The research studies related to traumatic spinal cord injuries (to obtain information needing long term rehabilitation), patient education (for comparison of patient education strategies amongst individuals with spinal cord injuries), teaching and learning in the settings related to health care were accounted for inclusion. Research studies focusing on the rehabilitation of spinal cord injuries (only base for comparing the patients with spinal cord injuries), patients gaining education during spinal cord injury, from year 2000 to till date (to compare and contrast the information related to the subject and make an up-date on the patient education) and multidisciplinary methodologies to patient education were included. In addition, studies encompassing spinal patients (to record and understand their personal experiences), implementation of measures related to patient education and international research (for gaining culturally rich information from various countries and use them for making trials on the multi-disciplinary populations of the United Kingdom) were considered for inclusion. But, the specialist literature considering spinal cord and sustained head injury (head injury with spinal cord injury is more complex and need different approach for dealing), minor spine surgeries (as they need minimal hospitalisation), learning complexities, back pain (as it is not associated to the research aim of the present study), spinal cord injuries in children (since the spinal unit I work doesn’t deal with children), and studies older than 2000 (explore more up to date information) were excluded.
Following tables clearly tabulate the inclusion and exclusion criteria followed for the study:
Search Terms or Keywords
For the collection of data, in relevance to the research topic, various key words and related combinations were used. The search phrases of-“Patient education”, “education in health care setting”, “factor affecting education”, “learning in hospital”, “hinderance in education after spinal injury”, “failing factors in patient education”, “learning after loss”, “un effective education”, and “adult learning” assisted in gaining needed information. At certain instances, use of key words related to “Leaning theories”, “spinal cord injuries”, “spinal cord rehabilitation”, “effective rehabilitation”, “health promotion for people with disabilities”, “effective patient education”, “rehabilitation of the spinal cord injured patients”, “goal planning for spinal patients”, “long term rehabilitation”, “complications after spinal injuries”, “implementation of health education”, “the need of rehabilitation”, “effectiveness of education”, “the right time for education in rehabilitation”, “the experience of spinal cord injury”, “cost of readmission after spinal injury”, and “Spinal Cord Injury Interdisciplinary education” enabled in gathering much information for developing well-defined conclusions. Boolean operators (AND, OR and NOT) were even used for this project to explore the research reviews related to the topic. Use of these operators assisted in collecting the research studies that considered spinal cord injuries and patient education.
Critical Appraisal Tool
Carrying out the literature search for the present topic is guided through well-established set of principles and procedures. For this purpose, a relevant and much effective critical appraisal tool was used and this aided in systematically critiquing the articles explored in the literature. The use of critical appraisal tool developed by Aveyard and Sharp in 2011 helped in investigating the answers for questions such as-“who is the author of the paper?”, “In which journal the relevant article for appraisal have been published?”, “has review been carried out in a systematic manner?”, “what are the crucial methods utilised by the researchers to meet the aims underlined in the review?”, “Does researchers completely demonstrated the facts that they carried out every thing?”, “what are the benefits and limitations governing the research?”, and “what are the future implications for the research?”. I have rated overall usefulness within table 4.2 (page 35) where * equate to some part of the study meet the criteria **equates to partially met usefulness criteria with very few weaknesses while *** meaning fully met.
Besides, the questions linked to senstivity of the research context (does the research design possess considerable flexibility in making changes?”), primary marker (does the chosen research sampling method (does study sample purposefully shaped the theoretical perspectives and levied focus on the diverse contexts and meanings?”), quality of information (what different knowledge sources were used for understanding about the issues being explored or compared?”, theoretical appropriateness, generalisability (does the study enable in making generalisations in a logical and theoretical way?), validity and applicability.
Theoretical Frameworks
This framework includes methods and processes for exploring the future implications and suggestions for practice. The theoretical framework or gap analysis model developed by Parasuraman (1985) was used to obtain the needed information. This model aims at exploring differences between standards and their delivery. The underlying reason for choosing this model is to explore the gaps and limitations existing in the current practice. It is important to keep up the service package, since the expectations and assumptions of patients and service users are rising. Use of this gap analysis model has enabled exploration of the patients’ expectations, service providers, and users together with the staff.
This gap analysis model also helped in investigating on possible reasons as why the associated expectations are not met in an effective manner. Since the gap analysis tool was found to be considerably cohesive with the research findings, it is even used to explore the gaps in offering effective patient education in the unit related to spinal cord injuries. The process of current patient education and its associated implications were analysed thoroughly and any possible gaps (that existed if any) were identified by using gap analysis theory (A diagram is attached for reference in figure 1).This model was even applied to the patients’ education process in the present study to look for the possible gaps and weaknesses.
(Figure. 1)
Assessment of Validity
The internal validity pertaining to each of the selected research studies was analysed depending on the pre-defined set of criteria developed by the Aveyard and Sharp in 2011. . At certain points, the external validity, applicability and generalisability was even assessed, however, this not effectively influenced the quality ratings. Each and every selected study was rated as per the fatal limitations and benefits and studies failing to meet the criteria were excluded.
In the present project, a considerable number of studies attained fair ratings. The information collected through literature search methodology was pooled by assessing the relative risks and sizes. Different tests were used to assess the publication bias, though the validity of methods was minimal. All the research studies that effectively satisfied the inclusion criteria were analysed through the utilisation of quality assessment tool. Assessment of each of the found pieces of research work was made in terms of quality to ensure about the incorporation of best quality of studies. Since the appraisal of the study is important as indicated by Parahoo (2006), each of the studies was assessed for validity, reliability and precision before making a conformity and inclusion in the report. This type of quality assessment through the use of above questions outlined in the critical appraisal tool has helped in efficient reflection of internal validity of various research studies (Greenhalgh, 2010).
Summary
This chapter has outlined the search terms, strategies, study design, inclusion and exclusion criteria and quality assessment tools used for the research. Further chapters will consider the relevant research studies and outline the illustrations that form a basis for well-defined conclusions.
