Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 221 Understanding the Barriers Towards Delivery of Patient Education and Perceptions on Health Education Delivery During Covid Pandemic among the Nurses in One of the Hospitals in Bhutan Sangay Chozom Clinical Nurse, JDWNRH *Corresponding author: csangay101@gmail.com ABSTRACT Background: Patient education is a dynamic process, including formal and informal interactive activities, which influences patients’ behavior and produces changes in knowledge, attitudes and skills for better health care outcomes. Educating patient and their relatives are a source of satisfaction for the nurses; however, they felt powerless to deliver patient education consistently due to some obstacles. Purpose: This qualitative study aims to explore barriers towards patient education among nurses and also to understand the perceptions of nurses towards patient education delivery during Covid pandemic. Methods: The study design is qualitative and the study was conducted using semi-structured interview. Recruitment of participants for the interview was based on purposive sampling techniques in order to gain broad range of perspective. Interviews were conducted with a maximum of 12 participants or until the point of saturation was achieved. Thematic analysis technique was used in order to analyze the data. Results: The findings of the study revealed that nurse related factors, patient related factors and inadequate infrastructure hindered the delivery of patient education. Only health education which required patients’ co-operation for undergoing procedure was delivered and the health education on disease condition was usually not imparted. It was also found out that the change in hospital policy during Covid pandemic has an impact on patient education delivery and that during the pandemic, Covid related education was strengthened. Conclusion: Understanding nurses’ perceptions and factors influencing the delivery of patient education may lead to information to develop strategies to promote nursing engagement in patient educational activities. Keywords: covid, health education, nurse, pandemic Received February 10, 2023; Revised March 12, 2023; Accepted April 3, 2023 DOI: https://doi.org/10.30994/jnp.v6i2.270 The Journal of Nursing Practice, its website, and the articles published there in are licensed under a Creative Commons Attribution-Non Commercial- ShareAlike 4.0 International License. https://thejnp.org/ mailto:csangay101@gmail.com https://doi.org/10.30994/jnp.v6i2.300 Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 222 BACKGROUND Patient education has become more important now than ever before due to the reasons such as changing disease panorama, increase in chronic diseases and also due to the increase in health care cost. (Avsar G, Kas¸ikçi M, 2011). Patient education is a dynamic process, including formal and informal interactive activities, which influences patients’ behavior and produces changes in knowledge, attitudes and skills for better health care outcomes (Oyetunde & Akinmeye, 2015; Avs¸ar G, Kas¸ikçi M, 2011; Ghorbani et al., 2014). Educating the patient also helps to improve the motivation of patients in terms of maintaining their health and improving health outcome (Abbasi M, Rabiei L & Masoudi. R 2018). Moreover, patient education is a significant component of high-quality healthcare services (Yael L, Ilana P & Janna S.,2017) and is an important and an essential aspect of nursing (Hui-Lian Che, et al., 2016). During this process, nurse takes the role of a resource provider, mobilizes and teaches patients how to use resources, and improves their sense of control (Hui-Lian Che et al., 2016). In addition, patient education should be carried out from the time of patients’ admission till the time of discharge from the health facility (Abbasi M, Rabiei L & Masoudi. R 2018). More than 28% of nurses reported they have primary responsibility for patient education and almost 64 % perceive they have a great deal of responsibility for overall patient education activities. Although nurses consider patient education as an integral part of their care, they fail to implement patient education as much as they desire in the face of work constraints (Park, M. Y. 2005). Although, educating patient and their relatives are a source of satisfaction for the nurses, they felt powerless to deliver patient education consistently due to some obstacles (Hui-Lian Che et al., 2016). Several quantitative studies on barriers to patient education showed that excessive workload, inadequate staffs and lack of time were few of the major factors hindering patient education (Oyetunde, M. O., & Akinmeye, A. J. 2015; Livne, Y., Peterfreund, I., & Sheps, J.,2017; Karimi Moonaghi, H., Emami Zeydi, A., & Mirhaghi, A.,2016 ; Abdi, A., Izadi, A., Vafaeei, K., & Lorestani, E. 2014 ; Abbasi, M., Rabiei, L., & Masoudi, R. 2018; Ghorbani et al., 2014; ). Similarly, a qualitative study among the Tawanese nurses also revealed that excessive workload was one of the factors hindering patient education (Hui-Lian Che et al., 2016). In addition, Abdi and his colleagues reported mismatch of personnel to patients, job dissatisfaction and lack of managerial attention to patient education as the main barriers of patient’s education (Abdi, A., Izadi, A., Vafaeei, K., & Lorestani, E..2014). Similarly, Bergh and the colleagues also reported lack of support from the managers as the obstacles faced by hospital nurses in attempting to educate patients (Bergh et al., 2012). The other obstacles to implementation of patient education were lack of evaluation and documentation of what patients learned. 