It comes as no surprise to any health professional that one of the most important, time consuming and arguably, the most rewarding aspects of our practice is providing ‘advice and education’. This includes discussing patients concerns, teaching skills and in many cases re-educating unhelpful beliefs and behaviours. The World Health Organisation has brought patient-centred education to the fore, highlighting the need for adequate training of health professionals in communication skills that elicit the patient’s point of view, concerns and needs and provides professionals with the skills to support and promote patient self-management (World Health Organisation, 2005).
What I found very quickly into my journey to undertake a PhD in the area of patient education is that it’s one of those things we all do, think we do fairly well, but no one really discusses how we do it or how it looks when it’s effective. Furthermore, as a University lecturer and clinical educator, it was apparent how we often expect students to demonstrate patient education in examinations and with patients, however we often don’t give the time, practice or theoretical underpinnings for them to become effective educators. We often pride ourselves on our ability teach patients, whether it be teaching exercises or skills, explaining a diagnosis or giving specific advice and information and we often consider these skills to come naturally with experience (Rindflesch, 2009). Research however suggests similar levels of patient education competence between novice and experienced clinicians (Wouda & van de Wiel, 2015; Forbes et al, 2017). A major reason for this is health professionals receive minimal training in patient education including appropriate pedagogical approaches to learning (Dandavino et al, 2007; Svavarsdottir et al, 2015) and ongoing professional development activities are rarely aimed at patient education skills (Friberg et al, 2012; Bergh et al, 2014).
My PhD in patient education focussed on physiotherapy practice and aimed to understand how physiotherapists’ use patient education. I also wanted to understand what physiotherapists should be able to do in relation to patient education practice and ultimately, find effective ways in which we can teach these skills to physiotherapy students and professionals. My PhD journey firstly uncovered that early research suggests as physiotherapists (and wider health professionals) we are fairly therapist-centred when it comes to providing patient education and our approaches tend to be didactic and not centred on the patients expectations (Kerssens et al, 1999; Trede, 2000; Dierckx et al, 2013; Bergh et al, 2014). Given the emphasis on a patient-centred approach to education, tailoring teaching to the needs of the patient becomes an imperative (Friedman et al, 2011) and has been recognised by both health professionals and patients as the most important characteristic of an effective educator (Hyrkas et al, 2014; Forbes et al, 2018). Focussing education on patients’ needs and preferences have demonstrated positive effects such as improving patient motivation, self-efficacy, recall, adherence and health outcomes (Hoving et al, 2010).
Assessing the learning needs of the patient
Just as assessment is the crucial first step in understanding the physical needs of the patient; it is considered an important initial stage in determining learning needs (Smith et al, 2007; Friedman et al, 2011; Fredericks & Yau, 2017). Furthermore, clinicians who are unaware of their patients’ educational needs and readiness to learn have the potential to inadvertently contribute to poor outcomes such as ongoing symptoms, patient passivity and increasingly complex treatment regimens (Needleman, 2013).
Assessing the educational needs of the patient may include:
- Patient generated goal setting
- Actively seeking out the patients main concerns
- Exploring patients existing knowledge, perceptions or beliefs about their condition
- Understanding what the patient has been told before – and how they have interpreted this information
- Assessing the ability of the patient to undertake physical tasks or skills
- Seeking from the patient their expectations relating to the physiotherapy treatment, including their expectations of their own role
Evaluation is considered the last phase of effective patient education to appraise patient learning and progress the educational process (Frank-Bader et al 2011; Friberg et al, 2012), however it receives little attention in health professional teaching and training (Forbes et al, 2017). The teach-back approach offers not only an approach that checks for lapses in recall and understanding but can also uncover health beliefs, reinforce and tailor health messages and generate dialogue between patient and health professional and allows the educator to identify and correct any misunderstandings. There is significant support of the use of the teach-back approach in patient education literature (Crumlish & Magel, 2011; Frank-Bader et al 2011; Friberg et al, 2012). Research demonstrates that this approach improves patient recall, understanding and self-recognition of health emergencies (Schillinger et al, 2003; Kripilani, 2008).
Other explicit evaluation approaches may include:
- Seeking return demonstrations
- Communicating with patients’ family or other health care providers to seek patient progress
- Assessing wider patient skills such as problem solving
- Providing the patient with a hypothetical challenge to assess their course of action
Future of patient education
Over the last five years there has been increasing evidence to support patient education approaches in specific populations who seek musculoskeletal physiotherapy care. With cost containment studies showing significant savings and lowering of health care costs through primary prevention efforts, we should anticipate increased recognition of patient education efforts, particularly those aimed at patient self-management and health promotion. Health professionals currently have more access to formal training in patient education techniques, such as counselling, therapeutic neuroscience education and motivational interviewing. We also have increasing access to inter-professional networks, peer observational activities and mentoring, and internet based professional development resources, all of which are recognised as effective approaches in the development of patient education expertise.