CHAPTER-3: A CRITICAL REVIEW OF THE LITERATURE REVIEW
Spinal cord injuries can be considered as insult to the spinal cord resulting into traumatic implications instead of disease. The symptoms of Spinal Cord Injuries and its associated factors influencing patient education vary widely from pain to paralysis and even to incontinence (Yunchen and Boore, 2006). More particularly, these involve if the injuries associated to the patient interfere with their daily activities of living (Bennett et al., 2004). A critical exploration of factors influencing the success of effective patient education in the rehabilitation unit for individuals with spinal cord injuries is important for diagnosing the condition and this chapter makes an effort in outlining such illustrations. A systematic overview on different statements outlined in different research reviews, conference abstracts and articles will be provided in the further sections.
In general, spinal cord injuries enhance the physical and psychologic declines and cause changes within musculoskeletal, cardiovascular, gastro-intestinal, pulmonary and other integumentary systems (Valliant and Loghin, 2009). A considerable proportion of long term follow-up studies have been carried out and numerous researchers have documented the inherent ability of patients with spinal cord injuries to age at a faster rate than the potentially bodied population does. Individuals with spinal cord injuries inherit characteristics and medical complexities more usually related with the process of ageing at a very younger age (Tranfield et al., 2003). Various research studies (Valliant and Loghin, 2009, Tranfield et al., 2003, Loghin, 2009, Bloeman et al., 2003, and Yunchen and Boore, 2006) have indicated the fact that patients with spinal cord injuries of fifteen years or more experience 93% decline in the functional status. Rehabilitation of different spinal cord injuries has an increasingly important role. Prevention of secondary complications, enhancement of physical functioning and reintegration into the community are the prime goals of rehabilitation (Bloeman et al., 2007). In line with the enhanced demand for the patient education over the past few years, there was been a dramatic shift from the paternalistic intervention by health care professionals to an increasing identification of patient independence with regard to their personal health care (Krassioukov, 2009). Much emphasis was laid on patient rights to evidence-based, customer oriented, precise and balanced information to enlighten patients to be actively involved in their care. To enable efficient and optimal use of medications during spinal cord injuries, there is a need for research that focus on the assessment on how patients use their available education (Loghin, 2009).
Various secondary conditions related to spinal cord injuries can be minimised by relevant self-care or self-management. But, the present scenario of minimal rehabilitation stays for spinal cord injuries illustrate difficulties in accessing the information. The specialists associated to spinal cord injuries need patient and their family members to absorb information on self-care more quickly whilst in hospital. As per the study of Loghin (2009) study, patients need to be much proactive in exploring information about health care once they get discharged from the hospital. There is still evidence that information overload on minimal rehabilitation stays involve with the patients and their family’s ability to completely master the skills and information needed to avoid secondary complexities subsequent to leaving of hospital. Much more than before, patients with spinal cord injuries require more timely and high quality information on health and medical issues following discharge and all throughout their lifetime to decrease secondary conditions, remain healthy, promote well-being and quality of life (Matter et al., 2006). The injuries associated to spinal cord are explained at different levels of incomplete, varying from no significant effect on the patient to a “full” injury reflecting a complete loss of functional abilities. Diagnosing various spinal cord injuries initiate with restraining the spine and regulating the inflammation to minimise further damage (Zemper et al., 2003). The usual treatment can differ widely relying on the location to the level of injury. In most of the cases, the injuries associated to spinal cord need substantial physical therapy and rehabilitation (Williams, 2007).
Research on the spinal cord injuries has been carried out, but minimal information prevailed on the impact of ineffective patient education in spinal cord injuries. An effective and efficient understanding on different factors impacting patient education will allow health care professionals to shape the design and delivery of care to spinal cord injured patients in meeting their needs (May et al., 2007). Various patients actively seek a wide range of health related information. Nevertheless, as the information can be passively collected, there are certain individuals who even fail in looking for information. With regard to patient education, the factors that influence patients to undertake an interest can be active or even passive and much of it is largely unknown. Possible factors exerting impact on successful patient education can be arbitrarily divided into those that are related to the patient and even the environment (Cortez and Levi, 2007).
In the research study by Loghin (2009) patients with spinal cord injuries indicate significant utilisation of the Internet for health information. But in contrary, the studies of Burkell and co-workers have found that about one third of populations utilised Internet for spinal cord injury information. On the other hand, the general and specialist health care professionals used three fourth’s of the sample. Internet was the prime source rated to be as the most accessible and least reliable. Interpersonal resources, like the spinal cord injured patients and other health care professionals use, was rated to be as the reliable source for enhancing patient knowledge. Quite a close examination of the studies indicate the fact that the findings are inconsistent regarding the use of Internet and suggest the need of more research to determine the Internet application of individuals with spinal cord injuries. Hart et al (2010) carried out a survey of patients with spinal cord injuries residing in the community to recognise the information and education needs. Topics were completely limited to three prime domains (sexuality, wellness and medical). Significant proportion of patients indicated “increased interest” in various exercise programmes (53.25), nerve testing (51.4%), bladder and kidney complexities, pain, sexuality issues, and spasticity and stress reduction issues. Another small study by Hart et al (2010) have found that patients most identified information needs persisted in the areas of aging, research, financial aid and recognition. Research study by Matter et al in 2009 have explored the information needs and effective measures to be undertaken to improve patient education during rehabilitation of spinal cord injuries. As indicated in the study, patients with spinal cord injuries possess enhanced life time risk for clinical complexities and other health implications secondary to their injury. Various secondary conditions can be minimised or mitigated with the use of effective patient education, relevant self-care and self-management. To enable effective and successful patient education, patients with spinal cord injuries require timely and high quality information on health and medical issues. But, this needs to be prevailed following discharge and all through the lifetime to enhance self-care and quality of life. Results of this study confirm the fact that, though patients with spinal cord injury obtain information from experts, the Internet is most and effective source for reliable information. Level of education and race- the most influential factors hinder the implementation of successful patient education (Potter et al., 2004).
Through a rapid communication with the relevant health care provider, on medical status, healthcare concerns and personal medical information, patients with spinal cord complexities would potentially gain benefit. In addition, exploring about the vital signs, information about blood sugar and use of medication could also assist in gaining considerable benefits (Cortex and Levi, 2009). Patients suffering with spinal cord injuries possess complex, medical, social and discharge planning needs. According to Cortez and Levi (2007), Krassioukov (2009) and Loghin (2009), spinal cord injuries expose the individual towards deleterious consequences. The financial costs associated to this type of injury are immense and its associated injury complications following the disease can even boost up the costs (Matis and Birbilis, 2009; Drigotaite and Krisciūnas, 2006). The consequences subsequent to the spinal cord injury usually influence the life of an individual in a negative manner. The associated spinal cord complexities can be resolved through the access to effective and efficient patient education. But, this delivery can be a challenging process (Potter et al. 2004).
