patient education among nurses: bringing evidence … · bringing evidence into clinical...

16

Review

Patient education among nurses: bringing evidence into clinical

applicability in Iran

Hossein Karimi Moonaghi1

Amir Emami Zeydi2

Amir Mirhaghi3

1 RN Ph.D. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email: [email protected] RN, PhD Candidate. Mashhad University of Medical Sciences, Mashhad, Iran. email: [email protected] RN, PhD. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email: [email protected] of interests: none.Received on: June 15, 2015.Approved on: December 4, 2015.How to cite this article: Karimi Moonaghi H, Emami Zeydi A, Mirhaghi A. Patient education among nurses: Bringing evidence into clinical applicability in Iran. Invest Educ Enferm. 2016; 34(1): 137-151.DOI: 10.17533/udea.iee.v34n1a16

Patient Education among nurses: bringing evidence into clinical applicability in Iran

Objective. The aim of this study was to present a comprehensive review of the literatures describing barriers and facilitators of patient education (PE) perceived by Iranian nurses in order to explain clinical applicability of patient education. Methods. Review of the literature was undertaken using the international databases including PubMed/Medline, Scopus, ScienceDirect, as well as Google Scholar. Also, Persian electronic databases such as Magiran, SID and IranMedex were searched. Electronic databases were searched up from conception to September 2014 using search terms: “patient education”, “ patients education”, “patient teaching”, “patient training”, “nurse”, “ nurses”, “ nursing”, “ and “Iran”. Only studies were included that were related to barriers and facilitators of PE among Iranian nurses. Results. Twenty-seven studies were included. The main influential barriers were categorized into three major areas: 1) Nurse-related factors: nursing shortage 2) Administration-related factors: unsupportive organizational culture, and

3) Patient-related factors: low compliance. The most perceived facilitators were recognized as “increasing, selecting and training special nurses for providing PE” and “providing PE courses for nurses and appropriate facilities for PE”. Conclusion. Iranian nurses encounter barriers in PE, and the most frequently encountered barriers were related to administration factors. These findings have implications for administrators and managers in health settings. In order to promote PE among nurses, administrators should create a supportive environment and use effective strategies to smooth the progress of PE by nurses in their practice in order to ensure optimal outcomes for patients.

Key words: patient education as topic; health services; nurses; Iran.

La educación al paciente entre las enfermeras: brindando evidencia en la

aplicabilidad clínica en Irán

Objetivo. Identificar las barreras y facilitadores de la Educación del Paciente (EP) percibida por las

138 Invest Educ Enferm. 2016; 34(1)

Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi

enfermeras iraníes con el fin de explicar la aplicabilidad clínica de la educación al paciente. Métodos. Revisión de la literatura que se llevó a cabo utilizando las bases de datos internacionales PubMed-Medline, Scopus, ScienceDirect y Google Scholar. Además, se realizaron búsquedas en las bases de datos electrónicas persas Magiran, SID e IranMedex. Se realizaron búsquedas desde la creación de las bases de datos hasta septiembre de 2014 usando los términos de búsqueda: “educación del paciente”, “educación de pacientes”, “enseñanza del paciente”, “entrenamiento del paciente”, “enfermera”, “enfermeras”, e “Irán”. Solo se analizaron los estudios relacionados con las barreras y facilitadores de EP entre enfermeras iraníes. Resultados. Se incluyeron 27 estudios. Las principales barreras se clasificaron en tres grandes áreas: 1) Factores relacionados con la enfermería: escasez de este recurso humano, 2) Factores relacionados con la administración: inapropiada cultura organizacional y 3) Factores relacionados el paciente: bajo cumplimiento. Los facilitadores más percibidos se reconocieron como “el aumento, la selección y formación especial de las enfermeras para proporcionar EP” y “disponibilidad de cursos de EP para las enfermeras y la disponibilidad de instalaciones adecuadas para brindar el EP”. Conclusión. Las enfermeras iraníes encuentran barreras en la EP, siendo las más frecuentes las relacionadas con factores de la gestión de los recursos. Estos resultados tienen implicaciones para los administradores y directivos de las instituciones de salud, pues para promover que las enfermeras en su práctica brinden la EP, se debe crear un ambiente de apoyo y utilizar estrategias eficaces con el fin de garantizar resultados óptimos en los pacientes.

Palabras clave: educación del paciente como asunto; servicios de salud; enfermeros; Iran.

A educação ao paciente entre a enfermeiras: brindando evidência na

aplicabilidade clínica no Irã

Objetivo. Identificar as barreiras e facilitadores da educação do paciente (EP) percebida pelas enfermeiras iranianas com o fim de explicar a aplicabilidade clínica da educação ao paciente. Métodos. Revisão da literatura que se levou a cabo utilizando as bases de dados internacionais PubMed-Medline, Scopus, ScienceDirect e Google Scholar. Ademais, se realizaram buscas nas bases de dados electrónicas persas Magiran, SID e IranMedex. Se realizaram buscas desde a criação das bases de dados até setembro de 2014 usando os termos de busca: “educação do paciente”, “educação de pacientes”, “ensinamento do paciente”, “treinamento do paciente”, “enfermeira”, “enfermeiras”, e “Irã”. Só se analisaram os estudos relacionados com as barreiras e facilitadores de EP entre enfermeiras iranianas. Resultados. Se incluíram 27 estudos. As principais barreiras foram classificadas em três grandes áreas: 1) Fatores relacionados com a enfermagem: escassez deste recurso humano, 2) Fatores relacionados com a administração: inapropriada cultura organizacional y 3) Fatores relacionados o paciente: baixo cumprimento. Os facilitadores mais percebidos foram reconhecidos como “o aumento, a seleção e formação especial das enfermeiras para proporcionar EP” e “disponibilidade de cursos de EP para as enfermeiras e a disponibilidade de instalações adequadas brindar o EP”. Conclusão. As enfermeiras iranianas encontram barreiras na EP, sendo as mais frequentes as relacionadas com fatores da gestão dos recursos. Estes resultados têm implicações para os administradores e diretivos das instituições de saúde, pois para promover que as enfermeiras em sua prática brindem a EP, se deve criar um ambiente de apoio e utilizar estratégias eficazes com o fim de garantir resultados ótimos nos pacientes.

Palavras chave: educação de pacientes como assunto; serviços de saúde; enfermeiras e enfermeiros; Iran.

IntroductionPatient education (PE) is a fundamental aspect of patient care and increasingly recognized as an essential function and one of the professional standards in nursing practice.1 It is considered as a dynamic and continuous process including

formal and informal interactive activities performed to improve patients’ knowledge and behaviors in ways to achieve better health care outcomes.2,3 There is a growing body of research evidence that illustrates the effectiveness of PE on enhancing patients’ levels of empowerment,


Patient education among nurses: bringing evidence into clinical applicability in Iran

self-care behaviors, compliance with health care recommendations, satisfaction in health care settings, and quality of their life, and reducing their levels of anxiety.3,4

Nurses are the largest group of the health care providers. They are at the forefront of patient care, and spend the most time with the patients and their family members. This extensive contact provides excellent opportunities for providing patient and family education.2 In addition, providing PE is both a legal and ethical responsibility of nurses.5,6 For all these reasons, PE is considered to be an integral part of high quality nursing care.3 Despite increasing availability of research findings and broad consensus on the importance of PE, there are many barriers to nurses’ capacity to provide effective PE.2 PE needs strict adherence to educational principles,7 so all variables that have an impact on teaching-learning process play an important role. Patients usually get involved in some type of limiting conditions that was imposed by their disease, aging and etc. Conditions such as functional and cognitive limitations, misconceptions, low motivation and self-esteem should be carefully addressed.8 Other factors such as environment, organization, interdisciplinary cooperation, collegial teamwork that are related to health care context also have unique role.5 However principles of education have been well-defined and widely recognized, environmental factors are unique in that significant differences exist among healthcare systems worldwide. Therefore it`s necessary to investigate contextual factors effects on PE. Some studies even called for special attention to changing the environment in which patients care for themselves.9 It has been clearly demonstrated that contextual factors as a glass ceiling barrier could play a big role in PE, so it makes sense to investigate contextual factors in different countries in order to reveal the extent of potential discrepancy.

