View
232
Download
0
Category
Preview:
Citation preview
16
Review
Patient education among nurses: bringing evidence into clinical
applicability in Iran
Hossein Karimi Moonaghi1
Amir Emami Zeydi2
Amir Mirhaghi3
1 RN Ph.D. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email: karimih@mums.ac.ir2 RN, PhD Candidate. Mashhad University of Medical Sciences, Mashhad, Iran. email: EmamiZA911@mums.ac.ir3 RN, PhD. Professor, Mashhad University of Medical Sciences, Mashhad, Iran. email: mirhaghia@mums.ac.irConflicts of interests: none.Received on: June 15, 2015.Approved on: December 4, 2015.How to cite this article: Karimi Moonaghi H, Emami Zeydi A, Mirhaghi A. Patient education among nurses: Bringing evidence into clinical applicability in Iran. Invest Educ Enferm. 2016; 34(1): 137-151.DOI: 10.17533/udea.iee.v34n1a16
Patient Education among nurses: bringing evidence into clinical applicability in Iran
Objective. The aim of this study was to present a comprehensive review of the literatures describing barriers and facilitators of patient education (PE) perceived by Iranian nurses in order to explain clinical applicability of patient education. Methods. Review of the literature was undertaken using the international databases including PubMed/Medline, Scopus, ScienceDirect, as well as Google Scholar. Also, Persian electronic databases such as Magiran, SID and IranMedex were searched. Electronic databases were searched up from conception to September 2014 using search terms: “patient education”, “ patients education”, “patient teaching”, “patient training”, “nurse”, “ nurses”, “ nursing”, “ and “Iran”. Only studies were included that were related to barriers and facilitators of PE among Iranian nurses. Results. Twenty-seven studies were included. The main influential barriers were categorized into three major areas: 1) Nurse-related factors: nursing shortage 2) Administration-related factors: unsupportive organizational culture, and
3) Patient-related factors: low compliance. The most perceived facilitators were recognized as “increasing, selecting and training special nurses for providing PE” and “providing PE courses for nurses and appropriate facilities for PE”. Conclusion. Iranian nurses encounter barriers in PE, and the most frequently encountered barriers were related to administration factors. These findings have implications for administrators and managers in health settings. In order to promote PE among nurses, administrators should create a supportive environment and use effective strategies to smooth the progress of PE by nurses in their practice in order to ensure optimal outcomes for patients.
Key words: patient education as topic; health services; nurses; Iran.
La educación al paciente entre las enfermeras: brindando evidencia en la
aplicabilidad clínica en Irán
Objetivo. Identificar las barreras y facilitadores de la Educación del Paciente (EP) percibida por las
138 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
enfermeras iraníes con el fin de explicar la aplicabilidad clínica de la educación al paciente. Métodos. Revisión de la literatura que se llevó a cabo utilizando las bases de datos internacionales PubMed-Medline, Scopus, ScienceDirect y Google Scholar. Además, se realizaron búsquedas en las bases de datos electrónicas persas Magiran, SID e IranMedex. Se realizaron búsquedas desde la creación de las bases de datos hasta septiembre de 2014 usando los términos de búsqueda: “educación del paciente”, “educación de pacientes”, “enseñanza del paciente”, “entrenamiento del paciente”, “enfermera”, “enfermeras”, e “Irán”. Solo se analizaron los estudios relacionados con las barreras y facilitadores de EP entre enfermeras iraníes. Resultados. Se incluyeron 27 estudios. Las principales barreras se clasificaron en tres grandes áreas: 1) Factores relacionados con la enfermería: escasez de este recurso humano, 2) Factores relacionados con la administración: inapropiada cultura organizacional y 3) Factores relacionados el paciente: bajo cumplimiento. Los facilitadores más percibidos se reconocieron como “el aumento, la selección y formación especial de las enfermeras para proporcionar EP” y “disponibilidad de cursos de EP para las enfermeras y la disponibilidad de instalaciones adecuadas para brindar el EP”. Conclusión. Las enfermeras iraníes encuentran barreras en la EP, siendo las más frecuentes las relacionadas con factores de la gestión de los recursos. Estos resultados tienen implicaciones para los administradores y directivos de las instituciones de salud, pues para promover que las enfermeras en su práctica brinden la EP, se debe crear un ambiente de apoyo y utilizar estrategias eficaces con el fin de garantizar resultados óptimos en los pacientes.
Palabras clave: educación del paciente como asunto; servicios de salud; enfermeros; Iran.
A educação ao paciente entre a enfermeiras: brindando evidência na
aplicabilidade clínica no Irã
Objetivo. Identificar as barreiras e facilitadores da educação do paciente (EP) percebida pelas enfermeiras iranianas com o fim de explicar a aplicabilidade clínica da educação ao paciente. Métodos. Revisão da literatura que se levou a cabo utilizando as bases de dados internacionais PubMed-Medline, Scopus, ScienceDirect e Google Scholar. Ademais, se realizaram buscas nas bases de dados electrónicas persas Magiran, SID e IranMedex. Se realizaram buscas desde a criação das bases de dados até setembro de 2014 usando os termos de busca: “educação do paciente”, “educação de pacientes”, “ensinamento do paciente”, “treinamento do paciente”, “enfermeira”, “enfermeiras”, e “Irã”. Só se analisaram os estudos relacionados com as barreiras e facilitadores de EP entre enfermeiras iranianas. Resultados. Se incluíram 27 estudos. As principais barreiras foram classificadas em três grandes áreas: 1) Fatores relacionados com a enfermagem: escassez deste recurso humano, 2) Fatores relacionados com a administração: inapropriada cultura organizacional y 3) Fatores relacionados o paciente: baixo cumprimento. Os facilitadores mais percebidos foram reconhecidos como “o aumento, a seleção e formação especial das enfermeiras para proporcionar EP” e “disponibilidade de cursos de EP para as enfermeiras e a disponibilidade de instalações adequadas brindar o EP”. Conclusão. As enfermeiras iranianas encontram barreiras na EP, sendo as mais frequentes as relacionadas com fatores da gestão dos recursos. Estes resultados têm implicações para os administradores e diretivos das instituições de saúde, pois para promover que as enfermeiras em sua prática brindem a EP, se deve criar um ambiente de apoio e utilizar estratégias eficazes com o fim de garantir resultados ótimos nos pacientes.
Palavras chave: educação de pacientes como assunto; serviços de saúde; enfermeiras e enfermeiros; Iran.
IntroductionPatient education (PE) is a fundamental aspect of patient care and increasingly recognized as an essential function and one of the professional standards in nursing practice.1 It is considered as a dynamic and continuous process including
formal and informal interactive activities performed to improve patients’ knowledge and behaviors in ways to achieve better health care outcomes.2,3 There is a growing body of research evidence that illustrates the effectiveness of PE on enhancing patients’ levels of empowerment,
139 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
self-care behaviors, compliance with health care recommendations, satisfaction in health care settings, and quality of their life, and reducing their levels of anxiety.3,4
Nurses are the largest group of the health care providers. They are at the forefront of patient care, and spend the most time with the patients and their family members. This extensive contact provides excellent opportunities for providing patient and family education.2 In addition, providing PE is both a legal and ethical responsibility of nurses.5,6 For all these reasons, PE is considered to be an integral part of high quality nursing care.3 Despite increasing availability of research findings and broad consensus on the importance of PE, there are many barriers to nurses’ capacity to provide effective PE.2 PE needs strict adherence to educational principles,7 so all variables that have an impact on teaching-learning process play an important role. Patients usually get involved in some type of limiting conditions that was imposed by their disease, aging and etc. Conditions such as functional and cognitive limitations, misconceptions, low motivation and self-esteem should be carefully addressed.8 Other factors such as environment, organization, interdisciplinary cooperation, collegial teamwork that are related to health care context also have unique role.5 However principles of education have been well-defined and widely recognized, environmental factors are unique in that significant differences exist among healthcare systems worldwide. Therefore it`s necessary to investigate contextual factors effects on PE. Some studies even called for special attention to changing the environment in which patients care for themselves.9 It has been clearly demonstrated that contextual factors as a glass ceiling barrier could play a big role in PE, so it makes sense to investigate contextual factors in different countries in order to reveal the extent of potential discrepancy.
In Iran, nursing is the largest healthcare profession which is directly responsible for the care of their patients and has a central role in PE.10 Nevertheless; PE is a growing concern for the Iranian healthcare system as well. The results
of conducted studies about the topic in Iran have been demonstrated that the implementation of PE in nursing practice is often an undervalued intervention, thus poor education is one of the most common source of patient’s complaints in the health-care sector.3,6 A study with aim to evaluate Iranian nurses’ perceptions about PE showed that the majority of nurses believed that one of the major and important parts of their responsibility in caring of patients in daily clinical practice is PE. Nevertheless, they give a lower priority to it as compared to other nursing tasks such as medication administration, physical patient care, nursing care planning and documentation.8 Because contextual and country-specific factors may influence the implementation of PE, it is important to study facilitators and barriers to PE specific to the Iranian context.6,11,12 So the aim of the current study was to presents a comprehensive review of the literatures, exploring barriers and facilitators of PE among Iranian nurses, in order to identify strategies to promote enhanced PE within the Iranian healthcare system context.