The study by Potter et al (2004) has examined factors inhibiting learning in the health care settings. As per this study, presence of symptom and absence of knowledge, medical awareness, high pressure and work load as well as waiting are the prime barriers to efficient and effective patient discharge education for spinal cord injured patients (Potter et al., 2004). The presence of continual care and support, detention and inclusion of pharmacological interventions prevailing in the setting of spinal cord injury rehabilitation will definitely contribute in the need for health care practitioners to ensure that they do not violate patient rights (legal and ethical). Certain inpatients experience more complexities while reading the patient education materials in the rehabilitation and hospital settings. This can be attributed to the noise and activity. The modification in the maintenance of information immediately subsequently to learning and two weeks following the study was effective for patients who were not completely distracted by their children. The previous studies offered insight to a wide variety of factors that contributed to decrease in the patient education (Matis and Birbilis, 2009; Drigotaite and Krisciūnas, 2006). Although the studies included the significance of controlled measure of inhibitor, the dose of Midazolam, what still remains unclear is the level of distraction influencing patient education under similar conditions.
Presence of background noise and disturbance in teaching patients frequently prevail in health settings. Both of these factors indicate a form of distraction. But, no significant variation in learning was encouraged between patients in the distraction condition to that of the ones not distracted by the spaceship information. Patients who were distracted took considerably more time to understand the implications of spinal cord injuries than the non-distracted individuals.
Time commitment, cost of therapy, income and social support are some of the social and economic factors influencing success of patient education in spinal cord rehabilitation. Cost is one of the crucial issues in patient education, more specifically for patients with the chronic spinal cord injuries. This is because the treatment period appears to be too long and may be even life-threatening. Though, cost and income are interrelated, the health care costs must not become an overburden if the patient possesses relatively more income and health insurances (Harrison, 2006). Patient compliance and education towards the spinal cord injuries are even dependent on the degree of behaviour and therapeutic outcomes attained. Since an enormous amount of time and energy is spent establishing and reinforcing care routines with SCI individuals as well as their carers, an effective follow-up of different recommendations will definitely help in attaining positive outcomes. Information and philosophies of care must be offered to service users; especially patients and their families according to their needs. This should reflect information with the background of why and how things can go wrong. For instance, to minimise pressure sores, the patients with spinal cord injuries need to be educated to maintain the regular intervals of turning during the periods of enforced bed rest or at night. But if community patients ignore these instructions they often end up with pressure sores which are the major cause of readmission to the hospital (Harrison, 2006). To overcome and avoid secondary complications after SCI there is a need of adhering to a well-structured and effective patient education programme (Gélis et al. 2011; Matter et al, 2009).
Amongst the broad range of factors, the ones related to the patient arguably influence the patient’s education in spinal cord injury rehabilitation. Presence of symptoms in diseased state is considered as one of the main factors impacting the symptoms of patient use of education (Potter et al., 2004). Functional health literacy, termed as the underlying ability to understand and act accordingly to the health information is one the basic requisite influencing the patient education. A minimal level of health literacy is linked to deleterious health condition and enhanced use of health services. Despite of the fact that patients with poor health literacy will possess complexity in getting relieved of the spinal cord injuries, it is still unknown as whether this will limit the patient education (Tooth et al., 2004). Health locus of control relates to the degree at which individuals attributes their personal health outcomes to outsiders and themselves. Internal health locus of control is found to be intricately influencing the behaviour of patients and health care professionals towards education. Besides, it is also known to impact the adherence to medical treatment and screening of diseases (Matter et al., 2009).
Patient education is a crucial part of spinal cord injury rehabilitation. With an underlying objective of preparing individuals with spinal cord injuries to meet their day to day challenges, the study by May et al (2006) evaluated the experiences of patient education programme from the patient’s viewpoint. The qualitative study involved a semi-structured interview format with twenty two patients gathering relevant information on the factors influencing patient education. Learning readiness, learning effects, exploration of complexities, involvement of families were the prime factors that influenced patient education. Besides, partnership learning and individuality were even recognised as some of the implications. Although the study by May et al (2006) offered valuable information from the patient’s viewpoint (used to enhance the patient education programmes), it still needs highlighting of adult learning principles (May et al., 2006).
With the help of in-patient education programmes, the patients with spinal cord injuries learns to assess and control the physical, emotional and social well-being (D’Hondt and Everaert, 2011). Determining the knowledge, problem solving skills with regard to spinal cord injuries at admission, discharge and six months follow-up is crucial and this research was laid forward by May and his co-workers in 2007. This study even determined the perceived important of each context topic included in the education programme (Dahlberg et al., 2004). Knowledge and associated factors influencing patient education were evaluated with the Multiple Choice Questionnaire (MCQ) and perceived significance of each implication was rated on a five point Likert scale (May et al., 2007). Considerable improvements in the MCQ scores were evident from admission to discharge, problem solving ability and improvement from follow-up to bowel care. Bowel, bladder and associated skin care seemed to as the most crucial education topics. The study indicated the fact that improvements in knowledge do not completely translated to problem solving ability improvements. Although the study was effective in outlining the relevant considerations about patient education, it still needs to include more active learning strategies and other contextually dependent interventions within the programmes related to patient education. Use of these will definitely facilitate the transfer of knowledge within the life situations (May et al., 2007).
The retrospective study by Tooth et al in 2004, predicted the satisfaction levels with medical rehabilitation after the spinal cord injury. The study explored the information submitted to the Uniform Data System for Medical Rehabilitation. Different socio-demographic factors, case mix groupings, length of stays, rehospitalisation, and follow- on therapy and maintenance of health were examined (Tooth et al., 2004). The conclusions of study ascertain the fact that satisfaction with medical rehabilitation services following the spinal cord injuries is completely linked to the functional skills, marital status and other hospitalisation measures. Certain levels of different results were even found for whether satisfaction was even rated through the patient and their family. But, quite a close examination of the study indicated the fact that the complex relationships amongst satisfaction, demographic implications and functional levels need persistent investigation (Tooth et al., 2004).
