From patient education to patient engagement: Implications for the field of patient education

Objective

Advances in health care require that individuals participate knowledgeably and actively in their health care to realize its full benefit. Implications of these changes for the behavior of individuals and for the practice of patient education are described.

Methods

An “engagement behavior framework” (EBF) was compiled from literature reviews and key informant interviews. To assess the focus of research and interventions on the identified engagement behaviors, the EBF was used to code scientific sessions in professional conferences relevant to patient education in the US in 2006–2007.

Results

Many specific behaviors constitute engagement. Professional conferences on patient education show only modest attention to the full range of relevant behaviors.

Conclusion

People must make informed choices about insurance and clinicians, coordinate communications among providers and manage complex treatments on their own. Not doing so risks preventable illness, suboptimal outcomes and wasted resources.

Practice Implications

Increased responsibilities of individuals, sick and well, to find and actively participate in high quality health care provides an opportunity for patient education researchers and clinicians to improve health outcomes by developing innovative strategies to support all individuals to effectively participate in their care to the extent possible.     

Exhibits facilitate histology laboratory instruction: student evaluation of learning resources.

Some professional schools have replaced microscopes for histology laboratory instruction with printed and electronic media. It is recognized that these media cannot replace experience with the microscope and that there is a cognitive dissonance of completely replacing microscope study. In addition, students believe that their time is not optimally used in the traditional histology laboratory. Therefore, at Loma Linda University, nine weekly microscope exhibits consisting of 10-15 slides each were prepared. For each exhibited slide, a one page "atlas" is provided, consisting of labeled low- and high-power color micrographs taken from that slide and an informative legend. By referring to the atlas, the student can easily identify the exact field and the labeled features with little help from an instructor. A live or taped video demonstration of the microscope exhibit is available on the first day of the exhibit. During the eighth week of the quarter, students were asked to evaluate the various learning resources available to them. No resource was valued significantly more than the microscope exhibits, but the video demonstrations were valued significantly more than the printed black and white atlas or the color atlas on CD. These exhibits have been used for 2 years to instruct a class of 90 dental students. Advantages are (1) students' time is used efficiently, (2) only one slide set and a fourth as many microscopes need be maintained compared with a traditional laboratory, and (3) one-of-a-kind slides derived from research activities provide for high impact learning.     

Impact of organizational interventions on the delivery of patient education in a diabetes clinic.

Patient education is widely regarded as an essential component of chronic disease care and effective health promotion. Nevertheless, the patient education process is seldom the subject of systematic investigation. In a previous study we determined that only a minimal amount of patients' time was devoted to education in a multidisciplinary diabetes clinic. The present study was designed to assess whether organizational manipulations would influence the delivery of patient education. Nurses' responsibility for management of patient flow was reduced, and an education checklist was included in the medical record. These simple modifications of clinic operation to increase the availability of professional time for patient education and to stimulate educational interactions were successful in significantly increasing patient education time. Time spent in assessing patient need increased by about one half (P less than 0.05) and in instruction by about two thirds (P less than 0.05). The process of patient education can be facilitated at low cost to the facility through targeted attention to organizational issues other than providers' knowledge or interest.     

The Complementary Medicine Education and Outcomes (CAMEO) program: A foundation for patient and health professional education and decision support programs

Objective

This paper describes the background, design and evaluation of a theory-informed education and decision support program for cancer patients considering complementary medicine (CM).

Methods

The program was informed by the Shared Decision Making theory, the Ottawa Decision Support Framework and the Supportive Care Framework. Previous empirical evidence and baseline research were used to identify patients’ and health professionals’ (HPs) information and decision support needs related to CM.

Results

To address the continuum of CM needs, a variety of education and decision support interventions were developed, including basic CM information and resources for patients and HPs, a group education program and one-on-one decision support coaching for patients, and an on-line education module for HPs. Evaluation of the program and individual interventions is underway.

Conclusions

This education and decision support program addresses a significant gap in care and offers an evidence-informed framework in which to translate CM evidence to conventional care settings and promote communication about CM.

Practice implications

Evidence-informed CM education and decision support interventions are needed to shift the culture around CM within conventional care settings and promote open communication that will lead to CM therapies being safely integrated into care.     