In Iran, nursing is the largest healthcare profession which is directly responsible for the care of their patients and has a central role in PE.10 Nevertheless; PE is a growing concern for the Iranian healthcare system as well. The results

of conducted studies about the topic in Iran have been demonstrated that the implementation of PE in nursing practice is often an undervalued intervention, thus poor education is one of the most common source of patient’s complaints in the health-care sector.3,6 A study with aim to evaluate Iranian nurses’ perceptions about PE showed that the majority of nurses believed that one of the major and important parts of their responsibility in caring of patients in daily clinical practice is PE. Nevertheless, they give a lower priority to it as compared to other nursing tasks such as medication administration, physical patient care, nursing care planning and documentation.8 Because contextual and country-specific factors may influence the implementation of PE, it is important to study facilitators and barriers to PE specific to the Iranian context.6,11,12 So the aim of the current study was to presents a comprehensive review of the literatures, exploring barriers and facilitators of PE among Iranian nurses, in order to identify strategies to promote enhanced PE within the Iranian healthcare system context.

MethodsA systematic search of the relevant literature were performed within international databases including PubMed/Medline, Scopus, ScienceDirect as well as Google Scholar search engine using the following search terms or their combinations: “patient education”, “ patients education”, “patient teaching”, “patient training”, “nurse”, “ nurses”, “ nursing”, “ and “Iran”. These keywords equivalents in Farsi were searched in Persian electronic databases such as Iranian Journal Database (Magiran), Scientific Information Databases (SID) and IranMedex (Iranian Biomedical Journal Database). In addition, a hand search of article references was done to ensure completeness of the search. The search was limited to the English and Persian languages. Applying no time limit, all articles having the selected keywords in the title, abstract and text, including quantitative as well as qualitative approaches in Iranian context, from conception up to September 2014 were included and evaluated. The articles had to be focused on



the barriers or facilitators of PE among Iranian nurses as inclusion criteria. We did not actively search the gray literature to find studies not in the peer-reviewed literature and excluded studies published exclusively in abstract form (e.g., conference proceedings), because they are not typically peer reviewed, and only partially report results which may change substantially when fully published.

The search strategy generated 4 000 titles and abstracts. After initial screening and evaluation by two researchers independently (HKM and AEZ), 3 933 articles were rejected and 67 articles were identified as potentially eligible for the review. These articles were retrieved for full text review. Removing duplicates and using secondary screening resulted in 26 articles to be included for the review. Also, a manual search of article references added a further one paper. In total, 27 peer-reviewed articles were eligible for final inclusion (Figure 1). Two authors independently extracted data from the studies including author and year, objective, method and data collection, sample and setting and key findings. Data were summarized into tables and compared to reveal organizing categories. Any disagreements were discussed and resolved by consensus. Extracted data were also coded and organized in order to facilitate analysis and weight categories. Coding process was employed using MaxQDA 10. This review included 27 studies which, including 20 that used quantitative designs, six that used qualitative designs, and one that used a mixed method design. All articles included in this review had been published between 2002 and 2014 and were published in peer-reviewed journals. Seven of the studies were conducted at the Tehran University of Medical Sciences affiliated hospitals. Sixty-two per cent (17 out of 27) of PE studies has only focused on barriers while 10 studies have reported both facilitators and barriers regarding PE simultaneously. Seventy-four per cent (20 out of 27) of PE studies have been designed cross-sectional descriptive method and other studies were used qualitative methods including content

analysis (18%), grounded theory and mixed method. Researcher-generated questionnaire has been used by all quantitative research that they were content validated.

Most studies have used convenience or stratified sampling. Some of them included only participants who had at least two years work experience. Eighty per cent (22 out of 27) of studies have collected only nurses` viewpoints and only five studies have included in other participants such as physicians, patients and patients` family members. Ninety-nine per cent of total sample were nurses (4281 out of 4340). All studies have collected their data in hospital. Thirty per cent of studies were originated from capital city of Tehran as most common place and only three cities have involved in twice. Figure 1 includes a summary of the articles that were included in this review.

ResultsPerceived barriers to PE The main barriers reported in the most papers can be categorized in three overall areas: 1) Nurse-related factors 2) Administration-related factors and 3) Patient-related factors. Overall, nurses have placed greater emphasis on nurse and administration related factors and less on patient-related factors.

Nurse-related factors. The most reported barrier in this area was “nursing shortage, excessive workload and inadequate time”. The other barrier was “lack of knowledge among nurses about PE” including “lack of awareness of nurses about educational methods and teaching/learning principles”, “lack of awareness and appropriate knowledge of nurses regarding patient’s educational needs”, “insufficient attention of nurses to the educational, cultural and habitual needs of patients and their families”, “negative attitude to PE”, “believing that patient teaching is not nurses responsibility”, “lack of knowledge about illness” and “ nurses’ lack of communication skills”.



Figu

re 1

. Lit

erat

ure

sear

ch a

nd r

etri

eval

flow

dia

gra

m



Administration-related factors. The most barriers that perceived by nurses in this area were “inappropriate organizational culture” and “inappropriate place and facilities for PE”. Nurses believed that there is not a supportive culture among managers as well as hospitals, so there is no effective management and collaboration either. They have reported “inadequate support from the managers”, , “lack of appropriate educational facilities in hospital”, “lack of specialized nurse for PE”, “no division of labor”, “lack of financial incentives for nurses”, “poor cultural adaptation for educator and patients in terms of sex”, “lack of coordination by other members of the healthcare professionals with nurses” and “lack of evaluating PE activities”.

Patient-related factors. The main patient-related barrier perceived by nurses in PE was patients have low compliance and readiness to receive PE. This barrier includes “Patient’s low literacy or illiteracy”, “lack of awareness of patients about the educational responsibility of nurses”, “knowledge deficit of patient about their rights”, “lack of patients’ interest to change their behavior”, “inconsistencies in the culture, social and mental status of patients and their families”, and “unwillingness to adhering to comments” were the most perceived barriers in this area.

Perceived facilitators to PE The most perceived facilitators of PE that could be considered as potential strategies to promote PE were “selecting and training special nurses for providing PE” and “increasing nursing staff in each working shift”, “holding courses and seminars on teaching and learning strategies” and “providing appropriate place and facilities for PE”, “considering special privilege for PE in annual evaluation of nurses”, “development of more inclusive information guidance sheets to assist nurses in teaching specific topics to patients” and “developing PE protocols for each ward”, “enhancing patient’s interest and participation in education”, “increasing nurses interested to identifying the learning needs of the patients”, “registration of PE process in their medical record”,

“applying feedbacks for educational reform by nurses”, “revision in supervision and feedback system”, and “establishing a good relationship between patients, nurses and physicians”.

DiscussionThere is a growing body of research literature that focuses on the barriers to and facilitators of PE perceived by nurses in Iran. The result of the present review showed that the inadequate time and nursing staff, heavy workload, inadequate support of managers, inappropriate organizational culture, and lack of appropriate educational facilities in hospital were reported as an administration related barriers to PE by Iranian nurses. The findings were supported by other studies have been conducted in other countries such as United States, China and Colombia that pointed out the nurses’ heavy workload as a major barrier to PE.38-41 Also the result of the study by Barret et al. referred to additional time to teach patients, more educational materials, peers feedback regarding teaching effectiveness, and sufficient medical information as effective factors for PE based on nurses’ perspective.42 Nursing shortage is a serious issue in many Asian countries such as Iran; and nurses are practicing under an overwhelming workload.43,44 This issue results in less nurses being available for patients, and the resulting time restriction dissuade the nurses from providing the education for their patients.45 In addition to the unbalanced nurse-patient ratio due to nurse shortage and large number of hospitalized patients, nurses are expected to do nonprofessional tasks such as coordinating, transporting patients and performing ancillary services which leading to increased workload. This excessive workload definitely affects the nurses’ decision to allocate enough time to various tasks such as communicating with patients and their education.46,47 The results of a study by Park et al. has been shown that although nurses consider PE as an essential part of their care planning, in the face of work limitations, they are not able to provide their education as needed. Also, patient education is basically informal and reactional. Therefore, this activity can be considered as a low priority when nurses faced with time limitations.2



Tabl

e 1.