The study by Franks in 2007 indicated the financial implications associated to pressure sores. By outlining its equivalence to the price of diagnosing mental health, the study outlined the requirement of around 2.5 billion Euros. Although, effective patient education helps in resolving the issue, other secondary complications influence the experiences of disability for individuals with spinal cord injuries (Potter et al., 2007). These experiences impact the quality of life, long term health conditions, dignity, mobility and mortality and independence of patients (Franks, 2007). As per the study of Dorsett and Geraghty (2008), the associated social and psychological factors related to patient education even delay the admission of new patients from acute wards to the community level (Roy and Saunders, 1999). Critically speaking, these factors and its underlying implications appear to be frustrating for the unit as it completely hampers the attainment of success and required goals (Dorsett and Geraghty, 2008; Hammell, 2010).
Provision of information (and associated philosophies) is the most important measure offered to service users. This information includes patients and their families as per their needs with the background of why and how things can go wrong. Individuals with spinal cord injuries need to be educated to maintain the regular intervals of turning and offered rest at night. However, if the patients (more specifically the ones sustaining in community) ignore these instructions, they completely end up with the serious consequences (such as pressure sores). According to the Makhsoos et al (2007) study, relieving of pressure is the most important step of preventing the influential factors related to patient education. Educating patients during their stay in the rehabilitation unit is important to attain significant benefits. But, numerous patients with spinal cord injuries ignore the significance of pressure relieving procedure and result themselves in getting exposed to pressure ulcers (Makhsoos et al., 2007).
The important elements of patient education-skill building and responsibility help in offering an improved understanding of medical condition, diagnosis and disease. Knowing when, how and why the individuals need to make a lifestyle change is important to increase motivation and self-efficacy. Through the more effective utilisation of medical services, satisfaction and referrals, risk management techniques, informed consent and patient outcomes information, each member of the health care team can make a positive approach. Coping style, levels of literacy in health and occupation, health locus of control and disease state are the main patient related factors influencing their interest and education (Makhsoos et al., 2007). By assessing the utility of medical information and patient education for various patient groups and more specifically meeting the patient needs could help in reducing the effect of factors (Koo et al., 2006). Presence of finances, communication ability of doctor and patient (about the location of medical resources), location and race, gender and ethnicity are some of the factors influencing patient education in spinal cord injury rehabilitation. In addition, factors associated to personal beliefs on medical care and practitioners also exert considerable impact on the health and overall well-being of patients (Makhsoos et al., 2007; Koo et al., 2006).
Certain demographic factors play a crucial role in influencing patient education. In accordance to the literature outlined on the health behaviour, younger age, socio-economic status, level of education are completely associated with the involvement of health promoting behaviours (May et al., 2007). In addition to these, higher socio-economic status and being female are also related with the patient education and seeking of health related information. But, it is completely uncertain whether these factors impact the patient interest and use of treatment strategies for spinal cord injuries (Makhsoos et al., 2007; Koo et al., 2006). Depression after SCI is a common condition (Krause et al. 2010; Kemp and Krause, 1999). This can significantly hinder the understanding and perception process (Kemp and Krause, 1999). The assessment and identifying such hurdles is vital and is a skill in the delivery of patient education (Yuchen and Boore, 2006).
The recovering or coping style of an individual play a crucial role in determining the interest of patients in spinal cord injuries. Whilst some of them cope in an active manner by involving in the treatment, others tackle the spinal cord injuries through avoidance. Offering detailed, clear and concise information would definitely help these patients in future (Tooth et al., 2004).
Patients with sufficient health literacy levels appear to be more interested than the associated counter parts in successful patient education. Health professionals must encourage the utilisation of appropriate information and ensure the access to reliable information sources (May et al., 2006). Assisting patients by referring them to various credible sources and being prepared to solve potential questions arising from the information search could help to a considerable extent. Understanding the underlying reasons about the disinterest in patient education could help the health care professionals in deciding the best way to tailor the information. Relying more on the simple verbal information, keeping in mind that patients with poor health literacy abilities is another strategy (May et al., 2007). Promoting the ways to attain information and using sufficient time to explain the information could serve as a useful reference for the medication use and successful patient education during spinal cord injuries. Considering the individual as a bio-psycho social being and enhancing adaptation ability to social, mental and psychological change (as a health indicative) could help in promoting well-being. The fundamental aims of patient education for the people with spinal cord injuries-promotion of healthy living and environment, reduction and prevention of secondary conditions (such as pressure ulcers, obesity and bladder complications), managing own physical and health conditions, maintaining functional independence and enhancing quality of life need to be placed in mind (Tooth et al., 2004).
Achieving the goals involve hard and crucial parts. These include choosing the best way of implementing patient education process (Dorsey, 2005). By knowing about the quality improvement measures and adverse effect tests for spinal cord injury rehabilitation, patients can minimise the complications that may occur in future. However, it is much more important even for the health care practitioners to make a check on a timely manner as this may lead to potential complexities (May et al., 2007). Adhering to a well-structured patient education programme and avoiding mistakes help to a considerable extent in minimising complications. Presence of a state of adaptation assists in freeing individual’s energy to respond to various other stimuli. With a multi-disciplinary team based approach involving physical therapists, occupational therapists, rehabilitation nurses, psychologists, speech language pathologists, rehabilitation of spinal cord injuries can be effectively attained (Kemp and Krausse, 1999). In order for the patients to attain more benefits out of their rehabilitation programmes, it is much necessary for them to work hard. High expectations for patient involvement need to be set at the time of admission through discharge. It is important for patients to understand the fact that rehabilitation is different from other types of models, where patients are usually taken care of. Patients need to be encouraged to possess input in to their programme and schedule, comply with the different educational requirements, involve in outings and use the fullest advantage of all possible resources (Makhsoos et al., 2007).