MethodsA systematic search of the relevant literature were performed within international databases including PubMed/Medline, Scopus, ScienceDirect as well as Google Scholar search engine using the following search terms or their combinations: “patient education”, “ patients education”, “patient teaching”, “patient training”, “nurse”, “ nurses”, “ nursing”, “ and “Iran”. These keywords equivalents in Farsi were searched in Persian electronic databases such as Iranian Journal Database (Magiran), Scientific Information Databases (SID) and IranMedex (Iranian Biomedical Journal Database). In addition, a hand search of article references was done to ensure completeness of the search. The search was limited to the English and Persian languages. Applying no time limit, all articles having the selected keywords in the title, abstract and text, including quantitative as well as qualitative approaches in Iranian context, from conception up to September 2014 were included and evaluated. The articles had to be focused on
140 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
the barriers or facilitators of PE among Iranian nurses as inclusion criteria. We did not actively search the gray literature to find studies not in the peer-reviewed literature and excluded studies published exclusively in abstract form (e.g., conference proceedings), because they are not typically peer reviewed, and only partially report results which may change substantially when fully published.
The search strategy generated 4 000 titles and abstracts. After initial screening and evaluation by two researchers independently (HKM and AEZ), 3 933 articles were rejected and 67 articles were identified as potentially eligible for the review. These articles were retrieved for full text review. Removing duplicates and using secondary screening resulted in 26 articles to be included for the review. Also, a manual search of article references added a further one paper. In total, 27 peer-reviewed articles were eligible for final inclusion (Figure 1). Two authors independently extracted data from the studies including author and year, objective, method and data collection, sample and setting and key findings. Data were summarized into tables and compared to reveal organizing categories. Any disagreements were discussed and resolved by consensus. Extracted data were also coded and organized in order to facilitate analysis and weight categories. Coding process was employed using MaxQDA 10. This review included 27 studies which, including 20 that used quantitative designs, six that used qualitative designs, and one that used a mixed method design. All articles included in this review had been published between 2002 and 2014 and were published in peer-reviewed journals. Seven of the studies were conducted at the Tehran University of Medical Sciences affiliated hospitals. Sixty-two per cent (17 out of 27) of PE studies has only focused on barriers while 10 studies have reported both facilitators and barriers regarding PE simultaneously. Seventy-four per cent (20 out of 27) of PE studies have been designed cross-sectional descriptive method and other studies were used qualitative methods including content
analysis (18%), grounded theory and mixed method. Researcher-generated questionnaire has been used by all quantitative research that they were content validated.
Most studies have used convenience or stratified sampling. Some of them included only participants who had at least two years work experience. Eighty per cent (22 out of 27) of studies have collected only nurses` viewpoints and only five studies have included in other participants such as physicians, patients and patients` family members. Ninety-nine per cent of total sample were nurses (4281 out of 4340). All studies have collected their data in hospital. Thirty per cent of studies were originated from capital city of Tehran as most common place and only three cities have involved in twice. Figure 1 includes a summary of the articles that were included in this review.
ResultsPerceived barriers to PE The main barriers reported in the most papers can be categorized in three overall areas: 1) Nurse-related factors 2) Administration-related factors and 3) Patient-related factors. Overall, nurses have placed greater emphasis on nurse and administration related factors and less on patient-related factors.
Nurse-related factors. The most reported barrier in this area was “nursing shortage, excessive workload and inadequate time”. The other barrier was “lack of knowledge among nurses about PE” including “lack of awareness of nurses about educational methods and teaching/learning principles”, “lack of awareness and appropriate knowledge of nurses regarding patient’s educational needs”, “insufficient attention of nurses to the educational, cultural and habitual needs of patients and their families”, “negative attitude to PE”, “believing that patient teaching is not nurses responsibility”, “lack of knowledge about illness” and “ nurses’ lack of communication skills”.
141 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
Figu
re 1
. Lit
erat
ure
sear
ch a
nd r
etri
eval
flow
dia
gra
m
142 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
Administration-related factors. The most barriers that perceived by nurses in this area were “inappropriate organizational culture” and “inappropriate place and facilities for PE”. Nurses believed that there is not a supportive culture among managers as well as hospitals, so there is no effective management and collaboration either. They have reported “inadequate support from the managers”, , “lack of appropriate educational facilities in hospital”, “lack of specialized nurse for PE”, “no division of labor”, “lack of financial incentives for nurses”, “poor cultural adaptation for educator and patients in terms of sex”, “lack of coordination by other members of the healthcare professionals with nurses” and “lack of evaluating PE activities”.
Patient-related factors. The main patient-related barrier perceived by nurses in PE was patients have low compliance and readiness to receive PE. This barrier includes “Patient’s low literacy or illiteracy”, “lack of awareness of patients about the educational responsibility of nurses”, “knowledge deficit of patient about their rights”, “lack of patients’ interest to change their behavior”, “inconsistencies in the culture, social and mental status of patients and their families”, and “unwillingness to adhering to comments” were the most perceived barriers in this area.
Perceived facilitators to PE The most perceived facilitators of PE that could be considered as potential strategies to promote PE were “selecting and training special nurses for providing PE” and “increasing nursing staff in each working shift”, “holding courses and seminars on teaching and learning strategies” and “providing appropriate place and facilities for PE”, “considering special privilege for PE in annual evaluation of nurses”, “development of more inclusive information guidance sheets to assist nurses in teaching specific topics to patients” and “developing PE protocols for each ward”, “enhancing patient’s interest and participation in education”, “increasing nurses interested to identifying the learning needs of the patients”, “registration of PE process in their medical record”,
“applying feedbacks for educational reform by nurses”, “revision in supervision and feedback system”, and “establishing a good relationship between patients, nurses and physicians”.
DiscussionThere is a growing body of research literature that focuses on the barriers to and facilitators of PE perceived by nurses in Iran. The result of the present review showed that the inadequate time and nursing staff, heavy workload, inadequate support of managers, inappropriate organizational culture, and lack of appropriate educational facilities in hospital were reported as an administration related barriers to PE by Iranian nurses. The findings were supported by other studies have been conducted in other countries such as United States, China and Colombia that pointed out the nurses’ heavy workload as a major barrier to PE.38-41 Also the result of the study by Barret et al. referred to additional time to teach patients, more educational materials, peers feedback regarding teaching effectiveness, and sufficient medical information as effective factors for PE based on nurses’ perspective.42 Nursing shortage is a serious issue in many Asian countries such as Iran; and nurses are practicing under an overwhelming workload.43,44 This issue results in less nurses being available for patients, and the resulting time restriction dissuade the nurses from providing the education for their patients.45 In addition to the unbalanced nurse-patient ratio due to nurse shortage and large number of hospitalized patients, nurses are expected to do nonprofessional tasks such as coordinating, transporting patients and performing ancillary services which leading to increased workload. This excessive workload definitely affects the nurses’ decision to allocate enough time to various tasks such as communicating with patients and their education.46,47 The results of a study by Park et al. has been shown that although nurses consider PE as an essential part of their care planning, in the face of work limitations, they are not able to provide their education as needed. Also, patient education is basically informal and reactional. Therefore, this activity can be considered as a low priority when nurses faced with time limitations.2
143 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
Tabl
e 1.
Sum
mar
y o
f th
e b
asic
fea
ture
s o
f th
e re
sear
ch a
rtic
les
that
wer
e in
clud
ed in
the
rev
iew
Aut
hor
&
Year
Obj
ectiv
eM
etho
d an
d
data
col
lect
ion
Sam
ple
& s
ettin
gK
ey F
indi
ngs
Bor
hani
13
20
02
To
eval
uate
nu
rses
an
d nu
rse-
man
ager
s’
opin
ion
tow
ard
the
impo
rtan
ce o
f ba
rrie
rs o
f PE.
Des
crip
tive
cros
s-se
ctio
nal
stud
y w
as
carr
ied
out.
Dat
a w
ere
colle
cted
by
a re
sear
cher
-mad
e qu
estio
n-na
ire.
126 n
urse
s an
d 50 n
urse
man
ag-
ers
who
wor
ked
in s
ix h
ospi
tals
af
filia
ted
to K
erm
an U
nive
rsity
of
Med
ical
Sc
ienc
es
wer
e se
lect
ed
thro
ugh
cens
us m
etho
d.
The
mos
t im
port
ant b
arrie
rs to
PE
wer
e: “
lack
of a
p-pr
opria
te e
duca
tiona
l fac
ilitie
s in
hos
pita
l”,
“lac
k of
aw
aren
ess
of n
urse
s ab
out
educ
atio
nal
met
hods
”,
“lac
k of
aw
aren
ess
of n
urse
s re
gard
ing
patie
nts’
ed
ucat
iona
l nee
ds”
and
“lac
k of
bel
ief a
bout
edu
ca-
tiona
l rol
e of
nur
ses”
. G
ouda
rzi
et a
l.14
20
04
Eval
uatio
n of
th
e ba
rrie
rs
and
faci
litat
ors
of P
E fro
m
the
view
poin
ts o
f nu
rses
in
hosp
itals
of
Tehr
an U
nive
r-si
ty o
f Med
ical
Sci
ence
s.
Des
crip
tive
cros
s-se
ctio
nal
stud
y w
as c
arrie
d ou
t. D
ata
wer
e co
llect
ed
by
Hon
an
ques
tionn
aire
.15
317 n
urse
s w
orki
ng in
hos
pita
ls o
f Te
hran
Uni
vers
ity o
f M
edic
al S
ci-
ence
s w
ere
sele
cted
usi
ng s
trat
i-fie
d ra
ndom
sam
plin
g.
