patient education journal article nursing

This paper is in the following e-collection/theme issue:

Published on 13.4.2020 in Vol 22 , No 4 (2020) : April

Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review

Authors of this article:

• Thomas Timmers 1, 2 , MSc   ; 
• Loes Janssen 3 , PhD   ; 
• Rudolf B Kool 1 , MD, PhD   ; 
• Jan AM Kremer 1 , MD, PhD  

1 IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands

2 Interactive Studios, Rosmalen, Netherlands

3 Máxima Medical Center, Veldhoven, Netherlands

Corresponding Author:

Thomas Timmers, MSc

IQ healthcare

Radboud Institute for Health Sciences

Radboud University Medical Center

Geert Grooteplein Zuid 10

Nijmegen, 6525 GA

Netherlands

Phone: 31 73 644 6069

Email: [email protected]

Background: Patient education is a crucial element within health care. It is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and even better treatment outcomes. Unfortunately, often patients only remember a very limited amount of medical information. An important reason is that most patients are simply not capable of processing large amounts of new medical information in a short time. Apps for smartphones and tablets have the potential to actively educate patients by providing them with timely information through the use of push notifications.

Objective: The objective of this systematic review is to provide an overview of the effects of using smartphone and tablet apps to educate patients with timely education. Within this review, we focused on patients that receive their care in a hospital setting. We assessed the effects of the interventions on outcomes, such as patients’ knowledge about their illness and treatment, adherence to treatment instructions and to medication usage, and satisfaction with the care they received.

Methods: A comprehensive search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science was conducted. Randomized controlled trials (RCTs) published between January 2015 and November 2019 were eligible for inclusion. Two reviewers independently searched and screened articles, assessed study quality and risk of bias, and extracted the data. Due to the heterogeneity of populations, interventions, and outcomes, a meta-analysis was not deemed appropriate. Instead, a narrative synthesis is presented.

Results: A total of 21 RCTs with 4106 participants were included. Compared to usual care, overall effectiveness of the interventions was demonstrated in 69% of the outcomes. Effectiveness increased to 82% when the intervention had a duration shorter than one month and increased to 78% when the intervention provided at least one push notification per week. The interventions showed the highest effects on satisfaction with information, adherence to treatment instructions and to medication usage, clinical outcomes, and knowledge.

Conclusions: This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messages to patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

Introduction

Patient education is a crucial element within health care. Health care professionals provide patients with information about the origins of complaints, treatment options, prognosis, how to prepare for treatment, or how to manage one’s health during the recovery phase. Health care professionals educate their patients because knowledge is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and better outcomes [ 1 , 2 ].

Unfortunately, patients often only remember a limited amount of the medical information they receive. Many different factors contribute to this. Some of these factors are related to the health care professional, such as using jargon or communicating in a passive way. Other factors are related to the patient, such as age, learning style, and stress [ 3 ]. Another important reason is the fact that most patients are simply not capable of processing large amounts of new medical information in a short amount of time [ 4 ].

During the last decade, smartphones, tablets, and apps have become commonplace in our society. These innovations offer many new opportunities within health care, such as optimizing the process of patient education. Apps, for example, allow patients to look at medical information as often as they like, at any place, and at any time. The information is comprehensive and different modes of information delivery and interaction are available. Furthermore, push notifications allow health care providers to actively educate patients with timely information, which, in this review, is defined as providing patients with small pieces of information at the time that these are actually relevant to them.

Although interventions like these appear to have much potential in allowing patients to better understand and to remember medical information, an overview of all available evidence on the effectiveness of these technologies has thus far not been published. The objective of this systematic review is to provide an overview of the effectiveness of educating patients by providing timely information using smartphone and tablet apps. With this systematic review, we focused on patients that receive care in a hospital setting rather than in primary care. We have chosen to do so since projects in primary care have already demonstrated effectiveness of electronic health (eHealth) apps, but these primarily focused on chronically ill patients from a population perspective and on telemonitoring services from an intervention perspective.

In this paper, we assess the effects that these interventions have on outcomes, such as patients’ knowledge about their illness and treatment options, adherence to medication or instructions, and satisfaction with the information or the care they received.

Search Strategy and Data Sources

To identify relevant studies, we used a two-step strategy. First, we conducted a preliminary search in PubMed to identify key articles, relevant keywords, and Medical Subject Headings (MeSH) terms. The second step was to have the search strategy be peer reviewed by an information specialist from the Radboud academic medical center’s medical library. Multimedia Appendix 1 shows the search strategy for the final search. We comprehensively searched the following databases: MEDLINE (Medical Literature Analysis and Retrieval System Online) (Ovid); Embase (Elsevier); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (EBSCO); and Web of Science. Relevant systematic reviews were also assessed for eligible articles. In order to compare the effectiveness of interventions, we preferred to only include randomized controlled trials (RCTs). Since we were unsure about the number and quality of RCTs, our primary search also included cohort and quasi-experimental studies. After assessing the number and quality of RCTs, we decided to only include these in the review. Reporting was done in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [ 5 ].

Based on the results of our preliminary search, we deliberately limited our search to articles published between January 1, 2015, and November 1, 2019, as the interventions described before this period did not meet the eligibility criteria or could no longer be repeated since the technique was outdated or no longer available. We searched for papers in English and looked at reference lists of included studies to optimize our search.

Eligibility Criteria

RCTs were included if they met a number of eligibility criteria: (1) interventions had a focus on patient education through a smartphone or tablet app, used in a hospital setting; (2) interventions had to use push notifications to actively notify patients about newly available information in the app; and (3) the intervention had to be available for multiple days.

We excluded trials that focused solely on the acceptance or feasibility of technology, content or design of the intervention, availability in app stores, telemedicine (ie, remote care), websites or online platforms, or trials that only described the usage of an SMS. Furthermore, articles focusing on data collection, security, behavior or characteristics of patients, and health care professionals were excluded, as were study protocols. Studies were not excluded on the basis of sociodemographic characteristics of patients, such as age, gender, ethnicity, or any other related characteristic.

Data Selection, Extraction, and Management

The search results from different electronic databases were combined within a single Endnote library, version 8.2 (Clarivate Analytics), and duplicates were removed. Two reviewers (TT and LJ) independently screened titles and abstracts to identify studies that potentially met the inclusion criteria. The full text of these articles was retrieved and read. Two review authors (TT and LJ) independently assessed these articles against the eligibility criteria and extracted the data from the included studies using a structured data extraction form. Disagreements were resolved through discussion and, if necessary, a third reviewer (RBK) was consulted. We extracted information about the patient population, outcomes, interventions, controls, results, and outcome measures.

Assessment of Risk of Bias

Two reviewers (TT and LJ) independently assessed the risk of bias of included RCTs using the Cochrane Collaboration’s risk of bias tool [ 6 ]. Judgements concerning the risk of bias for each study were classified as high, some concerns, or low.

Data Synthesis

Included studies were insufficiently homogenous in terms of patient population, outcomes, and type of intervention. The decision not to perform a meta-analysis was made as a consensus by all authors. For any outcome that was investigated in three or more studies, we present a narrative synthesis of results. In order to compare the effects of the different interventions over the different studies, a standardized mean difference (SMD) is reported, including the 95% CI for the effect. SMD is reported only when results are normally distributed and mean and SD are available. The magnitude of the effect is interpreted according to Cohen’s guidelines: small (SMD is 0.2 or lower), medium (SMD is between 0.2 and 0.8), or large (SMD is 0.8 or higher) [ 7 ].

Furthermore, we created a narrative synthesis of overall results per outcome in relation to the duration of the intervention or the frequency with which messages were sent to the patient. Therefore, the duration of the intervention was subdivided into short (<1 month) and long (≥1 month). The frequency of messaging was subdivided into high (>1 message per week) or low (≤1 message per week). The relative effectiveness was calculated by dividing the total number of participants in studies that demonstrated an effect for the outcome by the total number of participants in studies linked to the outcome. Finally, a weighted overall effect was calculated summarizing all outcomes, specified for the duration of the intervention and the frequency of messages.

Our searches yielded a total of 5497 articles from which 2041 unique articles were derived. After screening titles and abstracts, 1970 records were excluded. A total of 71 articles were assessed for eligibility by full-text screening. A total of 50 articles were excluded after full-text reading because of study type (ie, cohort, quasi-experimental, or other) or because the intervention used did not actually deliver timely education. In total, 21 RCTs were included in the review, including 4106 participants (see Figure 1 ). Sample sizes ranged from 34 participants [ 8 ] to 650 participants [ 9 ].

Included Studies: Study Designs and Populations

Nine studies were conducted in Europe [ 10 - 18 ], four studies in North America [ 8 , 19 - 21 ], five studies in Asia [ 9 , 22 - 27 ], and one study in Africa [ 28 ]. In total, 4106 patients participated in the studies. Studies were divided over many different medical departments: gastroenterology [ 9 , 18 , 22 , 24 , 28 ], orthopedics [ 10 , 12 , 13 ], cardiology [ 17 , 20 , 25 , 26 ], oncology [ 21 ], surgery [ 11 , 19 , 23 ], urology [ 16 ], internal medicine [ 27 ], sports medicine [ 14 ], pulmonary disease [ 8 ], and neurology [ 15 ]. Six studies used a social media platform as the medium for the intervention [ 9 , 22 - 24 , 26 , 27 ]. Eight studies used apps that were already commercially available [ 10 , 12 - 14 , 16 , 17 , 19 , 20 ] and five studies used apps that were developed specifically for the study [ 8 , 18 , 21 , 25 , 28 ]. A total of five interventions that were used provided the possibility to interact with a health care provider [ 9 , 22 , 26 - 28 ].

Two studies included detailed information about the content and timing of notifications used in the intervention [ 10 , 17 ] and eight provided some details or images [ 9 , 12 , 13 , 15 , 21 , 22 , 25 , 28 ]. Regarding the phase of the treatment in which the study was conducted, seven studies focused on the period before the start of the treatment [ 9 , 12 , 18 , 21 , 22 , 24 , 28 ], 12 studies focused on the period after the start of the treatment [ 8 , 10 , 11 , 13 - 16 , 19 , 20 , 25 - 27 ], and one focused on both [ 23 ].

Details of the population, type of intervention, outcomes, and mean age of participants are presented in Table 1 . The details of the interventions used, their duration, phase of the treatment, and frequency of notifying patients are presented in Table 2 . An overview of all the measurement instruments used per study to assess these outcomes can be found in Multimedia Appendix 2 .

a QoL: quality of life.

b Age of the children who underwent surgery. In the study, their parents (age not mentioned) used the app and provided the data.

c Study only reports that 75% of the participants were 41 years or older.

a Pre: before the start of the treatment; post: after the start of the treatment.

b eHealth: electronic health.

Risk of Bias of Included Studies

All 21 included studies were assessed for risk of bias in the following domains: selection of the reported result, measurement of the outcome, missing outcome data, deviations from intended interventions, and randomization process. The levels of risk—low, some concerns, or high—per study, per domain are presented in Figure 2 . An overview of the percentage of studies related to the level of risk and domain of bias is presented in Figure 3 .

