al. reported validating their questionnaire readability, accuracy, adaptability and reliability [ 31 ]. Dykes et al. rated patient self-perceived falls risk using a Likert scale [ 54 ]. All of these investigators noted that self-perceived falls risk improved post falls-prevention intervention. Hill et al., Huang et al. and Kuhlenschmidt et al. also showed that patient education was effective in increasing knowledge about predisposing factors to slips, trips and falls [ 29 , 31 , 55 ].

Additional outcomes included patient confidence and fear of falling. Cerilo et al., Kiyoshi-Teo et al. and Huang et al. measured patient confidence in completing daily activities together with fear of falling [ 29 , 56 , 63 ]. Cerilo et al. and Kiyoshi-Teo et al. used the Falls Efficacy Scale (FES) and Falls Efficacy Scale International-Short (FESI-S) respectively [ 56 , 63 ], while Huang et al. developed their own survey to quantify self-efficacy [ 29 ]. Only Huang et al. and Kiyoshi-Teo et al. showed an increase in self-efficacy following hospital falls education [ 29 , 56 ].

Cerilo et al. and Kiyoshi-Teo at al. quantified the level of patient engagement in self-management behaviours using the Patient Activation Measure (PAM) instrument [ 56 , 63 ]. Neither found significant improvements in patient engagement. Hill et al. [ 55 ] reported that patients who received videotaped education were able to name more falls strategies than patients who received written education. They also had higher levels of motivation to carry out falls mitigation strategies compared to the group that received only written education [ 55 ]. Participants in the study by Dykes et al. gained knowledge of falls prevention strategies [ 54 ] while Kiyoshi-Teo et al. did not find changes in falls prevention behaviours on the Modified Falls Behavioural (M-FaB) scale [ 56 ]. Kuhlenschmidt et al. assessed participant willingness to ask for assistance as well as their satisfaction with the falls prevention education program [ 31 ]. They did not find any change in willingness to ask for help although their satisfaction with the program was high [ 31 ].

Fall-related outcomes

The fall-related outcomes varied. Most studies analysed falls rates per 1000 patient days in control and experimental groups [ 30 , 32 , 38 , 52 , 53 , 54 , 65 , 71 , 73 , 74 , 76 ]. Others either reported the raw number of falls in intervention and control groups [ 35 , 52 , 53 , 56 , 69 , 70 , 71 , 75 , 76 ], falls risk ratio (ratio of cumulative fall incidence in intervention group to control group) [ 30 , 34 , 38 , 52 ], falls rate ratio (ratio of fall incidence rate in intervention group to control group) [ 38 , 53 , 57 ], or odds ratio (ratio of the odds of falling in the presence or absence of the intervention) [ 38 , 65 ]. The injury rates associated with falls were sometimes given [ 28 , 32 , 38 , 54 , 68 , 70 , 71 , 73 ]. Most of the trials showed an improvement in falls outcomes, with seven reporting otherwise [ 28 , 30 , 52 , 53 , 56 , 66 , 71 ]. Other outcomes included the impact of falls prevention interventions on staff knowledge and practice [ 31 , 58 , 71 ], patient adherence to the falls prevention interventions [ 32 , 61 , 69 ], changes in gait and balance [ 66 ], and economic outcomes [ 64 , 68 , 69 ]. Overall, the literature showed positive benefits of hospital falls education.

A sub-group analysis of patients with cognitive impairment was performed in two trials [ 30 , 38 ]. While Haines et al. [ 30 ] found similar rates of falls overall between patient education intervention and control groups, cognitively impaired participants had a higher rate of falls with injury compared with the control group. Hill et al. [ 38 ] found that patients with cognitive impairment had less reduction in falls compared to those with intact cognition.

Quality of falls education programs

The studies reviewed scored comparatively low ( n  = 19) or moderately low on quality appraisals ( n  = 12) (Additional file  6 ). None had a high rating on the patient education quality metric tool. Although most of the education programs had clear aims and purposes, there was seldom recognition of the learner’s prior knowledge or experience. Many did not state if the clinicians or teachers were qualified in teaching or whether they had received training on the falls education program. Several studies included descriptions of the patient learning activities, although only a few assessed the learner’s knowledge or skills post intervention [ 29 , 31 , 35 , 54 , 55 , 56 , 61 , 63 , 73 ]. One investigation described evaluating the process of the falls prevention education program by assessing patient satisfaction with the program [ 31 ]. Hill et al. [ 60 ] published an evaluation of patient awareness, knowledge and confidence to engage in falls prevention strategies after they received education whilst in hospital [ 38 ]. None of the remaining trials planned an evaluation of the education program, such as seeking feedback from participants.

Systematic reviews

Five systematic reviews examined falls prevention interventions in different hospital settings (Table 1 ). The settings included acute, sub-acute, rehabilitation, community and residential care facilities. All systematic reviews evaluated multifactorial interventions that incorporated a component of patient education. Two assessed patient education as a single intervention [ 14 , 37 ]. Each systematic review used a different critical appraisal tool. Three concluded that multifactorial interventions may reduce falls rates [ 14 , 47 , 49 ], whereas one was not able to determine if patient falls education alone was effective [ 14 ]. One systematic review of 26 studies that was conducted in 2014 concluded that patient education alone or as a multifactorial intervention reduced falls rates [ 37 ].

This scoping review showed patient education to be an important part of falls prevention in hospitals, whether given as a single intervention or delivered within a multifactorial fall mitigation context. Several knowledge gaps were identified. Most notably, many of the identified studies had a minimal focus on educational design and the quality of education. Many were not designed according to evidence-based educational principles or learning theories. Few engaged patients in active learning, which is argued to be associated with gaining a deeper level of understanding and higher engagement [ 81 ].

Some links were found between the quality of education programs and a reduction in falls and fall-related injuries. Twenty-eight trials assessed falls-related outcomes and eight of these were RCTs with level II evidence [ 82 ], three of which scored moderate for patient education quality [ 30 , 38 , 56 ]. Of these, Hill et al. [ 38 ] achieved a significant reduction in falls post-education. However, Haines et al. [ 30 ] and Kiyoshi-Teo et al. [ 56 ] did not find a difference in falls rates and monthly incidence rates following patient education. Hill et al. [ 38 ] reported teacher characteristics and provided age-appropriate learning activities for patients as well as specific falls education content. The trial design used by Hill et al. [ 38 ] also appeared to facilitate a growing safety culture in the ward and was developed specifically for hospital inpatients. The content focused on encouraging patients to interact with staff who could have provided reinforcement for the learning that occurred. The use of videotapes delivered on screens and with headphones aimed to assist patients with visual and auditory impairments. This may have increased the uptake of falls prevention strategies as falls rates were reduced across whole units. These units included patients with impaired cognition who did not receive personalised falls education.

The finding that patient education reduces hospital falls was also evident in many of the non-RCT studies [ 82 ]. Those which scored high on the quality metric appeared to be more effective in reducing falls-related outcomes, regardless of whether the intervention was single or multifactorial. For example, Martin [ 61 ] trialled patient education as a single intervention. They utilised a validated model of the “teach-back” method [ 83 ] and found that falls were reduced post-intervention. The trial by Quigley et al. [ 73 ] conducted falls education using “teach-back” which was part of a multifactorial intervention and was reported to reduce hospital falls rates.

For the remaining studies, there was a trend towards multifactorial interventions with a component of targeted patient education being most helpful. Five of these were RCTs, and three of them reported a statistically significant reduction in hospital falls rates with multifactorial interventions [ 32 , 34 , 57 ]. This trend was also reflected in non-RCT studies, most of which trialled patient education as part of a multifactorial bundle (Additional file  7 ). These data need to be interpreted cautiously due to the heterogeneity in education modes, environments and hospital types. It is difficult to ascertain the influence of the patient education component alone within multifactorial interventions.

Few trials applied educational theory, educational principles or a patient engagement framework to inform the design of patient education programs. Incorporating these factors has been shown to optimise health education in other chronic diseases, such as heart failure [ 84 , 85 ] and cancer [ 86 , 87 ]. Engaging participants in active learning can also be advantageous [ 81 ]. By actively participating in the learning process, patients are more likely to improve their self-efficacy and level of knowledge about falls prevention [ 88 ]. Adults are intrinsically motivated to learn, and education can improve their self-perceived falls risk and promote positive changes in health behaviours [ 89 , 90 ]. Applying health behaviour change models with adequate descriptions is therefore recommended when designing and implementing hospital falls prevention programs [ 91 , 92 , 93 ].

The literature that we reviewed suggested that patients can sometimes experience feelings of stress or loss of control during their hospitalisation [ 94 , 95 ]. This has the potential to affect their ability to process and retain new information [ 94 , 95 ], such as how to prevent falls in different contexts. When designing new falls prevention programs for hospital patients, it seems important to consider the context, task demands and individual needs.

A recurring theme in the literature that we reviewed was that cognitive impairment can have an adverse effect on the ability of patients to prevent falls [ 30 , 38 ]. The design and modification of patient education programs for people with cognitive impairment needs careful consideration. A study by Kiegaldie et al. [ 96 ] illustrated the challenges associated with delivering education to people with cognitive impairment. They recommended the use of specific techniques such as “chunking”, repetition, simplification, rephrasing, using concrete examples/stories and frequent positive reinforcement when designing education programmes for patients with cognitive impairment [ 46 , 96 ]. The overall message is that more research is needed on how to modify existing falls education programmes to these patients and how best to measure educational outcomes when cognition is impaired.

There were some limitations of this review, such as not including articles that were published in languages other than English and the exclusion of paediatric and non-hospital populations. Not all trials gave falls rates, and some only conducted pre-post analyses on falls-related outcomes. We found numerous falls prevention strategies for use in hospitals yet many had low levels of supporting evidence [ 14 ]. In a recent Cochrane systematic review, Cameron et al. [ 14 ] reported the quality of most studies on hospital falls prevention to be low. Although that review concluded that some multifactorial interventions and some single methods may reduce falls rates in hospitals, further high quality controlled clinical trials are needed to verify whether this is always the case. Few investigations explored whether physically restricting mobility could reduce hospital falls, possibly due to ethics concerns pertaining to physical restraints. A strength of this review was the scoping methodology [ 42 , 43 , 44 ] which allowed a broad examination of the literature to identify and clarify key concepts in hospital falls prevention education [ 41 , 43 ].

Evidence is accumulating that hospital falls prevention interventions that include patient education have the potential to reduce falls. Although no single model of patient education was found to be effective for every person, this scoping review identified key themes. These were: (i) the design and delivery of falls education needs to take into account individual falls risks and environmental context [ 38 ]; (ii) a combination of education modes (e.g. face to face discussions, handouts, videotapes) can sometimes be more effective than using a single modality, although this varies according to hospital settings and patient characteristics; (iii) falls education interventions are most helpful when their design incorporates theories of health behaviour change and educational principles; (iv) incorporation of an active learning design can better engage some patients. In addition, reporting of interventions should follow established guidelines to ensure transparency and improve the quality of hospital falls research [ 8 , 97 ].

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

National Institute for Health and Care Excellence

Falls Risk Assessment Tool

St Thomas’s Risk Assessment Tool

Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews

Cumulative Index to Nursing and Allied Health Literature

Medical subject headings

Allied and Complementary Medicine Database

Cochrane Central Register of Controlled Trials

Education Resources Information Center

Randomised Controlled Trial

Prevention of Falls Network Europe

Falls Risk Awareness Questionnaire

Falls Efficacy Scale

Falls Efficacy Scale International-Short

Patient Activation Measure

Modified Falls Behavioural scale

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Acknowledgements

The authors thank Healthscope, ARCH and Holmesglen Institute for their valuable support, Yvonne Harvey, Holmesglen Institute librarian, Brent Seymour for his assistance in screening studies and a consumer representative for providing valuable advice.