Shor
tage
of
nurs
es,
lack
of
prop
er p
lace
, tim
e an
d pa
tient
mot
ivat
ion
for
rece
ivin
g ed
ucat
ion,
nur
ses
and
nurs
e ad
min
istr
ator
s’ i
natt
entio
n to
PE
and
nega
tive
attit
ude
of d
octo
rs t
owar
d P
E by
nur
ses
wer
e m
ost
barr
iers
to
PE.
Mar
dani
an
Deh
kord
i et
al.1
1
20
05
Expl
orin
g th
e ba
rrie
rs a
nd
faci
litat
ors
of P
E fro
m t
he
view
poin
ts o
f nur
ses
in h
os-
pita
ls o
f Esf
ahan
Uni
vers
ity
of M
edic
al S
cien
ces.
Cro
ss-s
ectio
nal
stud
y. U
s-in
g a
rese
arch
er-g
ener
ated
qu
estio
nnai
re.
259
clin
ical
nur
ses
and
head
nur
s-es
at
hosp
itals
affi
liate
d to
Esf
a-ha
n U
nive
rsity
of M
edic
al S
cien
ces
wer
e se
lect
ed t
hrou
gh a
str
atifi
ed
sam
plin
g m
etho
d.
Top
thre
e ba
rrie
rs t
o P
E w
ere
insu
ffici
ent
nurs
-in
g st
aff,
inad
equa
te t
ime
on t
he j
ob a
nd l
ack
of
educ
atio
nal
faci
litie
s. T
he m
ost
thre
e im
port
ant
faci
litat
ors
wer
e al
loca
tion
of o
ne t
o tw
o nu
rses
for
PE,
pro
vidi
ng m
ore
time
for
nurs
es to
do
it an
d de
-ve
lopm
ent
of m
ore
incl
usiv
e in
form
atio
n gu
idan
ce
shee
ts t
o as
sist
the
m in
tea
chin
g sp
ecifi
c to
pics
to
patie
nts.
Hes
hmat
i N
abav
i et
al.1
6
20
06
Iden
tifyi
ng
adm
inis
trat
ive
barr
iers
to
PE
and
thei
r ra
nkin
g from
the
vie
wpo
int
of n
urse
s.
Des
crip
tive
stud
y.
Usi
ng
a re
sear
cher
-gen
erat
ed
ques
tionn
aire
.
65 n
urse
s an
d nu
rse
man
ager
s at
a
one
hosp
ital
whi
ch a
ffilia
ted
to
the
Tehr
an U
nive
rsity
of
Med
ical
Sc
ienc
es s
elec
ted
thro
ugh
prop
or-
tiona
l sam
plin
g.
The
mos
t im
port
ant
barr
iers
to
PE
wer
e: p
atie
nt’s
lo
w l
itera
cy l
evel
s or
illi
tera
cy,
inad
equa
te t
ime
for
nurs
es,
inad
equa
te e
duca
tiona
l fa
cilit
ies,
and
lac
k of
fina
ncia
l inc
entiv
es fo
r nu
rses
.
Hek
mat
-po
u et
al
.17
20
07
Eval
uatin
g pa
tient
edu
ca-
tion
proc
ess
and
answ
er-
ing
to t
hese
que
stio
ns:
1-
Wha
t is
the
pro
cess
of P
E?
2-
Wha
t ar
e th
e ba
rrie
rs o
f co
rrec
t im
plem
enta
tion
of
PE?
Qua
litat
ive
stud
y us
ing
a co
nten
t an
alys
is a
ppro
ach
was
use
d. D
ata
wer
e co
l-le
cted
thr
ough
sem
i-str
uc-
ture
d in
terv
iew
s.
33 n
urse
s an
d nu
rse
stud
ents
and
10 h
ospi
taliz
ed p
atie
nts
wer
e in
-cl
uded
. Th
e se
ttin
g of
the
stu
dy
was
sch
ools
of
Nur
sing
and
Mid
-w
ifery
and
2 g
ener
al h
ospi
tals
af-
filia
ted
to A
rak
Uni
vers
ity o
f Med
i-ca
l Sci
ence
s.
The
stud
y fin
ding
s sh
owed
tha
t fa
ctor
s re
late
d to
: 1
- C
urri
culu
m p
lann
ing
in s
choo
ls o
f nu
rsin
g an
d m
idw
ifery
2-
PE
cour
ses
3-
Insu
ffici
ent
atte
ntio
n to
nur
ses
cond
ition
s 4
- In
suffi
cien
t at
tent
ion
to
educ
atio
nal,
cultu
ral
and
habi
tual
nee
ds o
f pa
-tie
nts
and
thei
r fa
mili
es 5
- Ed
ucat
iona
l m
anag
e-m
ent
and
6-
Att
itude
of
part
icip
ants
to
PE,
wer
e ke
y is
sues
in
the
proc
ess
of P
E th
at w
as r
elat
ed
to i
napp
ropr
iate
im
plem
enta
tion
of P
E in
clin
ical
se
ttin
gs.
Maz
aher
i et
al.1
8
20
07
Eval
uatio
n th
e ba
rrie
rs
of
PE fo
r el
derly
pat
ient
s fro
m
the
heal
th p
erso
nnel
’s p
oint
of
vie
w in
Ard
abil.
Des
crip
tive
cros
s-se
ctio
n-al
stu
dy w
as c
arrie
d ou
t.
Dat
a w
ere
colle
cted
by
a re
sear
cher
-mad
e qu
es-
tionn
aire
.
380
heal
th p
rofe
ssio
nals
inc
ludi
ng
nurs
es, p
hysi
cian
s, a
nd n
ursi
ng a
nd
med
ical
stu
dent
s w
orki
ng in
hos
pi-
tals
affi
liate
d to
Ard
abil
Uni
vers
ity o
f M
edic
al S
cien
ces
wer
e se
lect
ed u
s-in
g pu
rpos
eful
sam
plin
g,
Poor
col
labo
ratio
n be
twee
n he
alth
pro
fess
iona
ls i
n PE,
exc
essi
ve w
orkl
oad,
ina
dequ
ate
time,
and
in-
adeq
uate
att
entio
n to
PE
wer
e th
e m
ost
perc
eive
d ba
rrie
rs.
144 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
Aut
hor
&
Year
Obj
ectiv
eM
etho
d an
d
data
col
lect
ion
Sam
ple
& s
ettin
gK
ey F
indi
ngs
Abb
asi e
t al
.19 2
00
8Id
entif
ying
pe
rcei
ved
bar-
riers
to
PE b
y nu
rses
and
pr
ovid
ing
a m
odel
fo
r its
fa
cilit
atin
g in
tea
chin
g ho
s-pi
tals
affi
liate
d to
Qom
Uni
-ve
rsity
of M
edic
al S
cien
ces.
Des
crip
tive
cros
s-se
ctio
nal
stud
y w
as
carr
ied
out.
D
ata
wer
e co
llect
ed b
y a
rese
arch
er-m
ade
ques
tion-
naire
.
351 n
urse
s an
d he
ad n
urse
s, w
ho
wor
ked
in t
each
ing
hosp
itals
affi
li-at
ed t
o Q
om U
nive
rsity
of M
edic
al
Scie
nces
, wer
e se
lect
ed u
sing
con
-ve
nien
ce s
ampl
ing.
Mos
t im
port
ant
perc
eive
d ba
rrie
rs w
ere:
“La
ck o
f aw
aren
ess
of p
atie
nts
abou
t th
e ed
ucat
iona
l re
-sp
onsi
bilit
y of
nur
ses”
, “t
he la
rge
num
ber
of h
ospi
-ta
lized
pat
ient
s”,
“no
divi
sion
of
labo
r” a
nd “
time-
cons
umin
g nu
rsin
g ta
sks
such
as
patie
nt c
are
and
docu
men
tatio
n”.
The
mos
t im
port
ant
faci
litat
ors
wer
e fo
und
to b
e: “
time
dedi
catio
n fo
r P
E”, “
allo
ca-
tion
of o
ne t
o tw
o nu
rses
for
PE”
and
“pr
epar
atio
n of
fina
ncia
l sou
rces
for
nurs
es”.
Mor
idi e
t al
.20
20
09
Det
erm
ine
the
view
poin
ts
of n
urse
s ab
out
PE,
and
its
perc
eive
d ba
rrie
rs a
nd fa
cili-
tato
rs.
Des
crip
tive
cros
s-se
ctio
n-al
stu
dy w
as c
arrie
d ou
t. D
ata
wer
e co
llect
ed b
y a
rese
arch
er-m
ade
ques
tion-
naire
.
155 n
urse
s w
ho w
orke
d in
tea
ch-
ing
hosp
itals
affi
liate
d to
Kur
dis-
tan
Uni
vers
ity o
f Med
ical
Sci
ence
s w
ere
sele
cted
th
roug
h ce
nsus
m
etho
d.