Characteristics of the included studies are presented per outcome. Per study, the effect of the intervention on the outcome is described as in favor of the intervention group , in favor of the control group , or no effect .

Satisfaction

A total of 12 RCTs [ 10 - 12 , 15 , 17 - 19 , 21 , 22 , 25 , 28 ], in which 2466 patients participated, reported results related to satisfaction. Two main themes emerged from these studies: satisfaction with the information provided [ 10 - 12 , 17 , 19 , 21 , 28 ] and satisfaction with the overall care that was delivered [ 10 - 12 , 18 , 22 , 25 ] (see Table 3 ).

Regarding patients’ satisfaction with the information, an effect in favor of the intervention group was demonstrated in eight out of 10 studies. Interventions included an app that was used to educate patients about the preparation for their colonoscopy [ 28 ], consultation with an orthopedic surgeon [ 12 ], postoperative self-management after knee replacement surgery [ 10 ], breast cancer screening [ 21 ], healthy lifestyle interventions in myocardial infarction patients [ 17 ], and return to normal activities after abdominal surgery [ 11 ]. One study, which focused on enhanced recovery education after colorectal surgery [ 19 ], showed no difference in terms of satisfaction between the intervention and control groups. SMD ranged from medium to large in five studies [ 10 - 12 , 17 , 21 ] and could not be calculated for the two other studies.

Regarding patients’ satisfaction with the overall care they received, an effect in favor of the intervention group was demonstrated in four out of eight studies. These studies measured the patient-perceived level of involvement by the hospital after discharge [ 10 ], satisfactory bowel preparation [ 22 ], satisfaction with anticoagulation therapy [ 25 ], level of patient-centered care in Parkinson disease [ 15 ], and overall experience with the bowel preparation process [ 18 ]. Three other studies showed no differences between groups in patients’ overall satisfaction with care related to abdominal surgery [ 11 ], patients’ satisfaction related to the consultation with their orthopedic surgeon [ 12 ], and patients’ overall satisfaction with the recovery process after pediatric surgery [ 23 ]. SMD ranged from small to large in six studies [ 10 - 12 , 15 , 18 , 22 , 25 ] and could not be calculated for the other study.

a All items were patient reported versus clinician reported.

b Effects were in favor of the intervention group (+) or there were no effects (=). No study had effects in favor of the control group (–).

c SMD: standardized mean difference.

d Outcome only measured in intervention group.

e No SD available (only average and P value).

f Nonnormal distributed data.

A total of 11 RCTs [ 9 , 15 , 17 - 19 , 22 , 24 - 28 ], in which 2573 patients participated, reported results related to adherence. Two main themes emerged from these studies: adherence to treatment instructions [ 9 , 18 , 19 , 22 , 24 , 26 - 28 ] and adherence to medication usage [ 15 , 17 , 25 ] (see Table 4 ).

Regarding patients’ adherence to treatment instructions, an effect in favor of the intervention group was demonstrated in five out of eight studies, focusing on patients’ self-management in diabetes mellitus [ 27 ], hypertension [ 26 ], and adherence to purgative and dietary instructions for bowel preparation before their colonoscopy [ 9 , 22 , 24 ]. No differences between groups were reported in two other studies focusing on preparation for colonoscopy [ 18 , 28 ] and a postoperative recovery program after colorectal surgery [ 19 ]. SMD ranged from small to large in six studies [ 9 , 18 , 24 , 26 - 28 ], was negative in one study [ 19 ], and could not be calculated for the other study.

Regarding patients’ adherence to their medication usage, an effect in favor of the intervention group was demonstrated in all three studies addressing this theme. These studies focused on drug adherence in Parkinson disease [ 15 ], anticoagulation adherence in patients who suffered from atrial fibrillation [ 25 ], or myocardial infarction [ 17 ]. With regard to the latter, patients in the intervention group reported lower missed medication doses. However, the same study also reported that there were no differences between groups in results related to the medication adherence questionnaire that was assessed. SMD ranged from small to medium in two studies [ 15 , 17 ] and could not be calculated for the other study.

a Items were either clinician reported (CR) or patient reported (PR).

d No SD available (only average and P value).

e Nonnormal distributed data.

Quality of Life

Seven RCTs [ 10 , 11 , 15 - 17 , 20 , 25 ], in which 1300 patients participated, reported results related to quality of life (see Table 5 ). An effect in favor of the intervention group was demonstrated in four studies. These studies measured the effect of the intervention on quality of life at four weeks after knee replacement surgery [ 10 ], three months after starting a program for cardiac rehabilitation [ 20 ], three months after starting a program for pelvic floor muscle training [ 16 ], and three months after starting a program for enhanced self-management after atrial fibrillation [ 25 ]. Three studies did not report an effect in the intervention group at the following time points: 6 months after intermediate-grade abdominal surgery [ 11 ], 4 months after starting a self-management program in Parkinson disease [ 15 ], and 6 weeks after starting a support program on lifestyle changes and drug adherence in myocardial infarction patients [ 17 ]. SMD ranged from small to large in five studies [ 10 , 15 , 20 ] and could not be calculated for two studies [ 11 , 25 ].

Clinical Outcomes

A total of 11 RCTs [ 8 , 10 , 11 , 13 - 16 , 20 , 22 , 24 , 28 ], in which 1783 patients participated, reported results related to clinical outcomes. Three main themes emerged from these studies: physical functioning and pain [ 10 , 11 , 13 , 14 ], clinical values [ 20 , 22 , 24 , 28 ], and symptoms [ 8 , 15 , 16 ] (see Table 6 ).

Regarding physical functioning, an effect in favor of the intervention group was demonstrated in three out of four studies, albeit not on all outcomes. These results were related to physical functioning after abdominal surgery [ 11 ] and pain and knee function after knee replacement surgery [ 10 , 13 ]. No differences between groups were reported concerning pain and activities after abdominal surgery [ 11 ] or concerning knee function and physiotherapy assessment tests [ 13 ]. One study related to ankle function after sports-related trauma did not demonstrate a difference between groups either [ 14 ]. SMD was medium in one study [ 10 ] and could not be calculated for the other studies.

Regarding clinical values, an effect in favor of the intervention group was demonstrated in at least one of the outcomes of all four included studies. These effects were related to weight loss during cardiac rehabilitation [ 20 ] and adenoma detection during colonoscopy [ 22 , 24 , 28 ]. No differences between groups were found concerning cholesterol, glucose, and exercise capacity in cardiac rehabilitation [ 20 ]. SMD ranged from small to large in two studies [ 15 , 16 ] and could not be calculated for the other study.

Regarding symptoms, an effect in favor of the intervention group was demonstrated in one out of three studies. These results were related to a decrease in symptom severity after using an intervention to train pelvic floor muscles in women who suffer from stress-related urinary incontinence [ 16 ]. No differences between groups were reported in nonmotor symptoms related to Parkinson disease [ 15 ] and asthma [ 8 ]. SMD ranged from small to large within one study [ 20 ] and could not be calculated for the other studies.

a Items were either patient reported (PR) or clinician reported (CR).

Health Care Economics

Five RCTs [ 10 , 11 , 19 , 23 ], in which 860 patients participated, reported results related to health care economics (see Table 7 ). An effect in favor of the intervention group was demonstrated in three studies, concerning patients’ contact with health care providers after total knee replacement surgery [ 10 ] and after pediatric day-care surgery [ 23 ], as well as after returning to work after abdominal surgery [ 11 ]. The other studies did not report an effect in favor of the intervention group for patients undergoing colorectal or abdominal surgery [ 11 , 19 ] or patients attending a cardiac rehabilitation program [ 20 ]. Regarding 30-day hospital readmissions, an effect in favor of the control group was demonstrated after colorectal surgery [ 19 ]. SMD ranged from small to large in two studies [ 19 , 23 ] and could not be calculated for the other studies.

b Effects were in favor of the intervention group (+), in favor of the control group (–), or there were no effects (=).

d Nonnormal distributed data.

Four RCTs [ 10 , 21 , 25 , 27 ], in which 634 patients participated, reported results related to condition- or treatment-specific knowledge acquisition (see Table 8 ). An effect in favor of the intervention group was demonstrated in all four studies. All studies focused on disseminating disease-specific information, ranging from treatment options for patients with knee complaints due to osteoarthritis [ 12 ] to self-management in atrial fibrillation patients [ 25 ] or diabetes mellitus [ 27 ] and general knowledge about breast cancer and screening options [ 21 ]. SMD ranged from medium to large in three studies [ 12 , 21 , 27 ] and could not be calculated for one study.

b Effects were in favor of the intervention group (+) for all studies, versus effects in favor of the control group (–) or no effects (=).

Narrative Synthesis of Overall Results

Overall results demonstrate an average effectiveness of the intervention of 69% (see Table 9 ). Satisfaction with information, adherence to instructions and medication, clinical outcomes (eg, weight loss or adenoma detection), and knowledge acquisition showed the highest effects (>70%). When taking into account the duration of the intervention, a clear advantage in terms of effect is demonstrated by the interventions that have a duration of less than one month, compared to the interventions that take more than one month: 82% effectiveness versus 69%. A clear difference is noted in the comparison between the frequencies of messaging patients with information as well: an average effectiveness of 78% in the high-frequency group (more than once per week, on average) versus 64% in the low-frequency group (once per week, on average).

a Average effectiveness is the weighted average of the population linked to an outcome and the part of the population with a positive effect on the outcome.

b High frequency is >1 message per week, on average.

c Low frequency is ≤1 message per week, on average.

d N/A: not applicable.

Principal Findings

The objective of this systematic review was to evaluate the effectiveness of educating patients by providing timely information using smartphone and tablet apps. In particular, we focused on patients that had undergone treatment in a hospital. A total of 21 studies were identified, most with some concerns in terms of risk of bias. Included studies showed low levels of homogeneity in terms of populations and outcomes. Overall results demonstrate an average effectiveness of the interventions in 69% of the studies. Satisfaction with information, adherence to instructions and medication, improved clinical values (eg, weight loss or adenoma detection), and knowledge acquisition showed the highest effects (>70%). An overall effect of 82% was observed in studies that lasted less than one month. Studies with a higher frequency of messaging (ie, more than once per week) were associated with an average effect of 78%. These results should not only be considered effective from a single outcome point-of-view, but should be, from a more holistic perspective, considered as important components required for effective patient self-management support as well [ 29 ].

Our results are in line with earlier reviews that focus on the effect of eHealth interventions on multiple outcomes in chronic health conditions [ 30 , 31 ]. A review by Schoeppe et al reported a positive effect in terms of prevention by focusing on lifestyle changes, such as diet, exercise, and sedentary behavior [ 32 ]. The average duration of the interventions in the Schoeppe et al review was 8 weeks, which is longer than the average duration of interventions in our review. However, this is probably due to the fact that the interventions in the Schoeppe et al review focused on behavioral changes related to lifestyle, whereas studies in our review sometimes lasted only 3 or 4 days, in which the aim is not to change one’s lifestyle, but to optimize one’s preparation for a one-time event such as a colonoscopy. The usage of frequent notifications has been recognized to encourage greater exposure to the intervention’s content without deterring engagement [ 33 ].