The important implications of patient education-patient behaviour, readiness to learn and compliance and its usual reason for failure should be explored. The concept of readiness in patients with spinal cord injuries is much critical and information linking to these should be a definitive implication (Moullin, 2002). But, as the common acute conditions such as spasticity, pain and urinary tract infections may hamper effective learning process, the readiness for accepting information tend to be more challenging. Sufficient resources and staff, another crucial requirement for thriving learning and maintaining its presence is most important for achieving success. Collecting more culturally sensitive and personally relevant information is one of the crucial strategies. Instead of overlooking the information, patients need to be enabled to discharge to community to face the reality on their own without the expert on site (Harrison, 2006). Investigating and looking into the life of the individual with spinal cord injuries, whilst they are in the communities will appear to be interesting to explore the review studies. This could definitely help in discerning how the individual copes in the community after being discharged from the rehabilitation unit. It is not uncommon for SCI patients to overlook the information once they are discharged to community to face the reality on their own without the expert on site (Harrison, 2006).
Although, the above mentioned research studies have indicated that patients with spinal cord injuries are concerned in exploring health related information and other data linked to spinal cord injuries, data is completely sparse with regard to the specific information needs (Potter et al., 2004). Besides, the data relating to patient education and information seeking behaviours was inconsistent and non-reliable. It is crucial that successful patient education must make the patients as independent as possible and also enable them to act as a part of the society (Parasuraman et al., 2007). Since patients with spinal cord injuries, experience complexities to finish up the daily activities of dressing, cooking, cleaning and working, it is more crucial for them to obtain suggestions on the different ways of using strategies for successful education and other devices. Carrying out more in-depth research to improve the particular activity to be added within the patient education intervention could assist in obtaining useful implications (Pagnotta et al., 2005). More specifically, with regard to the spinal cord injuries, research is still needed to conduct and estimate how benefits from successful patient education and stimulating activities are persuading on the patient performance in overcoming day to day challenges.
The findings of this critical review of the literature illustrated in this chapter can provide extensive information for the effective and efficient implementation of strategies as a therapeutic measure for patient education. Many positive findings are presented in the review, indicating the value of patient education as an approach for spinal cord injured patients; however, current research was ineffective in outlining the areas that are under threat. Much research is still needed to develop effective activities and areas prone to immense impact. In relation to spinal cord injury rehabilitation, much research is needed to explore the effective strategies on successful patient education and how its associated factors influence the attainment of positive outcomes. Despite contrasting interpretations, the research reviewed highlighted the strategies for effective patient education. Patients suffering with spinal cord injuries can use the holistic and problem solving approaches to address the relevant challenges and complexities. The therapists and professionals working with patients are highly accountable for safeguarding that exercise and approaches directed are effective and based on recent evidences. The standards of accountability, awareness, advocacy (carrying out best for patients and their relatives), sensitivity (respecting the patient), objectivity (considering all patients in a similar manner), consideration and respect (ensuring about the patients as whether they are always treated with dignity) enable patients and family in offering relevant information about the clinical condition. In addition, the ethical issues linked to confidentiality, co-operation, protection, development, alertness, accountability, good character and consent succour the health care professionals in moving along with the interests of patients and their families (Doel and Shardlow, 2009).
Implementation of above mentioned strategies for successful patient education can allow patients and their health care workers in overcoming complexities related to the capability, defiance of lifelong learning, functioning policies and guidelines, specialized malpractices and supplementary tasks allied to the work load. With these strategies and above outlined illustrations, the patients need to keep an update with trends, maintain competence, learn new technical and interpersonal skills, develop policies and protocols and safeguard their health and quality of life (Doel and Shardlow, 2009). Through a summary of main provisions with regard to the treatment of spinal cord injuries and patient education, the different frameworks function as support for the care principles developed by rehabilitation settings. It is therefore, crucial for patients to explore in depth on the information about successful patient education that applies to spinal cord injured patients in their professional capacity, along with the responsibilities it aims to protect (Leathard, 2003). Regardless of place, period and age, the spinal cord injuries are causing a foreseeable part of operating practice for health care professionals. In addition, the field of successful patient education can allow in effective team work, improve work environment, and increase mutual respects and share knowledge within different fields (Jackson, 2007). But, the numerous practice based factors such as unrealistic expectations, lack of knowledge, perceived threat, professional jealousies, and impaired autonomy that result in witnessing serious consequences need to be resolved in an efficient and effective manner (Miller and Freeman, 2001).
Despite of above factors, the effect of learning environment need to be explored and tested to implement successful patient education (Koo et al., 2006). Replication of different research studies in the health care environment would definitely assist in clarifying the findings. Furthermore, they also help in making them applicable to health care settings. Testing the role of patients and their interest in patient education will definitely clarify the issues surrounding the inconsistency of information influencing learning (Kemp et al., 1999). By examining different patient outcomes, along with the potential for much effective and efficient learning, avoiding misunderstandings on self-care, patient anxiety could help in enhancing patient satisfaction (Kroll et al., 2007). As patient education empowers patients with sufficient information, greater efforts need to be made to design environments with minimal disturbance, more particularly at times when understanding the information supplemented on health is critical (Mahoney et al., 2007).
Thus, patient education, in developing a more visible activity needs to be effectively established and maintained in terms of quality (Rimmer, 1999). It needs knowledge of the subject and accurate assessment of abilities, motivation and readiness (Saunders et al., 2007). Presence of clear and hands-on presentation using visual and other aids as appropriate is important to minimise the consequences (May et al., 2006). Feedback, as one of the most essential implication enable in gaining rewards and benefits. It is important for the patient to draw attention to areas that necessitate further clarification (Sarhan, 2008). Presence of long term, repetition and flexible approach are crucial, at times of change the lifestyle of patient. Supplementation of text with pictures assists in offering self-care or medication instructions (Miller and Freeman, 2001). By tailoring medication schedules to fit the daily routine of patients, using colour coding medicines and daily events such as reminders help in increasing compliance (Pozgar, 2010). Use of video-taped patient education materials, podcasts or blogs enable in increasing knowledge and enhance correct self-care. Emphasising on the desired behaviour instead of medical facts could aid in obtaining effective implications as patients find it complex to relate abstract statistics with self-experience (Jackson, 2001). In conclusion, the above mentioned strategies possess the potential to enhance the development of efficient and effective patient education and disease management in caring for complex patients in outpatient setting (Kay et al., 2007). The implemented patient education measures must improve the efficacy of managing patients, improving their overall health and decreasing the complete cost of offering care. Ideally,, a well-designed research studies potentially free from bias need to be conducted to assess the medical and economic influence of factors related to patient education and spinal cord injury management.