Lack
of k
now
ledg
e an
d sk
ills
for i
dent
ifyin
g th
e sp
e-ci
fic n
eeds
of t
he p
atie
nts,
insu
ffici
ent nu
rsin
g st
aff,
insu
ffici
ent t
ime,
and
non
phy
sica
l and
men
tal r
ead-
ines
s of
pat
ient
s’ f
or e
duca
tion
wer
e th
e m
ost
per-
ceiv
ed b
arrie
rs t
o P
E. T
he m
ost
perc
eive
d fa
cilit
a-to
rs w
ere
the
patie
nt’s
inte
rest
and
par
ticip
atio
n in
ed
ucat
ion,
nur
ses
inte
rest
ed t
o id
entif
y th
e le
arni
ng
need
s of
pat
ient
s, a
ppro
pria
te s
ettin
g fo
r ed
ucat
ion
and
cons
ider
ing
the
spec
ial
poin
ts f
or p
erfo
rmin
g PE
at a
nnua
ls a
ppra
isal
.A
shgh
ali-
Fara
hani
et
al.2
1
20
09
Iden
tifyi
ng
an
obst
acle
w
hich
lea
ds t
o th
e la
ck o
f ef
fect
ive
PE
base
d on
nur
s-es
`, p
hysi
cian
s` p
atie
nts`
an
d fa
mily
mem
ber
of p
a-tie
nts`
vie
wpo
ints
.
A q
ualit
ativ
e re
sear
ch a
p-pr
oach
(gr
ound
ed t
heor
y)
was
use
d. D
ata
wer
e co
l-le
cted
us
ing
open
-end
ed
inte
rvie
ws
and
field
obs
er-
vatio
ns.
18 n
urse
s, 4
car
diov
ascu
lar
spe-
cial
ists
, 9 p
atie
nts
with
car
diov
as-
cula
r di
seas
e an
d 4 f
amily
mem
-be
rs w
ere
sele
cted
int
ervi
ewed
at
two
educ
atio
nal
hosp
itals
in
Teh-
ran
thro
ugh
Purp
osef
ul T
heor
etic
al
sam
plin
g.
Inef
fect
ive
man
agem
ent,
in
appr
opria
te
orga
niza
-tio
nal c
ultu
re,
and
cultu
ral o
bstr
ucts
wer
e th
e m
ost
barr
iers
to
PE.
Org
aniz
atio
nal c
ultu
re p
laye
d an
im-
port
ant
and
cent
ral r
ole
in P
E.
Azi
znej
ad
et a
l.22
20
10
Iden
tifyi
ng t
he p
oten
tial i
m-
plem
enta
tion
barr
iers
in t
he
PE p
rogr
am f
rom
the
poi
nt
of v
iew
of n
urse
s an
d nu
rse
man
ager
s w
orki
ng
in
the
Bab
ol u
nive
rsity
of
med
ical
sc
ienc
es a
ffilia
ted
hosp
itals
.
Cro
ss-s
ectio
nal s
tudy
. Dat
a w
ere
colle
cted
by
a re
sear
ch-
er-m
ade
ques
tionn
aire
.
150 n
urse
s an
d nu
rse
man
ager
s,
with
at
leas
t 6 m
onth
of
nurs
ing
expe
rienc
e,
in
the
hosp
itals
af
-fil
iate
d to
Bab
ol m
edic
al u
nive
rsity
from
wer
e se
lect
ed t
hrou
gh c
en-
sus
met
hod.
The
mos
t im
port
ant
barr
iers
to
the
PE
wer
e as
fol
-lo
ws:
lack
of p
ropo
rtio
nalit
y be
twee
n th
e nu
mbe
r of
pa
tient
s an
d nu
rses
, tim
e pr
essu
re a
nd e
xces
sive
w
orkl
oad,
lac
k of
att
entio
n an
d ad
equa
te s
uppo
rt
from
the
man
ager
s, la
ck o
f pro
per
envi
ronm
ent a
nd
educ
atio
nal
equi
pmen
t in
the
hos
pita
l, an
d la
ck o
f co
ordi
natio
n of
oth
er h
ealth
car
e pr
ofes
sion
als
with
nu
rses
. R
osta
mi e
t al
.23
20
10
Eval
uatio
n of
ba
rrie
rs
to
PE
from
the
vie
wpo
int
of
nurs
es a
nd p
atie
nts.
A de
scrip
tive
cros
s-se
ctio
n-al
stu
dy w
as c
arrie
d ou
t. D
ata
wer
e co
llect
ed b
y a
rese
arch
er-m
ade
ques
tion-
naire
.
50 n
urse
s w
ith a
t le
ast
one
year
s of
wor
king
exp
erie
nces
in o
ne h
os-
pita
l af
filia
ted
to T
abriz
Uni
vers
ity
of M
edic
al S
cien
ces
wer
e se
lect
ed
usin
g th
e ce
nsus
met
hod.
From
vie
wpo
int
of n
urse
s, m
ajor
’s b
arrie
rs w
ere
know
ledg
e de
ficit
of
patie
nt
abou
t th
eir
right
s,
lack
of
patie
nts’
inte
rest
to
chan
ge t
heir
beha
vior
s,
nurs
es d
iffer
ent
set
of r
espo
nsib
ilitie
s, i
nade
quat
e nu
rsin
g st
aff a
nd b
udge
t, in
adeq
uacy
of e
duca
tiona
l en
viro
nmen
t, a
nd d
isag
reem
ent
betw
een
diffe
rent
sp
ecia
lists
.
Tabl
e 1.
Sum
mar
y o
f th
e b
asic
fea
ture
s o
f th
e re
sear
ch a
rtic
les
that
wer
e in
clud
ed in
the
rev
iew
(C
ont
.)
145 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
Aut
hor
&
Year
Obj
ectiv
eM
etho
d an
d
data
col
lect
ion
Sam
ple
& s
ettin
gK
ey F
indi
ngs
Bei
ran-
vand
et
al.2
4
20
10
Iden
tifyi
ng t
he b
arrie
rs i
n PE
from
the
vie
w p
oint
of
nurs
es a
nd n
urse
man
ag-
ers
in t
he h
ospi
tals
affi
li-at
ed to
Ahv
az U
nive
rsity
of
med
ical
sci
ence
.
A de
scrip
tive
cros
s-se
ctio
n-al
stu
dy w
as c
arrie
d ou
t. D
ata
wer
e co
llect
ed b
y a
rese
arch
er-m
ade
ques
tion-
naire
.
100 n
urse
s an
d nu
rse
man
ager
s,
who
wor
ked
in t
he h
ospi
tals
affi
li-at
ed t
o Ahv
az m
edic
al u
nive
rsity
in
2012,
wer
e se
lect
ed b
y co
nve-
nien
ce s
ampl
ing
met
hod.
The
mos
t im
port
ant
barr
iers
to
the
PE
wer
e; l
ack
of p
ropo
rtio
nalit
y be
twee
n th
e nu
mbe
r of
pat
ient
s an
d nu
rse
staf
f, tim
e pr
essu
re a
nd e
xces
sive
wor
k-lo
ad,
lack
of
atte
ntio
n an
d su
ppor
t fr
om m
anag
ers
rega
rdin
g P
E, l
ack
of c
oord
inat
ion
betw
een
nurs
es
and
othe
r he
alth
car
e pr
ofes
sion
als.
Hek
ari e
t al
.25
20
10
Det
erm
ine
qual
ity o
f PE
by
nurs
ing
stud
ents
and
sta
ff nu
rses
an
d its
ef
fect
ive
fact
ors
in T
abriz
hos
pita
ls.
A de
scrip
tive
cros
s-se
ctio
n-al
stu
dy w
as c
arrie
d ou
t. D
ata
wer
e co
llect
ed b
y a
rese
arch
er-m
ade
ques
tion-
naire
.
352 s
taff
nurs
es a
nd 2
41 n
ursi
ng
stud
ents
in
Tabr
iz w
ere
sele
cted
th
roug
h st
ratifi
ed
rand
om
sam
-pl
ing.
The
mos
t im
port
ant
perc
eive
d ba
rrie
rs b
y nu
rses
w
ere:
in
crea
sed
num
ber
of
patie
nts,
in
adeq
uate
tim
e, i
nade
quat
e nu
rsin
g st
aff,
lack
of
prop
er e
nvi-
ronm
ent
and
educ
atio
nal e
quip
men
t in
the
hos
pita
l, an
d la
ck o
f coo
pera
tion
betw
een
heal
th c
are
prof
es-
sion
als.
Th
e m
ost
perc
eive
d fa
cilit
ator
s in
clud
es:
patie
nt’s
int
eres
t an
d pa
rtic
ipat
ion
in p
lann
ing
and
impl
emen
tatio
n of
edu
catio
n to
the
m,
sele
ctin
g an
d tr
aini
ng s
peci
ally
nur
ses
for P
E, a
vaila
bilit
y of
edu
ca-
tiona
l eq
uipm
ent
in t
he w
ard,
and
tak
ing
a sp
ecia
l pr
ivile
ge fo
r PE
on
an a
nnua
l ass
essm
ent o
f nur
ses.
M
anso
ur
ghen
aati
et a
l.26
20
11
Eval
uatin
g st
aff
nurs
es’
opin
ion
rega
rdin
g th
e im
-po
rtan
ce o
f PE
and
dete
r-m
inat
ion
of its
mai
n fa
cili-
tato
rs a
nd b
arrie
rs.
Des
crip
tive
cros
s-se
ctio
nal
stud
y.
Dat
a ga
ther
ing
in-
stru
men
t was
a re
sear
cher
- ge
nera
ted
ques
tionn
aire
.
99
nurs
es
who
ar
e w
orke
d in
go
vern
men
tal
hosp
itals
in
Ea
st
of G
uila
n pr
ovin
ce w
ere
sele
cted
th
roug
h th
e ce
nsus
met
hod.