Even though results seem to indicate that interventions of a short duration with a high frequency of notifications are beneficial to the patient, the low level of homogeneity across these studies makes it impossible to extract an optimal structure, duration, or frequency for messaging patients. Such a challenge has also been reported in a 2018 review on education via strategies and structures [ 34 ]. Unfortunately, only a few studies reported detailed information about the content that was provided to patients, its format (eg, text, photo, or video), and the actual timing of the content delivery. This information could have provided additional insights on what makes interventions successful or not.

Our results demonstrate the emerging character of this field of research: the 21 included studies were conducted in 10 different medical departments, covering 15 different types of treatments. Four medical specialties—cardiology, orthopedics, surgery, and gastroenterology—have had more than three studies included. Only interventions related to colonoscopy and knee replacement were studied more than once. The results regarding the number of studies that we excluded from this review also demonstrate that many studies still focus on feasibility, acceptance of technology, and the design and content of apps, rather than on the actual effect of this type of intervention.

Strengths and Limitations

To our knowledge, this review is the first to assess the effectiveness of educating patients in preparation of, during, or after their treatment in the hospital using an app for smartphones or tablets. This review adopted a detailed and comprehensive search strategy, followed by robust screening, data extraction, and risk-of-bias assessment, adhering to the PRISMA guidelines. A total of 21 studies were found eligible for inclusion, seven of them having a low risk level of bias and 14 of them having a level of bias with some concerns according to Cochrane’s risk of bias assessment. The relatively large sample sizes allowed us to calculate SMDs and therewith enabled us to compare study outcomes. The observed high level of heterogeneity in terms of outcomes, population, and intervention characteristics, such as interaction models, commercial and noncommercial products, or social media platforms, made it inappropriate to perform a meta-analysis for any outcome.

In this review, we focused on the timely delivery of educational information to overcome patient-perceived information overload. The duration of the interventions within these studies ranged from 3 days to 6 months. In our opinion, this range is another indicator that this type of research is still at an early stage, in which the focus of the trial is really on the intervention itself instead of its long-term effects.

Implications for Practice

The results of our review demonstrate the effective application of smartphone and tablet apps to educate patients with timely information. The effects are visible within various outcomes and across various medical specialties. Medical practices could benefit from these effects by combining two already-existing resources: patient education materials and smartphones and tablets. Patient education is already available on hospital websites, brochures, and through the oral advice of health care professionals. Additionally, more and more patients, as well as their surrounding caretakers, possess a smartphone or tablet. By adding the concept of timing to existing educational materials, one could improve the likelihood that patients receive the right information at the right time. By using the push notification mechanism on smart devices, patients can also be actively made aware of newly available information related to their treatment. Medical practices may choose to either build an app themselves or use already-available commercial products or platforms, social media or otherwise. After the initial development of an app, little or no further adjustments to existing workflows are needed for successful implementation, which is regarded as a crucial factor for successful eHealth implementation [ 35 ]. Of course, some patients may require support during the initial downloading or configuring of the app, but when this effort is compared to the possible benefits in terms of improved outcomes, satisfaction, and health care consumption as described in this review, these efforts appear worthwhile.

Future Research

Delivering timely education to patients through an app for smartphones or tablets has the potential to contribute to the emerging field of patient education research, which may lead to a positive effect on numerous outcomes. Given the novelty of this area of research, more studies need to be performed in order to demonstrate the generalizability of the concept, as well as its long-term effects. In this review, we chose to include only RCTs, since this study design is currently considered to be the gold standard research design to assess the effectiveness of interventions. Yet, we believe it is legitimate to question whether this is the only appropriate study design, as eHealth innovations and research projects could be characterized by what we would like to refer to as “moving objects” and “moving targets.” By moving objects, we refer to the interventions themselves, as these may easily be adapted to the real-time needs of patients and health care providers by their inventors. By moving targets, we refer to outcomes that might not have been defined in the original research protocol but arose from the data and insights that were gathered during the study. Changing the intervention itself or adding outcomes during the course of a study is, however, often considered not done , as it could quickly lead to a high risk of bias and a lower overall quality of the research. As a consequence, many interventions might not be studied at all, because from a supplier’s or producer’s perspective, it feels unnatural not to be able to respond to these real-world demands “just because a study design won’t allow you to.” This challenge was also reported by two recent studies focusing on eHealth interventions in general [ 36 ] and, more specifically, in the field of psychiatry [ 37 ].

We suggest that other study designs, such as pragmatic RCTs, action research, or even real-world data, are considered to be eligible to demonstrate the effectiveness of these interventions. These designs more closely mimic a routine clinical setting from a health care provider’s perspective (ie, no double blinding or placebo-controlled setting) and allow the interventions to be altered by the supplier during the course of the study if needed. This could lower some of the existing barriers and may convince more stakeholders to participate in eHealth research.

Conclusions

This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messaging patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

Acknowledgments

The authors would like to thank Elmie Peters, medical librarian at Radboud University Medical Center (Radboudumc), for her input in shaping and optimizing the search strategy. Furthermore, the authors would like to thank Samuel Credgington for language editing.

Authors' Contributions

All authors were involved in the design of the protocol, development of the search strategy, and selection of data sources. TT and LJ independently screened articles and assessed the risk of bias of the included studies. TT drafted the manuscript. LJ, RBK, and JAMK critically revised the manuscript. All authors read and approved the final manuscript.

Conflicts of Interest

None declared.

MEDLINE (Medical Literature Analysis and Retrieval System Online) search strategy.

Overview of outcomes per study and instruments used to assess them.

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Abbreviations

Edited by G Eysenbach; submitted 08.12.19; peer-reviewed by L Whitehead, D Reukers, MC Chang, G Dermody, C Mullens; comments to author 15.01.20; revised version received 21.02.20; accepted 22.03.20; published 13.04.20

©Thomas Timmers, Loes Janssen, Rudolf B Kool, Jan AM Kremer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 13.04.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

10 Ways Nurses and Nurse Leaders Can Improve Patient Education

Patient education is the key to long-term patient outcomes. Yet, nurses juggle many responsibilities. They often work on short-staffed units and care for patients with complex healthcare needs.

It can be difficult to fit teaching into a crammed schedule. Nurses often need to think on their feet and teach patients under less than ideal circumstances.

However, there are several ways to improve patient education. Three nursing experts discuss how hospitals can promote patient teaching and how nurses can include patient education in their skill set.

A Nurses’ Role in Patient Education

It is essential that hospital and nursing management value patient education because it can help build stronger patient outcomes. Nurses play an important role in patient education by increasing a patient’s knowledge and confidence in skills they will need after being released from the hospital. These skills can prepare a patient at discharge.

One study found that patient education was influenced by economic barriers. The data also suggested managers should offer more support for educational development.

Craig Laser has a background in clinical nursing and managerial roles. In his experience, patients may have received education before discharge, but this doesn’t guarantee patients fully understand, comprehend, or know what to do next, he says.

Patient education is a learned skill. Nurses who are unfamiliar with strong teaching techniques may find continuing education for nurses helpful. Remember to take advantage of the resources you have in your unit, too. Ask to shadow an experienced nurse who can share their patient education tips and strategies.

1. Keep It Simple

Nurses and other healthcare professionals can speak in a language all their own. Myocardial infarction, cerebral embolism, dorsiflexion, and ganglion may all be everyday terms for a nurse but not for a patient. During patient education, these terms should be parked at the door.

Avoid using medical terminology and abbreviations. For example, a CBC may seem simple enough, but make sure you use “complete blood count” for your patient.

Keeping it simple also means not waiting till discharge to educate your patient. Patient education should begin during the initial assessment and continue until discharge.

Providing education in bite-sized pieces also helps your patient retain more information. Retaining information can be challenging during stressful times but is especially important during these times in a patient’s life.

2. Provide Educational Paperwork in Patient’s Native Language

Health literacy rates are not linked with literacy rates. A person may have excellent comprehension skills yet still have difficulty understanding healthcare information to make informed decisions.

Michelle Kotte, a psychiatric mental health nurse practitioner, emphasizes the importance of providing healthcare paperwork in the patient’s native language. If language barriers impact patient care, you can use apps for nurses like MediBabble or even Google Translate to improve the quality of healthcare and patient education.

Here are a few ways to make patient education easily understood.

• Relay the information and instructions for the patient clearly.
• Do not go in-depth into disease processes with a patient who is just learning about the disease.
• Make sure the information is written down so the patient can review it later as needed.
• Remember that the patient may be feeling overwhelmed by receiving too much information at once, so keep it simple.

3. Consider a Patient’s Communication Barriers

In addition to patients whose native language is not English, you may have patients with other communication barriers. Your patient education strategies should include teaching patients who have sensory impairments.

Barriers may include sight or hearing impairment or those who have cognitive issues. Nurses can overcome communication barriers with planning, compassion, and patience.

For example, you might have to rethink teaching a procedure like a dressing change. For individuals without a visual impairment, you can show where to place the tape. For visually impaired patients, you will need to talk through each step and demonstrate by touch.

4. Use the Teach-Back Method

Ann Kriebel-Gasparro, DrNP, FNP-BC, advises nurses to use the “teach-back” method in their patient education. Kriebel-Gasparro is a faculty member at Walden University and holds credentials as a family and gerontological nurse practitioner.

Despite evidence that the method is effective, many physicians do not use it. They cite time constraints or that patients may take offense as their reasons.

“Make sure the patient understands that you are not trying to test them, but want to understand whether you have explained things so that they understand,” Kriebel-Gasparro advises.

Another name for this method is “closing the loop.” After finishing a short bite of information, you can ask the patient to repeat it in their own words. For example, after explaining how insulin works in the body, you may say, “Just to be sure I was clear, could you tell me why you’ll be taking insulin?”

Making sure your patient repeats back accurate information ensures they understand and allows you to fill any gaps in communication.

5. Write Down Important Information

When a patient struggles with pain, nausea, or breathing, they will have difficulty learning new concepts or remembering details. This is how the body responds to distress. Kotte advises nurses to write detailed instructions for patients to reference later to avoid valuable patient education getting lost.

Nurses should also give patients phone numbers of people they can contact if they have questions. It is also helpful if patients have a family member with them, so someone else can help re-educate the patient if needed.

6. Promote Health by Continuously Educating Patients

Some of the lifestyle changes patients must make that promote health are challenging. Eating a healthier diet, quitting tobacco products, or reducing or eliminating alcohol will likely not change unless the patient is aware of how these behaviors affect their health and wellness. Patients may be in a precontemplative stage of change, says Kotte.

“This means that at that time, they have no intention of changing behavior,” Kotte explains. “This can be an emotionally challenging experience as a nurse.”