Sum

mar

y o

f th

e b

asic

fea

ture

s o

f th

e re

sear

ch a

rtic

les

that

wer

e in

clud

ed in

the

rev

iew

Aut

hor

&

Year

Obj

ectiv

eM

etho

d an

d

data

col

lect

ion

Sam

ple

& s

ettin

gK

ey F

indi

ngs

Bor

hani

13

20

02

To

eval

uate

nu

rses

an

d nu

rse-

man

ager

s’

opin

ion

tow

ard

the

impo

rtan

ce o

f ba

rrie

rs o

f PE.

Des

crip

tive

cros

s-se

ctio

nal

stud

y w

as

carr

ied

out.

Dat

a w

ere

colle

cted

by

a re

sear

cher

-mad

e qu

estio

n-na

ire.

126 n

urse

s an

d 50 n

urse

man

ag-

ers

who

wor

ked

in s

ix h

ospi

tals

af

filia

ted

to K

erm

an U

nive

rsity

of

Med

ical

Sc

ienc

es

wer

e se

lect

ed

thro

ugh

cens

us m

etho

d.

The

mos

t im

port

ant b

arrie

rs to

PE

wer

e: “

lack

of a

p-pr

opria

te e

duca

tiona

l fac

ilitie

s in

hos

pita

l”,

“lac

k of

aw

aren

ess

of n

urse

s ab

out

educ

atio

nal

met

hods

”,

“lac

k of

aw

aren

ess

of n

urse

s re

gard

ing

patie

nts’

ed

ucat

iona

l nee

ds”

and

“lac

k of

bel

ief a

bout

edu

ca-

tiona

l rol

e of

nur

ses”

. G

ouda

rzi

et a

l.14

20

04

Eval

uatio

n of

th

e ba

rrie

rs

and

faci

litat

ors

of P

E fro

m

the

view

poin

ts o

f nu

rses

in

hosp

itals

of

Tehr

an U

nive

r-si

ty o

f Med

ical

Sci

ence

s.

Des

crip

tive

cros

s-se

ctio

nal

stud

y w

as c

arrie

d ou

t. D

ata

wer

e co

llect

ed

by

Hon

an

ques

tionn

aire

.15

317 n

urse

s w

orki

ng in

hos

pita

ls o

f Te

hran

Uni

vers

ity o

f M

edic

al S

ci-

ence

s w

ere

sele

cted

usi

ng s

trat

i-fie

d ra

ndom

sam

plin

g.

Shor

tage

of

nurs

es,

lack

of

prop

er p

lace

, tim

e an

d pa

tient

mot

ivat

ion

for

rece

ivin

g ed

ucat

ion,

nur

ses

and

nurs

e ad

min

istr

ator

s’ i

natt

entio

n to

PE

and

nega

tive

attit

ude

of d

octo

rs t

owar

d P

E by

nur

ses

wer

e m

ost

barr

iers

to

PE.

Mar

dani

an

Deh

kord

i et

al.1

1

20

05

Expl

orin

g th

e ba

rrie

rs a

nd

faci

litat

ors

of P

E fro

m t

he

view

poin

ts o

f nur

ses

in h

os-

pita

ls o

f Esf

ahan

Uni

vers

ity

of M

edic

al S

cien

ces.

Cro

ss-s

ectio

nal

stud

y. U

s-in

g a

rese

arch

er-g

ener

ated

qu

estio

nnai

re.

259

clin

ical

nur

ses

and

head

nur

s-es

at

hosp

itals

affi

liate

d to

Esf

a-ha

n U

nive

rsity

of M

edic

al S

cien

ces

wer

e se

lect

ed t

hrou

gh a

str

atifi

ed

sam

plin

g m

etho

d.

Top

thre

e ba

rrie

rs t

o P

E w

ere

insu

ffici

ent

nurs

-in

g st

aff,

inad

equa

te t

ime

on t

he j

ob a

nd l

ack

of

educ

atio

nal

faci

litie

s. T

he m

ost

thre

e im

port

ant

faci

litat

ors

wer

e al

loca

tion

of o

ne t

o tw

o nu

rses

for

PE,

pro

vidi

ng m

ore

time

for

nurs

es to

do

it an

d de

-ve

lopm

ent

of m

ore

incl

usiv

e in

form

atio

n gu

idan

ce

shee

ts t

o as

sist

the

m in

tea

chin

g sp

ecifi

c to

pics

to

patie

nts.

Hes

hmat

i N

abav

i et

al.1

6

20

06

Iden

tifyi

ng

adm

inis

trat

ive

barr

iers

to

PE

and

thei

r ra

nkin

g from

the

vie

wpo

int

of n

urse

s.

Des

crip

tive

stud

y.

Usi

ng

a re

sear

cher

-gen

erat

ed

ques

tionn

aire

.

65 n

urse

s an

d nu

rse

man

ager

s at

a

one

hosp

ital

whi

ch a

ffilia

ted

to

the

Tehr

an U

nive

rsity

of

Med

ical

Sc

ienc

es s

elec

ted

thro

ugh

prop

or-

tiona

l sam

plin

g.

The

mos

t im

port

ant

barr

iers

to

PE

wer

e: p

atie

nt’s

lo

w l

itera

cy l

evel

s or

illi

tera

cy,

inad

equa

te t

ime

for

nurs

es,

inad

equa

te e

duca

tiona

l fa

cilit

ies,

and

lac

k of

fina

ncia

l inc

entiv

es fo

r nu

rses

.

Hek

mat

-po

u et

al

.17

20

07

Eval

uatin

g pa

tient

edu

ca-

tion

proc

ess

and

answ

er-

ing

to t

hese

que

stio

ns:

1-

Wha

t is

the

pro

cess

of P

E?

2-

Wha

t ar

e th

e ba

rrie

rs o

f co

rrec

t im

plem

enta

tion

of

PE?

Qua

litat

ive

stud

y us

ing

a co

nten

t an

alys

is a

ppro

ach

was

use

d. D

ata

wer

e co

l-le

cted

thr

ough

sem

i-str

uc-

ture

d in

terv

iew

s.

33 n

urse

s an

d nu

rse

stud

ents

and

10 h

ospi

taliz

ed p

atie

nts

wer

e in

-cl

uded

. Th

e se

ttin

g of

the

stu

dy

was

sch

ools

of

Nur

sing

and

Mid

-w

ifery

and

2 g

ener

al h

ospi

tals

af-

filia

ted

to A

rak

Uni

vers

ity o

f Med

i-ca

l Sci

ence

s.

The

stud

y fin

ding

s sh

owed

tha

t fa

ctor

s re

late

d to

: 1

- C

urri

culu

m p

lann

ing

in s

choo

ls o

f nu

rsin

g an

d m

idw

ifery

2-

PE

cour

ses

3-

Insu

ffici

ent

atte

ntio

n to

nur

ses

cond

ition

s 4

- In

suffi

cien

t at

tent

ion

to

educ

atio

nal,

cultu

ral

and

habi

tual

nee

ds o

f pa

-tie

nts

and

thei

r fa

mili

es 5

- Ed

ucat

iona

l m

anag

e-m

ent

and

6-

Att

itude

of

part

icip

ants

to

PE,

wer

e ke

y is

sues

in

the

proc

ess

of P

E th

at w

as r

elat

ed

to i

napp

ropr

iate

im

plem

enta

tion

of P

E in

clin

ical

se

ttin

gs.