This scoping review was conducted as part of a National Health & Medical Research Council Australia grant (1152853) in partnership with Healthscope, Holmesglen Institute, La Trobe University, Curtin University and several other Australian universities. The NHMRC had no active role in the design of the study, data collection, data analysis, interpretation of data and in writing the manuscript.

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HH, MEM, DJ and DK conceptualised the study. All authors were involved in the design and writing. HH and LS were responsible for searching, screening and selecting studies. HH was the main author. MEM, DJ, DK, LS and AMH were critical readers and revisers of the manuscript. All authors gave final approval to submit this paper.

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Additional file 1..

Search strategy for CINAHL. Example of search strategy used in the literature database of CINAHL.

Additional file 2.

Modified quality metric of education design. Modified quality metric tool used to assess the quality of education program design.

Additional file 3.

PRISMA flow diagram of search results. PRISMA flow diagram of search results.

Additional file 4.

Table of included studies. Characteristics of all included studies in this scoping review.

Additional file 5.

Table of content, delivery and design of each education program. Descriptive characteristics of content, delivery and design of each education program in included studies.

Additional file 6.

Quality metric scores of patient education programs. Quality metric scores of each patient education program presented in included studies.

Additional file 7.

Characteristics of non-RCT studies. Descriptive characteristics of all non-RCT studies including setting, intervention type, patient education content, delivery, design, outcomes and quality.

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Heng, H., Jazayeri, D., Shaw, L. et al. Hospital falls prevention with patient education: a scoping review. BMC Geriatr 20 , 140 (2020). https://doi.org/10.1186/s12877-020-01515-w

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Patient-centered care and interprofessional collaboration in medical resident education: Where we stand and where we need to go

• Arpita Gantayet-Mathur   ORCID: orcid.org/0000-0001-5263-5444 1 ,
• Karenn Chan 2 &
• Meena Kalluri   ORCID: orcid.org/0000-0003-4645-6292 3  

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Patient centered care (PCC) and interprofessional collaboration (IPC) remain important goals for all healthcare systems. While these tenets are a cornerstone of training for nursing and allied health professionals (AHPs), their role in internal medicine resident (IMR) training is unstructured and limited. We performed a narrative review to answer two questions, firstly ‘what is known about the attitudes and behaviors of internal medicine (IM) physicians and trainees with respect to PCC and IPC and how does this compare to AHPs?’ and secondly, ‘what evidence based interventions have been trialed to promote PCC and IPC in medical training?’ We searched databases including Cochrane, Medline, Embase, CINAHL and MedPortal. We reviewed 102 publications and found that medical residents tend to value PCC less than non-physician trainees. Hierarchical professional attitudes and a poor understanding of AHP roles are barriers to IPC, whereas diminished time for direct patient care, neglect of the patient’s context and social determinants of health, and lack of self-reflection are barriers to PCC. Published educational interventions for IMRs and AHPs have included classroom sessions, structured ward- and clinic-based interprofessional (IP) work, post-discharge care, home visits, and reflective practice. Interventions were evaluated using questionnaires/surveys, focus groups, tests, primary outcome assessments and ethnographic analysis. The most promising interventions are those that allow learners time for multidisciplinary observation, holistic patient assessments, engagement in care transitions and reflective practice. Based on the review findings we have made recommendations for integration of IPC and PCC training into IMR curricula. Future educational interventions should allow IMR observerships in a multidisciplinary team, introduce residents to the patient’s environment through home visits, incorporate patient/family perspectives in care, and include narrative reflections as part of professional development. Based on our findings and recommendations, these experiences can provide IMRs with much-needed exposure to collaborative, patient-centric care early in postgraduate training.

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Introduction.

There is a rising focus on patient-centered care (PCC), interprofessional collaboration (IPC) and medical home models within healthcare systems around the world (Doolittle et al., 2015 ). However, medical training does not emphasize the skills and values needed to provide ‘compassionate, collaborative care’ (CCC) (Lown et al., 2016 ). Orchard et al. ( 2005 ) define interdisciplinary care as “a partnership between a team of health professionals and a client in a participatory, collaborative, and coordinated approach to share decision-making around health issues” (Orchard et al., 2005 ). While these tenets are a cornerstone of training for nursing and allied health professionals (AHPs) (Macdonald et al., 2010 ; Rotegard et al., 2010 ), their role in traditional internal medicine (IM) residency training has been unstructured and limited. Current IM residency programs tend to be acute care based; within this setting, PCC training is limited due to inadequate time for direct patient care, lack of follow-up once the patient is discharged, and focus on medical more than the social determinants of health (Schattner, 2017 ). Another major factor thought to negatively impact PCC is ineffective collaboration amongst health care professionals (Reynolds et al., 1994 ; Gallagher and Gallagher, 2012 ) likely attributable to power imbalances, poor communication, lack of confidence and an inadequate understanding of the scope of practice of other disciplines (Orchard et al., 2005 ). Interprofessional education and collaborative interventions have been shown to have a positive impact on health care processes and patient outcomes (Zwarenstein and Reeves, 2006 ). Transformation of current medical education models is required to meet to the needs of the future healthcare work force.

A scoping review of 43 articles concluded that PCC must be reinforced as a core value during early postgraduate years so that it becomes systemic, while also shifting education from a uni-professional to inter-professional focus (Gillespie et al., 2017 ). It is thus increasingly important for internal medicine residents (IMRs) to be trained in patient-centered skills, including communication with patients and community members, and collaboration with multidisciplinary teams in non-acute care settings. The Canadian Interprofessional Health Collaborative has identified six interprofessional competency domains: interprofessional communication, patient/client/family/community-centered care, role clarification, team functioning, collaborative leadership and interprofessional conflict resolution (Canadian Interprofessional Health Collaborative, 2020 ). It is the responsibility of IM programs to ensure training in these core competencies to promote skills and positive attitudes in the arena of IPC and PCC.

In this qualitative narrative study, we review the attitudes and behaviors of IM physicians and residents with respect to IPC and PCC as compared to other AHPs. Appreciation of these values is a prerequisite for their adoption through training. In addition, we review educational interventions that have been trialed and observed to promote IPC and PCC amongst IMRs and AHPs. Based on these findings, we make recommendations for enhanced PCC interventions in IMR postgraduate training.

Identifying the review question

The review questions were discussed and agreed upon by all authors. The first question identified was ‘what is known from existing publications about the attitudes and behaviors of IM physicians and trainees with respect to PCC and IPC and how does this compare to AHPs?’ The second question was ‘what interventions have been trialed and presented in the literature to promote PCC and IPC amongst IM trainees and physicians?’

Identifying and selecting relevant studies

Figure 1 summarizes the search strategy used. We searched MEDLINE, CINAHL plus, Cochrane Library, MedEdPortal and Pubmed. Keywords used were internal medicine, training/education/residency, patient/client-centered care, inter-professional/multi-disciplinary/inter-disciplinary and nursing/allied health. Screening of search results was done by the first author using inclusion and exclusion criteria described in Fig. 1 . Following the removal of duplicate abstracts, 111 studies were shortlisted for review. However, 3 papers could not be accessed and 6 were found to be irrelevant.

PCC patient-centered care, IPC interprofessional collaboration, IM internal medicine, IPE interprofessional education, IMR internal medicine residents.

Summarizing and reporting the relevant studies

The remaining 102 papers were reviewed by the first author and manually sorted into one of the following three themes using an inductive approach: (1) description of attitudes and behaviors surrounding IPC and/or PCC; (2) description of one or more interventions to target IPC and/or PCC; and, (3) non-primary research articles describing a need for IPC and/or PCC curriculum or system-based change. The third author then independently reviewed the 102 papers and assigned each to one of the three themes identified by the first author. Subsequently, the two authors met to discuss differences and re-assigned papers to themes as needed. Papers from the three themes are summarized and presented in Tables 1 – 3 , respectively. In instances where multiple articles stemmed from the same research project, the overlapping publications were summarized into the same row. Following summarization, one or more categories was assigned to each paper. Categories were not predetermined but were discerned by the first author after the first round of reviews. The final categories were coded into each theme/table (summarized in Fig. 1 ). The first author assimilated the findings from papers with a particular category assignment and used the conclusions to design a discussion section that would answer one of the two review questions. The second and third authors then took turns reviewing the categories and the resulting discussion sections and made the necessary changes. Some papers, especially those with multiple assigned categories, were used in more than one discussion section. The discussion sections generally transcend multiple themes, that is, they include papers from one or more tables. Given the variability of publication types, study populations, methods, and outcome measures, we used a qualitative narrative approach to summarize and report data.

Table 1 summarizes 37 primary research papers that provided a description of attitudes and behaviors surrounding IPC and/or PCC amongst physicians, medical trainees and/or allied health. Evaluations of attitudes in these papers was done by varying combinations of patients, physicians, trainees, nurses, AHPs and administrative staff, as noted under the ‘study population’ column. In addition, we summarized salient points regarding the study design and evaluation methods used and provided insights into relevant study conclusions.

Table 2 summarizes 36 papers that reported one or more real-time or simulated interventions to target IPC and/or PCC. Real-time interventions were conducted in real patient care scenarios and in the context of real interprofessional teams, whereas simulated interventions included standardized scenarios, theoretical cases and classroom-based learning. In studies involving IMRs/physicians, study populations ranged from ‘only IM physicians/residents’ to ‘collaboration with AHPs or specialities’ to working in ‘interprofessional teams’. Amongst other non-physician health professionals, the study populations ranged from graduate non-physician programs, pharmacy, nursing and medical students, internationally educated health professionals, multidisciplinary ward teams, and miscellaneous participants. PCC interventions included classroom sessions, structured ward-based rotations with a focus on post-discharge care, home visits, palliative care experience, reflective practice and a combined IM/alternative medicine program. IPC interventions included one or more classroom sessions, online sessions, structured ward-based IP learning, continuity clinics, home visits, and systems based practice training. Interventions were evaluated using a combination of questionnaires/surveys, focus groups, one-on-one interviews, pre- and post-tests, objective structural clinical examinations (OSCEs), primary outcome assessments and ethnographic analysis. When coding categories, in addition to categories for IPC or PCC simulated or real-time interventions, we also assigned categories for IMR or non-IMR attitudes to IPC/PCC if these were revealed during an intervention. An additional category was assigned for the use of narrative reflective practice as an intervention; only 2 such interventions were identified for IMRs and 5 for non-IMRs.

Table 3 summarizes 29 articles, reviews, opinions, personal views, reflections, perspectives, commentaries and best practice guidelines that discussed a need for system-based change and/or PCC/IPC curriculum change in medical education. Three of these described a need for narrative reflective practice in curricula.

The Institute of Medicine’s 2001 report strongly advocated for adoption of PCC (Institute of Medicine Committee on Quality of Health Care in America, 2001 ) but changes in clinical practice and medical education reform have been slow. We undertook this study to explore the attitudes of physicians and learners towards PCC and IPC and to catalog educational interventions designed to promote these skills in medical education and training. Our review finds concerning trends in attitudes based on professional cultures (Table 1 ). Physicians think of PCC as an individualized approach to care with a focus on systematic evidence and objective knowledge to improve care (Smith et al., 2015 ; Sidani et al., 2018 ). In contrast, nurses and other allied staff perceive it as a team approach with a focus on patient experiences and developing therapeutic relationships (Smith et al., 2015 ; Sidani et al., 2018 ). This significant difference may underlie many physician-related barriers to IPC including lack of patient centered communication, team engagement, and inclusion of patients, families and other team members in decision-making. Overall, physicians appear to value PCC less than other allied health staff (Gachoud et al., 2012 ). Alarmingly, this trend was noted even amongst medical students and residents who appear to value IPC and PCC learning significantly less than non-physician counterparts with a lack of improvement in attitudes as training progressed (Kashner et al., 2017 ). In fact, IMRs in a PCC initiative reported that the physical and learning environment had more impact on their satisfaction than practicing patient- and family-centered care (Byrne et al., 2013 ).