During this time, patients are often unaware or poorly understand how their behavior affects their health. Nurses play a role in helping move patients to the contemplative stage. During this time, patients become aware that the problem exists and begin to think they can overcome the issue.

Through patient education and support, patients can be encouraged to make a plan and take action. In this role, nurses can promote health by continuously and compassionately educating patients.

7. A Fully Staffed Floor Aids in Patient Education

Nurse-to-patient ratios have a direct impact on patient safety, outcome, and education. A high ratio may compromise a nurse’s ability to provide safe care and will affect patient outcomes. Safe ratios are dependent on patient acuity, technology, monitoring, experience, and the physical layout of the unit.

The importance of this factor led California to establish minimum ratios in 2004. To date:

• 15 states have staffing regulations in place
• Eight states require hospitals to have staffing committees

Kriebel-Gasparro encourages nurses to take action if they find themselves short-staffed. Options include:

• Joining a nursing union if your hospital has one
• Creating a safe staffing group
• Becoming a nurse advocate for safe staffing in your hospital

Taking advantage of nursing organizations is also an option. For instance, in Pennsylvania a group called the Nurses of PA is advocating on behalf of nurses and patients. It is a grassroots organization that has banded together to contact legislators to change laws for safe staffing in hospitals.

8. Telehealth Increases Education Opportunities for Nurses

The role of telehealth nursing services grew significantly during the pandemic, and it is here to stay. Nurses must develop solutions to promote the use of technology.

There are some telehealth limitations with patient education, such as communicating over a camera. Healthcare professionals and telehealth nurses need to become comfortable with the technology and practice telehealth communication skills.

Telehealth can increase access to care and patient education. Telehealth offers the opportunity to provide health screenings, patient education, and discuss the importance of vaccinations.

Kriebel-Gasparro is excited by the option to expand patient care to greater geographic areas. She also likes how technology can be used for various aspects of patient care such as Medicare assessments and psychiatry.

“One of the benefits of telehealth is the education on health, diseases, and screenings that nurses can provide,” she says.

9. Manage Expectations for Change

Clinical nurses work in a high-stress environment, and many have experienced nurse burnout . Burnout is a state of emotional, physical, and mental exhaustion. It’s often triggered by long hours caring for patients with poor outcomes, a perceived lack of control, and not enough support. The consequences of burnout include a stressed immune system, overwhelming fatigue, and anxiety.

One way to deal with nurse burnout is to manage your expectations for patient outcomes. It’s vital to educate your patients to motivate them to choose a healthier lifestyle. But Kotte cautions that you can do this without becoming personally involved in your patient’s outcome.

By acknowledging your patient may not be ready to make changes, “we are able to better manage our expectations and ultimately provide the best patient care,” she says.

10. Provide Educational Content in Various Forms

Every person has a learning style. Your learning style increases the amount of information you can absorb and use in your decision-making.

There are four basic learning styles.

1. Visual Learners

• Absorb by seeing and observing
• Do best with diagrams, flow charts, pictures, and written instruction

2. Auditory Learners

• Retain more information from speaking than from written information
• Can reinforce the information by saying it out loud
• Benefit from the “teach-back” method

3. Kinesthetic/Tactile Learners

• Experience things through touch, like handling equipment
• Might struggle to sit through demonstrations

4. Reading and Writing Learners

• Can be similar to visual learners
• Understand content best when expressed with words

As you are preparing to engage your patient, ask them how they learn best. Most people know if they want a lecture, material to read, or equipment to learn.

By meeting your patient’s needs, you can improve their level of patient education and possibly their outcome. Laser advises nurses to think broadly about the types of educational material they may use.

“Some patients may prefer a multimedia approach to support their learning needs,” he says. “Some patients may need a video format to maximize their learning. What about text messages, Instagram pictorials, or a Tik Tok format?”

Meet Our Contributors

Ann Kriebel-Gasparro, DrNP, FNP-BC, GNP-BC

Ann Kriebel-Gasparro , faculty member in Walden University’s master of science in nursing program, has more than 26 years of experience in nursing and is credentialed as both a family and gerontological nurse practitioner. Kriebel-Gasparro is a current member of the Gerontological Advanced Practice Nurses Association and previously served on the Rare Disease Advisory Council for the Commonwealth of Pennsylvania’s Department of Health.

Michelle Kotte, DNP, PMHNP-BC

Michelle Kotte is a faculty member in Walden University’s master of science in nursing program. She practices as a psychiatric mental health nurse practitioner at Emerald Psychiatry in Dublin, Ohio. Kotte has taught assessment, pathophysiology, and psychiatric nursing in online , in-person, and hybrid courses.

Craig Laser, Ed.D., BSN, RN

Craig Laser is a clinical associate professor at Arizona State University within the master of global management in healthcare services program. Laser has worked as a clinical nurse, nurse leader, and consultant. His clinical background includes critical care nursing, emergency/trauma nursing, and critical care transport/flight nursing. Laser’s interests include the practice of leadership, workforce dynamics, and cultural transformation.

Reviewed by

Shrilekha Deshaies, MSN, CCRN, RN

Shri Deshaies is a nurse educator with over 20 years of experience teaching in hospital, nursing school, and community settings. Deshaies’ clinical area of expertise is critical care nursing and she is a certified critical care nurse. She has worked in various surgical ICUs throughout her career, including cardiovascular, trauma, and neurosurgery.

Page last reviewed November 28, 2021. Shri Deshaies is a paid member of the Red Ventures Education freelance review network. Learn more about our review partners here .

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Effective communication between nurses and patients: an evolutionary concept analysis

Affiliation.

• 1 Student Nurse, University of West London, Brentford.
• PMID: 32881615
• DOI: 10.12968/bjcn.2020.25.9.438

Communication can be considered as the basis of the nurse-patient relationship and is an essential element in building trust and comfort in nursing care. Effective communication is a fundamental but complex concept in nursing practice. This concept analysis aims to clarify effective communication and its impact on patient care using Rodgers's (1989) evolutionary framework of concept analysis. Effective communication between nurses and patients is presented along with surrogate terms, attributes, antecedents, consequences, related concepts and a model case. Effective communication was identified to be a multifactorial concept and defines as a mutual agreement between nurses and patients. This influences the nursing process, clinical reasoning and decision-making. Consequently, promotes high-quality nursing care, positive patient outcome and patient's and nurse's satisfaction of care.

Keywords: Communication; Concept analysis; Nurse-patient relationship; Nursing traits; Trust.

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Open Access

Peer-reviewed

Research Article

A scoping review of Deaf awareness programs in Health professional education

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Medicine Health and Life Science, Swansea University, Swansea, Wales, United Kingdom

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation Faculty of Science and Engineering, Swansea University, Swansea, Wales, United Kingdom

• Julia Terry, 
• Rhian Meara

• Published: August 19, 2024
• https://doi.org/10.1371/journal.pgph.0002818
• Peer Review
• Reader Comments

Deaf awareness aims to promote understanding about Deaf and hard of hearing people, with the goal of reducing barriers between Deaf and hearing populations; and is particularly pertinent for health professional students as they need to learn to communicate effectively with a range of population groups. This scoping review aims to provide an overview of literature examining Deaf awareness programs provided to health professional students during their initial training. We searched four medical and public health databases and registers using terms related to Deaf awareness. We used the PRISMA-ScR reporting standards checklist for scoping reviews. We identified 10,198 citations, with 15 studies included in the final review. Searches were performed during August to September 2022, and April 2023. Studies were included provided they examined Deaf awareness content or programs within health professional education. Data were extracted by two independent reviewers who screened all abstracts using Rayyan software, followed by discussion to achieve knowledge synthesis and agreement. In all, a total of 15 articles from six countries were identified across health professional student disciplines including pharmacy, nursing, audiology, inter-professional and medical programs. The review found sparse evidence of research into Deaf awareness programs delivered to health professional students, with delivery often solely to small groups of students, indicating why so few students can access information about how to communicate effectively with Deaf and hard of hearing patients during their initial training programs. This scoping reviewed showed evidence of promising benefits for health professional students undertaking Deaf awareness programs during their undergraduate education. The importance of communicating with Deaf and hard of hearing patients and attaining Deaf cultural competencies for health professional students should be investigated in future research.

Citation: Terry J, Meara R (2024) A scoping review of Deaf awareness programs in Health professional education. PLOS Glob Public Health 4(8): e0002818. https://doi.org/10.1371/journal.pgph.0002818

Editor: Julia Robinson, PLOS: Public Library of Science, UNITED STATES OF AMERICA

Received: December 21, 2023; Accepted: July 9, 2024; Published: August 19, 2024

Copyright: © 2024 Terry, Meara. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Submitted as Supporting Information files.

Funding: This work was supported by the Burdett Trust for Nursing, grant number 101010662\737073 – JT. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Deaf awareness training aims to promote understanding about Deaf and hard of hearing people, with the goal of reducing barriers and increasing accessibility between Deaf and hearing populations and combating discrimination. In this paper the terms Deaf and hard of hearing people will be used throughout. The heterogeneity of Deaf and hard of hearing people are often not fully known to health staff [ 1 ] and that a person-centred approach is required according to individual communication needs. People who identify as culturally and profoundly Deaf may be referred to using a capital D for Deaf, with a lower case ‘d’ for deaf, more commonly used for people who are hard of hearing.

Despite the numbers of Deaf and hard of hearing people increasing globally from around 466 million people currently, to 900 million by 2050 [ 2 ], there is limited preparation and training for health professionals and health professional students to communicate and work with Deaf patients [ 3 – 5 ]. Health professionals themselves have reported that their communication skills and knowledge of working with Deaf and hard of hearing people could be greatly improved [ 6 ], as they lack tailored communication skills in caring for Deaf and hard of hearing populations [ 7 ]. There is a dearth of evidence about the effectiveness of provider-oriented disability programs, specifically those relating to sensory loss, and those in existence tend to be focused on general disability awareness [ 8 ] or about attitudes and behaviours towards specific population groups [ 9 , 10 ].

Challenges for Deaf and hard of hearing patients are many and are often not known to health professional groups with whom they engage. Difficulties for Deaf and hard of hearing people often relate to a lack of accessible services and provision in education [ 11 ], in society [ 12 ], and in disaster response [ 13 ] as well as difficulties accessing health services [ 14 , 15 ]. It is also acknowledged that health professional students need to be trained in Deaf cultural competencies [ 1 ] so they develop relevant knowledge and skills about Deaf and hard of hearing culture. For example, a person may use a Signed language as their preferred communication method, whilst others may prefer information literature in written form. However, literacy levels in Deaf and hard of hearing people are often lower than in hearing populations [ 16 ], so it is essential that health workers learn to ask about preferred communication methods for each individual. Students may demonstrate attitudes to Deaf people stemming from their own lack of knowledge that results in a negative stigma toward anyone who is Deaf (referred to as audism) [ 17 ], particularly if they lack experience of working with Deaf and hard of hearing patients [ 18 ].