Maz

aher

i et

al.1

8

20

07

Eval

uatio

n th

e ba

rrie

rs

of

PE fo

r el

derly

pat

ient

s fro

m

the

heal

th p

erso

nnel

’s p

oint

of

vie

w in

Ard

abil.

Des

crip

tive

cros

s-se

ctio

n-al

stu

dy w

as c

arrie

d ou

t.

Dat

a w

ere

colle

cted

by

a re

sear

cher

-mad

e qu

es-

tionn

aire

.

380

heal

th p

rofe

ssio

nals

inc

ludi

ng

nurs

es, p

hysi

cian

s, a

nd n

ursi

ng a

nd

med

ical

stu

dent

s w

orki

ng in

hos

pi-

tals

affi

liate

d to

Ard

abil

Uni

vers

ity o

f M

edic

al S

cien

ces

wer

e se

lect

ed u

s-in

g pu

rpos

eful

sam

plin

g,

Poor

col

labo

ratio

n be

twee

n he

alth

pro

fess

iona

ls i

n PE,

exc

essi

ve w

orkl

oad,

ina

dequ

ate

time,

and

in-

adeq

uate

att

entio

n to

PE

wer

e th

e m

ost

perc

eive

d ba

rrie

rs.



Aut

hor

&

Year

Obj

ectiv

eM

etho

d an

d

data

col

lect

ion

Sam

ple

& s

ettin

gK

ey F

indi

ngs

Abb

asi e

t al

.19 2

00

8Id

entif

ying

pe

rcei

ved

bar-

riers

to

PE b

y nu

rses

and

pr

ovid

ing

a m

odel

fo

r its

fa

cilit

atin

g in

tea

chin

g ho

s-pi

tals

affi

liate

d to

Qom

Uni

-ve

rsity

of M

edic

al S

cien

ces.

Des

crip

tive

cros

s-se

ctio

nal

stud

y w

as

carr

ied

out.

D

ata

wer

e co

llect

ed b

y a

rese

arch

er-m

ade

ques

tion-

naire

.

351 n

urse

s an

d he

ad n

urse

s, w

ho

wor

ked

in t

each

ing

hosp

itals

affi

li-at

ed t

o Q

om U

nive

rsity

of M

edic

al

Scie

nces

, wer

e se

lect

ed u

sing

con

-ve

nien

ce s

ampl

ing.

Mos

t im

port

ant

perc

eive

d ba

rrie

rs w

ere:

“La

ck o

f aw

aren

ess

of p

atie

nts

abou

t th

e ed

ucat

iona

l re

-sp

onsi

bilit

y of

nur

ses”

, “t

he la

rge

num

ber

of h

ospi

-ta

lized

pat

ient

s”,

“no

divi

sion

of

labo

r” a

nd “

time-

cons

umin

g nu

rsin

g ta

sks

such

as

patie

nt c

are

and

docu

men

tatio

n”.

The

mos

t im

port

ant

faci

litat

ors

wer

e fo

und

to b

e: “

time

dedi

catio

n fo

r P

E”, “

allo

ca-

tion

of o

ne t

o tw

o nu

rses

for

PE”

and

“pr

epar

atio

n of

fina

ncia

l sou

rces

for

nurs

es”.

Mor

idi e

t al

.20

20

09

Det

erm

ine

the

view

poin

ts

of n

urse

s ab

out

PE,

and

its

perc

eive

d ba

rrie

rs a

nd fa

cili-

tato

rs.

Des

crip

tive

cros

s-se

ctio

n-al

stu

dy w

as c

arrie

d ou

t. D

ata

wer

e co

llect

ed b

y a

rese

arch

er-m

ade

ques

tion-

naire

.

155 n

urse

s w

ho w

orke

d in

tea

ch-

ing

hosp

itals

affi

liate

d to

Kur

dis-

tan

Uni

vers

ity o

f Med

ical

Sci

ence

s w

ere

sele

cted

th

roug

h ce

nsus

m

etho

d.

Lack

of k

now

ledg

e an

d sk

ills

for i

dent

ifyin

g th

e sp

e-ci

fic n

eeds

of t

he p

atie

nts,

insu

ffici

ent nu

rsin

g st

aff,

insu

ffici

ent t

ime,

and

non

phy

sica

l and

men

tal r

ead-

ines

s of

pat

ient

s’ f

or e

duca

tion

wer

e th

e m

ost

per-

ceiv

ed b

arrie

rs t

o P

E. T

he m

ost

perc

eive

d fa

cilit

a-to

rs w

ere

the

patie

nt’s

inte

rest

and

par

ticip

atio

n in

ed

ucat

ion,

nur

ses

inte

rest

ed t

o id

entif

y th

e le

arni

ng

need

s of

pat

ient

s, a

ppro

pria

te s

ettin

g fo

r ed

ucat

ion

and

cons

ider

ing

the

spec

ial

poin

ts f

or p

erfo

rmin

g PE

at a

nnua

ls a

ppra

isal

.A

shgh

ali-

Fara

hani

et

al.2

1

20

09

Iden

tifyi

ng

an

obst

acle

w

hich

lea

ds t

o th

e la

ck o

f ef

fect

ive

PE

base

d on

nur

s-es

`, p

hysi

cian

s` p

atie

nts`

an

d fa

mily

mem

ber

of p

a-tie

nts`

vie

wpo

ints

.

A q

ualit

ativ

e re

sear

ch a

p-pr

oach

(gr

ound

ed t

heor

y)

was

use

d. D

ata

wer

e co

l-le

cted

us

ing

open

-end

ed

inte

rvie

ws

and

field

obs

er-

vatio

ns.

18 n

urse

s, 4

car

diov

ascu

lar

spe-

cial

ists

, 9 p

atie

nts

with

car

diov

as-

cula

r di

seas

e an

d 4 f

amily

mem

-be

rs w

ere

sele

cted

int

ervi

ewed

at

two

educ

atio

nal

hosp

itals

in

Teh-

ran

thro

ugh

Purp

osef

ul T

heor

etic

al

sam

plin

g.

Inef

fect

ive

man

agem

ent,

in

appr

opria

te

orga

niza

-tio

nal c

ultu

re,

and

cultu

ral o

bstr

ucts

wer

e th

e m

ost

barr

iers

to

PE.

Org

aniz

atio

nal c

ultu

re p

laye

d an

im-

port

ant

and

cent

ral r

ole

in P

E.

Azi

znej

ad

et a

l.22

20

10

Iden

tifyi

ng t

he p

oten

tial i

m-

plem

enta

tion

barr

iers

in t

he

PE p

rogr

am f

rom

the

poi

nt

of v

iew

of n

urse

s an

d nu

rse

man

ager

s w

orki

ng

in

the

Bab

ol u

nive

rsity

of

med

ical

sc

ienc

es a

ffilia

ted

hosp

itals

.

Cro

ss-s

ectio

nal s

tudy

. Dat

a w

ere

colle

cted

by

a re

sear

ch-

er-m

ade

ques

tionn

aire

.

150 n

urse

s an

d nu

rse

man

ager

s,

with

at

leas

t 6 m

onth

of

nurs

ing

expe

rienc

e,

in

the

hosp

itals

af

-fil

iate

d to

Bab

ol m

edic

al u

nive

rsity

from

wer

e se

lect

ed t

hrou

gh c

en-

sus

met

hod.