Physician overconfidence in PCC skills can affect attitude to learning

Physicians’ negative attitudes and misperceptions regarding PCC likely influence their perception of need for such training (Table 1 ). Sidani et al. ( 2016 ) showed that physicians rated their PCC abilities higher than their patients’ ratings of their skills (Sidani et al., 2016 ). In an ethnographic study in a cardiology clinic, patients found it difficult to understand and participate in decision-making and indicated that physicians lacked skills related to the non-medical aspects of their diagnosis (Thrysoee et al., 2018 ), potentially because physicians focus more on the biomedical aspects of their patient’s care than on psychosocial domains (Weiner et al., 2007 ). Physicians probed fewer contextual (51%) than biomedical (63%) hints during patient interviews (Weiner et al., 2010 ). IMRs and physicians are overconfident in their own PCC skills but in reality, lack the necessary knowledge and communication skills. They inadvertently develop negative attitudes and perceptions regarding this type of learning and therefore, view them as less valuable. These misperceptions must be explicitly corrected; PCC curricula must clearly demonstrate the need for teamwork and create appreciation for the value of AHPs. As noted by Kathol and Kathol ( 2010 ) in Table 3 , learners must attend to the patient’s narrative and environment, not as an afterthought, but as part of the clinical reasoning process (Kathol and Kathol, 2010 ).

Physicians practice and value IPC less than allied health professionals

Evidence suggests that physicians do not value IPC as much as AHPs (Table 1 ) likely because they do not understand the varied interprofessional roles or fully appreciate their impact on patients (Muller-Juge et al., 2013 ; Card et al., 2014 ; Blondon et al., 2017 ; Bochatay et al., 2017 ; Kashner et al., 2017 ; Garth et al., 2018 ). A qualitative study of General Internal Medicine (GIM) wards in Toronto identified several gaps in communication and collaboration between physicians and other AHPs (Zwarenstein et al., 2017 ). AHPs had frequent deliberative discussions about patients amongst themselves whereas physician interactions with AHPs were limited mostly to structured rounds; physicians made decisions mostly in isolation (Zwarenstein et al., 2017 ). In another ethnographic field analysis, Chesluk et al. 2010 found that physicians set a hectic pace within an isolated ‘bubble’, seeing patients non-stop and isolating themselves from their staff and other office professionals (Chesluk et al., 2010 ). In another study, residents were least inclined, amongst AHP students, towards interdisciplinary work; they were less likely to agree that IPC benefits patients and is a good use of time (Leipzig et al., 2002 ). Profession-focused rather than patient- or team-focused goals, negative stereotyping and hierarchical communication (Thomson et al., 2015 ) may result in physicians not always prioritizing multidisciplinary rounds, not asking team members for input, or keeping them informed (Garth et al., 2018 ). Physicians have been trained in a culture where they believe that the team exists to support them: this attitude is negative to team functioning as members may feel disrespected and ignored, leading to decreased confidence and reciprocity (Sidani et al., 2016 ). Physicians likely lack insight into their own deficiencies (Sidani et al., 2016 ) thus highlighting the need for ongoing interprofessional education through school, residency, and practice.

Transforming medical culture is an important first step in promoting PCC and IPC

As shown in Table 3 , quality of care improves when it is patient-centered, but medical education is still predominantly disease-centered and teaches individual approach to care (Heyrman, 1995 ). In order to transform healthcare, it is important to change the culture of the people who practice it (Ruddy et al., 2016 ) and the institutions where they work. When Horsburgh et al (found in Table 1 ) surveyed students accepted into undergraduate medicine, nursing and pharmacy programs, they found that professional sub-cultures were present even before they had commenced their education (Horsburgh et al., 2006 ). Medical students believed that clinical work was the responsibility of individuals, nursing students believed in a collective view, and pharmacy students were at a midpoint in views (Horsburgh et al., 2006 ). This raises the possibility that our current approaches to selection may be biased towards selecting students for different healthcare professions based on their attitudes and social predilections (Horsburgh et al., 2006 ). Medical school admission committees must be able to select for learners in medicine with more patient-centric attitudes.

Additionally, IM physicians must also be encouraged to role model patient-centric and collaborative behaviors. Rice et al. ( 2010 ) (Table 2 ) found that senior physicians, nurses and AHPs minimally explained plans for an intervention to junior colleagues and rarely role-modeled PCC supportive attitudes and behaviors. Role-modeling cannot be done well in the current fast paced, interruptive environment with rare and impersonal interprofessional communication and absence of continued leadership and management support (Rice et al., 2010 ). In addition, staff may themselves not have the required training given what we know about shortcomings in medical education with respect to PCC. Changing individual and institutional culture requires long and sustained efforts. As suggested in Table 3 , in addition to training future physicians, academic programs must focus on faculty development and evaluation for existing staff (Coleman and Johnson, 2016 ). Institutions need to provide a supportive and accommodating environment and further skills development, for example training physicians in competence based evaluations. Other strategies include promoting diverse and longitudinal mentorship for learners (Coleman and Johnson, 2016 ).

PCC curricula including didactic learning, observerships, home/hospice visits and patient/family participation report improvements in PCC amongst IMRs

Several PCC educational interventions have been developed and evaluated. Majority of curricula reported a subjective or objective improvement in PCC delivery (Table 2 ). A curriculum with didactic learning using patient simulations and interview techniques showed objective improvements in a scoring system based on biomedical versus patient-centric conversation analysis (Maatouk-Burmann et al., 2016 ). IMRs who joined a ward team as a quality officer reported improved awareness of fragmented care, interprofessional roles and patient perspectives (Meade et al., 2015 ). Improvements were also noted when IMRs observed and managed gaps in post-discharge care through phone-calls, clinics and home visits (Record et al., 2011 ; Ratanawongsa et al., 2012 ; Schoenborn and Christmas, 2013 ; Meade et al., 2015 ). Residents who participated in home hospice visits were more likely to discuss bereavement support and recommend hospice in subsequent practice (Espada et al., 2015 ). Both IMRs and patients in the Aliki initiative reported higher satisfaction in transitional care, medication adherence and patient understanding, likely attributable to decreased IMR workload, structured post-discharge care and reflective exercises (Ratanawongsa et al., 2012 ; McMahon et al., 2010 ; Hanyok et al., 2012 ). The deliberate practice of observing and working with teams enhanced communication and collaboration skills. IMRs must understand the value of effective interprofessional teamwork for the PCC curricula to change behavior.

As future healthcare workers, our learners will be called upon to deliver more community-based care through patient-centered medical home (PCMH) models and home visits. In a survey of 179 participants, both residents and faculty felt unprepared and reported lacking knowledge for PCMH activities; the authors attributed this to the lack of a formal PCMH curriculum (Block et al., 2017 ). Medical education should provide training that is sensitive to various care settings and not focus on acute care alone. Home visits can facilitate PCC learning by opening IMR’s eyes to the patient’s contextual environment, may ensure effective care transitions, and better end of life care through home hospice exposure (Record et al., 2011 ; Espada et al., 2015 ). In Table 3 , Gillespie emphasizes that PCC curricula needs to train residents in patient-centric tasks such as planning and managing care, educating the patient on navigating the system and enhancing continuity through effective teamwork beyond evidence based care (Gillespie et al., 2017 ).

As suggested by Weinberger et al. ( 2014 ) in Table 3 , patients and families can be involved as more active participants to promote Patient and Family-Centered Care (PFCC). They could act as ‘faculty’, advisors and discussion facilitators in postgraduate resident education and not only be a source of learning but could also provide feedback to the resident and program (Weinberger et al., 2014 ). Students in a longitudinal curriculum described in Table 2 perceived this intervention to have a positive impact on PFCC (Parent et al., 2016 ). This is essential for learners to understand the value of team based care from the patient’s perspective.

IPC curricula promote interprofessional understanding especially with IMRs as active observers

IPC interventions as part of PCC curricula (Table 2 ) involving didactic learning (Kowitlawakul et al., 2014 ; Nothelle et al., 2015 ; Gupte et al., 2016 ; Janssen et al., 2017 ; Sordahl et al., 2018 ) and/or ward-based (Nabors et al., 2011 ; Hemming et al., 2016a ) or clinic-based patient care (Soones et al., 2015 ) might improve IMRs understanding of AHP roles and create greater appreciation for their work. A longitudinal interprofessional education (IPE) experience comprising didactic learning, clinic and home visits led to significant improvement in interprofessional attitudes, respect and conflict management even though the intervention did not affect beliefs regarding the effects of IPE on patient outcomes (Hanyok et al., 2013 ). IMRs are better able to “learn” PCC and IPC traits when observing AHPs, versus interactions in traditional clinical contexts where meaningful collaborations may not occur. A classroom-based IP curriculum with modules, case studies, simulation and shared case planning (Zook et al., 2018 ) as well as a ward-based IP curriculum focused solely on teaching communication (Rice et al., 2010 ) had minimal impact on attitudes to IP care. Soones et al. ( 2015 ) noted that including residents in IP teams may not be enough to teach the impact of team-based care and that the culture of ultimate resident responsibility negatively impacted team based care (Soones et al., 2015 ). This suggests that effective educational interventions should allow residents to be a learner in the team with the flexibility to observe AHP roles and not be the responsible provider.

Narrative self-reflection through story-telling and conversation analysis has a positive impact on PCC

Kirkpatrick et al. ( 1997 ) (Table 3 ) state that narrative reflections and storytelling “enhance the learner’s sensitivity to the illness experience” and help develop respect and empathy for patients, other professionals and self (Kirkpatrick et al., 1997 ). As described in Table 2 , self-reflection is now regarded as an essential professional skill that can be developed through the practice of narrative writing. The John Hopkins Aliki initiative incorporated narrative self-reflective practice into their IM program (McMahon et al., 2010 ; Ratanawongsa et al., 2012 ; Schoenborn et al., 2013 ) with good results. Their residents noted an improvement in their ability to know their patients as people and rates of patient satisfaction also improved (Ratanawongsa et al., 2012 ). Creating pedagogical space for reflections and mutual sharing can help break down power differentials and reform worldviews based on shared values (Dellasega et al., 2007 ). Despite benefits, self-reflection is not frequently used in medical training; it has been studied more frequently in interprofessional curricula created for AHPs (Dellasega et al., 2007 ; Hanson, 2013 ; Schwind et al., 2014 ; King et al., 2017 ).

Conversation analysis (CA) is a tool to help increase personal awareness and facilitate self-reflection (Table 3 ). It can also be used as an evaluation tool in medical education for feedback and improving patient centered communication competency (Maynard and Heritage, 2005 ). Reviewing recorded conversations with skilled educators can shed light on unrecognized tendencies and behaviors in trainees during patient interviews including fear of losing control, performance anxiety, over-control by interrupting the patient, avoidance of psychological material such as death, and superficial behavior such as being overly reassuring and passivity (Smith et al., 2005 ). These attitudes are incompletely recognized by learners and are difficult to change without help (Smith et al., 2005 ).

Strategies for curriculum and system-based changes to promote PCC and IPC in healthcare

Unfortunately, in the current model of IMR training, PCC is presumed to occur but not directly addressed. Several reviews and opinion pieces in Table 3 highlight the inadequacies and provide suggestions for curriculum and system-based changes (Reynolds et al., 1994 ; Orchard et al., 2005 ; Meyers et al., 2007 ; Horwitz et al., 2011 ; Jean - Jacques and Wynia, 2012 ; Doolittle et al., 2015 ; Coleman and Johnson, 2016 ; Ruddy et al., 2016 ). When an interdisciplinary American initiative tried to transform residency training in family medicine, IM and pediatrics, their efforts were limited by institutional missions, difficulty in engaging stakeholders, and collaborative challenges in developing uniform measures, despite 97% of faculty members reporting an intention to implement PCC (Carney et al., 2015 ). PCC initiatives will have to overcome many such barriers to implement changes. As alluded to previously, entraining supportive institutional cultures is key to developing the education and clinical space for practice of PCC.