“The
pat
ient
’s i
nter
est
and
coop
erat
ion
in p
lann
ing
and
exec
utin
g th
e ed
ucat
ion”
was
the
mos
t im
port
ant
faci
litat
or a
nd “
sele
ctin
g an
d ed
ucat
ing
of s
peci
al p
er-
sonn
el fo
r pro
vidi
ng P
E” w
as th
e le
ast i
mpo
rtan
t fac
ili-
tato
r in
PE. “
Lack
of a
ppro
pria
te k
now
ledg
e an
d sk
ills
rega
rdin
g re
cogn
ition
of
patie
nt e
duca
tiona
l ne
eds”
w
as t
he m
ost
impo
rtan
t fa
ctor
and
“po
or c
ultu
ral a
d-ap
tatio
n fo
r nu
rses
and
pat
ient
s in
ter
ms
of s
ex”
was
as
the
leas
t im
port
ant f
acto
r act
as
barr
iers
to P
E.
Had
dad
M.2
7
20
11
To a
sses
s ba
rrie
rs in
PE
from
nu
rses
’ vi
ewpo
ints
wor
king
in
Birj
and
hosp
itals
.
Des
crip
tive
cros
s-se
ctio
nal
stud
y. U
sing
the
rese
arch
er-
mad
e qu
estio
nnai
re w
hich
as
sess
th
e vi
ew
poin
t of
nu
rses
reg
ardi
ng b
arrie
rs to
PE in
fou
r do
mai
ns:
“man
-ag
emen
t”,
“wor
king
con
di-
tion”
“nu
rses
atti
tude
” an
d “t
rain
ing
skill
s”.
125
nurs
es
who
em
ploy
ed
and
wor
ked
in
all
Birj
and
hosp
itals
w
ith a
t le
ast
1 y
ears
of
wor
king
ex
perie
nce
wer
e se
lect
ed th
orou
gh
cens
us s
ampl
ing.
“Wor
king
con
ditio
ns”
was
the
mos
t im
port
ant o
ut o
f fo
ur d
omai
ns o
f bar
riers
for
PE.
The
follo
win
g ar
eas
cons
iste
d of
: “m
anag
emen
t”,
“tra
inin
g sk
ills”
and
“n
urse
’s a
ttitu
de”.
Vahe
dian
A
zim
i et
al.2
8
20
11
Eval
uate
nur
ses’
pro
blem
s in
PE.
Des
crip
tive
cros
s-se
ctio
nal
stud
y.
Dat
a ga
ther
ing
in-
stru
men
t was
a re
sear
cher
- ge
nera
ted
ques
tionn
aire
.
145
nurs
es,
wor
king
in
di
ffer-
ent
war
ds,
wor
king
in
a ho
spita
l af
filia
ted
to T
ehra
n U
nive
rsity
of
Med
ical
Sc
ienc
es
wer
e se
lect
ed
thro
ugh
sim
ple
rand
om s
ampl
ing.
The
mos
t co
mm
on p
erce
ived
bar
riers
to
PE
wer
e:
no s
peci
aliz
ed n
urse
for
PE,
inc
onsi
sten
cies
in
the
cultu
re,
soci
al a
nd m
enta
l st
atus
of
patie
nts
and
thei
r fa
mili
es, a
nd n
urse
s’ lo
w le
vel o
f kno
wle
dge
of
nurs
es a
bout
edu
catio
nal m
etho
ds.
Tabl
e 1.
Sum
mar
y o
f th
e b
asic
fea
ture
s o
f th
e re
sear
ch a
rtic
les
that
wer
e in
clud
ed in
the
rev
iew
(C
ont
.)
146 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
Aut
hor
&
Year
Obj
ectiv
eM
etho
d an
d
data
col
lect
ion
Sam
ple
& s
ettin
gK
ey F
indi
ngs
Fara
hani
et
al.2
9
20
11
Expl
orin
g co
mm
unic
atio
n ba
rrie
rs f
rom
the
per
spec
-tiv
e of
nur
ses
them
selv
es,
as w
ell
as p
hysi
cian
s, p
a-tie
nts
and
fam
ilies
in
a
hosp
ital-b
ased
car
diac
car
e se
ttin
g.
A q
ualit
ativ
e st
udy
usin
g a
cont
ent
anal
ysis
app
roac
h.
Usi
ng
face
-to-
face
, se
mi-
stru
ctur
ed in
terv
iew
.
18 n
urse
s w
ith a
t le
ast
2 ye
ars
of
wor
king
exp
erie
nce
in t
he c
ardi
ac
care
uni
t and
pos
t car
diac
car
e un
it w
ard,
fo
ur
card
iova
scul
ar
phys
i-ci
ans,
ni
ne
patie
nts
with
kn
own
card
iac
dise
ase
and
four
fa
mily
m
embe
rs o
f tw
o ed
ucat
iona
l hos
pi-
tals
in
Tehr
an w
ere
sele
cted
usi
ng
purp
osiv
e sa
mpl
ing
tech
niqu
e.
The
thre
e m
ajor
the
mes
ide
ntifi
ed w
ere:
1)
lack
of
colle
gial
ity a
nd c
omm
unic
atio
n be
twee
n nu
rses
and
ph
ysic
ians
; 2) p
robl
emat
ic c
omm
unic
atio
n be
twee
n th
e he
alth
-car
e te
am,
patie
nts
and
thei
r fa
mili
es;
and
3)
cultu
ral c
halle
nges
.
Vahe
dian
A
zim
i et
al.3
0
20
12
Des
crib
e nu
rses
’ ex
peri-
ence
s of
bar
riers
and
faci
li-ta
tors
of
PE
in y
ear
2008
at S
haria
ti H
ospi
tal i
n Te
h-ra
n.
Tria
ngul
atio
n re
sear
ch w
ith
thre
e st
eps
Del
phi m
etho
d w
as u
sed.
Dat
a co
llect
ion
met
hods
wer
e an
uns
truc
-tu
red
inte
rvie
w,
follo
wed
by
a
ques
tionn
aire
from
in
terv
iew
s, a
nd in
the
third
st
ep,
focu
sed
grou
ps.
Part
icip
ants
inc
lude
d 25 n
ursi
ng
staf
f (1
mat
ron,
8 s
uper
viso
rs,
8
head
nur
ses
and
8 n
urse
s).
Dat
a w
ere
colle
cted
in
the
nurs
ing
of-
fice
and
diffe
rent
war
ds o
f Sha
riati
Hos
pita
l, a
teac
hing
hos
pita
l affi
li-at
ed t
o Te
hran
Uni
vers
ity o
f Med
i-ca
l Sci
ence
s.
Mos
t im
port
ant
barr
iers
wer
e: n
urse
s’ lo
w s
cien
tif-
ic k
now
ledg
e an
d in
form
atio
n, s
hort
age
of n
ursi
ng
staf
f, ex
cess
ive
wor
kloa
d, in
appr
opria
te c
linic
al s
u-pe
rvis
ion
and
feed
back
, and
ext
ra ta
sks
dem
ande
d du
e to
wor
king
in
a te
achi
ng h
ospi
tal.
The
mos
t im
port
ant
faci
litat
ors
wer
e fo
und
to b
e: d
evel
opin
g P
E pr
otoc
ols
for
each
war
d, m
odifi
catio
n in
sup
er-
visi
on a
nd f
eedb
ack
syst
em,
esta
blis
hing
a g
ood
rela
tions
hip
betw
een
patie
nts,
nur
ses
and
phys
i-ci
ans,
ass
igni
ng a
rot
atin
g nu
rse
for
PE.
Agh
akha
ni
et a
l.6
20
12
Expl
ore
nurs
es’ a
ttitu
des
to
the
barr
iers
of P
E.C
ross
-sec
tiona
l st
udy.
The
da
ta w
as g
athe
red
with
a
two
part
res
earc
her-
mad
e qu
estio
nnai
re.
240 n
urse
s, w
ho w
orke
d in
uni
-ve
rsity
affi
liate
d ho
spita
ls o
f U
re-
mia
, w
ere
sele
cted
usi
ng c
ensu
s m
etho
d.
Mos
t of
the
nur
ses
belie
ved
that
PE
is n
ot t
heir
du-
ties.
Mos
t im
port
ant
perc
eive
d ba
rrie
rs b
y nu
rses
in
clud
e: i
nade
quat
e fa
cilit
ies
in h
ospi
tals
and
als
o in
adeq
uate
tim
e.G
hoba
di e
t al
.31
20
12
Iden
tifyi
ng t
he b
arrie
rs a
nd
faci
litat
ors
of P
E fro
m t
he
view
poin
ts
of
nurs
es
and
head
nur
ses
in h
ospi
tals
of
Shira
z U
nive
rsity
of M
edic
al
Scie
nces
.
Des
crip
tive
cros
s-se
ctio
nal
stud
y. D
ata
wer
e co
llect
-ed
by
a re
sear
cher
-mad
e qu
estio
nnai
re.
106 n
urse
s w
ho w
orke
d in
med
i-ca
l or
sur
gica
l w
ards
of
sele
cted
ho
spita
ls a
ffilia
ted
to S
hira
z un
i-ve
rsity
of
med
ical
sci
ence
s w
ere
sele
cted
th
orou
gh
stra
tified
ra
n-do
m s
ampl
ing.