Variation in perceived competence, glycemic control, and patient satisfaction: relationship to autonomy support from physicians

There is considerable variation in care provided to patients with diabetes related to metabolic control, preventive services, and degree of patient-centered support. This study evaluates the relation of self-determination theory (SDT) constructs of clinician autonomy support, and patient competence to glycemic control, depressive symptoms, and patient satisfaction from baseline surveys of 634 patients of 31 Colorado primary care physicians participating in a program to improve diabetes care. Spearman correlations of autonomy support from one's clinician with patient competence, HbA1c, depressive symptoms and satisfaction were significant (R = -0.11 to 0.55, P < 0.005). Structural equation modeling demonstrated that autonomy support was significantly related to perceived competence, depressive symptoms, patient satisfaction, and indirectly to glycemic control. Perceived competence was significantly related to depressive symptoms, patient satisfaction and glycemic control. Further, the motivation constructs from SDT accounted for 5% of the variance in glycemic control, 8% of the variance in depression, and 42% of the variance in patient satisfaction. Quality improvement efforts need to pay greater attention to patient competence, satisfaction, and depression, in addition to glycemic control. Clinician autonomy support was found to be reliably measured and moderately correlated with psychosocial and biologic outcomes related to diabetes self-management. These results suggest training clinicians to increase their support of patient autonomy may be one important avenue to improve diabetes outcomes.     

Social support and barriers to family involvement in caregiving for persons with AIDS: implications for patient education

If efforts to promote family involvement in patient education and other caregiving activities for people with AIDS (PWAs) are to be successful, clinicians need information concerning PWAs' family network and the barriers PWAs face in obtaining support. Using data from interviews with 224 PWAs in New York City, we assessed the size and composition of their family network and the self-identified barriers to support. Overall, respondents mentioned having an average of less than two sources of close support. Women relied on children for support more than men did. Male injection drug users and men reporting sex with men relied on friends and traditional family almost equally, while men at risk for HIV via heterosexual contact relied more on traditional family sources. Barriers to support included interpersonal costs, lack of access, lack of acceptance, lack of intimacy, negative interactions and fear of disclosure. Health professionals need to conduct comprehensive network assessments with PWAs in order to determine the full scope of support resources available to each patient. Educational initiatives that provide information about family conflict resolution and the course and transmission of HIV may assist in alleviating these barriers. Clinicians can facilitate family involvement in patient education by addressing the informational needs that are salient to both PWAs' and their family caregivers.     

A computerized decision support system for patient selection in dental education

A computerized decision support system is presented. The system is used to aid in the situation of patient selection for the purpose of dental education and utilizes the PERT/CPM methodology and decision tables. It runs on a microcomputer and written in Basic. The input is a list of patient's needs, and the output is a tentative treatment plan, the chair time needed to complete the treatment, its cost, and the probability that the student will finish it on time.     

Parent-adolescent relationship education (PARE): program delivery to reduce risks for adolescent pregnancy and STDs

The first author recruited parent-adolescent dyads (N = 192) into after-school prevention education groups at middle schools in southeast Texas. This author placed participants in either (1) an Interactive Program (IP) in which they roleplayed, practiced resistance skills, and held parent-child discussions or (2) an Attention Control Program (ACP) that used the same curriculum but was delivered in a traditional, didactic format. Questionnaires administered at the beginning and end of the 4-session program and again after booster sessions in 3 subsequent semesters provided measures of social controls (eg, communication with parents) and self controls (eg, protection against risk) on the youths' sexual health behaviors. Linear mixed models adjusted for gender, age, and ethnicity showed that the IP, in comparison with the ACP, achieved significant gains in social control by increasing parental rules about having sex and other risky behaviors and also enhanced students' self-control by increasing their knowledge about prevention and enhancing resistance responses when pressured to have sex.     