Further challenges are reported by Deaf and hard of hearing patients who note they do not understand health providers instructions in nearly half of appointments, with few clinicians checking patient understanding [ 19 ] suggesting potential risk of misunderstanding and resultant health risks. Difficulties often result when a Sign language interpreter is required as health staff have little notion how to book or how to work with a Deaf patient and a Sign language interpreter [ 20 ]. Similarly, few health professional staff have used remote video interpreting services during health consultations [ 21 ], which involves either the health facility or the patient using a sign language interpreter via an app or remote video interpreting service (either in a booked capacity or on-demand). Few health professionals or students know the challenges members of Deaf and hard of hearing communities experience accessing health services, and specifically care routes that may or may not be open to them [ 22 ].

Notably in healthcare settings few staff have Deaf awareness training which leads to persistent health inequalities for Deaf and hard of hearing patients who often have poor experiences and outcomes in healthcare settings [ 23 ]. These negative experiences can relate to discrimination around booking procedures and face to face appointments, as well as assessments and testing visits [ 24 , 25 ], often due to limited accessibility for communication options [ 26 ], with services unprepared and ill-equipped to meet the needs of Deaf and hard of hearing people [ 27 ]. It is imperative that health service experiences improve for this population group. It has been described as a silent epidemic with global efforts needed to address the unmet needs of Deaf and hard of hearing adults and children who experience poorer health and care [ 28 ].

The Deaf awareness knowledge gap is likely unknown by health workers, who may have had limited exposure to this population group, and consequently do not appreciate the healthcare barriers Deaf and hard of hearing people experience [ 29 ]. Furthermore, there is increasing evidence that Deaf and hard of hearing people experience poorer health, with increased risk of preventable ill-health with chronic illness often undiagnosed and untreated, such as diabetes and cardiac disease [ 22 ]. Many diverse groups are disadvantaged because of assumptions around health literacy that may relate to English not being a first language, and ability to read and write, which in turn impacts on a person’s ability to understand healthcare and pharmacy directions and information [ 30 ]. Deaf people are aware health information is often not in accessible formats, so consequently they may rarely seek health material and be disadvantaged as a result by not being aware of common risks or solutions within their own control.

Knowledge of Signed language and the use of telecommunication equipment, such as Sign language relay services is not prevalent in health providers [ 31 ]. Deaf awareness programs highlight the different forms of communication that Deaf and hard of hearing people may use [ 32 ], including sign language, lip reading, note taking and oral methods, but few health workers are aware of this. Individual education providers may offer opportunities for students that challenge their knowledge about diversity, increase knowledge and communication, and break down stereotypes [ 33 ]. Certainly, there is a need for increased disability training in health professional education [ 34 ], with the most effective programs noted to be those that include people with disabilities themselves.

The aim of this scoping review was to report on the published evidence of Deaf awareness programs experienced by health professional students during their initial training. Given the health inequalities that Deaf and hard of hearing people experience, we wanted to explore the range of interventions and approaches used with health professional students to understand the current evidence about Deaf awareness programs.

Methods and analysis

Ethics statement.

As this study only included published data, ethics approval was not sought. The methods and results are reported according to the relevant items of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [ 35 ]. According to Verdejo et al. [ 36 ] the main aim of a scoping review is to identify and map the available evidence for a specific topic area. The approach to the review was based on Arksey and O’Malley’s framework [ 37 ] which consists of the following stages: i) identifying the research question; ii) identifying relevant studies; iii) selecting studies; iv) charting the data; and v) collating, summarising, and reporting the results.

Search strategy

A scoping review seeks to present an overview of a potentially large and diverse body of literature pertaining to a broad topic, whereas a systematic review attempts to collate empirical evidence from a relatively smaller number of studies [ 38 ]. This scoping review is not intended as a conclusive synthesis of evidence but does provide an overview of the evidence of Deaf awareness programs that exist, primarily for health professional students. The study has been funded by the Burdett Trust for Nursing and was conducted in Wales, UK. It was not registered online. The overall project had a steering group which included lay members, Deaf and hearing professionals. The focus of the steering group was on the empirical aspects of our study and building a Deaf awareness course for Wales, UK, with this scoping review discussed at early meetings, and members contributing ideas for search terms.

Identifying the research question.

The core aim of this scoping review was to find out ‘what is the existing evidence on Deaf awareness programs that are included in health professional education training?’. Deaf and hard of hearing people’s experiences in health services and poor health literacy are frequently linked to the poor knowledge of health professionals about how to communicate with Deaf and hard of hearing people; including a lack of training for medical and nursing students, and students studying to become allied health professionals [ 1 , 39 , 40 ].

Identifying relevant studies.

The scoping review research question was left intentionally broad. The evidence was searched using four electronic databases (CINAHL, MEDLINE, ASSIA and Proquest Central), registers and key journals and repositories (such as PROSPERO), and contact made with key authors; as well as internet site searches for policies and reports. An experienced information specialist’s help was sought in reviewing the search strategy tool (PICO framework), which included students (P- population), Deaf awareness (I- intervention), health professional education (C–context); and learning (O–outcome). Search terms used included: Deaf OR hard of hearing or DHH or sensory loss; combining "deaf aware*" OR "deaf culture*") AND ("learn*" OR "educat*" OR "train*" OR "course*" OR "program*" OR "teach*". The databases included were CINAHL, Medline, ASSIA and Proquest Central, as well as Cochrane registers, with searches conducted between August and September 2022; and again in April 2023 (an example of the search strategy for one database is provided as an additional file). Different techniques and terms were used to expand and narrow searches, including tools such as medical subject headings (MESH), Boolean operators and Truncation. Single and combined search terms included key subject areas on: Deaf, hard of hearing, and Deaf awareness. Education related search terms included learning, education, training, course, program and teaching. Limitations were set to include papers in the English Language and research since 2000. Initial searches found papers in languages other than English did not relate to Deaf awareness programs but to Deaf students. Papers not in English language were excluded to reduce volume, and this remains a common decision for researchers [ 41 ]. In addition, key journals, professional organisation websites and reference lists of key studies were searched to identify further relevant documents. The final search strategy and terms were agreed and verified by a health librarian.

Inclusion criteria were: published research articles specific to: a) a focus on Deaf awareness, training on Deaf awareness/Deaf culture and b) were published in the English Language between 2000–2023. Exclusion criteria were: papers published before 2000, not in English language, papers without a focus on Deaf awareness, training/courses/understanding Deaf and hard of hearing patient experience for health professional students.

Study selection.

The initial search produced a total of 10,159 from database searches and 39 from registers. Once duplicates were removed (n = 5804), a further 4049 records were excluded that did not meet the inclusion criteria, 345 publications remained, and titles and abstracts were screened. All 345 records were screened by two separate reviewers independently using Rayyan software [ 42 ] and annotated spreadsheets of retrieved papers. We began by excluding sources that did not describe empirical studies of Deaf awareness courses for health professional students, such as opinion articles, newspaper reports, and papers without a Deaf awareness focus. Inter-rater discrepancies were resolved by discussion. 26 records were then removed in line with the eligibility criteria, and the remaining 15 publications are included in this review (see Fig 1 ).

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https://doi.org/10.1371/journal.pgph.0002818.g001

Charting the data.

A data-charting form was developed by one reviewer, and then updated iteratively through discussion with a second reviewer. The 15 included sources were charted initially to examine authors, year of publication and country of origin, study design, sample population, study aim and main findings, which was piloted and found to be effective. Through this process sources were all identified as primary research studies. Papers related to the following health professional student disciplines: Pharmacy (n = 2), Nursing (n = 2), Audiology (n = 2), Inter-professional (n = 1), and Medicine (n = 8).

Collating, summarising and reporting results.

In the final scoping review, six individual countries were represented. Most publications came out of the USA, which may be due to greater funding or interest in this area of research compared to other nations. Due to the heterogeneity of the range of study contexts, a narrative synthesis was a reasonable way to approach the reporting of retrieved studies which included: four pre and post intervention surveys; eight cross-sectional studies; two comparative studies and one evaluation of experiential role play.

After summarising the information from sources, then studies were sorted into categories regarding Deaf and hard of hearing awareness courses for specific health professional education program by discipline, as follows: i) pharmacy students; ii) nursing students; iii) audiology students; iv) inter-professional students and v) medical students; and also regarding methodological approach. In addition, main findings of the sources are presented in Table 1 . Context from the grey literature is included in this paper’s introduction as this clinical wisdom provides additional information and context.

https://doi.org/10.1371/journal.pgph.0002818.t001

Identification of studies

The 15 papers included in this scoping review were carried out geographically in the USA (n = 8), Canada (n = 2), the UK including Ireland (n = 3), with one study each from Germany and Puerto Rico. All studies’ samples were university students undertaking undergraduate study, and included pharmacy students (n = 3), nursing students (n = 2), medical students (n = 7), and other/mixed groups (n = 5), accounting for some overlap of participant groups.

Findings are reported under four deductive themes: i) provision of Deaf awareness training ii) Deaf awareness: reflections iii) Deaf awareness: examining knowledge and iv) Deaf awareness: exploring confidence and communication.

i) Provision of Deaf awareness training

One article examined the provision of Deaf awareness training across medical schools in the UK and Ireland and was the only paper retrieved [ 43 ] to survey education providers and to ask about Deaf awareness provision. Medical schools in the UK (n = 38) were asked to complete a survey as to whether they included Deaf and hard of hearing awareness training in their curriculum, with 23 respondents [ 43 ]. 7/23 medical schools reported they did not provide any Deaf and hard of hearing awareness training, and of the 16 medical schools who said they provided training, 8 made it compulsory. 6/16 provided a formal qualification in Sign Language or Deaf and hard of hearing awareness. Time spent training varied from 1–2 hours to six weeks, and 13/16 involved a Deaf and hard of hearing tutor in teaching delivery [ 43 ]. No other papers have been retrieved that have enquired about provider provision of Deaf awareness training for health professional programs.

ii) Deaf awareness: Reflections

As seen in Table 1 , among the 15 studies reporting Deaf awareness training, five studies delivered a workshop and undertook either a post training reflection or evaluation to enquire about participants’ experiences [ 3 , 44 – 47 ] (there was no pre-testing or baseline knowledge enquiry for these studies), and all involved training delivery with members of local Deaf and hard of hearing communities. Of these evaluation studies, one involved pharmacy students [ 47 ], one further paper discussed Deaf awareness introduced across ten health professional disciplines [ 3 ], and the remaining three were conducted solely with medical students [ 44 – 46 ].

One study [ 3 ], led as a medical student project, was run as a collaboration with students and hard of hearing people, with general evaluations very positive, and one of the ten professional student groups who attended (occupational therapy students) completing reflective journals post workshop. The authors, who reported their interest in the logistics of delivery with patients and community partners, strongly recommend delivery of Deaf awareness training in using Deaf people as mentors to students, initially as a panel, which was replaced for subsequent sessions with mentors and students in small groups for more informal interactions.