The Alliance for Academic Internal Medicine Education Redesign Task Force has made six recommendations to improve IMR education including improving longitudinal and ambulatory care training, aligning institutional resources with educational needs and adopting resident-specific competency-based education (Meyers et al., 2007 ). The move towards competency-based education requires that entrustable professional activities (EPAs) such as “recognizes nonverbal cues”, “actively listens”, “responds to emotions” and “practices self-reflection” be developed for resident evaluations (Lown et al., 2016 ). Other strategies include reduction in patient load that provides time for meaningful, deep reflection (Jean - Jacques and Wynia, 2012 ); effective, deliberate IPC (Gallagher and Gallagher, 2012 ), implementation of PFCC (Weinberger et al., 2014 ), continuous quality improvement (Kane et al., 2011 ) and as discussed in Table 2 , introduction of humanities courses (Dellasega et al., 2007 ). Smith et al. ( 2005 ) present a method for teaching personal awareness of negative attitudes; this can be used by faculty/teachers/mentors to facilitate IMR insight needed for change (Smith et al., 2005 ). At a foundational level, departments of medicine must address physician shortages, create adaptable clinical programs that are more responsive to patient preferences, prioritize PCC curricula and training, promote investments in interdisciplinary research teams and “team science”, ensure diversity in educational leaders and focus on population management and social determinants of health (Coleman and Johnson, 2016 ).

Recommendations for educational interventions

Postgraduate medical education must include a curriculum to foster competency in interprofessional PCC. IMRs must develop clarity in their own role as physicians and understand the roles of AHPs in order to allow positive collaboration, shared decision making and patient-centric goals. The focus of patient interviews must expand from biomedical assessment to a broader patient context including appropriate needs assessment.

An interprofessional PCC curriculum may be a mix of didactic, simulation and real-world experiences that allow IMRs to observe, participate and deliver PCC over the learning continuum. Educational interventions should allow IMRs to be observers of AHPs in the team rather than continuing their professional role in the context of an IP team. Observation plays a key role as it liberates learners from additional responsibility of actual care delivery during these periods.

In addition to acute care, multiple care settings must be integrated into curricula such as ambulatory care, community-based programs and multidisciplinary practices.

Home visits, hospice and palliative care should be integrated into curricula to help residents develop a global overview of patients’ experience and develop an insight into humanistic individualized approaches from initial presentation to disease progression to end of life care spanning the entire patient journey.

Narrative self-reflection should be integrated into curricula. We recommend one or more narrative reflection exercises for IMRs to encourage consolidation of their experiences. This will lay the foundation for empathetic care while focusing on the patients’ psychosocial context and recognizing their own personal journey through medicine. Conversation analysis (CA) is an additional tool to help increase personal awareness and facilitate self-reflection.

PCC evaluation must be revamped by developing entrustable professional activities (EPAs) to assess communication, respect, and empathy in the curriculum and by adopting learner-specific competency-based education.

Patients and families should be included in postgraduate resident education as ‘faculty’ and advisors who can educate and provide feedback. Dedicated space and time for IMRs to understand illness from the patient perspective will promote awareness of gaps in care and learning.

Faculty development is needed to facilitate culture change in education and practice. IM physicians need to role model patient centric and collaborative behaviors to support and sustain a patient centered attitude in care and education.

Medical school admission committees must select for learners with more patient-centric attitudes.

Interventions should be implemented at the institutional level. These include decreasing IMR workload, targeting physician shortages, structuring post-discharge care, engaging stakeholders, aligning institutional resources with educational needs, creating flexible educational programs, increasing funding for interdisciplinary research and hiring diverse educational leaders and physicians skilled in PCC.

Limitations and future directions

This is a narrative summary of the literature and many interventions did not measure or report objective findings, making it challenging to assess usefulness of the intervention (Table 2 ). The majority of interventions described an objective or subjective impact on IPC and/or PCC; only a few were considered to have failed and thus our review lacks dissenting views. This raises a potential for bias and a possibility that the search strategy was not broad enough. This review has focused on PCC and IPC interventions for IM residents and physicians while excluding interventions based solely on medical students from the search. In recent years there has been a significant uptake of interprofessional education (IPE) curricula across programs that teach medical, nursing, and allied health students in a combined, structured curriculum. Further reviews could be undertaken to explore the success of these curricula in promoting PCC and IPC as these students progress in their careers.

As healthcare transitions towards patient centered, community-based care and medical home models, it is becoming increasingly important to train medical residents with the skills to achieve competency in these extended practice areas. This review sheds light on deficient physician skills and attitudes in the arena of patient-centered care, especially when compared to AHPs who receive this foundation early in training. Hierarchical professional attitudes, poor understanding of AHP roles, diminished time for direct patient care, neglect of the patient’s context, inability to identify and address non-medical problems through effective communication and interprofessional collaboration, and lack of self-reflection are barriers to PCC. This review also highlights the need to deliberately expose and train medical residents in interprofessional interventions and collaborations early in their education in order to improve their outlook and understanding of the roles of other disciplines. The most promising PCC and IPC interventions are those that allow learners time for observation of a multidisciplinary team in action, making holistic patient assessments, developing collaborative care plans and opportunity for reflective practice. Future educational interventions should make space for IMRs to be observers, provide experiential opportunities in non-acute care settings, introduce residents to the patient’s environment through home visits and patient/family feedback, and incorporate narrative reflections to deconstruct experiences and assimilate new learning.

Data availability

All data generated or analyzed during this study are included in this published article

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Gantayet-Mathur, A., Chan, K. & Kalluri, M. Patient-centered care and interprofessional collaboration in medical resident education: Where we stand and where we need to go. Humanit Soc Sci Commun 9 , 206 (2022). https://doi.org/10.1057/s41599-022-01221-5

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Patient education and health literacy

Affiliations.

• 1 Research Group Lifestyle and Health, Utrecht University of Applied Sciences, Heidelberglaan 7, 3584 CS, Utrecht, The Netherlands. Electronic address: [email protected].
• 2 Research Group Lifestyle and Health, Utrecht University of Applied Sciences, Heidelberglaan 7, 3584 CS, Utrecht, The Netherlands.
• PMID: 30017902
• DOI: 10.1016/j.msksp.2018.06.004

Introduction: Patient education is a relatively new science within the field of health care. In the past it consisted mainly of the transfer of knowledge and mostly biomedically based advice. Research has shown this to not be effective and sometimes counterproductive. As health care has moved away from applying a traditional paternalistic approach of 'doctor knows best' to a patient-centred care approach, patient education must be tailored to meet persons' individual needs.

Purpose: The purpose of this master paper is to increase awareness of patients' health literacy levels. Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course. Many patients have low health literacy skills, and have difficulty with reading, writing, numeracy, communication, and, increasingly, the use of electronic technology, which impede access to and understanding of health care information.

Implications: Multiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension by using the teach back cycle. Printed information should be written at or below sixth-grade reading level. Visual aids can enhance patient understanding.

Keywords: Biopsychosocial; Health literacy; Patient centred care; Patient education.

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Bridging the generational gap between nurses and nurse managers: a qualitative study from Qatar

• Ahmad A. Abujaber 1 ,
• Abdulqadir J. Nashwan   ORCID: orcid.org/0000-0003-4845-4119 1 ,
• Mark D. Santos 1 ,
• Nabeel F. Al-Lobaney 1 ,
• Rejo G. Mathew 1 ,
• Jamsheer P. Alikutty 1 ,
• Jibin Kunjavara 3 &
• Albara M. Alomari 2  

BMC Nursing volume  23 , Article number:  623 ( 2024 ) Cite this article

Metrics details

The nursing workforce comprises multiple generations, each with unique values, beliefs, and expectations that can influence communication, work ethic, and professional relationships. In Qatar, the generational gap between nurses and nurse managers poses challenges to effective communication and teamwork, impacting job satisfaction and patient outcomes.

This study investigates the generational gap between nurses and nurse managers in Qatar, aiming to identify strategies to enhance collaboration and create a positive work environment.

A qualitative research design was used, involving semi-structured interviews with 20 participants, including frontline nurses and senior nurse managers. Participants were purposively sampled to represent different generations. Data were collected through face-to-face and virtual interviews, then transcribed and thematically analyzed.

Four key themes emerged: Optimizing the Work Environment : Older generations preferred transformational and situational leadership, while younger nurses valued respect, teamwork, accountability, and professionalism. Strengthening Work Atmosphere through Communication and values : Older nurses favored face-to-face communication, while younger nurses preferred digital tools. Cultivating Respect and Empathy : Younger nurses emphasized fairness in assignments and promotions, while older nurses focused on empathy and understanding. Dynamic Enhancement of Healthcare Systems : Younger nurses were more adaptable to technology and professional development, while older nurses prioritized clinical care and patient outcomes.

The study reveals significant generational differences in leadership preferences, communication styles, and adaptability to technology. Addressing these gaps through effective leadership, ongoing education, and open communication can improve job satisfaction and patient care.

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Introduction

The nursing profession faces a significant challenge of a multigenerational workforce that can cause conflict and hinder effective communication, especially between nurse managers and nurses [ 1 ]. In addition, a literature review of studies conducted over the past two decades indicates that the generational gap between nurses and nurse managers is a complex phenomenon requiring concerted efforts to address it [ 2 , 3 ].

The nursing workforce comprises four generations, including the Baby Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1979), Generation Y or Millennials (born between 1980 and 1994), and Generation Z (born after 1995) [ 4 ]. These generations have unique values, beliefs, attitudes, and expectations that influence their communication style, work ethic, and approach to work [ 4 ].

In 2013, Hendricks and Cope discussed the impact of generational differences on the nursing workforce and the challenges it presents for nurse managers [ 5 ]. They searched various databases electronically and found that generational diversity affects nurses’ attitudes, beliefs, work habits, and expectations. The paper suggested that accepting and embracing this diversity can lead to a more harmonious work environment and facilitate nurse retention [ 5 ].

The article focused on the cultural and work ethic differences between Baby Boomers and Generation Xers, with Baby Boomers primarily managing the workforce [ 6 ]. Baby Boomers are described as driven and dedicated, equating work with self-worth and personal fulfillment [ 6 ]. At the same time, Generation Xers have ideas of an acceptable workplace, and their terms of employment are usually non-negotiable [ 6 ]. The article summarized recent literature and studies to guide healthcare leadership in recruiting, retaining, and managing Generation X workers in the nursing field [ 6 ].

Similarly, Carver & Candela (2008) conducted a study to inform nurse managers about the generational differences among nurses and how they affect the work environment [ 7 ]. With four generations in the nursing workforce, understanding the characteristics of each generation can lead to increased job satisfaction, productivity, and decreased turnover [ 7 ]. Considering generational differences as part of an overall strategy to increase organizational commitment can improve nursing work environments and address the global nursing shortage [ 7 ]. Managers should increase their knowledge of generational diversity to tap into the strengths of each generation [ 7 ]. In addition, Younger nurses have different career expectations than their older colleagues [ 8 ]. They seek a balanced lifestyle with reasonable work hours, demand to use the latest technology, and expect to be vocal team members [ 8 ].

Managing a multigenerational workforce requires recognizing and valuing the strengths of each generation. Leaders who maximize everyone’s talents and address individual and generational needs can create synergy and improve team performance. Each generation brings unique strengths to the workforce that should be celebrated and utilized to the organization’s advantage. Meeting the needs of each employee, such as providing opportunities for advancement, work/life balance, compensation, benefits, and learning and development, can lead to higher-functioning work teams [ 9 ]. Nurse leaders should know their employees’ multigenerational characteristics and expectations and provide timely and specific feedback to manage them effectively [ 9 ]. With an appreciation of multigenerational differences and a commitment to higher-functioning work teams, leaders can improve organizational efficiency and patient care outcomes [ 9 ].