59% of the nurses and 69.6% of the students reported that lack of consideration of patient education activities in their work appraisal discouraged them to perform patient education as it was time consuming (Ghorbani et al., 2014). ). Moreover, alternating between patients, not knowing who to provide patient education, difficulty in communication and disrupted confidence and work rhythm were some of the factors which hindered delivery of patient education (Hui-Lian Che et al., 2016). Lack of educational materials and environmental factors such as overcrowded patient rooms and lack of educational facilities were also few of the factors hindering patient education (Ghorbani et al., 2014). Few studies conducted among nurses and nursing student in Iran showed that patient’s related factors such a lack of demand to receive education, severe illness, lower educational levels, inability to communicate with the nurse, patients’ attitudes and length of hospital stay, and patient’s lack of interest in provided knowledge were few of the barriers to patient https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 223 education. (Abbasi, M., Rabiei, L., & Masoudi, R. 2018; Ghorbani, R., Soleimani, M., Zeinali, M. R., & Davaji, M. 2014; Karimi Moonaghi, H., Emami Zeydi, A., & Mirhaghi, A. 2016). Quick discharge of the patients from the hospital also poses challenges for the nurses to incorporate patient education as a consequence of busy routine (Hui-Lian Che et al., 2016). Patient education has been considered as an important part of nursing for years. However, it is unknown how the Bhutanese nurses perceive about patient education. Understanding nurses’ perceptions on factors influencing the delivery of patient education may provide healthcare and educational managers with information to develop strategies to promote nursing engagement in patient educational activities. Therefore, this qualitative study is conducted in order to understand and explore barriers towards patient education among nurses and also to understand the perceptions of nurses in delivering health education during Covid pandemic. METHODS Study Design The study design is qualitative and the study is conducted using semi-structured interview. The inclusion and exclusion criteria for the selection of participants are based on the following criteria: Inclusion criteria: 1. All categories of nurses (clinical, staff, and Assistant nurses) 2. Having at least 1 year experience working as a nurse 3. Having experience in dealing and providing care to the patients. Exclusion Criteria 1. Other health professionals besides nurses. 2. Less than 1 years of working experience. 3. Having no experience dealing or providing care to patients. Recruitment of participants In order to have a representative sample, equal number of nurses from all the 3 different categories, different age groups, and equal number of male and female nurses were selected. Recruitment of participants for the interview was based on purposive sampling in order to gain broad range of perspective. RESULTS Nurses agreeing to participate in the study were asked to thoroughly read the information sheet, besides delivering detailed additional oral briefings on the points in the information sheet and then they were asked to sign in the consent form prior to the conduction of interview. Interviews were conducted with a maximum of 12 participants or until the point of saturation has reached. Interviews were recorded, transcribed and read exhaustible on the day of conducting the interview in order to not to miss on any minute details. The data collection was carried out from the first week of October 2021 till the first week of November 2021. Data Analysis Thematic analysis technique was used in order to analyze the data. The first step was to familiarize with the data. The data transcribed was read repeatedly in order to identify themes or patterns among data. After this, the researcher identified the chunks of data (words/phrases/sentences/paragraphs) and started ascribing one- or two-words summary to the chunks of data (open coding). These common themes, statements and ideas were then analyzed for common relationships. Central themes and relationships were exhaustibly searched for until https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 224 they emerged. Central themes were identified and open codes were then grouped under different central themes (closed coding). The researcher then interpreted the perceptions of nurses towards patient education and the factors which influence patient education delivery in order to develop narrative description of the meaning the