In light of the need for patient-centred education skills of physiotherapists, it should be recognised that we must provide physiotherapists with the means to effectively incorporate these skills into physiotherapy practice. The importance of such practice for patient outcomes, decision making and patient and clinician satisfaction indicates the need for training providers, clinical education providers and workplaces to recognise the value of training and place emphasis on this area of practice.
Please click to link to full article: A comparison of patient education practices and perceptions of novice and experienced physiotherapists in Australian physiotherapy settings.
Dr Roma Forbes, PhD, BHSc (Physio), MHSc (Musculoskeletal, 1st Hons), GradCert (Higher Ed), APAM, NZSP
Roma is a Musculoskeletal Physiotherapist and Lecturer at The University of Queensland where she teach Musculoskeletal Physiotherapy. Her PhD is in patient education practice in physiotherapy and her current research investigates new-graduate readiness for practice and the use of simulation in enhancing patient-centred skills.
Bergh, A.L., Persson, E., Karlsson, J. & Friberg, F. (2014). Registered nurses’ perceptions of conditions for patient education–focusing on aspects of competence. Scandinavian Journal of Caring Sciences, 28(3), 523-536.
Crumlish, C.M. & Magel, C.T. (2011). Patient education on heart attack response: Is rehearsal the critical factor in knowledge retention. Medsurg Nursing, 20(6), 310-317.
Dandavino, M., Snell, L. & Wiseman, J. (2007). Why medical students should learn how to teach. Medical Teacher, 29(6), 558-565
Dierckx, K., Deveugele, M., Roosen, P. & devisch, I. (2013). Implementation of shared decision making in physical therapy: observed level of involvement and patient preference. Physical Therapy, 93(10), 1321-1330.
Forbes, R., Mandrusiak, A., Smith, M. & Russell, T. Training physiotherapy students to educate patients; a randomised controlled trial. Patient Education and Counselin, 101(2), 295-303
Forbes, R., Mandrusiak, A., Smith, M., & Russell, T. A comparison of patient education practices of novice and experienced physiotherapists in Australia. Musculoskeletal Science and Practice, 28; 46-53, 2017.
Frank-Bader, M., Beltran, K. & Dojlidko, D. (2011). Improving transplant discharge education using a structured teaching approach. Progress in Transplantation, 21(4), 332-339.
Friberg, F., Granum, V. & Bergh, A.L. (2012). Nurses’ patient-education work: conditional factors; an integrative review. Journal of Nursing Management, 20(2), 170-186.
Hoving, C., Visser, A., Mullen, P.D. & van den Borne, B. (2010). A history of patient education by health professionals in Europe and North America: from authority to shared decision making education. Patient Education and Counseling, 78 (3), 275-281.
Hyrkas, K. & Wiggins, M. (2014). A comparison of usual care, a patient‐centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute‐care setting. Journal of Nursing Management, 22(3), 350-361.
Kerssens, J.J., Sluijs, E.M., Verhaak, P.F., Knibbe, H.J. & Hermans, I.M. (1999). Bac care instructions in physical therapy: a trend analysis of individualized back care programs. Physical Therapy, 79(3), 286-295.
Kripilani, S., LeFevre, F., Phillips, C., Williams, M., Basaviah. P. & Baker, D. (2008) Deficits in communication and information transfer between hosptial-based and primary care physicians. Journal of Americal Medical Association, 297, 831-841
Needleman, J. (2013). Increasing acuity, increasing technology, and the changing demands on nurses. Nursing Economics, 31(4), 200-202.
Rindflesch, A B. (2009). A grounded-theory investigation of patient education in physical therapy practice. Physiotherapy Theory and Practice, 25(3), 193-202.
Schillinger, D.,Piette, J., grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C. & Bindman, A.B. (2003). Closing the loop: physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90.
Smith, S., Mitchell, C. & Bowler, S. (2007). Patient-centered education: applying learner-centered concepts to asthma education. Journal of Asthma, 44(10), 799-804.
Svavarsdottir, M.H., Sigueoardottir, A.K. & Steinsbekk, A. (2015). How to become an expert educator: a qualitative study on the view of health professionals with experience in patient education. Bio Med Central Medical Education, 15(1), 1-9.
Trede, F.V. (2000). Physiotherapists’ approaches to low back pain education. Physiotherapy, 86(8), 427-433.
World Health Organisation. (2005). Preparing a health care workforce for the 21st century: the challenge of chronic conditions. Geneva, Switzerland.
Wouda, J.C. & van de Wiel, H.B. (2015). Supervisors’ and residents’ patient-education competency in challenging outpatient consultations. Patient Education and Counseling, 98(9), 1084-1091.