To bridge the generational gap in nursing, the SIT offers a comprehensive approach to enhancing communication, collaboration, and teamwork between nurses and nurse managers [ 5 ]. This involves acknowledging and respecting each generation’s unique characteristics, values, and experiences, which fosters a better understanding and more effective cooperation. Establishing a shared vision and goal for patient care unites nurses and nurse managers, helping to overcome any multigenerational conflicts that might arise in the workplace [ 5 ]. Additionally, encouraging multigenerational communication and mentoring is vital. This can be facilitated through programs where experienced nurses share their knowledge and skills with younger colleagues, promoting a cohesive and supportive team environment. Furthermore, providing training and development opportunities tailored to each generation’s diverse learning styles and preferences is essential for building a more skilled and competent workforce [ 10 ].

The literature indicates that the generational gap between nurses and nurse managers is a global complex phenomenon that can affect communication, work values, job satisfaction, retention, and quality of care [ 11 ]. Nursing leaders can recognize generational differences in values and behaviors as potential strengths. By gaining a deeper understanding of generational influences, these insights can be harnessed to develop effective strategies that sustain the diverse yet shrinking nursing workforce. Leveraging generational differences can also create positive work environments, enhance quality and productivity, and ultimately improve patient care. As generational differences increasingly become a critical aspect of diversity, it is essential to understand the dynamics between work engagement and meaningful work across generational cohorts to tailor approaches that align with each organization’s unique needs [ 12 , 13 ].

Understanding how to bridge the generational gap in nursing is crucial for nurses and nurse managers to work together effectively and provide better patient care, ultimately leading to improved patient outcomes. This study aims to enhance workplace communication and collaboration by identifying and addressing the factors contributing to multigenerational workplace conflicts. By doing so, nurses and nurse managers can build more cohesive and supportive teams, resulting in a more positive work environment. Finally, addressing the generational gap in nursing benefits the workplace and enables the organization to develop a more engaged and motivated workforce. Multigenerational learning and development opportunities can increase job satisfaction and retention. Recognizing and valuing the unique perspectives and experiences each generation brings is essential.

Study significance

To the best of our knowledge, no studies have been conducted in Qatar that addressed the generational gap among nurses. In line with this, the study aims to identify and compare the work engagement levels and managerial approaches among nurses and nurse managers across different generations and explore and propose effective strategies for improving communication, collaboration, and job contentment in an intergenerational work environment. The findings will contribute to the nursing profession’s knowledge and provide practical solutions for managing a diverse nursing workforce in Qatar.

This study utilized a descriptive qualitative research design. After considering the participants’ time limits, commitments, and convenience, data were collected through semi-structured interviews with nurses and nurse managers (Executive and assistant executive directors of nursing). The authors developed the interview questions for this study (Supplementary File 1). Participants were recruited from healthcare facilities within the organization through purposive sampling. The sample size was determined based on the data saturation point, where no new themes or perspectives emerged. Interviews were conducted face-to-face or virtually, depending on the participant’s preference and availability. With the participant’s permission, interviews were audio-recorded to aid in accurate transcription and were thematically analyzed.

Development of the interview guide

The interview guide was thoughtfully developed to capture participants’ experiences and insights effectively. The process began with an in-depth review of studies examining the generational gap between nurses and managers, identifying key themes such as work engagement, organizational environment, communication, and technological advancement. These themes provided the framework for creating open-ended questions to elicit detailed and reflective responses. Probing questions were also included to deepen the data collected by clarifying and expanding on participants’ initial answers. The draft questions underwent multiple rounds of review and refinement to ensure clarity, relevance, and the elimination of bias, with potential input from qualitative research experts.

Qualitative research aimed to generate a deep understanding of the generational gap between nurses and their managers. This understanding could not be answered in a quantitative approach. Several strategies were employed throughout the research process to ensure the credibility of the findings.

Firstly, to ensure the credibility of the data collected, the researcher established trust and rapport with the participants. This was achieved by being transparent about the research aims, building rapport, and showing genuine interest in the participants’ experiences. The researcher also ensured that the participants felt comfortable sharing their experiences and opinions by creating a safe and non-judgmental environment.

Secondly, data triangulation was used to enhance the credibility of the data. Data triangulation involves using multiple data sources to provide a more comprehensive understanding of the phenomenon being studied.

Thirdly, the researcher conducted member checking to validate the data collected. Member checking involved sharing the findings with the participants and asking for their feedback on whether the findings accurately represented their experiences and opinions. This process ensured that the researcher’s interpretation of the data aligned with the participants’ experiences and perceptions.

Fourthly, the researcher engaged in reflexivity throughout the research process. Reflexivity involves reflecting on the researcher’s biases, values, and assumptions that might have influenced the research process and findings. By being aware of their biases, the researcher ensured they did not influence the data collection or interpretation of the findings.

Finally, the researcher used a systematic and rigorous approach to analyze the data collected. This study used thematic analysis to identify patterns and themes in the data. The analysis was conducted using a coding scheme, and the findings were supported with quotes from the participants, enhancing the credibility of the findings.

Study population and setting

The participants were approached using a purposive sampling technique. A total of 20 participants were expected to join the study. All participants were approached based on an email from the corporate nursing mail group. The participants of this study met the following criteria: they represented diverse generations, with 3–4 from each of the subsequent generations: Generation X (1965–1980), Generation Y (1981–1996), and Generation Z (1997–2012); they had joined HMC for at least one year; and they were willing to participate in the study.

Study procedures

Before conducting the study, the researcher had obtained the consent of the participants (Research Information Sheet). Interviews were done face-to-face or virtually, depending on the participants’ preferences and availability. During the interviews, conversations were audio-recorded to facilitate transcriptions of the responses, completed within 24 h of the interview, and reviewed by two study researchers. The data saturation was determined by redundancy of information is indicated when similar patterns, themes, or categories keep appearing in the data, and no new information is being uncovered during additional interviews or data collection efforts.

The richness and depth of the data collected are critical. Saturation is considered reached when the data sufficiently explores and explains the research questions and key concepts, providing a comprehensive understanding of the phenomenon. Data saturation was reached after twenty interviews; however, two additional interviews were conducted to confirm this. Ethical principles were strictly observed, primarily explaining the nature and purpose of the study before obtaining their consent to participate. Identifiers were removed from the transcripts, and codes were used to label participants (e.g., Participants 1, 2, etc.). Participants were informed that they had the right to withdraw from the study at any time should they decide not to participate in further sessions.

Data analysis

Initially, all interviews were professionally transcribed verbatim, with pseudonyms used to anonymize participants and protect their identities. Both authors (JK and NFA) thoroughly read and re-read the transcripts multiple times to become familiar with the content and ensure the transcripts accurately reflected the audio recordings. then applied an inductive coding approach, deriving codes directly from the data rather than imposing them beforehand. This involved systematically identifying and highlighting significant quotes and segments within the transcripts that were relevant to the research questions. These initial codes were subsequently organized into potential themes by grouping together codes that shared a common essence or underlying concept. Following this, the researchers organized these initial codes into potential themes by grouping codes that shared a common essence or underlying concept.

The potential themes underwent a two-phase review and refinement process. In the first phase, the researchers reviewed the coded data extracts to ensure they coherently supported the identified themes. In the second phase, the themes were examined in relation to the entire data set to confirm that they accurately represented the data and captured the full range of participants’ experiences. Some themes were modified, combined, or discarded during this process based on their relevance and data representation.

The final step involved crafting a coherent and compelling narrative that provided a detailed account of each theme. The report included illustrative quotes from participants to substantiate the themes and vividly depict their experiences. This structured approach ensured that the analysis was thorough and that the resulting themes were deeply rooted in the data. By following Braun and Clarke’s six-step process, the study moved from raw transcripts to well-defined themes that offer meaningful insights into the generational gap among nurses and Nurse managers.

This study had a cohort of ten frontline nurses from the new generation and ten senior nurse managers from the old generation, as shown in Table  1 . The mean age of the new generation was 32.4 years (SD 4.9 years). The nurses had an average of 8.3 years of overall work experience (SD 3.09 years), specifically at Hamad Medical Corporation (HMC); they had a mean work experience of 4.7 years (SD 1.1 years). Gender distribution among the participants was 80% male and 20% female. This demographic profile reveals a well-experienced group, particularly regarding their tenure at HMC, providing a stable basis for analyzing their professional perspectives and experiences.

On the other hand, the old generation demographics: 60% were Executive Directors and 40% were Assistant Executives. Most participants belonged to Generation X (ages 44 to 59 years old), suggesting a consistent age distribution. On average, the executives had 27.9 years of overall work experience (SD 9.46 years), highlighting substantial professional tenure with considerable variability. Specifically, their mean work experience at Hamad Medical Corporation (HMC) was 17.4 years (SD 8.24 years), reflecting a diverse range of service durations at this institution. The gender distribution was evenly split, with 50% male and 50% female participants. Details on the demographic data of the old generation participants are detailed in Table  2 . Three major themes were derived from the study, as illustrated in Fig.  1 .

The major themes and Sub-Themes derived from the study

Optimizing the working environment

Healthy work environments that maximize the health and well-being of nurses are essential in achieving good patient and societal outcomes, as well as optimal organizational performance. This theme consisted of three sub-themes: Influencing leadership style, Patient outcome and nurse satisfaction, and Adaptation of technological advancement.

Influential leadership styles

When investigating the leadership style, all older generations consistently agreed to prefer the transformational one because of its capacity to inspire and motivate frontline staff. However, to respond to specific situational demands, the older generation in our study modified and combined aspects of situational and democratic leadership.

Which type of leadership I’m following is transformational leadership. But sometimes , we can take that democratic leadership in some situations , but not all of it. We can say situational leadership at the same time. But any leadership style you will follow should be , I can tell , a combination of some practice and attitude toward your staff”. (Participant 17).

On the other hand, the new generation perceives leadership style by retrieving the inner values of their leaders, such as respect, teamwork, accountability, and professionalism.

“Actually , our leaders primarily lead by maintaining a good relationship , and he is making sense of decreasing the distance between the higher and lower positions. So , I can say that I share the same attitudes and values with my senior managers , but it might differ from one person to another.” ( Participant 1).

Enhanced patient outcomes and nurses’ satisfaction

The older generation perceived the working environment as a motivator for enhancing patient outcomes. Mainly, they are putting serving humanity at the top of their priority, which might be achieved through creativity, collaboration, and compassion. As articulated by Participant 7, “I believe that exerting the best effort in one’s job demonstrates ownership and respect for the profession. Serving humanity , I prioritize creativity , collaboration , and compassion in my work”.

This quote demonstrates the deep values held by this group, highlighting their strategy of combining individual achievement with a wider humanitarian influence.

The new generation views the working environment as a vital element in improving nurses’ satisfaction, considering many contributing factors, such as the current status of the global economy and the opportunities for nurses to work and move abroad. As elaborated by Participant 13,

“I think we can see a difference between the young and the old generation , and I think the way they look at nursing as a profession. There is a big difference between all the new generations , and I can see how the old generation looks at it. The older generation is looking at ways to help people. It is a way to provide support for older people. Unfortunately , I think the new generation has started looking at it as a job—more than a way of helping people. And I believe there are many different reasons for this. I think about the economic status around the world , and the other thing that you know is that I believe the world is open nowadays for nurses to travel around. Therefore , it’s started becoming a job more than a profession. Unfortunately , that’s why people start looking at it in a completely different way , which is not something good.” (Participant 13).

Adaptation to technological advancements

When examining the technological aspects, the older generation acknowledges the presence of the gab. Most of them believe the gap exists because they adhere to the old practices they learned previously.