Another study to use reflections to understand students’ (pharmacy) experience of a Deaf awareness session [ 47 ], engaged participants in a different learning style with members from a nearby centre for Deaf and hard of hearing people and participation in a role-reversal exercise as students ‘became’ Deaf patients. Members of the Deaf and hard of hearing community wrote scenarios for student learning, and prior to the exercise students had basic lessons in American Sign Language (ASL) and reading materials about Deaf and hard of hearing culture. Students then experienced the patient perspective and different parts of a mock hospital experience as they communicated symptoms without using their voices and moved through processes of asking for interpreters, consenting to treatment, and giving symptom information. The session included debriefing, reflection on the experience and students learned the frustrating experiences in healthcare that Deaf and hard of hearing people experience [ 47 ]. 65 pharmacy students agreed the experience would positively impact their attitudes and future behaviour towards Deaf and hard of hearing patients [ 47 ]. As part of course requirements students wrote two-page reflections on the experience. In terms of feasibility the authors [ 47 ] note the nearness of the centre for Deaf people being close by helped. Authors note a small number of students were involved with requirement for heavy resource, for example 12 faculty members were involved [ 47 ].

Three further studies, that included an evaluation only type design, were focused solely on medical students [ 44 – 46 ]. The first of these also involved a role reversal experience for students, as well as involvement from 40 local Deaf individuals [ 45 ]. Medical students in their new ‘Deaf’ role interacted across four stations/types of clinical setting and were given instruction cards and waited for their ‘appointment turn’ as a Deaf receptionist finger-spelled their names. The program evaluated positively and at a later time point over 12 months later, 97% recalled participating and reported finding it a valuable experience [ 45 ].

The final two evaluation only studies [ 44 , 46 ] involved a one-off Deaf awareness workshop and both studies involved participation from Deaf community trainers, with evaluations showing that students had highly rated the activities. Time lengths of the Deaf awareness workshops varied depending on content, from one three-hour workshop run in the evening [ 46 ] to a 72-hour activity which included a short series of workshops for learning British Sign Language [ 44 ]. In response to initial positive evaluations from medical students on a Sensory awareness Day, a special study module was developed including a short Sign language course taught by a Deaf and hard of hearing tutor and self-directed material to gain insight into Deaf and hard of hearing awareness [ 44 ]. The course included a written report, British Sign Language (BSL) tutorials and classes, a BSL objective structured clinical examination (OSCE) assessed by a certified BSL examiner, all totalling 72 hours of study activity [ 44 ]. To date 54 medical students have undertaken the course, and out of 52 completed evaluations 98% students found the sign language manageable and the content appropriate for clinical practice, although 19% would have liked more medical vocabulary [ 44 ].

iii) Deaf awareness: Examining knowledge

Four papers reported in this section focused on examining student knowledge after a Deaf awareness session with two studies involving a control group [ 48 , 49 ], and two studies seeking knowledge about students existing knowledge without participation in any Deaf awareness program [ 50 , 51 ].

First, two studies of medical students that sought to discover if students who attend Deaf and hard of hearing culture training demonstrated greater knowledge of Deaf and hard of hearing culture and Deaf and hard of hearing patients than medical students not given a Deaf and hard of hearing awareness educational opportunity (control group), one UK study [ 48 ] and one from USA [ 49 ]. A significant difference was noted on survey questionnaires to measure attitudes to and knowledge of Deafness in those taking an optional Deaf and hard of hearing awareness course (n = 29) and control group, who could perceive patient mannerisms as rude [ 48 ]. Students reported that without encountering Deaf and hard of hearing people it may be difficult to understand the issues they face [ 48 ]. For the USA study, students were asked to list up to five problems they thought a Deaf and hard of hearing person might experience on hospitalisation, with students who had attended Deaf and hard of hearing cultural training showing awareness about understanding terms and medical language as the number one difficulty, but also acknowledging awareness about maltreatment and mistreatment being a possibility, which others in control group did not show awareness about [ 49 ].

For the two studies that sought to know students’ existing knowledge about Deaf awareness without participation in a Deaf awareness program, surveys were undertaken with nursing students in the USA [ 50 ] and with medical students in Puerto Rico [ 51 ]. For nursing students [ 50 ], the survey included multiple choice questions then true/false statements [ 50 ]. Out of 131 respondents [ 50 ], 18 had taken an entry level sign language course previously. Only 17% (n = 22) answered more than half the questions correctly indicating that overall there were low levels of Deaf awareness across the cohort and low Deaf cultural competence. For the medical students’ study [ 51 ] (n = 158) were asked about their knowledge of Deaf culture and community in Puerto Rico, without any intervention [ 51 ], 21% of respondents had attended a sign language class, and generally students in more senior years reported more likelihood of working with a Deaf or hard of hearing patient and showed an increased understanding of Deaf culture in comparison to junior students. Studies that indicate low baseline knowledge about a particular patient group without preparation are to be expected, but also highlight the need to increase Deaf awareness in those student populations.

iv) Deaf awareness: Exploring confidence and communication

In this section of the scoping review findings, we report on five studies that involved a pre and post test for student groups before and after their participation in a Deaf awareness program [ 4 , 5 , 52 – 54 ].

The first example of a study in this review that involved USA pharmacy students [ 52 ], involved them embarking on a co-curricular course that consisted of four 90-minute sessions including Deaf and hard of hearing cultural competence and sign language words and phrases [ 52 ], with students who completed the course reporting significantly improved knowledge and feelings of confidence in relation to communicating with people who are Deaf and hard of hearing [ 52 ]. Initially the six-hour course had a cost of $50, reduced to $12 for each student by university sponsorship. As an external agency provided and co-ordinated the courses, it is noted that the workload was not additional for course staff.

Another university applied Deaf culture to an anatomy session

With US Medical students [ 5 ], while they studied the ear and hearing [ 5 ]. Deaf and hard of hearing panellists attended this 90-minute session and discussed their healthcare experiences, additionally a further 90-minute session on Deaf and hard of hearing culture was provided, with students given pre and post session questions. Students gave positive feedback about the cultural competencies relating directly to the anatomy and neuroscience session, with students recognising their previous low knowledge levels in relation to Deaf and hard of hearing communities

Medical students in Germany [ 4 ] were invited to attend an online workshop held on three consecutive occasions, and to engage in pre and post evaluations (n = 95) [ 47 ]. 65.3% of students had not been in contact with a Deaf and hard of hearing or person before. Students reported feeling substantially more confident working with Deaf and hard of hearing people after engaging in the online Deaf and hard of hearing awareness program. Students reported finding the Deaf awareness workshop particularly helpful from a personal and from a professional point of view. The workshop was elective and the only Deaf awareness intervention that was delivered online, out of the 15 papers found in this scoping review.

Similarly, osteopathic medical students in the USA [ 53 ] participated in a pre-test, a four-hour workshop, then post-test study two weeks later with significantly improved scores at post-test following workshop attendance [ 53 ]. Students reported the contact with Deaf and hard of hearing people as part of the workshop to be the most beneficial aspect of learning, and also commended the opportunities to practice their newly learned skills.

The final study included participating nursing students in the USA using newly acquired Deaf awareness knowledge to ‘assess’ a ‘deaf patient’ after a Deaf awareness lecture [ 54 ]. This study involved students interacting directly with Deaf and hard of hearing people acting as standardised patients [ 54 ]. On starting an initial history taking exercise students were unaware patients would be Deaf and hard of hearing, mirroring real-life practice situations. Initially several students were reported to have turned away, preventing lip-reading, or left the room without saying they were going in search of interpreters. Students then received further input about communicating with Deaf communities and several positive changes were noted in the second exercise. This study [ 54 ] is another good example of how local Deaf and hard of hearing communities can be directly involved in providing students with a meaningful learning experience, which Deaf and hard of hearing participating tutors reported benefits in contributing to nurse education and improving care for others [ 54 ].

Overall papers retrieved in this scoping review suggest that health professional students who have the opportunity to engage in Deaf and hard of hearing awareness education courses during their undergraduate training find it beneficial as an opportunity to increase their knowledge about Deaf and hard of hearing people, as well as increasing their confidence and competence when communicating with Deaf and hard of hearing patients.

This scoping review describes the extent and characterises existing research on Deaf awareness training in health professional programs. We found that there is significant variability in how Deaf awareness training and programs exist for health professional students as well as how the learning may be assessed and examined. Generally, health professional training does not include significant content about learning how to communicate with Deaf and hard of hearing people and few opportunities to develop Deaf and hard of hearing cultural competencies. The lack of content regarding the care of Deaf and hard of hearing people during education of all health professional students may be one of the explanations for the difficulty of interaction between professionals and the dissatisfaction Deaf and hard of hearing users of health services experience [ 55 , 56 ]. Evidence retrieved usually involved small samples, and providers were often supported by external agencies in terms of delivery of Deaf awareness training initiatives.

Several of the retrieved studies reported on one-off interventions with small participant numbers, some of which required heavy resource from either education faculties, local Deaf and hard of hearing centres or both [ 47 , 50 , 52 ]. Whilst direct involvement from Deaf and hard of hearing communities is admirable and probably the best experience for student learning, it may not be feasible for health professional programs to aspire to such learning opportunities due to high numbers of students. Providing the opportunities to a select few is not in the spirit of equity, and Deaf awareness knowledge and cultural competence surely need to be known to all undertaking a health professional program. Education providers with large student populations simply cannot over-burden local Deaf and hard of hearing communities to come on-site and provide teaching and practice opportunities, and the logistics of organising this for large cohorts are challenging, with providers aware of competing topics, and limited program time. One solution would be for the development of Deaf awareness eLearning packages that have been Deaf-led and include the development of knowledge about types of Deafness, best ways to communicate, what to avoid, as well as promoting positivity around Deaf and hard of hearing population, so that Deaf culture is not only learned about, but embraced.

In terms of approaches, it is unsurprising that Deaf awareness interventions increased student knowledge and cultural competence about working with Deaf and hard of hearing people. Collecting pre and post knowledge information would certainly demonstrate a more robust approach and supply feedback about the impact of interventions, as well as the opportunity for students to apply their Deaf awareness as evidence-informed practice [ 57 ].

A solution by some providers in terms of navigating competing timetable demands is to provide Deaf awareness as optional [ 48 ] resulting in probably the most motivated students attending, and again resulting in the student majority not having the opportunity for Deaf and hard of hearing awareness skill and knowledge development. Yet health professional comfort levels at communicating with Deaf and hard of hearing patients increase when they have more contact with Deaf and hard of hearing patients [ 58 ].

As with most skills workshops, and several of the studies in this review included a student opportunity to learn basic signed language, it is acknowledged that unless learners have the opportunity to regularly practice a skill it may soon be lost [ 58 ], so a thorough approach with regularity and informal practice time would be essential for success.

A scarcity of evidence was found from allied health professional programs regarding Deaf awareness content. This is notable in terms of audiology student programs, although anecdotally many claim to include a session on the topic. Regarding qualified audiologists, two studies examined audiologists’ current cultural competency [ 59 ] and the need for audiologists to have clinically relevant sign language [ 60 ]. There is a need for audiologists to increase their knowledge of Deaf awareness and proficiency in sign language starting during their professional training is clear, as well as their knowledge regarding how to work with sign language interpreters [ 59 ], which applies to all healthcare professionals. Similarly, others who work with patient groups, such as genetic counselling graduates [ 61 ], with over a quarter reporting no Deaf and hard of hearing awareness training and 51% reported limited training of just 1–2 hours during their initial training programs.