Summary
This chapter provided a comprehensive review on different research and evidence-based studies linked to patient education and spinal cord injuries. It also outlined strategies for implementing successful patient education. Further chapters will outline the discussions in relevant to the chosen studies and develop a valid conclusion.
CHAPTER-4: RESULTS
Process of Screening and Data Extraction
From the initial search, around one hundred peer reviewed research articles on spinal cord injuries and patient education were identified. From this list, the compliance with the inclusion and exclusion criteria, effective exploration of research aims, existed only on 40 papers. Within the process of second screening, around 30 studies were screened owing to their effective compliance with the inclusion and exclusion criteria. The agreement with respect to each individual study seemed to be perfect within the second stage of the screening process. In the third screening, around 10 studies were excluded, especially due to the fact that the researchers seemed to be futile in adhering to the standards. With the studies appearing to be completely appropriate, following the final screening, only 13 eligible studies were included for complete data extraction and critical examination. I have rated overall usefulness within table 4.2 using the critical appraisal tool of Aveyard and Sharp (2011) as discussed on page 17.
Figure-1: Figure depicting the steps used in the selection process of research studies for the critical literature review.
Summary
This chapter has critically outlined the information published in selected research reviews on patient education, its effectiveness, and factors influencing its success over long term. The final chapter (Chapter-5: Discussions and Conclusions) will underline the crucial interpretations and suggestions for attaining success in the various patient education programmes.
CHAPTER-5: DISCUSSION
The study (Study-1), by Williams in 2006, have indicated that, Spinal Cord Injury, a sudden and unplanned event needs effective rehabilitation programme to overcome with the acquired complexity. According to this study, patient centred goal planning and education helps in increasing self-autonomy, well-being and quality of life. The usual treatment can differ widely relying on the location to the level of injury. In most of the cases, the injuries associated to spinal cord need substantial physical therapy and rehabilitation. But, numerous psychological challenges are evident when progressing through the adjustment process. Although, this study was effective in outlining the importance of patient centred goal planning, it still possessed certain issues with the validity, generalisability and applicability.
The research study by May et al (Study-2) has highlighted the role of patient education as a key part of rehabilitation of spinal cord injuries. The qualitative study involved a semi-structured interview format with twenty two patients gathering relevant information on the factors influencing patient education. Learning readiness, learning effects, exploration of complexities, involvement of families were the prime factors that influenced patient education. As per this study, patient education enables individuals with spinal cord injuries in meeting day to day needs. Besides, partnership learning and individuality were even recognised as some of the implications. Despite of the fact that study provided useful interpretations on patient education, it failed in considering certain crucial points from the patient perspective. Incorporating principles and programmes related to such education will definitely enable in attaining effective results.
The research study by Manns et al (2007) (Study-3) was effective in attaining the needed outcomes. Through the utilisation of qualitative design and focus groups (five of them to be community dwellers and three as unpaid caregivers) the study explored the perceptions of individuals with spinal cord injuries on patient education, information needs and service delivery options. These factors with the use of content analysis procedures were captured into five different categories including readiness, information pathways, community health care, health promotion and contextual implications. As a recommendation, the study illustrated to target at programmes for reducing the secondary complications in patients with spinal cord injuries. Quite a close examination of the study helps in understanding the factors influencing patient education, however, it failed in effectively accounting their effects in an in-depth manner. In addition, due to the inclusion of minimal number of participants, the study failed to contain generalisability and applicability over larger populations.
This research study of Dorsett et al (Study-4) with an underlying objective of exploring health outcomes for individuals with spinal cord injuries utilised structured interview measures. By encompassing the measures related to perceived health, utilisation of medical services, hospitalisation and incidence of pressure sores, the study described the health outcomes for SCI patients using patient education. The findings of the study indicated a bio-psychological intervention integrating patient education, behavioural interventions, treatment and screening for primary complications. According to this study, patient education enables individuals with spinal cord injuries in promoting their well-being and quality of life. However, the study was less context sensitive and designed in a way to allow less flexibility for changes. The sampling strategy (purposeful sampling method) even failed to be effectively shaped through theoretical perspectives. Nevertheless, it utilised wide range of data sources and explored related issues. Furthermore, the study demonstrated considerable levels of theoretical adequacy (researchers of this study explicated the process when moving from data to other interpretations) and generalisability (study contained logical flow).
The retrospective study by Tooth et al in 2004, predicted the satisfaction levels with medical rehabilitation after the spinal cord injury. The study explored the information submitted to the Uniform Data System for Medical Rehabilitation. Different socio-demographic factors, case mix groupings, length of stays, rehospitalisation, and follow- on therapy and maintenance of health were examined (Tooth et al., 2004). The conclusions of study ascertain the fact that satisfaction with medical rehabilitation services following the spinal cord injuries is completely linked to the functional skills, marital status and other hospitalisation measures. Certain levels of different results were even found for whether satisfaction was even rated through the patient and their family. But, quite a close examination of the study indicated the fact that the complex relationships amongst satisfaction, demographic implications and functional levels need persistent investigation (Tooth et al., 2004). It was context sensitive and contained generalisability over larger populations, however failed to demonstrate needed levels of theoretical adequacy.
The research study by Scelza et al in 2005 aimed at identifying the barriers related to physical fitness and patient education amongst individuals with spinal cord injuries. Although, this cross sectional study illustrated three main areas (intrapersonal, resources and structural) as barriers to effective patient education, it still needs to effectively explore their influence on wellness and long term life quality of patients. The study was context sensitive in a way easily flexible to various modifications. But, the sampling strategy considered for the study was not completely purposeful shaped through theory. It failed to provide more attention on the diversified context and meanings. Owing to inclusion of minimal number of participants, the study failed to contain generalisability and applicability implications. Nevertheless, its usage of wide range of data sources enabled in gaining knowledge on various issues concerning the success of patient education amongst individuals with SCI.