The
mos
t im
port
ant p
erce
ived
bar
riers
by
nurs
es w
ere:
“i
napp
ropr
iate
nur
sing
sta
ff”, “
know
ledg
e de
ficit”
, “in
-ad
equa
te ti
me”
, and
“la
ck o
r ina
dequ
ate
supp
ort f
rom
th
e m
anag
ers”
. Th
e m
ost
impo
rtan
t fa
cilit
ator
s w
ere
foun
d to
be:
“ho
ldin
g co
ntin
uous
med
ical
edu
catio
n pr
ogra
m t
o in
crea
se k
now
ledg
e an
d at
titud
e of
nur
s-es
”, “
incr
easi
ng n
ursi
ng s
taff
in e
ach
wor
king
shi
ft”,
“pro
vidi
ng a
ppro
pria
te p
lace
and
faci
litie
s fo
r PE”
.
Fara
hani
et
al.3
2
20
13
Expl
orin
g fa
ctor
s in
fluen
c-in
g PE
from
the
per
spec
-tiv
es o
f nur
ses
in Ir
an.
Qua
litat
ive
stud
y us
ing
a co
nten
t an
alys
is a
ppro
ach
was
use
d. D
ata
wer
e co
l-le
cted
thr
ough
face
-to-
face
au
dio-
tape
d in
terv
iew
s an
d fie
ld o
bser
vatio
ns.
18 n
urse
s w
ith a
t le
ast
2 y
ears
of
wor
king
exp
erie
nce
who
wor
ked
in
two
educ
atio
nal
hosp
itals
whi
ch
affil
iate
d to
Teh
ran
Uni
vers
ity o
f M
edic
al S
cien
ces
wer
e re
crui
ted
and
inte
rvie
w;
usin
g a
purp
osiv
e sa
mpl
ing
tech
niqu
e.
The
maj
or t
hem
e ex
trac
ted
in t
his
stud
y w
as t
he
inap
prop
riate
org
aniz
atio
nal c
ultu
re w
hich
incl
udes
ei
ght
cate
gorie
s lis
ted
as fol
low
s: N
ot p
uttin
g va
lue
on e
duca
tion,
non
-pro
fess
iona
l act
iviti
es, p
hysi
cian
-or
ient
ed a
tmos
pher
e, c
onfli
ct a
nd la
ck o
f coh
eren
ce
in e
duca
tion,
ina
ppro
pria
te c
omm
unic
atio
n sk
ills,
ig
norin
g pa
tient
’s r
ight
in e
duca
tion,
lack
of m
otiv
a-tio
n, re
war
ding
sys
tem
in th
e or
gani
zatio
n, a
nd p
oor
supe
rvis
ion
and
cont
rol.
Tabl
e 1.
Sum
mar
y o
f th
e b
asic
fea
ture
s o
f th
e re
sear
ch a
rtic
les
that
wer
e in
clud
ed in
the
rev
iew
(C
ont
.)
147 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
Aut
hor
&
Year
Obj
ectiv
eM
etho
d an
d
data
col
lect
ion
Sam
ple
& s
ettin
gK
ey F
indi
ngs
Sulta
ni e
t al
. 33
20
13
Expl
ore
the
barr
iers
to
PE
from
th
e vi
ewpo
ints
of
nu
rses
and
nur
se m
anag
-er
s in
hos
pita
ls o
f R
afsa
n-ja
n U
nive
rsity
of
Med
ical
Sc
ienc
es in
2008.
Des
crip
tive
cros
s - s
ectio
nal
stud
y w
as c
arrie
d ou
t. D
ata
was
col
lect
ed b
y re
sear
ch-
er-
mad
e qu
estio
nnai
re.
253 n
urse
s an
d nu
rse
man
ager
s,
who
wor
ked
in a
ffilia
ted
hosp
itals
to
Raf
sanj
an U
nive
rsity
of M
edic
al
Scie
nces
in
2008,
wer
e se
lect
ed
and
eval
uate
d th
roug
h ce
nsus
m
etho
d.
The
mos
t per
ceiv
ed b
arrie
rs to
PE
wer
e “l
ack
of a
p-pr
opria
te s
uper
visi
on a
nd e
ncou
rage
men
t fr
om t
he
man
ager
s”,
“ina
ppro
pria
te t
ime”
, “e
xces
sive
wor
k-lo
ad”,
“La
ck o
f aw
aren
ess
of p
atie
nts
abou
t th
e ed
-uc
atio
n as
a p
atie
nt’s
rig
ht”,
and
“th
e nu
rses
’ la
ck
of a
ppro
pria
te s
kills
in P
E”.
Ala
vi e
t al
.34
20
13
Expl
orin
g pa
tient
s/fa
mily
m
embe
rs a
nd h
ealth
pro
-fe
ssio
nals
’ per
cept
ions
and
ex
perie
nces
of
the
barr
iers
to
ca
rdia
c re
habi
litat
ion
educ
atio
n in
an
Ir
ania
n co
ntex
t.
Qua
litat
ive
stud
y us
ing
a th
emat
ic a
naly
sis
appr
oach
w
as u
sed.
Dat
a w
ere
col-
lect
ed
thro
ugh
in-d
epth
, se
mi-s
truc
ture
d in
terv
iew
s
Part
icip
ants
(1
0
heal
th
prof
es-
sion
als,
15 p
atie
nts/
fam
ily m
em-
bers
) w
ere
recr
uite
d from
tw
o ed
ucat
iona
l-med
ical
ce
nter
s an
d ho
spita
ls i
n Is
faha
n us
ing
Purp
o-si
ve s
ampl
ing
Five
maj
or b
arrie
rs w
ere
iden
tified
rela
ting
to h
uman
re
sour
ces,
ser
vice
pro
visi
on,
avai
labl
e ed
ucat
iona
l se
rvic
es,
unfa
vora
ble
attit
udes
an
d co
llabo
ratio
n ga
ps.
Two
mai
n ch
alle
nges
exi
st t
o th
e pr
ovis
ion
of e
ffect
ive
PE;
in
adeq
uate
hu
man
re
sour
ces
in
the
hosp
ital
war
ds,
spec
ifica
lly i
n te
rms
of t
rain
ed
heal
th c
are
prof
essi
onal
s an
d se
rvic
e us
ers’
spe
cific
he
alth
rel
ated
vie
ws
and
beha
vior
s.G
horb
ani
et a
l.3
20
14
Des
crib
e th
e at
titud
es
of
Iran
ian
nurs
es a
nd n
ursi
ng
stud
ents
on
ba
rrie
rs
and
faci
litat
ors
to P
E.
Des
crip
tive
stud
y w
as c
on-
duct
ed.
Usi
ng a
res
earc
h-er
-mad
e qu
estio
nnai
re
All
nurs
es (
103)
deliv
erin
g di
rect
pa
tient
car
e an
d al
l ba
ccal
aure
-at
e nu
rsin
g st
uden
ts (
seco
nd a
nd
third
-yea
r st
uden
ts)
rece
ivin
g ed
ucat
ion
in
the
nurs
ing
war
ds
in h
ospi
tals
affi
liate
d to
Sem
nan
Uni
vers
ity o
f M
edic
al S
cien
ces
at
the
time
of d
ata
colle
ctio
n w
ere
eval
uate
d.
All
nurs
es a
nd t
he m
ajor
ity o
f th
e nu
rsin
g st
uden
ts
men
tione
d th
at th
ey p
erfo
rmed
PE.
The
nur
ses
stat
-ed
tha
t he
avy
wor
kloa
d, i
nade
quat
e tim
e an
d la
ck
of e
duca
tiona
l fa
cilit
ies
wer
e m
ain
barr
iers
to
PE.
Th
e st
uden
ts b
elie
ved
that
lack
of
know
ledg
e, la
ck
of c
omm
unic
atio
n sk
ills
and
heav
y w
orkl
oad
wer
e m
ain
barr
iers
to
PE
from
the
ir pe
rspe
ctiv
es.
Saei
dPou
r et
al.3
5
20
14
Ass
essi
ng n
urse
s an
d do
c-to
rs v
iew
poin
ts o
n ob
sta-
cles
and
faci
litat
ors
PE.
Des
crip
tive
cros
s-se
ctio
nal
stud
y. D
ata
wer
e co
llect
-ed
by
a re
sear
cher
-mad
e qu
estio
nnai
re.
85 n
urse
s an
d do
ctor
s w
ho w
orke
d in
Ker
man
shah
Raz
i hos
pita
l wer
e se
lect
ed b
y Si
mpl
e R
ando
m S
am-
plin
g m
etho
d.
Top
thre
e ba
rrie
rs t
o P
E w
ere:
sho
rtag
e of
nur
ses,
la
ck o
f su
ffici
ent
finan
cial
res
ourc
es,
and
nurs
es’
exce
ssiv
e w
orkl
oad.
Whi
le,
hold
ing
sem
inar
s on
te
achi
ng a
nd l
earn
ing
stra
tegi
es a
nd a
lso
cons
id-
erin
g sp
ecia
l pr
ivile
ge
for
patie
nts’
ed
ucat
ion
in
annu
al e
valu
atio
n of
nur
ses
wer
e m
ost
impo
rtan
t pe
rcei
ved
faci
litat
ors.
Deh
ghan
i et
al.3
6
20
14
Det
erm
ine
barr
iers
to
PE
from
nur
ses’
vie
wpo
ints
.D
escr
iptiv
e cr
oss-
sect
ion-
al
stud
y w
as
cond
ucte
d.
Dat
a w
ere
colle
cted
by
a re
sear
cher
-mad
e qu
estio
n-na
ire.