“There is a noticeable difference between the younger and older generations of nurses , primarily due to advancements in technology and medical knowledge. Younger nurses are often more up-to-date with the latest care techniques and medical research , as they can access various modern resources. Older nurses , however , may adhere to practices they learned earlier in their careers , which might not incorporate recent technological changes”. (Participant 16)

On the other hand, the new generation views new technologies as an easy-to-adopt opportunity. They like to use the new potentials that come with AI. For example, the new generation is becoming more dependent on technology due to the greater benefits it provides compared to traditional approaches in terms of diagnosis and treatment.

“Technology is a significant factor for us , being part of the newer generation. It’s very important in our year of nursing. We use computers , advanced machines , and electronic documentation , which differ from past practices.”(participant 10) . “The younger generation is adapting more easily to new technologies and software , like using EMR for documentation. The older generation , who are used to manual documentation , find it harder to adapt to this new system in patient care. I’ve also heard that some facilities are using GPS and AI systems to assist in diagnoses and results. So , artificial intelligence is becoming a part of nursing , and younger generations are adapting more easily to it. It will take time for the older generation to adapt because they are accustomed to different practices”. (Participant 8)

Strengthening the work atmosphere through communication and values

Effective communication enhances working relationships and knowledge translation and reduces conflict responsible for errors, improving patient safety. This theme consisted of three sub-themes, diverse and practical communication approaches, positive work atmosphere cultivation, and emphasis on shared values across teams.

Diverse and effective communication approaches

The older generation emphasizes the importance of training sessions on communication skills and advanced technologies to bridge the gap with the new generation. Moreover, they believe the new generation needs to be more skilled in direct interpersonal communication.

“Effective communication strategies that bridge generational gaps should be promoted. This could include training on communication best practices and the use of technology for older nurses and encouraging younger nurses to develop strong interpersonal skills for face-to-face interactions”. (Participant 20) “The older generations , always think of , they are more of insightful , in terms of , in the meetings they will be able to translate or interpret the information much differently. And that’s how I see.”( Participants − 18) .

According to the new generation, effective and direct communication without any mediator can enhance the work atmosphere and ease professional communication with older generations. It can help the new generation have more chances to interact with the old generation.

“Certainly , open and direct communication is helpful. As previously said , it is crucial to have someone who can assist in communicating with my manager in my home country. Establishing a direct line of communication with my management and developing a robust professional connection without intermediaries is vital. I appreciate the older generation’s facilitation of an open-door policy , as it cultivates a direct and efficient communication atmosphere.” (Participant 1).

Positive work atmosphere cultivation

When examining the intergenerational dynamics in the workplace, the findings indicated that differences in experience, training, and access to technology significantly impact the work environment and the level of collaboration among employees. As one participant articulated,

“The work atmosphere impacts collaboration. I think it does impact that and impacts these differences from one generation to another. It’s not about good and bad , but it’s rather about the differences in the experiences , differences in the training , and differences in the work environment as well as the availability of technology. So , I would say that there is a difference.” (Participant 19). However, the new generation focuses on the technological aspect and how that might affect the work atmosphere positively.

Emphasis on shared values across teams

Conflicts arise when older generations rely on experience while new generations prefer evidence-based practices. This affects workplace shared values.

“For instance , there might be a conflict over a non-scientifically backed common practice. The older generation might argue that they’ve been doing it for years without issues. However , from a knowledge-based perspective , the practice might be incorrect. Overall , the older generation’s viewpoint is based on their experience , where they haven’t seen negative outcomes. Conversely , the new generation would argue based on scientific principles and current best practices. The older generation might resist changing to these new practices. So , conflicts like these might arise from differing viewpoints on practices and approaches.” (Participant 9) .

The new generations perceive shared values as part of the staff-manager relationship and can’t isolate it. When the old generation leads, the staff investigates the old generation’s way of leading, which will affect the new generation’s attitudes and values. Consequently, the new generation still takes the old generation as an example to be followed. This meaning can be found in Participant 1 answers. “Actually , our leaders primarily lead by maintaining a good relationship , and he is making sense of decreasing the distance between the higher and lower positions. So , I can say that I share the same attitudes and values with my senior managers , but it might differ from one person to another.” ( Participant 1) .

Cultivating respect and empathy

This theme focuses on two subthemes: commitment to fairness and fostering a sense of purpose among staff.

Commitment to fairness

The results of the older generation highlight the importance of fostering empathy in the workplace. Participant 20 suggests promoting understanding by encouraging the new generation to consider their colleagues’ perspectives and motivations, enhancing mutual respect and cooperation.

“Encourage Empathy: Foster empathy among employees by encouraging them to put themselves in each other’s shoes. Encouraging individuals to consider the motivations and experiences of their colleagues can lead to better understanding” (Participant 20). “They can challenge you as a leader and they can challenge each other. That’s how you build a better workplace to have a conversation , a clear professional conversation. If you want to build a professional conversation , the two respect the critiques to respect the differences. So those differences are not conflicts. Differences are differences of opinion due to the experiences everybody can brings in.”(Participants 18) .

However, the new generation demands that older generations be more open to work-related discussions, assignments, and promotion opportunities. They believe the new generation has a greater chance to be promoted if they get a fair chance as they are equipped and well-educated. This was clear by Participant 9.“ Compared to the older generation , the new generation of nurses has more opportunities for service and promotion based on education. In the past , nurses often held diplomas or auxiliary nursing qualifications , with the attitude focused primarily on patient care. Now , there’s a trend towards having more knowledgeable nurses capable of providing advanced care”( Participant 9).

Fostering a sense of purpose among staff

A sense of purpose plays a crucial role in developing cohesive nursing teams by promoting transparent communication and mutual learning, as emphasized by Participant 18.

“The most effective way that I felt worked during this period is the mentorship , working closely with the people and letting them have open communication all the time , providing the proper support , and providing the platform to share the experience and knowledge while you are learning or why they are learning from , and this learning process will be from both. So , this sharing of information through a clear mentorship , in one way or another , will create a culture of mutual respect , and this will end with time; this is not just easy; it takes time. But eventually , if it is done appropriately from the beginning , it will formulate a more cohesive nursing team.“(Participant 18).

The sense of purpose was more obvious among the new generation’s responses, as can be seen in Participant 7’s response: “ Our teamwork is initially built on collaboration , where each nurse supports and enhances the work of others.”

Dynamic enhancement of healthcare systems

The new generation is more adaptable to technological changes and modern healthcare systems. They often embrace new approaches and value work-life balance and a more collaborative approach to patient care. Older nurses have been exposed to a traditional healthcare system and may have had to adapt to technological changes later in their careers.

Continuous education and professional development

The new generation is involved in all nursing and patient care areas. They are advancing in roles such as nurse advocates and nurse researchers. So, the new generation is expanding into new fields and trying to improve the nursing career by pursuing education and professional development. In contrast, the older generation focuses more on clinical areas and patient outcomes.

“There are more options available now , especially for the younger generations. Previously , options were limited. You would start at a hospital or a specific department and stay there. With education and different pathways , you can work in patient care or move into education or other areas. This variety of options makes it easier for the younger generations.” (Participant:8) . “The other thing that when you are dealing with the old generation , you’ll find the love to be with the patient , patient bedside dealing with the patient day today.” (Participant:13) .

Promotion of organizational openness and transparency

The old generation perceived transparency as the need for the new and old generations to openly discuss changes, address concerns, and collaboratively adapt to evolving practices, fostering a transparent and supportive environment in the nursing profession. “Create an environment where nurses and nurse managers can openly discuss changes in the profession , address concerns , and work together to adapt” (Participant 20).

The new generation perceives transparency as a valuable key to promoting change. Participant No. 1’s answers reveal this meaning: “By open communication , that will help. Straight communication and effective communication indeed will help in preparing for the change. As I mentioned before , I need some help or someone to communicate with my manager in my home country. Also , by ensuring that there is no second person between you and your manager , maintain good relationships.”(Participant:1).

This study assessed the generational gap between the new and the old generation. We have identified four main themes: optimizing the working environment, strengthening the work atmosphere through communication and values, cultivating respect and empathy, and dynamic enhancement of healthcare systems. Overall, the results of this study identify the generational gap between these two generations. Moreover, the findings of this research shed light on significant subthemes that highlight the evolving dynamics within the nursing profession, particularly the differences and similarities between new and old generations. The demographic data provided a clear understanding of the structure of both generations, with a notable representation of male staff nurses in the new generation and a diverse range of experiences in healthcare.

Working environment

Perceiving the work environment was evident as a generational gap in our study; the leadership style and other subthemes were also identified. This study discovered that the older generation significantly promotes effective leadership styles, including transformational and situational leadership. These styles enhance teamwork, promote autonomy, and ensure a supportive work environment. This is consistent with the findings of Cummings et al. (2018), who highlighted that transformational leadership positively impacts nurse satisfaction and patient outcomes by fostering a supportive and communicative work environment [ 14 ]. Furthermore, situational leadership is vital for the older generation in dynamic critical care units, offering flexibility to address staff readiness levels effectively [ 15 ].

On the other hand, the new generation stressed the importance of inner values such as respect, teamwork, accountability, and professionalism rather than the leadership style of the old generation. The new generation’s focus on internal values suggests a potential shift in organizational culture that prioritizes individual integrity and an attitude of collaboration over traditional hierarchical leadership approaches. This trend indicates that future healthcare entities’ strategies may incrementally prioritize cultivating an environment where ethical behaviors, mutual respect, and collective responsibility play crucial roles in achieving organizational success. This result is consistent with another study done by Boamah et al. (2018), who found that supportive leadership practices enhance nurses’ work engagement and patient care quality, emphasizing the need for recognition and acknowledgment strategies to boost job satisfaction [ 16 ].

In addition, our study evidently shows generational differences in adaptation to technological advancements, with the new generation demonstrating a higher ability to adopt new technologies into their practice. This finding is supported by Lera et al. (2020), who noted that the new generation is more comfortable with modern digital tools and evidence-based practices​ than the old generation [ 17 ].

Strengthening work atmosphere through communication and values

The current study has found that generational differences in communication preferences exist, with the new generation leveraging technology for more accessible communication. In contrast, the old generation prefers face-to-face interactions for clearer understanding. This aligns with the findings of Rosi et al. (2019), who noted that younger healthcare professionals are more likely to use digital communication tools, whereas the older generation favors traditional methods [ 18 ]. Effective communication strategies that bridge these generational gaps are crucial. Training on communication best practices and the use of technology for the old generation, as well as encouraging the new generation to develop strong interpersonal skills for face-to-face interactions, are crucial [ 19 ].

Regular feedback mechanisms are crucial for identifying and addressing concerns related to the work atmosphere. Boamah et al. (2018) suggest that understanding and addressing generational differences in work preferences can improve team cohesion and reduce conflicts, ultimately leading to better patient care [ 16 ]. The study participants also emphasized the importance of feedback in creating a positive work environment, consistent with the findings of Lin et al. (2021), who stressed the value of input in fostering a supportive workplace [ 20 ]. The current study found that creating a work culture where debate is encouraged, disagreements are respectful, and active listening helps build a team-oriented mindset. This finding aligns with research by Flores et al. (2023), who noted that promoting shared values and respectful communication enhances team cohesion and collaboration [ 21 ].

The current study has found another generational gap in respect and empathy. The new generation emphasizes the importance of having fair assignments, work-related discussions, and promotion opportunities [ 22 ]. Choi et al. (2018), consistent with our study, reported that fair clinical assignments will enhance staff satisfaction, improve nurses’ working conditions, and positively impact patient outcomes [ 23 ].