The

mos

t im

port

ant

barr

iers

to

the

PE

wer

e as

fol

-lo

ws:

lack

of p

ropo

rtio

nalit

y be

twee

n th

e nu

mbe

r of

pa

tient

s an

d nu

rses

, tim

e pr

essu

re a

nd e

xces

sive

w

orkl

oad,

lac

k of

att

entio

n an

d ad

equa

te s

uppo

rt

from

the

man

ager

s, la

ck o

f pro

per

envi

ronm

ent a

nd

educ

atio

nal

equi

pmen

t in

the

hos

pita

l, an

d la

ck o

f co

ordi

natio

n of

oth

er h

ealth

car

e pr

ofes

sion

als

with

nu

rses

. R

osta

mi e

t al

.23

20

10

Eval

uatio

n of

ba

rrie

rs

to

PE

from

the

vie

wpo

int

of

nurs

es a

nd p

atie

nts.

A de

scrip

tive

cros

s-se

ctio

n-al

stu

dy w

as c

arrie

d ou

t. D

ata

wer

e co

llect

ed b

y a

rese

arch

er-m

ade

ques

tion-

naire

.

50 n

urse

s w

ith a

t le

ast

one

year

s of

wor

king

exp

erie

nces

in o

ne h

os-

pita

l af

filia

ted

to T

abriz

Uni

vers

ity

of M

edic

al S

cien

ces

wer

e se

lect

ed

usin

g th

e ce

nsus

met

hod.

From

vie

wpo

int

of n

urse

s, m

ajor

’s b

arrie

rs w

ere

know

ledg

e de

ficit

of

patie

nt

abou

t th

eir

right

s,

lack

of

patie

nts’

inte

rest

to

chan

ge t

heir

beha

vior

s,

nurs

es d

iffer

ent

set

of r

espo

nsib

ilitie

s, i

nade

quat

e nu

rsin

g st

aff a

nd b

udge

t, in

adeq

uacy

of e

duca

tiona

l en

viro

nmen

t, a

nd d

isag

reem

ent

betw

een

diffe

rent

sp

ecia

lists

.

Tabl

e 1.

Sum

mar

y o

f th

e b

asic

fea

ture

s o

f th

e re

sear

ch a

rtic

les

that

wer

e in

clud

ed in

the

rev

iew

(C

ont

.)



Aut

hor

&

Year

Obj

ectiv

eM

etho

d an

d

data

col

lect

ion

Sam

ple

& s

ettin

gK

ey F

indi

ngs

Bei

ran-

vand

et

al.2

4

20

10

Iden

tifyi

ng t

he b

arrie

rs i

n PE

from

the

vie

w p

oint

of

nurs

es a

nd n

urse

man

ag-

ers

in t

he h

ospi

tals

affi

li-at

ed to

Ahv

az U

nive

rsity

of

med

ical

sci

ence

.

A de

scrip

tive

cros

s-se

ctio

n-al

stu

dy w

as c

arrie

d ou

t. D

ata

wer

e co

llect

ed b

y a

rese

arch

er-m

ade

ques

tion-

naire

.

100 n

urse

s an

d nu

rse

man

ager

s,

who

wor

ked

in t

he h

ospi

tals

affi

li-at

ed t

o Ahv

az m

edic

al u

nive

rsity

in

2012,

wer

e se

lect

ed b

y co

nve-

nien

ce s

ampl

ing

met

hod.

The

mos

t im

port

ant

barr

iers

to

the

PE

wer

e; l

ack

of p

ropo

rtio

nalit

y be

twee

n th

e nu

mbe

r of

pat

ient

s an

d nu

rse

staf

f, tim

e pr

essu

re a

nd e

xces

sive

wor

k-lo

ad,

lack

of

atte

ntio

n an

d su

ppor

t fr

om m

anag

ers

rega

rdin

g P

E, l

ack

of c

oord

inat

ion

betw

een

nurs

es

and

othe

r he

alth

car

e pr

ofes

sion

als.

Hek

ari e

t al

.25

20

10

Det

erm

ine

qual

ity o

f PE

by

nurs

ing

stud

ents

and

sta

ff nu

rses

an

d its

ef

fect

ive

fact

ors

in T

abriz

hos

pita

ls.

A de

scrip

tive

cros

s-se

ctio

n-al

stu

dy w

as c

arrie

d ou

t. D

ata

wer

e co

llect

ed b

y a

rese

arch

er-m

ade

ques

tion-

naire

.

352 s

taff

nurs

es a

nd 2

41 n

ursi

ng

stud

ents

in

Tabr

iz w

ere

sele

cted

th

roug

h st

ratifi

ed

rand

om

sam

-pl

ing.

The

mos

t im

port

ant

perc

eive

d ba

rrie

rs b

y nu

rses

w

ere:

in

crea

sed

num

ber

of

patie

nts,

in

adeq

uate

tim

e, i

nade

quat

e nu

rsin

g st

aff,

lack

of

prop

er e

nvi-

ronm

ent

and

educ

atio

nal e

quip

men

t in

the

hos

pita

l, an

d la

ck o

f coo

pera

tion

betw

een

heal

th c

are

prof

es-

sion

als.

Th

e m

ost

perc

eive

d fa

cilit

ator

s in

clud

es:

patie

nt’s

int

eres

t an

d pa

rtic

ipat

ion

in p

lann

ing

and

impl

emen

tatio

n of

edu

catio

n to

the

m,

sele

ctin

g an

d tr

aini

ng s

peci

ally

nur

ses

for P

E, a

vaila

bilit

y of

edu

ca-

tiona

l eq

uipm

ent

in t

he w

ard,

and

tak

ing

a sp

ecia

l pr

ivile

ge fo

r PE

on

an a

nnua

l ass

essm

ent o

f nur

ses.

M

anso

ur

ghen

aati

et a

l.26

20

11

Eval

uatin

g st

aff

nurs

es’

opin

ion

rega

rdin

g th

e im

-po

rtan

ce o

f PE

and

dete

r-m

inat

ion

of its

mai

n fa

cili-

tato

rs a

nd b

arrie

rs.

Des

crip

tive

cros

s-se

ctio

nal

stud

y.

Dat

a ga

ther

ing

in-

stru

men

t was

a re

sear

cher

- ge

nera

ted

ques

tionn

aire

.

99

nurs

es

who

ar

e w

orke

d in

go

vern

men

tal

hosp

itals

in

Ea

st

of G

uila

n pr

ovin

ce w

ere

sele

cted

th

roug

h th

e ce

nsus

met

hod.

“The

pat

ient

’s i

nter

est

and

coop

erat

ion

in p

lann

ing

and

exec

utin

g th

e ed

ucat

ion”

was

the

mos

t im

port

ant

faci

litat

or a

nd “

sele

ctin

g an

d ed

ucat

ing

of s

peci

al p

er-

sonn

el fo

r pro

vidi

ng P

E” w

as th

e le

ast i

mpo

rtan

t fac

ili-

tato

r in

PE. “

Lack

of a

ppro

pria

te k

now

ledg

e an

d sk

ills

rega

rdin

g re

cogn

ition

of

patie

nt e

duca

tiona

l ne

eds”

w

as t

he m

ost

impo

rtan

t fa

ctor

and

“po

or c

ultu

ral a

d-ap

tatio

n fo

r nu

rses

and

pat

ient

s in

ter

ms

of s

ex”

was

as

the

leas

t im

port

ant f

acto

r act

as

barr

iers

to P

E.

Had

dad

M.2

7

20

11

To a

sses

s ba

rrie

rs in

PE

from

nu

rses

’ vi

ewpo

ints

wor

king

in

Birj

and

hosp

itals

.

Des

crip

tive

cros

s-se

ctio

nal

stud

y. U

sing

the

rese

arch

er-

mad

e qu

estio

nnai

re w

hich

as

sess

th

e vi

ew

poin

t of

nu

rses

reg

ardi

ng b

arrie

rs to

PE in

fou

r do

mai

ns:

“man

-ag

emen

t”,

“wor

king

con

di-

tion”

“nu

rses

atti

tude

” an

d “t

rain

ing

skill

s”.

125

nurs

es

who

em

ploy

ed

and

wor

ked

in

all

Birj

and

hosp

itals

w

ith a

t le

ast

1 y

ears

of

wor

king

ex

perie

nce

wer

e se

lect

ed th

orou

gh

cens

us s

ampl

ing.