There may be certain professional groups who are viewed as more likely to encounter contact directly with a Deaf and hard of hearing person. For example in a study of emergency medical practitioners [ 62 ], out of 148 respondents, 109 reported having responded to an emergency call from a Deaf and hard of hearing person. In the same study, participants who attended training said it expanded their knowledge of Deaf and hard of hearing culture; and at 3 months all respondents reported the training to still be helpful and clinically relevant.

Any facilitators of Deaf awareness programs need to ensure accuracy in terms of context and relevant country/regional Sign language. Assumptions are often made, for example a study about Deaf awareness training for support staff with people with intellectual disabilities [ 63 ] talked about using signs but people are not always aware that sign for communication support differ considerably a recognised Signed language. For example, Makaton is not a recognised language but is a communication tool [ 64 ].

Health professional students themselves have noted that workshops similar to Deaf awareness would help considerably in increasing their knowledge and skills of how best to communication and work with under-served populations [ 51 ]. Despite moves to progress accessible standards in health services, we continue to know that populations continue to have poor experiences in healthcare which mostly relate to the limited knowledge and preparedness of those working in such professions.

Recommendations

Involving Deaf and hard of hearing individuals in the planning and delivery of activities at the outset will ensure content is accurate, relevant and may provide the opportunity for immediate feedback if practical exercises are included. Deaf awareness training during health professional training programs can serve as a timely introduction to the topic and ensure students thoughtfully evaluate their approach to communication and engagement with all individuals. At the very minimum all health professional programs need to provide basic Deaf awareness information that can be accessed on their student learning platforms, along with information about local Deaf communities and Sign Language training providers.

Strengths and limitations of this study

• Using the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), this study provides a detailed view of the evidence of Deaf and hard of hearing awareness content that feature in health professional student programs
• Literature from four electronic databases and registers were screened to comprehensively source and describe the literature.
• Only published peer-reviewed research articles in English were included (although initial searches for papers in other languages did take place with none located)
• Despite a systematic approach, there is a risk that further evidence may have been overlooked.

As Deaf and hard of hearing communities frequently report negative experiences in healthcare largely due to a lack of Deaf awareness knowledge in staff, it is important to understand more about the delivery of Deaf awareness programmes available to health workers. This scoping review outlined the available evidence regarding health professional programs that include Deaf awareness content aimed to increase students’ knowledge skills and Deaf cultural competencies as they move forwards in their careers. There is a lack of rigorous research in this field, although there is emerging evidence of benefits and increased Deaf awareness knowledge for student populations. All development of Deaf awareness education needs full involvement from Deaf and hard of hearing communities to ensure relevance and success. Programme regulators and providers have an important role here in reviewing program content to ensure disadvantaged communities do not remain under-served. There is potential to ensure that students emerge from health professional education with good knowledge about how to work with Deaf and hard of hearing patients.

Our review offers a starting point to educators and health and care providers to consider potential benefits to both health professional students and staff about increasing knowledge, confidence and competence about Deaf awareness, as well as modes of delivery. Further research on the acceptability of, and implementation of Deaf awareness programs on health professional students is needed. Knowledge gaps exist around the type of Deaf awareness programs, how such training might be accessed, length of course, content and device delivery. Knowing ultimately what communication approaches impact positively on Deaf people in healthcare services is the ultimate goal.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pgph.0002818.s001

S1 Text. Cinahl search.

https://doi.org/10.1371/journal.pgph.0002818.s002

Acknowledgments

The authors thank the project steering group, particularly Deaf and hard of hearing communities in Wales for their support and interest with the project.

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A scoping review protocol to map knowledge and attitudes about patient safety among students in healthcare undergraduate courses.

1. Introduction

2.1. inclusion criteria, 2.1.1. participants, 2.1.2. concept, 2.1.3. context, 2.2. types of sources, 2.3. search strategy.

• An initial limited search of PubMed and CINAHL will be undertaken to identify articles on the topic;
• The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles will be used to develop a full search strategy;
• The search strategy, including all identified keywords and index terms, will be adapted for each included information source;
• The reference lists of all included sources of evidence will be screened for additional studies.

2.4. Study Selection

2.5. data extraction, 2.6. data analysis and presentation, 3. discussion, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, public involvement statement, guidelines and standards statement, use of artificial intelligence, conflicts of interest.

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Share and Cite

Valença, F.R.T.; dos Santos Neto, M.F.; Sacardo, Y.; Oliani, D.C.M.V.; Santos, E.R.d.; Brienze, V.M.S.; Lima, A.R.d.A.; André, J.C.; Paschoal, V.D.A. A Scoping Review Protocol to Map Knowledge and Attitudes about Patient Safety among Students in Healthcare Undergraduate Courses. Nurs. Rep. 2024 , 14 , 2014-2019. https://doi.org/10.3390/nursrep14030150

Valença FRT, dos Santos Neto MF, Sacardo Y, Oliani DCMV, Santos ERd, Brienze VMS, Lima ARdA, André JC, Paschoal VDA. A Scoping Review Protocol to Map Knowledge and Attitudes about Patient Safety among Students in Healthcare Undergraduate Courses. Nursing Reports . 2024; 14(3):2014-2019. https://doi.org/10.3390/nursrep14030150

Valença, Fabricio Renato Teixeira, Martins Fideles dos Santos Neto, Yuri Sacardo, Denise Cristina Móz Vaz Oliani, Emerson Roberto dos Santos, Vânia Maria Sabadoto Brienze, Alba Regina de Abreu Lima, Júlio César André, and Vania Del Arco Paschoal. 2024. "A Scoping Review Protocol to Map Knowledge and Attitudes about Patient Safety among Students in Healthcare Undergraduate Courses" Nursing Reports 14, no. 3: 2014-2019. https://doi.org/10.3390/nursrep14030150

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Evidence-Based Practice Quality Improvement Critical Appraisal Tool

Waldrop, Julee Briscoe DNP, RN, FNP-BC, PNP-BC, CNE, EBP-C, FAANP, FAAN; Dunlap, Jayne Jennings DNP, RN, FNP-BC CNE, EBP-C; Reynolds, Staci S. PhD, RN, ACNS-BC, CPHQ, FAAN

Author Affiliations: Duke University School of Nursing, Durham, North Carolina (Drs Waldrop and Reynolds), and Texas Womans University, Houston, Texas (Dr Dunlap).

Correspondence: Julee Briscoe Waldrop, DNP, RN, FNP-BC, PNP-BC, CNE, EBP-C, FAANP, FAAN, Duke University School of Nursing, 307 Trent Dr. Durham, NC 27701 ( [email protected] ).

Staci S. Reynolds is the editor-in-chief of the Journal of Nursing Care Quality. As a co-author of this paper, she did not participate in editorial decision-making, which was handled by another editor.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website ( www.jncqjournal.com ).

Accepted for publication: May 10, 2024

Early Access: July 22, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

Optimal quality improvement in health care is based on research and other types of evidence. Critical appraisal of evidence is a fundamental component of evidence-based practice (EBP) and is also needed to evaluate the quality of quality improvement (QI) projects.

Problem: 

Currently available EBP or QI critical appraisal tools can be challenging for students learning the critical appraisal process and for practicing clinicians who desire access to a standardized EBPQI approach to inform health care decision-making. The currently available tools are incomplete, too brief, or too complicated for ease of use in education and practice.

Approach: 

This article introduces the first combined EBP and QI (EBPQI) critical appraisal tool, which is aligned with the new EBPQI mountain model.

Conclusion: 

This newly developed appraisal tool may be used in appraising evidence for an EBPQI initiative and to appraise the quality of disseminated EBPQI.

Evidence that informs health care practices is derived from research studies (with systematic reviews and meta-analyses often considered the highest level of evidence) and other types of evidence (eg, clinical practice guidelines, consensus statements, professional organizations’ recommendations). Evidence-based practice (EBP) and quality improvement (QI) reports are also increasingly being used to inform practice. Critical appraisal of evidence is a foundational component of EBP. Tools for critically appraising research studies are plentiful (Joanna Briggs Institute Global, Johns Hopkins University, Critical Appraisal Skills Programme Checklists), and their use is necessary for evidence critical appraisal and synthesis. However, critical appraisal guides for EBP and QI are few. 1 , 2

EBP requires a process of evaluating external research evidence for consideration with patient/family preferences and clinical expertise to inform care decisions based on the most current, highest quality, relevant evidence from research and other sources (eg, clinical practice guidelines, professional organization recommendations). QI occurs on an institutional level and requires relevant data from the organization that represents the outcome of the practice or process change over time. Therefore, with the complexity that is the reality of current health care, the need for EBP and QI (EBPQI) congruence is increasing. 3 , 4

There is an imminent need to develop a critical appraisal tool to assess the quality of EBPQI initiatives that is accessible across education and health care settings. This article introduces an EBPQI critical appraisal tool developed from a review of currently available EBP and QI appraisal tools.

Critically appraising EBP and QI

Lee et al 1 proposed criteria to appraise the methodological quality, as the Evidence-based Practice Process Quality Assessment (EPQA) guide for reporting and evaluating EBP projects. Using a Delphi method with 8 to 12 EBP experts, a guide of 32 criteria was developed. The guide was modified from the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (2009) 5 guide (since updated in 2020) 6 and is heavily focused on the search process and its results. The guide is very similar to the PRISMA guide in the methods section, which includes the title, abstract, and article screening, data collection process, data items, operational definitions, the use of a quality and risk of bias assessments and summary measures, and use of a PRISMA flow chart (or a similar flow diagram). However, the implementation section is weak, including only the 2 items of translation strategies and stakeholders, which outlines only a partial implementation plan. Outcome criteria simply asks if a plan was implemented and an evaluation of the effectiveness took place. The tool falls short once the evidence synthesis is complete.

Hempel et al 2 developed and psychometrically tested a critical appraisal instrument, the QI Minimum Quality Criteria Set (QI-MQCS). Sound methodology was used for the tool development, and many resources were consulted. A strength was the application of the critical appraisal criteria to published QI projects at the time of development. The tool includes 16 content domains which are evaluated as being met, partially met, or not met, and includes a user guide. The user guide for this tool is 17 single-spaced pages and, although helpful, makes completing this tool a lengthy process. Since the tool was disseminated, there have been only 2 publications that used the tool to review the quality of QI reports, with one specific to Ireland. 7 , 8

The Johns Hopkins University (JHU) critical appraisal tool for non-research evidence has sections for clinical practice guidelines, literature reviews, expert opinion, case reports, community standard, and another category labeled as organizational expeience. 9 Within the organizational experience category are QI, financial evaluation, and program evaluation. This section includes 6 yes, no, or not applicable criteria and spaces for describing the setting and findings that help answer the EBP question. It does include an assessment of quality, graded as A = high quality, B = good quality, and C = low quality or major flaws. Appraisers must be well versed in QI, program, or financial evaluation to critically appraise the 6 broad criteria. If not, it is highly likely the quality of the critical appraisal will vary. To use the JHU EBP tools, one must register on their website, although there is no associated cost.