Professional self-concept is crucial to staff satisfaction, retention, and well-being [ 24 ]. The sense of purpose is part of the nurse’s professional self-concept; hence, the old generation, especially the leaders, must promote staff well-being by considering their purpose and fostering an environment of mutual benefit [ 25 ]. This finding aligns with the current study, which revealed that the new generation views a sense of purpose as fundamental to their professional needs.

The healthcare system is generally considered a significant influence on nursing careers. Regardless of generation, the healthcare system affects nurses and healthcare providers as it is continuously changed, modified, and developed, creating new challenges and opportunities for healthcare providers.

The progression of nursing practice has been significantly influenced by advancements in education and professional development, leading to a shift in roles and opportunities for nurses. The new generation, who are more adaptable to technological changes and evidence-based practices, are increasingly moving into diverse roles beyond traditional clinical settings. They are now prominent in fields such as nurse advocacy, research, and education, reflecting a broadening of the nursing profession and ultimately enhancing healthcare systems. This shift contrasts with the experiences of the older generation who have primarily focused on direct patient care within clinical environments. Recent studies support this trend. For instance, a study found that new nurses are more likely to engage in continuous education and seek roles that allow for more incredible professional growth and diversification than older nurses [ 26 ].

Our study revealed that creating an environment that promotes openness and transparency is essential for fostering effective communication and collaboration between different generations of nurses. Fostering mentorship and knowledge sharing bridges the generational gap and ensures the transmission of valuable experiences and practices. An open dialogue between nurses and nurse managers about changes in the profession, concerns, and adaptation strategies is critical for cohesive teamwork. These findings are consistent with Bragadóttir et al. (2022), which indicate that organizational transparency and open communication channels significantly enhance teamwork and job satisfaction among nursing staff [ 24 ].

This study highlights the evolving dynamics within the nursing profession, focusing on generational differences and similarities. The new generation is more skillful at integrating technology and embracing diverse roles beyond traditional clinical settings, whereas the old generation brings valuable experience and historical perspectives. Effective leadership, continuous education, and open communication are critical for optimizing the work environment, enhancing nurse satisfaction, and improving patient outcomes. Bridging the generational gap through mentorship and fostering a culture of respect and empathy are essential for a cohesive and resilient healthcare system.

Recommendations

Future research should explore strategies to effectively bridge the generational gap in nursing by integrating leadership styles, communication preferences, and technology adoption across different generations. Longitudinal studies could examine how generational dynamics evolve as new generations enter the workforce and older generations transition out, providing insights into the sustainability of organizational changes. Additionally, expanding research to diverse healthcare settings and cultural contexts would enhance the generalizability of findings. At the same time, intervention studies could test the effectiveness of tailored mentorship programs, continuous education initiatives, and organizational transparency in fostering intergenerational collaboration and improving patient care outcomes.

The study’s methodology, including potential sampling bias due to purposive selection, interviewer bias, and the subjective nature of data saturation, could also influence the results. Additionally, the context-specific nature of the study and the use of virtual interviews might limit the depth and transferability of the findings. Finally, time constraints may have restricted the comprehensiveness of the data collected.

Implications for nursing management

Nurse managers should adopt a multi-faceted leadership approach, embracing both transformational and situational styles, to meet the diverse needs of a multigenerational workforce. Implementing targeted communication training and fostering an environment of respect and empathy can improve team cohesion and patient outcomes. Investing in continuous professional development and technological training will further support the integration of new and experienced nurses.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to acknowledge the nurses and nurse managers who participated in the study.

This study was funded by the Medical Research Center at Hamad Medical Corporation (MRC-01-23-206).

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Department of Nursing, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar

Ahmad A. Abujaber, Abdulqadir J. Nashwan, Mark D. Santos, Nabeel F. Al-Lobaney, Rejo G. Mathew & Jamsheer P. Alikutty

University of Doha for Science & Technology, P.O. Box 3050, Doha, Qatar

Albara M. Alomari

Nursing and Midwifery Research Department, Hamad Medical Corporation, Doha, Qatar

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AAA, AJN: Conceptualization. NFA, MDS, JK: Formal analysis.AAA, AJN, MDS, NFA, RGM, JPA, JK, AMA: Methodology, Data curation, Manuscript writing (draft and final review). All authors read and approved the final manuscript.

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Correspondence to Abdulqadir J. Nashwan .

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Abujaber, A.A., Nashwan, A.J., Santos, M.D. et al. Bridging the generational gap between nurses and nurse managers: a qualitative study from Qatar. BMC Nurs 23 , 623 (2024). https://doi.org/10.1186/s12912-024-02296-y

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Factors influencing the patient education: A qualitative research

Mansoureh a. farahani.

Department of Nursing, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Eesa Mohammadi

1 Medical Sciences Faculty, Tarbiat Modares University, Tehran, Iran

Fazlollah Ahmadi

Nooredin mohammadi, background:.

The related literatures revealed that there is a lack of effective patient/family education in the health care centers. Several studies indicate that patients, while getting discharged from hospitals, receive insufficient information about their illness and self-care. The purpose of the study was to explore the factors influencing patient education from the perspectives of nurses in Iran.

Materials and Methods:

We conducted a qualitative study using a content analysis approach. We used a purposive sampling technique to recruit and interview 18 nurses with at least 2 years of working experience in the cardiac care unit (CCU) and post-CCU ward of two educational hospitals in Tehran related to Tehran University. Data were collected through face-to-face audio-taped interviews and field observations. The interviews were transcribed verbatim and analyzed concurrently with data collection.

The major theme extracted in this study was the inappropriate organizational culture which includes eight categories listed as follows: Not putting value on education, non-professional activities, physician-oriented atmosphere, conflict and lack of coherence in education, inappropriate communication skills, ignoring patient's right in education, lack of motivation, rewarding system in the organization, and poor supervision and control.

Conclusions:

The results of this study show that according to the participants’ perspective, organizational culture is in a poor level. So, to improve the performance of nurses, it is necessary to increase their motivation through optimization of organizational culture.

I NTRODUCTION

Patient education is an essential component of the provided care by health care professionals, particularly nurses.[ 1 ] Since the nurses are in contact with the patients more than any other member of the health provider team, there is much more importance on the side of the nurses.[ 2 ] Research results have revealed that the patients receive the most portion of information from the nurses.[ 3 ] Therefore, nurses have more opportunities to assess the patients’ educational needs and prepare them for learning.[ 4 ] Patient education is one of the criteria to accredit institutions for providing health services.[ 5 , 6 ]

The outcomes of patient education have been taken into consideration in several studies. These outcomes fit into three categories: Patient's benefit, social benefits, and professional benefits.[ 7 ]

Considering patients’ benefits, attention should be given to aspects such as an increase in the level of the patients’ satisfaction and their participation in self-care, improvement of the quality of life, a decrease in stress and anxiety level, an enhancement in psychological and physiological outcomes, a decrease in the side effects of the disease, and treatment expenditure in the patients’ readmission.[ 8 , 9 ] Besides, it has also influenced the patient's motivation to follow the recommendations, and consequently treatment compliances.[ 10 ]

In spite of these facts, patient teaching has been ignored in some health care centers. ]11] The related literatures has revealed that there is a lack of effective patient/family education in the health care centers.[ 11 , 12 , 13 ] In this regard, the study of Mardanian et al . (2004) shows that patient's education in comparison to other tasks is the nurses’ seventh priority, and therefore it can be concluded that their performance has not been as satisfying as in other tasks.[ 8 ]

Several studies indicate that patients, while getting discharged from hospitals, receive insufficient information about their illness and self-care. In the study of Weetch (2003), patients were unsatisfied with the education acquired after being diagnosed with pectoris angina.[ 13 ] The research studies conducted regarding patients’ satisfaction from the nursing care indicate that the patients have had the least satisfaction from patient education among other nursing care.[ 14 ] In another study, 60% of the hospitalized patients felt that the information they receive from health care professionals could be considerably improved.[ 5 ] Visser et al . (2001) and Skelton (2001) have found that patient education involves all educational activities relevant to patient, patient's family, health education, prevention, care, and cure.[ 4 , 15 ] Therefore, patient education should be considered as a part of patient care, not as an aside activity.[ 5 ]

A study in Iran indicated that patient education has been either partially or inappropriately performed, so it has not been effective at all.[ 8 ] Research studies show that nurses face several obstacles in performing their educational role.[ 11 , 16 ]

Besides, the experiences of the researchers of this study in cardiovascular area verify the lack of appropriate patient education in this area. So, some questions are raised: Why is not patient education provided appropriately? What is (are) the problem(s)? What kind of barriers may exist? To find out the answers, the present qualitative study was carried out. Since patient education is a complicated issue, related to social, environmental, and psychological aspects of patients, families, and health care providers, the most appropriate approach to find answers for above questions is qualitative research. The purpose of the study was to explore the factors influencing patient education from the perspectives of nurses in Iran.

M ATERIALS AND M ETHODS

We conducted a qualitative study using a content analysis approach. It was a conventional content analysis[ 17 ] because in the study we had been looking for the factors influencing the patient education. We used a purposeful sampling technique to recruit and interviewed 18 nurses with at least 2 years of working experience in the cardiac care unit (CCU) and post-CCU wards of two teaching hospitals in Tehran, related to Tehran University. All the nurses who were involved in the study had bachelor or master degree in nursing. Inclusion criteria were at least 2 years experience of working at CCU or post-CCU, and giving consent to participate in the study and to share their experiences with the researchers.

Data were collected through face-to-face audio-taped interviews and field observations. All the nurses knew that the researcher observe their function in order to collect data. A written consent had been taken for observation by the researchers. The interview was conducted in a place where the participants felt comfortable, such as in the tea and the sitting room or even in the nurse's house. The interviews were commenced by using a series of open-ended questions such as “What are your experiences of patient education?” and “How do you educate your patient?.” Comments and questions were followed up with prompts such as “tell me more about what it is like.” Each interview was of 20-120 min duration and was completed in the period between May 2008 and November 2008. During the interviews, the participants were encouraged to give more information and to discuss their experiences. One of the other data collection methods applied in this study was to observe through “observer as participant” technique, performed during patients’ hospitalization in the ward.

The primary analysis team consisted of the first author and three other faculty supervisors experienced in qualitative research and with cardiovascular nursing backgrounds. The interviews were transcribed verbatim and analyzed concurrently with data collection. During data analysis, the principal investigator (the first author) read the data word by word several times to emerge data. The authors focused on the recorded words and phrases used repeatedly by the nurses, and also highlighted the areas that captured key meaning units expressed by the participants. The codes came straight from the data in the first level of coding. Words, phrases, or sections were noted and analyzed in context both within and between documents. As the next step, the aforementioned multiple codes were grouped based on their content and shared ideas, and led to creating categories. As an advantage of this categorization, the data came from the participants, so the data had not been predetermined.[ 18 ] After identification of the categories, they were relabeled and defined one by one, while each was illustrated to support quotes.

By sharing the results with the senior investigator and supervisors, we could achieve agreement and further suggestions. The data from the interviews demonstrated saturation, since data had become repetitive and nothing new appeared when coding data from the last interview.

To achieve trustworthiness of the data, Lincoln and Guba's credibility, transferability, dependability, and confirmability were used. Several techniques such as prolonged engagement, peer debriefing, time triangulation, and member checking were employed to enhance credibility of this study.

To make sure about the transferability of the study, information about the researchers, population studied, sampling, and coding decisions was provided. Audit trails helped the researchers establish dependability and confirmability of this research.

Through an inquiry audit of the process, dependability was achieved, which led to attesting and certifying that the process was acceptable, professional, legal, and ethical. In case of confirmability, it was achieved through a confirmability audit which examined the product (data), findings, interpretations, and recommendations, attesting that the findings were supported by the data.

It is also worth mentioning that continuous consultation with supervisors, who had extensive experience in qualitative research, was practiced to ensure dependability and confirmability.