The study by Potter et al (2004) has examined factors inhibiting learning in the health care settings. As per this study, presence of symptom and absence of knowledge, medical awareness, high pressure and work load as well as waiting are the prime barriers to efficient and effective patient discharge education for spinal cord injured patients (Potter et al., 2004). The presence of continual care and support, detention and inclusion of pharmacological interventions prevailing in the setting of spinal cord injury rehabilitation will definitely contribute in the need for health care practitioners to ensure that they do not violate patient rights (legal and ethical). Although, this study effectively accounted wide range of sources for collecting information, theoretical adequacy (researchers explicated the process by moving from the data to interpretation) and generalisability (logical and theoretical flow), it still failed in being context sensitive. Besides, the study sample was not even selected in a purposeful way and attention was not provided to diverse contexts and meanings.
The research study by Burkell et al in 2006 aimed at identifying the information seeking practices of patients with spinal cord injuries. The survey study through a sample of 207 individuals was explored with the ongoing information needs and other practices. The findings of this study pointed out to the need of an accessible information source in delivering high quality information. Although, the study utilised wide range of sources for information collection, it is less context sensitive. The study even failed to indicate the sampling strategy selected for the survey study. It contained numerous gaps in the design of information interventions. In addition, the study seemed to be less generalisable (owing to inclusion of only minimal number of participants) and theoretically inadequate.
To estimate the information needs, extent of internet access and sources of adult information, the study by Matter et al in 2009 have used the survey and other qualitative methodologies. According to this study, patients with spinal cord injuries contain enhanced life time risk for medical complications and other health issues. Most of the secondary complications of SCI can be minimised through the use of self-care and management. Patients with SCI can be educated with related information in multiple formats and wide variety of sources, besides the Internet, Health care professionals (like brochures, medical journals and other organisations). However, only minimal knowledge is actually known on the preferred use and format of other patient education sources. Respondent results from the survey study even indicated needing information on medical issues. Results from the study have outlined the role of patient education in relieving patient stress, secondary complications and other complexities. However, the study appeared to be less context sensitive and theoretically adequate. Most of its categories analysed through survey methodologies were not mutually exclusive. Use of this measure even creates considerable levels of ambiguity amongst respondents. Nevertheless, the study indicated useful facts on patient education as race and educational level as influencing factors.
The research study by May et al in 2006 has explored the actual purpose of patient education amongst individuals with spinal cord injuries through one-group repeated measure design. The evaluation of knowledge (through multiple choice questionnaires), problem solving ability (using life situation scenarios) and perceived importance (with Likert scale) enabled the researchers in obtaining needed information. The findings of this study confirmed the fact that improvements in knowledge may not be completely translated to problem solving ability improvement. Incorporating more of the active learning strategies into the patient education will enable in transferring knowledge over life based scenarios and minimising secondary complications. Although, this study demonstrated useful facts about success of patient education, it still failed in maintaining generalisability. It is less context sensitive and applicable over larger and healthier populations. The quality of data presented in the study was not effective and theoretically adequate to draw well-defined and valid conclusions.
This research study by Zemper et al in 2003 has tested the effectiveness of a holistic (comprehensive and combined) wellness patient education programme amongst adults with spinal cord injuries. The inclusion criteria for the study encompassed patients undertaking physical activity, life style management techniques and prevention of secondary complications. Despite of the fact that no group variations were witnessed, the results through regression analyses stressed on the participation in wellness programme for attaining improved health related outcomes. The findings of this study, though preliminary, focus on the crucial role of health behaviours and other patient education programmes in influencing the long term health outcomes and life quality. Due to inclusion of only minimal number of participants, the study seemed to be less generalisable and applicable over larger populations. It even appeared to be less flexible for further modifications.
This research study by Gelis et al in 2011 has considered the patient (more specifically therapeutic) education programme as a crucial part of physical medicine and rehabilitation care amongst SCI individuals. With the underlying objective of evaluating the effectiveness of patient education programmes, this study utilised the methodology of systematic reviews with Medline and Cochrane Library databases. However, the data quality for the present study seemed to be poor. It considerably failed in exploring the effects of therapeutic education amongst individuals with spinal cord injuries. Nevertheless, the analysis of literature enabled for exploring the organisation of therapeutic education in clinical practice.
The study by Hart et al (Study-13) illustrated the fact that much research has been carried out, but minimal information prevailed on the impact of ineffective patient education in spinal cord injuries. An effective and efficient understanding on different factors impacting patient education will allow health care professionals to shape the design and delivery of care to spinal cord injured patients in meeting their needs. However, owing to the utilisation of survey methodology encompassing minimal number of participants, the study appears to be less generalisable and applicable over healthier populations.
From the above research studies it is evident that, patient education enables individuals with spinal cord injuries in gaining self-efficacy, life quality and well-being. It is the key part of rehabilitation amongst spinal cord injured patients. Effective patient education measures as illustrated by May et al (2006) help in improving well-being and quality of life. Exploring the factors influencing effective delivery of patient education could help in shaping the design and delivery of care to spinal cord injured patients. By knowing about the quality improvement measures and adverse effect tests for spinal cord injury rehabilitation, patients can minimise the complications that may occur in future. It even assists in meeting their health needs in a most efficient way. Absence of collegiality and effective communication between health care providers, nurses and other physicians, complexities with the health care team, patients and families and cultural challenges act as crucial barriers to patient education. Addressing such types of barriers related to patient education is specifically important for patients who fail to meet the desired targets regardless of optimising clinical therapy. Most of the studies highlighted the role of patient related barriers in attaining success in education. According to them, health beliefs, absence of social support, pain, physical impairments, cultural sensitivity and social disadvantages as the prime are the prime barriers influencing success of patient education amongst SCI patients. It is important for patients to gain knowledge on the health beliefs, foods, complementary and alternative medicines available in the market.
The findings outlined in the present study seemed to be consistent with other studies that illustrated the patient education as a useful measure in minimising complications. According to the May et al (2006) study medical issues concerning to spinal cord injuries forms the most crucial information topic for patients with SCI. Although, most of the studies (such as by Hart et al, May et al, Burkell et al and others) ascertained Internet as the highly utilised source of information, many of the participants illustrated health care professionals and providers to be the most preferred source. The findings of various studies even indicates the fact that Internet is the most frequently available and used source. Access to health care providers as indicated by these research studies is even complex and less frequent.