271 n
urse
s, w
ho w
orke
d in
teac
h-in
g af
filia
ted
hosp
itals
of
Jahr
om
Uni
vers
ity
of
Med
ical
Sc
ienc
es,
wer
e se
lect
ed
thro
ugh
cens
us
met
hod.
The
mos
t im
port
ant
barr
iers
wer
e: la
ck o
f tim
e du
e to
wor
kloa
d, la
ck o
f P
E pl
anni
ng f
or n
urse
s in
the
ir da
ily w
ork
as a
dut
y, a
nd t
he u
nkno
wn
role
of
the
nurs
es a
s a
teac
hing
age
nt t
o th
e pa
tient
s an
d th
e co
mm
unity
.Est
eki e
t al
.37
20
14
Eval
uatin
g nu
rses
’ pe
r-ce
ptio
n of
PE
in t
he C
CU
w
ard
of
Valia
sr
Hos
pita
l, B
irjan
d, Ir
an.
Qua
litat
ive
stud
y us
ing
a co
nten
t an
alys
is a
ppro
ach
was
use
d. D
ata
wer
e co
l-le
cted
thr
ough
sem
i-str
uc-
ture
d in
terv
iew
s.
11
nurs
es
of
CC
U
war
ds
who
w
orke
d in
the
Val
iasr
Hos
pita
l of
B
irjan
d,
wer
e re
crui
ted
by
pur-
pose
ful s
ampl
ing
Thre
e th
emes
ha
ve
emer
ged
incl
udin
g cu
lture
, kn
owle
dge
of t
he p
atie
nt’s
bac
kgro
und,
and
edu
ca-
tion
proc
ess
suite
d to
pat
ient
s’ c
ultu
re a
nd s
ocie
ty.
Tabl
e 1.
Sum
mar
y o
f th
e b
asic
fea
ture
s o
f th
e re
sear
ch a
rtic
les
that
wer
e in
clud
ed in
the
rev
iew
(C
ont
.)
148 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
Inadequate support of managers, particularly in case of appropriate time allocation for nurses’ teaching activities and ineffective coordination of educational responsibilities among disciplines is a barrier to PE.38,48 Managerial and organizational support is an important element for the implementation of high-quality PE.49,50 The result of a study that was conducted in Iran showed that nurses were well informed of the importance of patient education and had accepted this role in clinical settings, but no managerial support was available to them for doing this activity.3 Moreover, other studies showed that hospital managers have less emphasize on PE.2,51 Modifying administrational support is crucial for effective PE. The context in which care is delivered, such as staffing levels, prioritizing of different aspects of care, provision of resources and support of other healthcare team members, influence the quality of PE.3 It been shown that PE was a less important task of healthcare professionals from the nurse managers’ perspective.51 PE was improved through changes in the management style, development of educative materials, and patient education protocols.3 Inappropriate educational facilities in hospital were one of the barriers perceived by Iranian nurses for PE. Accessibility of teaching materials is an important component to facilitate PE.40 It is known that face-to face PE time can be reduced by using paper materials and facilitate what must be transmitted to patients.51 It is important to provide teaching materials which are easily understood and are consistent with cultural issues and social norms.52 Allocation of specific space in every work-place setting for PE and assigning responsibility for this activity to one specialist nurse in the each ward by managers are another recommendations to improve and develop PE.49
Patient’s low literacy or illiteracy and cultural diversity of patients and nurses were among the most patient-related barriers perceived by Iranian nurses. Teaching is a dynamic process and is influenced by social and cultural factors. Thus, nurses must be sensitive to the effects of values, religion, language, cultural and socioeconomic factors.52 It seems that conflict among nurses
and patients’ beliefs can intensify the problems in PE. People strongly protect their cultural values and also they expect everyone to respect it.53 In a study that conducted by Heidari et al. have been shown that there is much cultural diversity among patients and concluded that all nurses are expected to be more sensitive to the cultural factors such as language, lifestyle, and social status of patients and their families in their education.52 Considering the cultural diversity backgrounds of patients and the health care providers, cultural sensitivity is an essential factor in improvement of comprehensive PE plans.54 Patients’ lower educational level and severity of illness prohibit their educational compliance.40 Most of the hospitalized patients in Iran are elderly with inadequate level of health literacy.3 Patients’ health literacy, as a resource which allows them to seek, understand and use health information, is an important determinant of their participation and engagement in their health care.55 Many patients may be able to read and write, but have trouble to understanding basic health information. Health literacy, as a set of individual capacities may be improved through educational programs or declined due to aging and disease process.3,56
Nurse-related barriers such as lack of awareness of nurses about educational methods and teaching/learning principles, believing that patient teaching is not nurses’ responsibility, and lack of knowledge about illness, were mostly perceived by Iranian nurses. For PE, the nurses must be aware of the learning pattern of patients, which includes visual, auditory, and kinesthetic. Once the learning style is established, the nurse adapts the preferred teaching strategies and methodologies to that style.56-58 Assessing patient learning style, in combination with the context in which learning occurs, allows for an individualized approach that incorporates teaching modalities to maximize patient learning.59 Disagreement between patients, nurses, and physician regarding responsibility of PE is another perceived barrier to patients’ education by nurses in Iran. Moret et al. found that nurses and physicians did not agree on patient information materials, so that nurses considered their role to be more important than what the
149 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
physicians gave them.50 However, this finding is inconsistent with that of Park’s study, in which nurses stated that information about medicine and treatment was not their responsibility.2 On the other hand, there is incongruence between nurses’ and patients’ perceptions regarding the nurses’ role in PE. Patients acknowledged a general teaching function for nurses; but when they were asked who they prefer to teach them specific information related to their situation, they most frequently chose a physician. Whereas the nurses most frequently acknowledged a nurse as the most desired patient educator.60
One potential limitation of this review was that we did not search the gray literature to find studies not in the peer-reviewed journals. Although we identified all papers that met our inclusion criteria, unpublished studies may be missed. However, our electronic search was extensive and complemented by hand-searches, so that the saturation was achieved. Another limitation was most of the studies have used investigator-developed instrument, so it may violate rigor of the studies. The results of our review indicate that, Iranian nurse’s encounter with somewhat high barriers in PE; so that of these, administration-related barriers were the predominant obstacle in order to bring evidence into clinical applicability. Therefore, health managers are expected to plan appropriate strategies to smooth the progress of PE by nurses in their practice.
Acknowledgement. We kindly thank Prof. Lynda Wilson for providing comprehensive comments and Dr. Reza Armat for his helpful comment on research methodology.
References1. Karimi Moonaghi H, Hasanzadeh F, Shamsoddini
S, Emamimoghadam Z, Ebrahimzadeh S. A comparison of face to face and video-based education on attitude related to diet and fluids: Adherence in hemodialysis patients. Iran J Nurs Midwifery Res. 2012;17(5):360-4.
2. Park M. Nurses’ perception of performance and responsibility of patient education. Taehan Kanho Hakhoe Chi. 2005;35(8):1514-21.
3. Ghorbani R, Soleimani M, Zeinali M, Davaji M. Iranian nurses and nursing students’ attitudes on barriers and facilitators to patient education: a survey study. Nurse Educ Pract. 2014;14(5):551-6.
4. Visser A, Deccache A, Bensing J. Patient education in Europe: united differences. Patient Educ Couns. 2001;44(1):1-5.
5. Friberg F, Granum V, Bergh A. Nurses’ patient-education work: conditional factors – an integrative review. J Nurs Manag. 2012; 20(2):170-86.
6. Aghakhani N, Nia HS, Ranjbar H, Rahbar N, Beheshti Z. Nurses’ attitude to patient education barriers in educational hospitals of Urmia University of Medical Sciences. Iran J Nurs Midwifery Res. 2012;17(1):12-5.
7. Mullen P, Mains D, Velez R. A meta-analysis of controlled trials of cardiac patient education. Patient Educ Couns. 1992;19(2):143-62.
8. Strömberg A. The crucial role of patient education in heart failure. Eur J Heart Fail. 2005; 7(3):363-9.
9. Mazzuca S. Does patient education in chronic disease have therapeutic value? J Chronic Dis. 1982; 35(7):521-9.
10. Mahmoudi H, Mohmmadi E, Ebadi A. Barriers to nursing care in emergency wards. Iran J Nurs Midwifery Res. 2013; 18(2):145-51.
11. Mardanian Dehkordi L, Salahshorian A, Mohammad Alayha J, Hosseini F. Nurses` Perception of patient teaching, Enhancing and Inhibiting Factors. Iran J Nurs. 2005; 17(40):18-27.
12. Bergh A, Karlsson J, Persson E, Friberg F. Registered nurses’ perceptions of conditions for patient education - focusing on organisational, environmental and professional cooperation aspects. J Nurs Manag. 2012; 20(6):758-70.
13. Borhani F. Nurses and nurse-Managers’ opinions about the importance of patients’ training barriers. J Qazvin U Med Sci. 2002; 5(4):84-90.
14. Goudarzi Z, Khosravi K, Bahrani N, Vaskooii K, Valipourgavgany P, Ghoghaei S, et al. A study of professional nurses’ perceptions of factors affecting the process of client education. Hayat. 2004; 0(4):57-65.
15. Honan S, Krsnak G, Petersen D, Torkelson R. The nurse as patient educator: perceived responsibilities and factors enhancing role development. J Contin Educ Nurs. 1998; 19(1):33-7.
