Patient Education: Responsibility Amidst Mandates

Nurses are educators. Providing education to patients, families, and members of the community is ingrained into the ethos of nursing and is a basic tenet of nursing practice. Nurses educate people across all stages of life and throughout the continuum of illness and health, and bariatric nurses are no exception. Nurses practicing in the bariatric surgery setting spend a great deal of time educating patients preoperatively, throughout hospitalization, and well into the postoperative period. Other nurses, who may or may not self-identify as bariatric nurses, spend time educating patients and communities about healthy lifestyles. The responsibility and duty to educate is so embedded in the work of the nurse that nurses often fail to recognize patient education as a nursing intervention.

Patient education is receiving considerable attention lately, and given the face of the current healthcare environment, this should not be a surprise. Hospital readmission rates are under scrutiny, and there is some evidence to support the idea that insufficient patient education is a contributing factor. Inpatient hospital stays have decreased, resulting in the need for treatments to be transitioned to the home environment. Medication regimens have become extremely complex, requiring education that involves side effects, compliance, and safe self-medication. Finally, the patient safety movement has encouraged healthcare providers to include patients and families in all aspects of care, which requires communication and education. In addition to these patient and healthcare delivery factors, regulatory agencies, such as the Centers for Medicare and Medicaid Services and The Joint Commission, have set education standards, and in certain disease states, reimbursement for services is dependent on the delivery of specific patient education. ¹ Other agencies such as the Leapfrog Group and the Magnet^® Recognition Program include patient satisfaction with education in their assessment and designation process. It is clear that in today's healthcare environment, nurses, physicians, allied health professionals, and healthcare executives have a vested interest in patient education.

If the solutions to the current issues were as simplistic as providing education, patients would know all about their diseases, comply with medications and treatments, engage in healthy behaviors, and decrease participation in unhealthy or risky behaviors. When the desired outcomes of patient education are considered, however, the literature is clear that knowledge does not consistently correlate with health behavior. Models of health behavior and behavior change do include knowledge as a contributing factor, but these models also purport that patient background factors such as social support and socio-demographic variables, as well as more complex patient factors such as readiness for change, perceived risk, and perceived barriers, are also significantly associated with behavior change.

According to the Centers for Disease Control, obesity does not affect all populations equally. ² The prevalence rate of obesity in the south is 29.4%, representing the highest prevalence of obesity in the United States. Among ethnic groups, non-Hispanic blacks have the highest prevalence of obesity at 44.1%, compared to a rate of 32.6% among non-Hispanic whites. Obesity rates differ among people of different socioeconomic status and education levels; non-Hispanic black and Mexican-American men with higher incomes are more likely to be obese than those with lower incomes, and among women, those with higher incomes are less likely to be obese than low-income women. Lastly, while there is no significant relationship between obesity and education among men, women with college degrees are less likely to be obese than women with less education. ³

Given the diversity of the obesity epidemic, the current evidence about methods of patient education, and the leading models of health behavior and behavior change, it is clear that different educational strategies are needed for these different populations. Research has consistently demonstrated that people respond to education differently and that the learning needs of each patient must be considered and incorporated into individual education plans. ³ Regulatory agencies are keenly aware of this research, and in 2012 the Joint Commission will require healthcare organizations to demonstrate cultural competency in the delivery of all patient care, including education. Specifically, this new standard requires that healthcare providers incorporate health literacy into patient education materials, as well as incorporate cultural competencies and patient- and family-centered care concepts. ⁴

This new standard is a tall order. Although the patient education research is extensive and describes the effectiveness of different intervention styles, the most effective strategies of actually incorporating the identified best practices into various clinical settings with different populations has not been as well described. Research studies are typically carried out by dedicated staff in a controlled environment with a select patient population. While this type of design controls for variability and allows the researcher to make specific conclusions, it does not address the real-world nuances of busy inpatient units, the availability of technology, and the opportunity for follow-up evaluation. Knowledge translation describes the process of synthesizing and applying the knowledge generated by research in a thoughtful and discriminating way that allows for the use of that knowledge in a specific clinical setting. ⁵ Given the increasing obesity rates in a diverse population and the mandates for culturally competent education, there is a great opportunity for bariatric nurses to contribute significantly to knowledge translation in the field of patient education and behavior change.

In this issue, Dr. Brenda Windemuth describes the implementation of an educational intervention aimed to increase knowledge and change behavior among a unique group of Maryland residents. As you will read, Dr. Windemuth developed an educational intervention that targeted the cultural and social challenges faced by this isolated population. Also in this issue, Ms. Amy Phipps describes the developmental stages of adolescence and how this information guides the education and support provided to adolescents undergoing the gastric Lap-Band^® procedure. These are not only examples of providing culturally competent care but also of translating current knowledge and best practices into the clinical setting.

As the healthcare environment evolves and regulations and reimbursement models change, one thing that will remain constant is the need to provide patient education. While best evidence should be utilized as new patient education programs are developed and existing educational programs are revised, it will be important to share translation and implementation strategies. Patient education is provided by many different healthcare provider roles, but this is an area of healthcare where nurses can take the lead in implementing evidence-based principles and developing successful methods of knowledge translation in various settings.

Nurses are, and always will be, educators. As emphasis and regulation continues to target patient education, nurses have a responsibility to do more than just meet regulatory requirements. As nurses, we must strive to ensure that education is thoughtfully delivered and that the desired outcomes of the education are ultimately achieved. Critically and systematically reviewing current patient education programs and implementing new programs through the lens of outcomes will provide valuable information for patients, as well as members of the scientific community.