“Wor

king

con

ditio

ns”

was

the

mos

t im

port

ant o

ut o

f fo

ur d

omai

ns o

f bar

riers

for

PE.

The

follo

win

g ar

eas

cons

iste

d of

: “m

anag

emen

t”,

“tra

inin

g sk

ills”

and

“n

urse

’s a

ttitu

de”.

Vahe

dian

A

zim

i et

al.2

8

20

11

Eval

uate

nur

ses’

pro

blem

s in

PE.

Des

crip

tive

cros

s-se

ctio

nal

stud

y.

Dat

a ga

ther

ing

in-

stru

men

t was

a re

sear

cher

- ge

nera

ted

ques

tionn

aire

.

145

nurs

es,

wor

king

in

di

ffer-

ent

war

ds,

wor

king

in

a ho

spita

l af

filia

ted

to T

ehra

n U

nive

rsity

of

Med

ical

Sc

ienc

es

wer

e se

lect

ed

thro

ugh

sim

ple

rand

om s

ampl

ing.

The

mos

t co

mm

on p

erce

ived

bar

riers

to

PE

wer

e:

no s

peci

aliz

ed n

urse

for

PE,

inc

onsi

sten

cies

in

the

cultu

re,

soci

al a

nd m

enta

l st

atus

of

patie

nts

and

thei

r fa

mili

es, a

nd n

urse

s’ lo

w le

vel o

f kno

wle

dge

of

nurs

es a

bout

edu

catio

nal m

etho

ds.

Tabl

e 1.

Sum

mar

y o

f th

e b

asic

fea

ture

s o

f th

e re

sear

ch a

rtic

les

that

wer

e in

clud

ed in

the

rev

iew

(C

ont

.)



Aut

hor

&

Year

Obj

ectiv

eM

etho

d an

d

data

col

lect

ion

Sam

ple

& s

ettin

gK

ey F

indi

ngs

Fara

hani

et

al.2

9

20

11

Expl

orin

g co

mm

unic

atio

n ba

rrie

rs f

rom

the

per

spec

-tiv

e of

nur

ses

them

selv

es,

as w

ell

as p

hysi

cian

s, p

a-tie

nts

and

fam

ilies

in

a

hosp

ital-b

ased

car

diac

car

e se

ttin

g.

A q

ualit

ativ

e st

udy

usin

g a

cont

ent

anal

ysis

app

roac

h.

Usi

ng

face

-to-

face

, se

mi-

stru

ctur

ed in

terv

iew

.

18 n

urse

s w

ith a

t le

ast

2 ye

ars

of

wor

king

exp

erie

nce

in t

he c

ardi

ac

care

uni

t and

pos

t car

diac

car

e un

it w

ard,

fo

ur

card

iova

scul

ar

phys

i-ci

ans,

ni

ne

patie

nts

with

kn

own

card

iac

dise

ase

and

four

fa

mily

m

embe

rs o

f tw

o ed

ucat

iona

l hos

pi-

tals

in

Tehr

an w

ere

sele

cted

usi

ng

purp

osiv

e sa

mpl

ing

tech

niqu

e.

The

thre

e m

ajor

the

mes

ide

ntifi

ed w

ere:

1)

lack

of

colle

gial

ity a

nd c

omm

unic

atio

n be

twee

n nu

rses

and

ph

ysic

ians

; 2) p

robl

emat

ic c

omm

unic

atio

n be

twee

n th

e he

alth

-car

e te

am,

patie

nts

and

thei

r fa

mili

es;

and

3)

cultu

ral c

halle

nges

.

Vahe

dian

A

zim

i et

al.3

0

20

12

Des

crib

e nu

rses

’ ex

peri-

ence

s of

bar

riers

and

faci

li-ta

tors

of

PE

in y

ear

2008

at S

haria

ti H

ospi

tal i

n Te

h-ra

n.

Tria

ngul

atio

n re

sear

ch w

ith

thre

e st

eps

Del

phi m

etho

d w

as u

sed.

Dat

a co

llect

ion

met

hods

wer

e an

uns

truc

-tu

red

inte

rvie

w,

follo

wed

by

a

ques

tionn

aire

from

in

terv

iew

s, a

nd in

the

third

st

ep,

focu

sed

grou

ps.

Part

icip

ants

inc

lude

d 25 n

ursi

ng

staf

f (1

mat

ron,

8 s

uper

viso

rs,

8

head

nur

ses

and

8 n

urse

s).

Dat

a w

ere

colle

cted

in

the

nurs

ing

of-

fice

and

diffe

rent

war

ds o

f Sha

riati

Hos

pita

l, a

teac

hing

hos

pita

l affi

li-at

ed t

o Te

hran

Uni

vers

ity o

f Med

i-ca

l Sci

ence

s.

Mos

t im

port

ant

barr

iers

wer

e: n

urse

s’ lo

w s

cien

tif-

ic k

now

ledg

e an

d in

form

atio

n, s

hort

age

of n

ursi

ng

staf

f, ex

cess

ive

wor

kloa

d, in

appr

opria

te c

linic

al s

u-pe

rvis

ion

and

feed

back

, and

ext

ra ta

sks

dem

ande

d du

e to

wor

king

in

a te

achi

ng h

ospi

tal.

The

mos

t im

port

ant

faci

litat

ors

wer

e fo

und

to b

e: d

evel

opin

g P

E pr

otoc

ols

for

each

war

d, m

odifi

catio

n in

sup

er-

visi

on a

nd f

eedb

ack

syst

em,

esta

blis

hing

a g

ood

rela

tions

hip

betw

een

patie

nts,

nur

ses

and

phys

i-ci

ans,

ass

igni

ng a

rot

atin

g nu

rse

for

PE.

Agh

akha

ni

et a

l.6

20

12

Expl

ore

nurs

es’ a

ttitu

des

to

the

barr

iers

of P

E.C

ross

-sec

tiona

l st

udy.

The

da

ta w

as g

athe

red

with

a

two

part

res

earc

her-

mad

e qu

estio

nnai

re.

240 n

urse

s, w

ho w

orke

d in

uni

-ve

rsity

affi

liate

d ho

spita

ls o

f U

re-

mia

, w

ere

sele

cted

usi

ng c

ensu

s m

etho

d.

Mos

t of

the

nur

ses

belie

ved

that

PE

is n

ot t

heir

du-

ties.

Mos

t im

port

ant

perc

eive

d ba

rrie

rs b

y nu

rses

in

clud

e: i

nade

quat

e fa

cilit

ies

in h

ospi

tals

and

als

o in

adeq

uate

tim

e.G

hoba

di e

t al

.31

20

12

Iden

tifyi

ng t

he b

arrie

rs a

nd

faci

litat

ors

of P

E fro

m t

he

view

poin

ts

of

nurs

es

and

head

nur

ses

in h

ospi

tals

of

Shira

z U

nive

rsity

of M

edic

al

Scie

nces

.

Des

crip

tive

cros

s-se

ctio

nal

stud

y. D

ata

wer

e co

llect

-ed

by

a re

sear

cher

-mad

e qu

estio

nnai

re.

106 n

urse

s w

ho w

orke

d in

med

i-ca

l or

sur

gica

l w

ards

of

sele

cted

ho

spita

ls a

ffilia

ted

to S

hira

z un

i-ve

rsity

of

med

ical

sci

ence

s w

ere

sele

cted

th

orou

gh

stra

tified

ra

n-do

m s

ampl

ing.