150 Invest Educ Enferm. 2016; 34(1)
Hossein Karimi Moonaghi • Amir Emami Zeydi • Amir Mirhaghi
16. Heshmati Nabavi F, Vanaki Z. Nurses opinions and ranking of patients training barriers. Quarterly Journal of Kerman Faculty of Nursing and Midwifery. 2006; 1:47-52.
17. Hekmatpou D, Anoosheh M, Alhani F. Pathology of Patient Education: A Qualitative Study. Iran J Nurs. 2007;20(49):51-60.
18. Mazaheri E, Mohammadi R. Health personnel’s opinions of Ardabil University of Medical Sciences about the aged patient training barriers. Dena. 2006;1(1):75-82.
19. Abbasi M, Nouroozi M, Mehran N. Evaluation of the barriers to patients education from the nurses view point and providing a facilitators model in teaching hospitals of Qom University of Medical Sciences in 2007. Quar J Hosp. 2008; 7:13-6.
20. Moridi G, Khaledi S, Barfi M. Education Inhibitory Factors and Facilitators in Sanandaj, Iran, 2007. Dena. 2009; 4(3-4):43-52.
21. Ashghali-Farahani M, Mohammadi E, Ahmadi F, Maleki M, Hajizadeh E. Obstacles of Patient Education in CCU and Post CCU: A Grounded Theory Study. Iran J Nurs. 2009; 22(58):55-73.
22. Aziznejad P, Zabihi A, Hosseini S, Bijani A. Nurses and Nurse Managers Opinions about the Patient’s Training Barriers. J Babol U Med Sci. 2010; 12(5):60-4.
23. Rostami H, Montazam S, Ghahremanian A. Survey of Education Barriers from Nurses and Patients Viewpoint. Scientific J Hamadan Nurs Midwifery Fac. 2010; 18(1):50-5.
24. Beiranvand S, Sheinijaberi P, Asadizaker M. Patient Education from the View Point of Nursing: The Main Executive Barriers. Aflak. 2010; 10(18-19):1-9.
25. Hekari D, Mohammadzadeh R. Quality of patients’ education by nursing students and employment nurses and its effective factors in Tabriz hospitals in 2007-2008. Med Sci J Islamic Azad U. 2010;20(1):58-63.
26. Mansour ghenaati R, Majidi S, Tabari R. Evaluation of staff nurses’ view point regarding the importance of the facilitators and barriers of patients education. Res Med Educ. 2011; 3:27-33.
27. Haddad M. Viewpoints of employed nurses in hospitals of Birjand city regarding existing barriers in patient education. Mod Care J. 2011;8(3):152-8.
28. Vahedian Azimi A, Payami Bosari M, Gohari Moghaddam K. A survey on nurses clinical problems in patient education. Bimonthly J Urmia Nurs Midwifery Fac. 2011; 9(4):295-305.
29. Farahani M, Sahragard R, Carroll J, Mohammadi E. Communication barriers to patient education in cardiac inpatient care: A qualitative study of multiple perspectives. Int J Nurs Pract .2011; 17 (3):322-8.
30. Vahedian Azimi A, Alhani F, Hedayat K. Barriers and Facilitators of Patient’s Education: Nurses’ Perspectives. Iran J Med Educ. 2012; 11(6):620-34.
31. Ghobadi A, Ghodsbin F, Majidipour P, Mohamadsalehi N. Study of barrier and facilitator factors of patient education in clinical nurse’s point of view in selected hospitals of Shiraz University of medical science. J Clin Res Paramed Sci. 2012; 1(1):8-15.
32. Farahani M, Mohammadi E, Ahmadi F, Mohammadi N. Factors influencing the patient education: A qualitative research. Iran J Nurs Midwifery Res. 2013; 18(2):133-9.
33. Sultani A, Hadavi M, Heydari S, Shahabinezhad M. Barriers to Patient Education Based on the Viewpoints of Nurses and Nurse Managers in Hospitals of Rafsanjan University of Medical Sciences, 2008. J Rafsenjan U Med Sci. 2013; 12(4):309-18.
34. Alavi M, Irajpour A, Giles T, Rabiei K, Sarrafzadegan N. Barriers to education in cardiac rehabilitation within an Iranian society: a qualitative descriptive study. Contemp Nurse. 2013; 44(2):204-14.
35. SaeidPour J, Ghazi Asgar M, Rahmani H, Khoshkho M. Surveying Doctors and Nurses Viewpoints on Enhancing and Inhibiting Factors of Educating Patients. Hosp J. 2014; 13(1):61-7.
36. Dehghani A, Orang M, Abdollahyfard S, Parviniyan nasab A, Vejdani M. Barriers to Patient Education in Clinical Care; Viewpoints of Nurses. Iran J Med Educ. 2014; 14(4):332-41.
37. Esteki R, Mahmoudirad G. Nurses’ Perception of Patient Education in Critical Care Units: A Content Analysis. J Qual Res Health Sci. 2014; 3(2):126-36.
38. Barber-Parker E. Integrating patient teaching into bedside patient care: a participant-observation study of hospital nurses. Patient Educ Couns. 2002; 48(2):107-13.
151 Invest Educ Enferm. 2016; 34(1)
Patient education among nurses: bringing evidence into clinical applicability in Iran
39. Tse K, So W. Nurses’ perceptions of preoperative teaching for ambulatory surgical patients. J Adv Nurs. 2008; 63(6):619-25.
40. Marcum J, Ridenour M, Shaff G, Hammons M, Taylor M. A study of professional nurses’ perceptions of patient education. J Contin Educ Nurs. 2002; 33(3):112-8.
41. Raffray M, Semenic S, Osorio Galeano S, Ochoa Marín S. Barriers and facilitators to preparing families with premature infants for discharge home from the neonatal unit. Perceptions of health care providers. Invest Educ Enferm. 2014; 32(3):379-92.
42. Barrett C, Doyle M, Driscoll S, Flaherty K, Dombrowski M. Nurses’ perceptions of their health educator role. J Nurs Staff Dev. 1990; 6(6):283-6.
43. Mehrdad N, Salsali M, Kazemnejad A. The spectrum of barriers to and facilitators of research utilization in Iranian nursing. J Clin Nurs. 2008; 17(16):2194-202.
44. Jafaraghaee F, Mehrdad N, Parvizy S. Influencing factors on professional commitment in Iranian nurses: A qualitative study. Iran J Nurs Midwifery Res. 2014; 19(3):301-8.
45. Huey F, Hartley S. What keeps nurses in nursing. 3,500 nurses tell their stories. Am J Nurs. 1988;88(2):181-8.
46. Aiken L, Clarke S, Sloane D, Sochalski J, Busse R, Clarke H, et al. Nurses’ reports on hospital care in five countries. Health Aff (Millwood). 2001; 20(3):43-53.
47. Griffith C, Wilson J, Desai N, Rich E. House staff workload and procedure frequency in the neonatal intensive care unit. Crit Care Med. 1999; 27(4):815-20.
48. Casey D. Findings from non-participant observational data concerning health promoting nursing practice in the acute hospital setting focusing on generalist nurses. J Clin Nurs. 2007; 16(3):580-92.
49. Bergh A, Persson E, Karlsson J, Friberg F. Registered nurses’ perceptions of conditions for patient education--focusing on aspects of competence. Scand J Caring Sci. 2014; 28(3):523-36.
50. Moret L, Rochedreux A, Chevalier S, Lombrail P, Gasquet I. Medical information delivered to patients: discrepancies concerning roles as perceived by physicians and nurses set against patient satisfaction. Patient Educ Couns. 2008;70(1):94-101.
51. Vafaee-Najar A, Ebrahimipour H, Shidfar M, Khani-Jazani R. Patient education services and the organizational factors affecting them at teaching hospitals affiliated with Mashhad University of Medical Sciences (MUMS), 2008. J Mens Health. 2012; 9(4):230-7.
52. Heidari M, Norouzadeh R. Factors affecting patient education from cultural perspectives. J Adv Med Educ Prof 2013; 1(4):136-9.
53. Tortumluoglu G, Okanli A, Ozyazicioglu N, Akyil R. Defining cultural diversities experienced in patient care by nursing students in eastern Turkey. Nurse Educ Today. 2006; 26(2):169-75.
54. Knoerl A, Esper K, Hasenau S. Cultural sensitivity in patient health education. Nurs Clin North Am. 2011; 46(3):335-40.
55. Jordan J, Buchbinder R, Osborne R. Conceptualising health literacy from the patient perspective. Patient Educ Couns. 2010; 79(1):36-42.
56. Beagley L. Educating patients: understanding barriers, learning styles, and teaching techniques. J Perianesth Nurs. 2011; 26(5):331-7.
57. Norouzi H, Tohidi S, Karimi Moonaghi H, Behnam Vashini H. The Comporison of the Effects of the Lecture and Self-Learning Module on Nurses, Teaching-Competency to Cardiac Patient Education. J Mazandaran U Med Sci. 2014; 24(1):197-202.
58. Mirhaghi A, Karimi-Moonaghi H, Sharafi S, Emami-Zeydi A. Role modeling: A Precious Heritage in Medical Education. Sci J Fac Med Niš. 2015; 32(1):31-42.
59. Inott T, Kennedy B. Assessing learning styles: practical tips for patient education. Nurs Clin North Am. 2011; 46(3):313-20.
60. Tilley J, Gregor F, Thiessen V. The nurse’s role in patient education: incongruent perceptions among nurses and patients. J Adv Nurs. 1987; 12(3):291-301.
Recommended