researcher assigned to the quotation of the participants by interweaving the exact quotations from the participants. Preparation of Interview Guide Interview questions were developed based on what the research questions were and checking if the questions could extract the answers for the overall research questions. A set of open- ended questions were developed to direct the interviewer/researcher and these questions usually ask for explanations such as “How” and “Why” with regard to nurses’ perceptions towards patient education and factors which hindered the delivery of patient education. Open ended follow-up questions were also prepared and were used in order to obtain rich and detailed information of the perceptions and barriers towards patient education. The interview guide was presented to two qualitative research experts and feedbacks/ suggestions were taken into consideration. Legal and Ethical Aspect The study protocol was submitted to the Research Ethics Board of Heath, Ministry of Health, prior to the conduction of the study for the ethical approval. Participation in the study was voluntary. Participants can withdraw from the study at any point of time without the need to state reasons and on the time of withdrawal, the collected data will be destroyed or the participant will be asked if he/she gives his/her consent to use his/her data. Nurses agreeing to participate in the study will be asked to thoroughly read the information sheet, besides delivering additional oral briefings on the points in the information sheet and after all of this is done, they will be asked to sign in the consent form prior to the interview The names and all other personal information will be maintained with confidentiality. The information will be recorded under a pseudonym (if need be) and the data will be secured from unauthorized access. Even if the results are published, the findings will be presented anonymously. The names of the participant will be kept anonymous and will not appear in the study. Implication of the study Understanding nurses’ perceptions on patient education and the factors influencing patient education may provide healthcare and educational managers with information to develop strategies to promote nursing engagement in patient educational activities during ordinary and pandemic times Limitation of study This study will be conducted on in JDWNRH. Therefore, it may not study the perceptions and factors towards patient education of the nurses in other districts. Sponsor/study funding This particular study has received no funding from any organization. The researcher declares no conflict of interest in this study. Findings/Results Three Themes on factors hindering patient education delivery to patients and two themes on perceptions on health education delivery during Pandemic emerged from the study 1. Themes on Factors hindering patient education delivery 1.1. Nurses related factors 1.2. Patient related factors 1.3. Inadequate Infrastructure https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 225 2. Theme on perception on delivery of health education 2.1. Only health education which require patients’ co-operation for undergoing procedure is delivered 3. Themes on Perceptions on delivery of patient education during pandemic 3.1. Change in hospital policy has an impact on patient education delivery during pandemic 3.2. Covid related education strengthened 1.1. Nurse related factors 1.1.1. Time constraints, excess workload and inadequate staffing Nurses reported that time constraints, excess workload and busy shift with inadequate number of nursing staff was one of the obstacles in delivering education to the patients. They reported that they were more focused on completing the nursing procedures/tasks first. Due to limited staffs and more workload, they did not have time to deliver health education to the patients. “When there are few staffs in a shift, we would prefer to do the procedures fast and then go to the next patient to do the procedure as there is less time to explain everything to the patients. When the tasks in the ward are not complete, we do not have enough time to explain to the patients. When there are only one or two staffs in a shift and when there are lots of procedures to carry out, we do not get time to explain to the patient. We do not feel like explaining to the patient when the tasks are not complete.” Participant 8. “I also feel that we do not do much of health education. It is because of time constraints. I do not see nurses communicating to the patients. It is because of lot of work load” Participant 2 “We do not have lot of time to sit and talk to them. We do it but it is very brief. We have to do nursing procedures such as intravenous cannulation and change intravenous fluid bottle every now and then. We have lots of procedures for only one patient” participant 3. 