The

mos

t im

port

ant p

erce

ived

bar

riers

by

nurs

es w

ere:

“i

napp

ropr

iate

nur

sing

sta

ff”, “

know

ledg

e de

ficit”

, “in

-ad

equa

te ti

me”

, and

“la

ck o

r ina

dequ

ate

supp

ort f

rom

th

e m

anag

ers”

. Th

e m

ost

impo

rtan

t fa

cilit

ator

s w

ere

foun

d to

be:

“ho

ldin

g co

ntin

uous

med

ical

edu

catio

n pr

ogra

m t

o in

crea

se k

now

ledg

e an

d at

titud

e of

nur

s-es

”, “

incr

easi

ng n

ursi

ng s

taff

in e

ach

wor

king

shi

ft”,

“pro

vidi

ng a

ppro

pria

te p

lace

and

faci

litie

s fo

r PE”

.

Fara

hani

et

al.3

2

20

13

Expl

orin

g fa

ctor

s in

fluen

c-in

g PE

from

the

per

spec

-tiv

es o

f nur

ses

in Ir

an.

Qua

litat

ive

stud

y us

ing

a co

nten

t an

alys

is a

ppro

ach

was

use

d. D

ata

wer

e co

l-le

cted

thr

ough

face

-to-

face

au

dio-

tape

d in

terv

iew

s an

d fie

ld o

bser

vatio

ns.

18 n

urse

s w

ith a

t le

ast

2 y

ears

of

wor

king

exp

erie

nce

who

wor

ked

in

two

educ

atio

nal

hosp

itals

whi

ch

affil

iate

d to

Teh

ran

Uni

vers

ity o

f M

edic

al S

cien

ces

wer

e re

crui

ted

and

inte

rvie

w;

usin

g a

purp

osiv

e sa

mpl

ing

tech

niqu

e.

The

maj

or t

hem

e ex

trac

ted

in t

his

stud

y w

as t

he

inap

prop

riate

org

aniz

atio

nal c

ultu

re w

hich

incl

udes

ei

ght

cate

gorie

s lis

ted

as fol

low

s: N

ot p

uttin

g va

lue

on e

duca

tion,

non

-pro

fess

iona

l act

iviti

es, p

hysi

cian

-or

ient

ed a

tmos

pher

e, c

onfli

ct a

nd la

ck o

f coh

eren

ce

in e

duca

tion,

ina

ppro

pria

te c

omm

unic

atio

n sk

ills,

ig

norin

g pa

tient

’s r

ight

in e

duca

tion,

lack

of m

otiv

a-tio

n, re

war

ding

sys

tem

in th

e or

gani

zatio

n, a

nd p

oor

supe

rvis

ion

and

cont

rol.

Tabl

e 1.

Sum

mar

y o

f th

e b

asic

fea

ture

s o

f th

e re

sear

ch a

rtic

les

that

wer

e in

clud

ed in

the

rev

iew

(C

ont

.)



Aut

hor

&

Year

Obj

ectiv

eM

etho

d an

d

data

col

lect

ion

Sam

ple

& s

ettin

gK

ey F

indi

ngs

Sulta

ni e

t al

. 33

20

13

Expl

ore

the

barr

iers

to

PE

from

th

e vi

ewpo

ints

of

nu

rses

and

nur

se m

anag

-er

s in

hos

pita

ls o

f R

afsa

n-ja

n U

nive

rsity

of

Med

ical

Sc

ienc

es in

2008.

Des

crip

tive

cros

s - s

ectio

nal

stud

y w

as c

arrie

d ou

t. D

ata

was

col

lect

ed b

y re

sear

ch-

er-

mad

e qu

estio

nnai

re.

253 n

urse

s an

d nu

rse

man

ager

s,

who

wor

ked

in a

ffilia

ted

hosp

itals

to

Raf

sanj

an U

nive

rsity

of M

edic

al

Scie

nces

in

2008,

wer

e se

lect

ed

and

eval

uate

d th

roug

h ce

nsus

m

etho

d.

The

mos

t per

ceiv

ed b

arrie

rs to

PE

wer

e “l

ack

of a

p-pr

opria

te s

uper

visi

on a

nd e

ncou

rage

men

t fr

om t

he

man

ager

s”,

“ina

ppro

pria

te t

ime”

, “e

xces

sive

wor

k-lo

ad”,

“La

ck o

f aw

aren

ess

of p

atie

nts

abou

t th

e ed

-uc

atio

n as

a p

atie

nt’s

rig

ht”,

and

“th

e nu

rses

’ la

ck

of a

ppro

pria

te s

kills

in P

E”.

Ala

vi e

t al

.34

20

13

Expl

orin

g pa

tient

s/fa

mily

m

embe

rs a

nd h

ealth

pro

-fe

ssio

nals

’ per

cept

ions

and

ex

perie

nces

of

the

barr

iers

to

ca

rdia

c re

habi

litat

ion

educ

atio

n in

an

Ir

ania

n co

ntex

t.

Qua

litat

ive

stud

y us

ing

a th

emat

ic a

naly

sis

appr

oach

w

as u

sed.

Dat

a w

ere

col-

lect

ed

thro

ugh

in-d

epth

, se

mi-s

truc

ture

d in

terv

iew

s

Part

icip

ants

(1

0

heal

th

prof

es-

sion

als,

15 p

atie

nts/

fam

ily m

em-

bers

) w

ere

recr

uite

d from

tw

o ed

ucat

iona

l-med

ical

ce

nter

s an

d ho

spita

ls i

n Is

faha

n us

ing

Purp

o-si

ve s

ampl

ing

Five

maj

or b

arrie

rs w

ere

iden

tified

rela

ting

to h

uman

re

sour

ces,

ser

vice

pro

visi

on,

avai

labl

e ed

ucat

iona

l se

rvic

es,

unfa

vora

ble

attit

udes

an

d co

llabo

ratio

n ga

ps.

Two

mai

n ch

alle

nges

exi

st t

o th

e pr

ovis

ion

of e

ffect

ive

PE;

in

adeq

uate

hu

man

re

sour

ces

in

the

hosp

ital

war

ds,

spec

ifica

lly i

n te

rms

of t

rain

ed

heal

th c

are

prof

essi

onal

s an

d se

rvic

e us

ers’

spe

cific

he

alth

rel

ated

vie

ws

and

beha

vior

s.G

horb

ani

et a

l.3

20

14

Des

crib

e th

e at

titud

es

of

Iran

ian

nurs

es a

nd n

ursi

ng

stud

ents

on

ba

rrie

rs

and

faci

litat

ors

to P

E.

Des

crip

tive

stud

y w

as c

on-

duct

ed.

Usi

ng a

res

earc

h-er

-mad

e qu

estio

nnai

re

All

nurs

es (

103)

deliv

erin

g di

rect

pa

tient

car

e an

d al

l ba

ccal

aure

-at

e nu

rsin

g st

uden

ts (

seco

nd a

nd

third

-yea

r st

uden

ts)

rece

ivin

g ed

ucat

ion

in

the

nurs

ing

war

ds

in h

ospi

tals

affi

liate

d to

Sem

nan

Uni

vers

ity o

f M

edic

al S

cien

ces

at

the

time

of d

ata

colle

ctio

n w

ere

eval

uate

d.

All

nurs

es a

nd t

he m

ajor

ity o

f th

e nu

rsin

g st

uden

ts

men

tione

d th

at th

ey p

erfo

rmed

PE.

The

nur

ses

stat

-ed

tha

t he

avy

wor

kloa

d, i

nade

quat

e tim

e an

d la

ck

of e

duca

tiona

l fa

cilit

ies

wer

e m

ain

barr

iers

to

PE.

Th

e st

uden

ts b

elie

ved

that

lack

of

know

ledg

e, la

ck

of c

omm

unic

atio

n sk

ills

and

heav

y w

orkl

oad

wer

e m

ain

barr

iers

to

PE

from

the

ir pe

rspe

ctiv

es.

Saei

dPou

r et

al.3

5

20

14

Ass

essi

ng n

urse

s an

d do

c-to

rs v

iew

poin

ts o

n ob

sta-

cles

and

faci

litat

ors

PE.