Use of gap analysis model in the present study assisted in investigating the possible reasons as why the research aims and expectations of the studies were not met in an effective manner. Gap analysis model, has helped in understanding the factors influencing service quality. The possible gaps between marketing promises and actual delivery of patient education were identified. In addition, the perceptions of different patients in using patient education for treating spinal cord injuries and possible complications (related to safety and protection) were even explored through this gap analysis tool. The gaps of current patient education (primarily the factors influencing these) and its associated implications were analysed thoroughly. The gaps such as conflicting information, improper knowledge and heavy work load, lack of awareness, self-efficacy, and self-esteem were identified by using gap analysis theory.
The fundamental gap that has been identified is the lack of communication between spinal unit and community team. There is no arrangement for spinal patients in community to improve and continue their education process, consequently patients fail to remember the given information and educations soon after facing the challenges of real life in the wheel chair (Lindsey et al., 2002).
The readiness to learn and taking responsibility is very important for learning process (chase, 2005, Kemp and Thompson, 2002). Many patients after spinal injury lose interest and are more worried about their finance, job, education and housing (Hillier et al, 2011). Therefore it is hard to educate someone who is not ready. Ongoing education and assessment in community can solve this gap and patient can be motivated to participate in learning process when ready and aware of the actual complications (Kemp and Thompson 2002).
CHAPTER-6: CONCLUSIONS
This is now apparent that the aim and objectives have been met by undertaking this study as mention on page number 8.
Recommendations and Action Plan
- Developing individual teaching plan and follow up
- Consider effectiveness of learning environment
- Explore strategies to strengthen inter-professional collaboration among healthcare professionals
- Incorporating more active learning strategies
- Developing robust action plan for local implementation
- Developing individual teaching plan and follow up
Through an understanding of factors influencing patient education, it can be recommended that considering individual teaching and frequent follow-up through below mentioned measures will help patients with significant barriers. Since patients hear conflicting information in the current practice about the complications of spinal cord injuries, it is important for patients to co-ordinate and develops consistent information on spinal cord injury care. Use of picture based handouts, repetitive and short teaching sessions covering the topics related to secondary and primary complications of spinal cord injuries even help in attaining success. Presence of effective social support from health care professionals and other support workers could even help patients in identifying their support systems (Cortez and Levi, 2000).
- Consider effectiveness of learning environment
The effect of learning environment need to be explored and tested to implement successful patient education. As patient education empowers patients with sufficient information, greater efforts need to be made to design environments with minimal disturbance, more particularly at times when understanding the information supplemented on health is critical. Health systems barriers arising due to lack of health educators, logistical and community resources also influence the patient education. Use of effective type of resources from the community, trained clinical staff and professionals will enable patients in attaining significant levels of success. Reviewing knowledge and skills as to whether patient is remembering and acting based on the information provided will help to a considerable extent. It is even crucial to continue in exploring at the barriers as what is making it complex for patients to use medicine while aiming to attain success (Dorsey, 2005).
- Explore strategies to strengthen inter-professional collaboration among healthcare professional
Growing research evidence in a wide variety of health care settings encourage the need to strengthen the communication and inter-professional collaboration amongst health care professionals to optimise patient health outcomes. Findings obtained from various studies even support the health care organisations to act in a more collaborative, co-operative, integrated and inclusive way. In addition, future research exploring on the success of patient education in spinal cord injured patients is much needed to effectively answer various questions. It would even appear to be beneficial to recognise the medical issues that can be explored through patient education (Cortez and Levi, 2000). It is even important to bear in mind the fact that if and how the information received by patient through patient education change following injury and time. Research studies are even needed to effectively identify the barriers to assessing patient education. The studies developed in future must be in a way to propose solutions for increasing access towards patient education. Patients with spinal cord injuries prefer to gain information from the individuals they assume to be as experts on the topic. As a reason, it is crucial to recognise whether individuals with Spinal cord injuries choose to talk with an expert owing to the fact that they perceive the information obtained is more likely to be accurate. Able to meet this need in the form of effective patient education measures in a more cost effective way could help in attaining needed implications. Researchers should also test the feasibility and effectiveness of supplied information and patient education from spinal cord injury experts (Dorsey, 2005).
- Incorporating more active learning strategies
Incorporating more active learning strategies or contextually based interventions as indicated by Hart et al (2010) and May et al (2006) within the programmes related to patient education help in facilitating the knowledge transfer within various situations of life. It is even important for information professionals to consider the existing gaps in the design and development of various information interventions. A supportive clinical patient relationship is the crucial to attain success in learning and aiming for change and success in the health related behavioural change.
- Developing robust action plan for local implementation
Furthermore I intend to visit different spinal injuries centre in the country to meet the clinical educators and explore their modes of patient education. This will help to collect accurate information and helpful tips about different forms and techniques for patient education. (Figure 2)
Recruiting of highly educated nursing assistance (support workers) can help in improving the current patient education programme. This is cost effective compare to recruiting qualified nurses.
To minimise the shortfalls and fulfil the gap in the current practice it is recommended to invite representatives from the social services and other authorities from community (like PCT) to multidisciplinary meetings for considering measures for ongoing education facilities. This will help patients to continue the learning process after discharge.
To discuss with the current liaison spinal team to liaise with community nursing more regularly to record any problems and raise those in multidisciplinary meetings.
The frequency of appointments for discharged patients should increase to every 3 months, for the first three years especially vulnerable and patients prone to further complications. The current practice of appointment is two appointments in the first year and then one every year. Increasing the appointment rate will minimise the threat of any possible complication and prompt action to deal with it.
Further research is required to obtain accurate strategies to address the factors in-depth which influence the process of patient education.
Action Plan (Figure 2)
Researcher Reflection
This dissertation project has given me the great opportunity of exploring the literature to give me the realistic insight of patient education for individuals with spinal cord injuries. Although it was a real challenge for me to take on the dissertation project as I had to give time to my family, job and other aspects of life. But the same time I was passionate during the whole process of this dissertation. Working with individuals with spinal injuries is my passion and this passion has grown during the course of the dissertation. This dissertation project has been an eye opener for me and has helped to develop my practice significantly.
I am confident to improve the patient education programme by implementing the evidence based practice learnt from this dissertation project.
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