1.1.2. Lack of knowledge among nurses The participants also attributed lack of knowledge among the nurses as the factor for not imparting health education to the patients. “Nurses working in the unit or ward should know about all types of surgery and then only the delivery of health education will be easier and can be delivered to the patient in a proper manner. All types of surgery do not have the same types of education because different types of surgery will have different types of dos and don’ts to follow during post operative period for few weeks. Nurses should be well acquainted with knowledge according to the types of surgery and types of disease” Participant 1. “Due to lack of knowledge among nurses, health education is not being imparted” participant 9. 1.1.3. Difficulty in converting /interpreting technical term The participants reported that their inability to explain the technical term to the patients and attendants was one of the reasons hampering the delivery of patients’ education. The other reason was there was no substitute for the technical term in the local language. “The technical terms are difficult to be converted to local language and explained to patients. This is quite difficult. We cannot convey the scientific term to the patients.” Participant 8. ‘There are certain English terms for which our native language does not have any term for that. In this kind of scenario, we are not able to explain the scientific term to the patient. This is also one of the challenges” participant 10. 1.2. Patient related factors 1.2.1. Illiteracy and language barriers https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 226 Participants reported illiteracy and language barriers among the patients and attendants as one of the obstacles for patient education delivery. “Sometimes, there is little bit of communication gap. When patient party is illiterate, it is difficult for the patient to comprehend and we have to keep our health education session at halt especially when there is no other nurse colleague who can explain and make the patient party understand” participate 9. “Language is a problem. Only if we talk to them in their native language, they are able to understand. Sometimes we do not speak their language. Therefore, we cannot deliver health education to them and our other colleagues who can speak the language will be engaged with other patients” participant 10. 1.2.2. Non-receptive patients and attendants The other hindering factor for delivery of patient education, as reported by the nurses, was non-receptive patients and attendants. Patients and attendants do not listen to the teachings/suggestions provided by the nurses as the patient party is tired or not interested. “Patient attendant are not receptive. This maybe because they have problem at home or they are weak or tired after taking care of the patient for the whole night” participant 3. “Some patients have only one attendant. The attendant is busy and not able to sleep at night, they are not able to concentrate and listen to heath education. In cases with two attendants, one attendant listens to health education and they concentrate properly during delivery of health education” Participant 8. “Sometimes, the patients are not interested in health education” Participant 8. “Health education is not delivered because our patients are not responsiveness and not very eager to know about their disease condition. They usually do not ask questions. if there are 10 patients in the ward, there will be only one or two patients who will be eager to know about the disease condition. They usually do not ask the health professionals as to how it is done and why it should be done etc.” participant 10. 1.3. Inadequate Infrastructure Participants expressed that limited or non-availability of infrastructure was also one cause of non-delivery of health education. “I think there should be health education delivery room in each ward where you can sit with your patient and provide health education. In our setting we have six patients in one cubicle and when we explain to one patient, it is not comfortable for us or for the patient as well and there are lots of interruption and noise disturbances from other patients and attendants. Similarly, there are disturbances from other patients and attendants even when we try to educate the patient at the nurse’s station or in the co-corridor. So, in such scenario, we will need a room where we can sit with the patient and attendants for delivery of patient education using educational material” participant 10. “We do not have a CME room so we provide in the ward. In my opinion I feel that facilities like CME room, videos or projectors should be there to facilitate health education delivery” participant 5. 