Des

crip

tive

cros

s-se

ctio

nal

stud

y. D

ata

wer

e co

llect

-ed

by

a re

sear

cher

-mad

e qu

estio

nnai

re.

85 n

urse

s an

d do

ctor

s w

ho w

orke

d in

Ker

man

shah

Raz

i hos

pita

l wer

e se

lect

ed b

y Si

mpl

e R

ando

m S

am-

plin

g m

etho

d.

Top

thre

e ba

rrie

rs t

o P

E w

ere:

sho

rtag

e of

nur

ses,

la

ck o

f su

ffici

ent

finan

cial

res

ourc

es,

and

nurs

es’

exce

ssiv

e w

orkl

oad.

Whi

le,

hold

ing

sem

inar

s on

te

achi

ng a

nd l

earn

ing

stra

tegi

es a

nd a

lso

cons

id-

erin

g sp

ecia

l pr

ivile

ge

for

patie

nts’

ed

ucat

ion

in

annu

al e

valu

atio

n of

nur

ses

wer

e m

ost

impo

rtan

t pe

rcei

ved

faci

litat

ors.

Deh

ghan

i et

al.3

6

20

14

Det

erm

ine

barr

iers

to

PE

from

nur

ses’

vie

wpo

ints

.D

escr

iptiv

e cr

oss-

sect

ion-

al

stud

y w

as

cond

ucte

d.

Dat

a w

ere

colle

cted

by

a re

sear

cher

-mad

e qu

estio

n-na

ire.

271 n

urse

s, w

ho w

orke

d in

teac

h-in

g af

filia

ted

hosp

itals

of

Jahr

om

Uni

vers

ity

of

Med

ical

Sc

ienc

es,

wer

e se

lect

ed

thro

ugh

cens

us

met

hod.

The

mos

t im

port

ant

barr

iers

wer

e: la

ck o

f tim

e du

e to

wor

kloa

d, la

ck o

f P

E pl

anni

ng f

or n

urse

s in

the

ir da

ily w

ork

as a

dut

y, a

nd t

he u

nkno

wn

role

of

the

nurs

es a

s a

teac

hing

age

nt t

o th

e pa

tient

s an

d th

e co

mm

unity

.Est

eki e

t al

.37

20

14

Eval

uatin

g nu

rses

’ pe

r-ce

ptio

n of

PE

in t

he C

CU

w

ard

of

Valia

sr

Hos

pita

l, B

irjan

d, Ir

an.

Qua

litat

ive

stud

y us

ing

a co

nten

t an

alys

is a

ppro

ach

was

use

d. D

ata

wer

e co

l-le

cted

thr

ough

sem

i-str

uc-

ture

d in

terv

iew

s.

11

nurs

es

of

CC

U

war

ds

who

w

orke

d in

the

Val

iasr

Hos

pita

l of

B

irjan

d,

wer

e re

crui

ted

by

pur-

pose

ful s

ampl

ing

Thre

e th

emes

ha

ve

emer

ged

incl

udin

g cu

lture

, kn

owle

dge

of t

he p

atie

nt’s

bac

kgro

und,

and

edu

ca-

tion

proc

ess

suite

d to

pat

ient

s’ c

ultu

re a

nd s

ocie

ty.

Tabl

e 1.

Sum

mar

y o

f th

e b

asic

fea

ture

s o

f th

e re

sear

ch a

rtic

les

that

wer

e in

clud

ed in

the

rev

iew

(C

ont

.)



Inadequate support of managers, particularly in case of appropriate time allocation for nurses’ teaching activities and ineffective coordination of educational responsibilities among disciplines is a barrier to PE.38,48 Managerial and organizational support is an important element for the implementation of high-quality PE.49,50 The result of a study that was conducted in Iran showed that nurses were well informed of the importance of patient education and had accepted this role in clinical settings, but no managerial support was available to them for doing this activity.3 Moreover, other studies showed that hospital managers have less emphasize on PE.2,51 Modifying administrational support is crucial for effective PE. The context in which care is delivered, such as staffing levels, prioritizing of different aspects of care, provision of resources and support of other healthcare team members, influence the quality of PE.3 It been shown that PE was a less important task of healthcare professionals from the nurse managers’ perspective.51 PE was improved through changes in the management style, development of educative materials, and patient education protocols.3 Inappropriate educational facilities in hospital were one of the barriers perceived by Iranian nurses for PE. Accessibility of teaching materials is an important component to facilitate PE.40 It is known that face-to face PE time can be reduced by using paper materials and facilitate what must be transmitted to patients.51 It is important to provide teaching materials which are easily understood and are consistent with cultural issues and social norms.52 Allocation of specific space in every work-place setting for PE and assigning responsibility for this activity to one specialist nurse in the each ward by managers are another recommendations to improve and develop PE.49

Patient’s low literacy or illiteracy and cultural diversity of patients and nurses were among the most patient-related barriers perceived by Iranian nurses. Teaching is a dynamic process and is influenced by social and cultural factors. Thus, nurses must be sensitive to the effects of values, religion, language, cultural and socioeconomic factors.52 It seems that conflict among nurses

and patients’ beliefs can intensify the problems in PE. People strongly protect their cultural values and also they expect everyone to respect it.53 In a study that conducted by Heidari et al. have been shown that there is much cultural diversity among patients and concluded that all nurses are expected to be more sensitive to the cultural factors such as language, lifestyle, and social status of patients and their families in their education.52 Considering the cultural diversity backgrounds of patients and the health care providers, cultural sensitivity is an essential factor in improvement of comprehensive PE plans.54 Patients’ lower educational level and severity of illness prohibit their educational compliance.40 Most of the hospitalized patients in Iran are elderly with inadequate level of health literacy.3 Patients’ health literacy, as a resource which allows them to seek, understand and use health information, is an important determinant of their participation and engagement in their health care.55 Many patients may be able to read and write, but have trouble to understanding basic health information. Health literacy, as a set of individual capacities may be improved through educational programs or declined due to aging and disease process.3,56

Nurse-related barriers such as lack of awareness of nurses about educational methods and teaching/learning principles, believing that patient teaching is not nurses’ responsibility, and lack of knowledge about illness, were mostly perceived by Iranian nurses. For PE, the nurses must be aware of the learning pattern of patients, which includes visual, auditory, and kinesthetic. Once the learning style is established, the nurse adapts the preferred teaching strategies and methodologies to that style.56-58 Assessing patient learning style, in combination with the context in which learning occurs, allows for an individualized approach that incorporates teaching modalities to maximize patient learning.59 Disagreement between patients, nurses, and physician regarding responsibility of PE is another perceived barrier to patients’ education by nurses in Iran. Moret et al. found that nurses and physicians did not agree on patient information materials, so that nurses considered their role to be more important than what the



physicians gave them.50 However, this finding is inconsistent with that of Park’s study, in which nurses stated that information about medicine and treatment was not their responsibility.2 On the other hand, there is incongruence between nurses’ and patients’ perceptions regarding the nurses’ role in PE. Patients acknowledged a general teaching function for nurses; but when they were asked who they prefer to teach them specific information related to their situation, they most frequently chose a physician. Whereas the nurses most frequently acknowledged a nurse as the most desired patient educator.60

One potential limitation of this review was that we did not search the gray literature to find studies not in the peer-reviewed journals. Although we identified all papers that met our inclusion criteria, unpublished studies may be missed. However, our electronic search was extensive and complemented by hand-searches, so that the saturation was achieved. Another limitation was most of the studies have used investigator-developed instrument, so it may violate rigor of the studies. The results of our review indicate that, Iranian nurse’s encounter with somewhat high barriers in PE; so that of these, administration-related barriers were the predominant obstacle in order to bring evidence into clinical applicability. Therefore, health managers are expected to plan appropriate strategies to smooth the progress of PE by nurses in their practice.

Acknowledgement. We kindly thank Prof. Lynda Wilson for providing comprehensive comments and Dr. Reza Armat for his helpful comment on research methodology.

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