The major theme extracted in this study was inappropriate organizational culture which includes eight categories. The categories are not putting value on education, non-professional activities, physician-oriented atmosphere, conflict and lack of coherence in education, inappropriate communication skills, ignorance of patient's right in education, lack of motivation and rewarding system in the organization, and poor supervision and control. Each category has been explained in detail subsequently.

Not putting value on education

Values play an important role in any organization and can be considered as determinants of organizational culture. Our findings indicated that one of the main reasons that leads to inappropriate organizational culture was “not considering patient's education as a value” in the system. A nurse said:

” It is very important to focus on education. When all patient education activities are delivered through a crumbled pamphlet exclusively by the ward secretary at discharge time, we found that education may not be highly valued .”

Another nurse said, “ The managers are not putting enough value on patient education; as an example, on requesting for blood sugar test for a patient, the head nurse wants us to enclose the result card to the patient's file, while she never asks us to provide the patient with any type of education regarding the blood sugar ”.

Non-professional activities

Having bureaucratic process in nursing (paper work) and doing non-professional activities, which are out of the nursing job description, are due to staff shortage, organizational structure of hospitals, weakness in nursing management, etc. The following quotation from one of the nurses confirms the issues mentioned above:

“… We need one extra nurse to support ward secretary in responding to clients questions and answering phone …”.

Most of the nurses and nurse managers believe the numerous patients’ visits by physicians and interns and residents may cause a great workload for the nursing staff. Based on the researchers’ observation in this study, nurses were always busy to administer new physician orders, check ECG, prepare patients for radiology or echocardiography units, etc. A nurse manager said:

“ Nurses are responsible for all of these tasks (administration of new orders, checking ECG, preparing patients for diagnostic and medical interventions) and these will lead to overloading indirect nursing activities .”

Physician-oriented atmosphere

In the hospital as an organization, physicians are in the highest level, and their position and salary are very much higher than other health care workers. They have access to most of the facilities in the hospital, such as library, internet, and parking space for their private vehicles, etc. The nurses must obey physicians’ orders without involving in any decisions for patients. It may cause a feeling of discrimination between physician and others (especially nurses). A nurse mentioned:

“ Physicians are paid for their tasks at hospital while it is not always the same in case of nurses .”

Furthermore, the research data have revealed that some symbols such as private parking spaces, welfare facilities, etc., are there for the physicians only, and lack of attention to the nurses’ needs in this regard has doubled a feeling of discrimination.

Conflict and lack of coherence in education

Coherence is an element and a key feature of organizational culture. A hospital nurse manager said:

“ Each group works separately and independently, and there is no interaction between them. I mean nurses, physicians and others do their duties separately without any cooperation as a team. That's why we do not achieve our objectives .”

On the other hand, the participants’ quotations clarify that inconsistency and lack of cooperation among health care providers caused a decrease in trust in patients and their families.

Most of the nurses and some patients mentioned some controversies in patient education, for example, the difference between medical recommendations and nutritional diets in the hospital. Confirming the aforementioned subjects, one of the head nurses said:

“ Although the patients have been told to have their food with low fat and salt, they are served a food which is rich in fat and salt. That's why there lays a conflict between what the patients are recommended and what they practically receive .”

Inappropriate communication skills

Inappropriate communication skill is one of the major elements that can leave an impact on organizational culture. The proposed issues include a broad level of communication between different groups such as manager and health care providers, physicians and nurses, and finally patients and health care providers. In terms of nurses’ and physicians’ communication, a nurse pointed out:

“… some of the physicians underestimate the role of nurses and do not consider them as professional health care workers. Their behavior inspires as if they do not see us! ”

Obviously, collaborative communication and positive cooperation between nurse and physician will improve patient health, quality of health care, and patients’ satisfaction. All participants believed that friendly cooperation between health care team members is a pre-requisite for patient education.

In this regard, a nurse mentioned that:

“ As a result of a positive relationship between the physician and the nurse, an empathy-oriented relationship between the nurse and the patient can be expected which hopefully leads to effective patient education .”

Ignoring patients’ rights

Patient education is a professional responsibility of nurses. Most patients and all health care providers participating in this study considered the patients’ awareness of their disease and treatment process as patients’ rights, and ignoring these rights is an unethical behavior.

One of the nurses put it like this: “ Knowing about the real diagnosis is the patients’ inalienable right; however due to cultural obstacles patients’ families expect us not to tell them about some disease diagnoses such as acute myocardial infraction and cancer because they are worried about the patient to feel scared which may lead to a reduction in the patient's life .”

On the other hand, patients have been considered like a machine by most of the health care workers. This perspective may play as a barrier for patient education.

A nurse said:

“… Health care providers have a mechanical look upon the patient rather than humanistic approach. They do not think that the person in the hospital is a human being and he can think and feel and understand all the problems well .”

Lack of motivation and rewarding system

Keeping the nurses motivated through internal or external rewards is an important issue in a good organizational culture. Motivation is a force which helps the people to achieve their goals and creates eagerness and more readiness to do their tasks.[ 19 ]

As our results indicated, the lack of motivation among nurses to educate patients is one of the most important reasons of ineffective patient education. The following quotation by one of the nurses confirmed our claim:

“ The nurses don't have enough motives for educating patients because in our hospital, punishment is more used by managers than reward. You may be asked just for primary care like patient hygiene, whereas you will not be rewarded for the professional care. For example, while shift changing, the head nurse just focuses on untidy sheets of patient. She doesn't pay attention to problems I had the night before, such as no time to have dinner or even a short rest because of my high workload. Even she may see the nurse looks pale and tired, but only considers the bed sheet of patient! This behavior leads to decrease in nurse's motivation, self-confidence and self-efficacy, and the patients may also not trust the nurse for educating them .”

On the other hand, the most frequently mentioned issue by nurses was managers’ inattention to employees. They believed that lack of managers’ support and their inattention to nurses led to the nurses’ unwillingness to care for the patients. They also believed that not putting value on their jobs resulted in their reluctance to educate patients. For example, a nurse supervisor said:

“… We have frequently heard from the nurses that no one cares us, so why should we waste our time and talk to the patients and educate them .”

As mentioned earlier, findings indicated that the interaction between nurses and physicians would result in an increase in the nurses’ motivation to play their educational roles. A clinical supervisor argued thus:

“ I can remember, when I was working in CCU, the physicians were coming to nurse station and discussing some scientific and medical topics with nurses. You can't believe how effective the discussion was in increasing the nurses’ knowledge and their self-esteem as well. We could easily consult with the physicians about the patients. This opportunity led to change the physicians’ attitude about knowledge level of the nurses .”

A hospital nurse manager believed thus:

“ People's perspectives about nursing as a low level job, and some primary care done by nurses such as changing bed sheet, will cause the patients not to accept the educational role of nurses. It may also influence nurses’ unwillingness for patient education. For example, when I was working as a nurse in a ward, I did emphasize on meeting patient's basic needs (providing bedpans and urinals). Although patients were very satisfied with it, they could not accept me as an educator. They thought I am not an expert person for educating them! ”

Poor supervision and control

Supervision and control is one of the other major elements that can leave an impact on organizational culture. Most of the nurses strongly believed that the patient education program is not supervised precisely. The head nurse controls and monitors all nursing activities except nurse's role in patient education. On the other hand, some nurses believed that the educational supervisors in their hospital do not play any role in supervising patient education programs. The researchers’ interviews with a supervisor, while observing her activities, confirmed what the nurses mentioned. When she had been asked about the way of monitoring and supervising the nurse's practice in patient education, she replied:

“ I have provided an educational program for each nurse, and according to the cardiovascular disorders which are mentioned in the text books, I’ve assigned educational homework for the staff. Then I evaluate their activities based on their assignments. So, not only their knowledge is always updated, but also ‘patient education’ is considered as an essential issue in their work. ”

D ISCUSSION

Studies have revealed that while playing their roles, nurses are facing several problems. From the nurses’ perspective, there are two groups of factors – those related to the nurses themselves and those related to their working environment – which act as the main factors slackening their educational performance. Among the factors related to the nurses, lack of information regarding the technics and tactics of education and lack of a recognition of the patient's educational needs,[ 19 , 20 ] and among those related to the working environment, nursing shortage, lack of time and working personnel, insignificance and absence of priority for the patient education in the organization, and absence of sufficient specific references are considered as the main barriers from the nurses’ view.[ 11 , 21 ] The present study concerns inappropriate organizational education as effectively main barrier in education. Organizational culture refers to the beliefs and values that have existed in an organization for a long time, and to the beliefs of the staff and the foreseen value of their work that will influence their attitudes and behavior.[ 12 ] As a system, organizational culture consists of values (what is important and what is not) and beliefs (how people act or do not).[ 22 ]

In this regard, the results of the present study show that in the hospitals investigated in this study, education dose not receive the attention it deserves. Participants believed that what they are expected to do in the hospital is simply a list of routine works such as taking care of the medication, dressing the wounds, visiting the patients, etc. Considering the same matter, studies show that factors such as human resources, organizational structure, the leadership style, and control system and types of behaviour can affect professional matters such as patient education.[ 23 ]

Also, the results indicate that poor control makes patient education as an unimportant task in health care system.[ 24 ] Nurses also believed that appropriate control and supervision could put value on their organizational and social position. Bragg (1982) believed that in any organization, the effectiveness of the staff activities mostly depends on the extent of control exerted on them. In other words, appropriate supervision will lead to improvement and promotion.[ 25 ] Not putting value on patient education also leads managers to focus on non-professional nursing practices or just routine work in nursing.

The culture within an organization is very important and plays a large role in making it is a happy and healthy working environment.[ 26 ] So, the goal of health care system is providing physical, mental, and social health of people. Besides, creating an atmosphere and culture where human resources can be prepared for more effective and more efficient services is another goal of this system.[ 24 , 27 ]

The relationship between organizational culture and employee behavior/attitude has been emphasized by different studies.[ 28 , 29 ]

The findings of this study have shown that inappropriate organizational culture is an important factor in dissatisfaction and unwillingness, and lack of commitment, responsibility, and motivation among staff. The hierarchical structure of the organization has caused a failure to provide a good atmosphere for educating patients as a nursing professional practice. Also, hierarchical structure creates a system whereby the relationship between physicians, managers, and nurses is that of “superior” and “subordinate” rather than a supportive and collaborative one;.[ 30 ] In this culture, a nurse has been seen as a person who just obeys the physician's orders and does routines. Salvadores et al . (2001) believe that such organizational culture is a hindrance in the nurses’ qualification and professional abilities to come out.[ 31 ] On the other hand, this kind of organizational culture has developed an unequal and one-way relationship between nurses and physicians that formed a state called physician-oriented atmosphere. Moreover, the paternalistic behavior of physicians and managers has caused an ineffective communication between nurses and them. This condition has caused failure to provide nurses’ needs that leads to a defective pattern of communication between nurses and patients.

Limitations

The study was conducted in two large referral hospitals in Tehran; thus, the findings should be interpreted in light of this context.

C ONCLUSION

The results of this study show that according to the participants’ perspective, organizational culture is in a poor level. So, to improve performance of nurses, it is necessary to increase their motivation through optimization of organizational culture.

Moreover, according to the results, managers play the main role in improving the organizational culture. Through the appropriate communication pattern and leadership style, they, as the change-making agents, can take control of the conflict, improve the organizational structure, or encourage nurses to do their professional duties in the best way, by valuing and supervising patient education.

A CKNOWLEDGMENT

We sincerely thank all participants in this study including nurses, physicians, patients, and their families who provided us an unsparing cooperation. The budget for conducting this study was provided by Nursing and Midwifery Faculty, Tehran University of Medical Sciences and by Tarbiat Modares University.

Source of Support: The budget for conducting this study was provided by Nursing and Midwifery Faculty, Tehran University of Medical sciences and by Tarbiat Modares University

Conflict of Interest: None

R EFERENCES