Pediatric patient education: the unanswered challenge to medical education

As many as 10-20% of pediatric patients in this country have a chronic illness. This number will likely increase. Unfortunately, there has not been a parallel growth in physicians acquiring knowledge and skills in patient education. The disparity between these high tech and high touch skills is the most logical explanation why the morbidity in some chronic illnesses like asthma has not improved despite recent advances in diagnosis and treatment. The discussion focuses on the barriers to patient education and why it has not been a more integral part of caring for chronically ill children and their families. The solutions to this problem are complex but must include the willingness of health care professionals to welcome patients and their families as partners in the process. In addition, there is a need for change in the medical education system so that patient education is taught as a continuum, beginning with principles and theory and concluding with application to patient care.     

Evaluating CAM education in health professions programs.

As medical, nursing, and allied health programs integrate complementary and alternative medicine (CAM) content into existing curricula, they face many of the same challenges to assessment and evaluation as do more traditional aspects of health professions education, namely, (1) specifying measurable objectives, (2) identifying valid indicators, and (3) evaluating the attainment of desired outcomes.Based on the experiences of 14 National Center for Complementary and Alternative Medicine (NCCAM) education grant recipients funded between 2000 and 2003, the authors cite selected examples to illustrate strengths and deficits to "mainstreaming" CAM content into established health professions curricula, including subjecting it to rigorous, systematic evaluation.In addition to offering recommendations for more strenuously evaluating key CAM-related educational outcomes, the authors discuss related attitudes, knowledge, and skills and how these, like other aspects of health professions training, may result in enhanced patient care through modifications in clinical (provider) behaviors.     

Multimedia support in preoperative patient education for radical prostatectomy: the physicians' point of view

Objective

To systematically assess the physicians’ point of view of multimedia support in preoperative patient education for radical prostatectomy.

Methods

We evaluated the view of physicians performing multimedia supported preoperative educations within a randomized controlled trial. Therein 8 physicians educated 203 patients for radical prostatectomy.

Results

All physicians rated multimedia supported education better than the standard procedure. Main reasons were better comprehensibility, the visual presentation, and greater ease in explaining complex issues. Objective time measurement showed no difference between both educations. The major disadvantage was the impression, that multimedia supported education lasted longer. Moreover, they had the impression that some details could be further improved. Given the choice, every physician would decide for multimedia support.

Conclusion

Physicians appreciate multimedia support in preoperative education and contrary to their impression, multimedia support does not prolong patient education. Therefore, patients and physicians likewise profit from multimedia support for education and counseling.

Practice implications

The readiness of physicians is a possible obstacle to this improvement, as their view is a key factor for the transition to everyday routine. Therefore, our results could alleviate this possible barrier for establishing multimedia supported education in clinical routine.     

Benchmarks of support in internal medicine residency training programs.

PURPOSE: To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality. METHOD: A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses. RESULTS: Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor). CONCLUSIONS: These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.     

Health education programs in U.S. medical schools.

To examine the status of teaching programs on health education in undergraduate medical education, the author in 1990-91 surveyed representatives of all 126 U.S. medical schools. Of the 97 institutions that responded, 63 (65%) offered instruction in patient education and 72 (74%) offered instruction in community health promotion. The responses indicated that a number of departments participated in instruction and that diverse methods of instruction and evaluation were used. Opinions of the representatives regarding the importance and adequacy of instruction in health education were quite favorable. The author concludes that more information is needed to determine the effectiveness of the instructional programs and their impact on the quality of medical care.     

O2 delivery to the pregnant uterus: its relationship to O2 consumption.

Normal sheep were studied at intervals of 3-5 days during the last weeks of pregnancy in order to evaluate variability in rate of O2 consumption (QO2) of the uterus in relation to several variables involved in delivery of O2 to the organ. Among-animal differences of uterine QO2 were statistically significant and directly related to birthweight of the lamb. Among-animal differences of uterine blood flow (UBF) and uterine arteriovenous O2 content difference [C(a-v)O2] also were statistically significant, though neither was related to birthweight, presumably since they tended to vary inversely with one another. In a given ewe relative magnitude of UBF and of C(a-v)O2 was related to maternal arterial O2 content (CaO2), day of pregnancy, and whether the animal carried singlets or twins. Variability in QO2 was most closely related to UBF, although its relations to C(a-v)O2 and CaO2 were significant also. These data suggest there are systematic relationships among variables involved in the delivery of O2 to the uterus of pregnant sheep.