The Helene Fuld Center for Evidence Based Practice Rapid Critical Appraisal of a Quality Improvement Project tool (2020) includes sections to critique the project description, purpose, QI method, participants, setting, and data collection. 10 There are also sections on validity, reliability, and applicability/transferability, for a total of 21 items. All questions are answered with yes, no, or unknown. The last section asks the reviewer to decide the strength of the QI initiative. Strength is defined as the level of evidence plus the quality of evidence. Again, the subjective nature of this assessment will vary with the experience of the appraiser. 10

Strengths of this tool are Criterion 10 and 17. Criterion 10 addresses an important neglected aspect of QI, the use of external evidence and the expected use of internal evidence. Another strength of the evidence section is that it includes the level of evidence; choices are levels I, II, III, IV, V, VI, and VII. Quality of evidence is listed as High, Medium, or Low. Appraisers using this tool must be familiar with the level of evidence pyramid used by the Helene Fuld Center for EBP and how to determine the quality of QI evidence ranking to make a critical appraisal of a QI project. 11 Criterion 17 addresses the clinical significance or meaningful aspect of QI, which is arguably the most important. 10

Contrary to Criterion 17, a weakness is Criterion 15 because it includes statistical analyses, which are more appropriate for research. 12 This may bias the appraiser toward a research model, perpetuating the problem by asking about pre/post-analysis and between-group comparisons with a specific assessment of statistical significance or effect size. This tool is proprietary, and permission must be sought and granted, with payment rendered to use it. As such, nursing students and clinicians may not be inclined to use this tool.

Dean and colleagues 13 built on the foundation of the prior MEDSURG NURSING continuous quality improvement author guidelines (2019, updated in 2022) to develop a dissemination guide or reporting guidelines for EBP. 14 The purpose of their work was to provide a guide for submitting manuscripts for publication and also for those reviewing EBP work in practice. The document is based on the 7 steps of EBP. 11 These steps are foundational to all EBP initiatives and include (1) develop a spirit of inquiry, (2) ask a clinical question in population, intervention, comparison, outcome, time format, (3) search for the best evidence, (4) critically appraise the evidence, (5) integrate evidence with patient and family preferences/values, (6) evaluate the outcomes of the practice change based on evidence, and (7) disseminate EBP project results. However, in this guideline, the majority of the focus is on the evidence-gathering process, culminating in practice recommendations with the integration of the evidence as a plan for or steps to include in implementation and evaluation. The evaluation component focuses on quasi-experimental designs with pre-post data analysis, and no mention is made of QI processes or data analyses (such as run charts or statistical process control [SPC] charts).

SQUIRE 2.0 is a reporting guide for QI work. 15 It was first developed in 2008 and its second edition was published in 2015 and includes 18 components. The area that is lacking in this guide is in the “available knowledge section,” as the instructions state to provide a “summary of what is currently known about the problem.” Without reporting on how the evidence was identified (ie, the search process and critical appraisal of the evidence) there is a large potential for bias in this summary.

SQUIRE 2.0 15 and Lee 1 reference ethical considerations or institutional review board (IRB) approval. All EBPQI initiatives and practice changes should follow ethical principles. However, including this in the tool may be considered a critical requirement and can confuse the clinician, as practice change should not require IRB approval to implement. At the very most, if an organization requires submission of the practice change to an IRB, there should be a pathway for the determination of non-human subjects research.

Although some tools have been psychometrically tested and others have not, all of them have strengths and weaknesses. Several criteria related to methods and evaluation have underlying research language that obfuscates the difference between a research study and EBPQI. Research language is inappropriate for EBPQI initiatives whose purpose is to put strongly supported evidence (from research studies) into practice, not to re-prove high-quality research results in a local setting. One of the biggest stumbling blocks to implementing effective EBPQI initiatives is the incorrect application of research methods to practice change. Similarly, EBPQI initiatives should not have control or comparator groups, but rather baseline data on the outcome metrics prior to the practice change as a way to determine if the change improved them. 16 , 17 Given the weaknesses of currently available tools, and the lack of a standard EBPQI critical appraisal tool, the purpose of this article is to describe the development of an EBPQI critical appraisal tool.

The EBPQI critical appraisal tool has important educational and practice implications. Educators have voiced challenges with teaching critical appraisal of evidence to students at entry and advanced nursing levels. Specifically, faculty frequently struggle to garner access to tools for appraising other types of evidence outside of research for student use, as some are proprietary. Positioned upstream to the health care system, educators must be prepared to guide students in critically appraising research and other evidence before entering the health care arena where patient care occurs.

Faculty development is also needed to prepare educators to optimally teach research, EBP, and QI and the differences and interrelatedness of these processes. 18 The Mountain Model maps to all 10 American Association of Colleges of Nursing New Essentials domains and offers a meaningful approach to faculty development and project oversight at prelicensure and advanced levels. 19 , 20

While not generalizable, findings from EBPQI initiatives may be transferable to other institutions, which may help close costly evidence-to-practice gaps. In a survey of over 2300 nurses, Melnyk and colleagues 21 found that nurses felt they were not competent in critical appraisal of evidence/published research. The newly developed EBPQI critical appraisal tool can provide needed guidance to nurses who may be unfamiliar with or unconfident in critically appraising evidence.

Indeed, many articles that directly relate to a nurse’s daily practice are EBPQI rather than formal research; as such, there is a need for a strong critical appraisal tool for this type of evidence. Critical appraisal tools and checklists are meant to assist nurses in identifying the presence of key components of a research study, or as in this case an EBPQI initiative, which if absent could jeopardize the success of the initiative. This is different from surveys or questionnaires that measure a concept or construct; therefore, expert and face validity are the primary concerns. Having access to a free, easy-to-use checklist-style tool may allow students and nurses the confidence and ability to formally appraise EBPQI, which can, in turn, help their own EBPQI initiatives to be completed with more rigor.

CONCLUSIONS

In an often fragmented and overburdened health care system, other types of evidence, in addition to research, hold promise to improve outcomes. While not generalizable to other settings, well-designed EBPQI initiatives may produce valuable findings that can be adapted appropriately to other settings and populations. The tool introduced in this article was designed to be accessible to health care teams and nursing students. Using a comprehensive critical appraisal tool to evaluate EBPQI initiatives provides greater confidence that the resulting recommendations are credible.

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Improving health outcomes through patient education and partnerships with patients

“Each patient carries his own doctor inside him.” —Norman Cousins, Anatomy of an Illness

To improve health care outcomes, physicians must spend more time with patients. The teaching physician's interaction with the patient must be enthusiastic, motivated, and responsive to the individual patient's needs. For individual members of our society to realize the benefits of physician health education, there is a need for a robust, hearty engagement between patients and physicians.

Interventions to improve self-care have led to documented improvements in self-efficacy. Self-efficacy is defined as one's belief in one's ability to succeed in specific situations, or accomplish certain tasks. One's sense of self-efficacy plays a major role in how one approaches goals, tasks, and challenges regarding one's health. Clinical benefits have been seen in trials of lifestyle intervention within a wide range of conditions such as diabetes, coronary heart disease, heart failure, and rheumatoid arthritis ( 1 ).

In the context of escalating health care costs and shocking future cost projections, the potential for improved health outcomes through patient education and self-management programs is immense. In the early 1990s, it was estimated that 50% of the annual mortality toll in the US was premature. Tobacco use, poor diet, a lack of physical exercise, alcohol consumption, exposure to microbial agents, use of firearms, risky sexual behavior, motor vehicle accidents, and illicit drug use were the culprits causing premature death. Approximately 80% of premature deaths were due to tobacco use, dietary patterns, and a low physical activity level ( 1 ). Clearly, these are all behaviors we could modify to reverse the trends. For those individuals who do not smoke, eat healthy food, and participate in regular exercise programs, the hazard ratio for diabetes, myocardial infarction, stroke or cancer was 0.22 ( 2 ).

There is a belief in the medical community that physical activity and diet can reduce the risk of developing coronary artery disease, hypertension, diabetes, and the metabolic syndrome. A comprehensive systematic review reinforced this notion by revealing that there is irrefutable, convincing evidence for the benefit of exercise in improving clinical outcomes in metabolic disorders, coronary heart disease, and heart failure ( 3 ).

Physicians must promote patient education and engagement through improvement in patients' health literacy. Health literacy is defined as the capacity to seek, understand, and act on health information ( 4 ). The presumption has been that low health literacy means that physician communication is poorly understood, leading to incomplete self-health management and responsibility and incomplete health care utilization ( 5 ). It is the responsibility of physicians to proactively enable patients to have more accessible interactions and situations that promote health and well-being. Health literacy is the primary responsibility of physicians, given that it is physicians who determine the parameters of the health interaction, including physical setting, available time, communication style, content, modes of information provided, and concepts of sound health care decision crafting and acquiescence. There are communication methodologies and behaviors that physicians can implement to ameliorate the potential risks associated with limited patient health literacy, including avoiding medical jargon, engaging in patient questions, explaining unfamiliar forms, and using “teach back” as a method to ensure understanding ( 6 ).

Critical to any educational process is time. The development of patient health literacy is crucial to our proven health prevention measures of exercise and diet. Patients must have a deep understanding of the impact healthy interventions can have on their present and long-term health. Physicians will need to spend time and energy educating patients to see behavioral change that results in improved health outcomes and reduced morbidity and mortality due to preventable chronic diseases such as diabetes, obesity, and coronary and cerebrovascular disease. As physicians, we will know when we have reached the threshold of being an excellent teacher by observing responsible patients.

The partnership between a physician and patient requires dual responsibility. Physicians have a duty to inform patients how to achieve health and wellness, and patients have a responsibility to act on the information provided in their best health interest. Medical informed consent is essential to the physician's ability to diagnose and treat patients, as well as the patient's right to accept or reject clinical evaluation, treatment, or both.

Medical informed consent should be an exchange of ideas that buttresses the patient-physician relationship. The consent process should be the foundation of the fiduciary relationship between a patient and a physician. Physicians must recognize that informed medical choice is an educational process and has the potential to affect the patient-physician alliance to their mutual benefit. Physicians must give patients equality in the covenant by educating them to make informed choices. Patients must use the educational process to make rational health choices.

When physicians and patients take medical informed consent seriously, the patient-physician relationship becomes a true partnership with shared decision-making authority and responsibility for outcomes. Physicians need to understand informed medical consent from an ethical foundation, as codified by statutory law in many states, and from a generalized common-law perspective requiring medical practice consistent with the standard of care. It is fundamental to the patient-physician relationship that each partner understands and accepts the degree of autonomy the patient desires in the decision-making process ( 7 ).