2. Perceptions on Health education delivery 2.1 Only health education which require patients’ co-operation for undergoing procedure is delivered Health education which requires the cooperation of the patient when carrying out a procedure is usually imparted to the patients so that there is proper compliance to the procedure. In addition, health education is also imparted on the time of discharge on medication intake and follows up. On the contrary health education of disease condition of the patients is not usually imparted. https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 227 “Nurses are busy and they are involved in task most of the time. So, health education delivery happens only when it is mandatory like when the patient in the ward has to undergo surgery/CT/MRI, then you provide health education so that he/she is ready for the procedure” participant 10. “Health education is usually given on the time of discharge regarding medication and follow up as per the discharge document. However, health education on specific disease condition is not usually given to patients. When there is procedure that the patient has to undergo, then the health education is given. Health education on disease condition is usually not given. Nurses educate the patient only if the procedure is compulsory and has to be done and if health education is not delivered, the procedure may fail. Participant 8. In our wards, for patients coming with conservative treatment, we are not able to provide health education. Our focus is more on pre-operative patients because when we educate them on how to prepare for the surgery, they are able to comply with it. Recently we had tonsilitis patient who came for tonsillectomy and it was during my second night shift that I provided health education during that time. Participant 3. 3. Perceptions on Health education delivery during Covid pandemic 3.1. Change in hospital policy has an impact on delivery of health education One participant expressed that due to the change in policy of the hospital related to the strict prohibition of OPD patients in the ward in order to keep the health facility free of Covid, the opportunity to provide health education has declined. “I think the patient after discharge is not allowed during in the ward during covid pandemic. Otherwise, patient used to come for follow up in the ward after surgery. Patients used to come here for post-operative review and nurses used to do the wound dressing and educate patient on the medication usage and follow up”. Participant 1. Another participant expressed that not allowing excess attendants and visitors in the ward/ unit has given them opportunity to provide health education to their patients. “During the pandemic, the hospital is less crowded, we are able to provide better health education. For example, in my unit before pandemic many attendant/ visitors were allowed in the unit and it was difficult to provide health education. Now it is quite better for providing health education” participant 8. Health education delivery to the patients is a challenge during the time of lock down during pandemic. “I think the delivery of health education before covid is quite different than now. During pandemic when there is lockdown, patient education is almost forgotten because the number of staff in a shift is decreased to half and therefore, we have two staffs catering to the needs of 14 to 16 patients for a duration of 12 hours. During such time, majority of us are not able to provide health education to the patients though we know that it is very important for the patients. This is also because we try to limit the contact with the patient and secondly the number of nurses is reduced to half and therefore, it is difficult to provide health education participant 10. 3.2. Covid related education has strengthened Participants also expressed that the health education related to Covid or educating patients on Covid protocols were initiated during the pandemic. “We can also educate patient more on hand washing and all as it is pandemic. before we also used to provide health education for the sake of it but now, we tell them you are more immunosuppressant patient so you have to take care of hand washing, usage of mask wherever you go you have to use mask. I think that is the only difference” Participant 3. https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 228 “Now we inculcate Covid topics while giving health education. We club covid topics along with other health education topics”. Participant 5. “I think the Covid related education has improved”. Participant 6 “I did not notice any differences in the health education delivery before pandemic and during pandemic. However, explanation of covid protocol has come up. Apart from that there are not much changes to health education”. Participant 7. DISCUSSION Barriers to patient education The study explores the factors hindering health education delivery by the nurses to the patients. The challenges are categorized as nurse related factors, patient related factors and limited infrastructure. The nurse related factors include time constraints, excess workload and inadequate staffing, lack of knowledge among the nurses and the inability of nurses to explain the technical terms to the patients. This finding is in line with a qualitative study among the Taiwanese nurses also revealed that excessive workload was one of the factors hindering patient education (Hui- Lian Che et al., 2016). Similarly, several quantitative studies on barriers to patient education that showed that excessive workload, inadequate staffs and lack of time were few of the major factors hindering patient education (Oyetunde, M. O., & Akinmeye, A. J. 2015; Livne, Y., Peterfreund, I., & Sheps, J.,2017; Karimi Moonaghi, H., Emami Zeydi, A., & Mirhaghi, A.,2016 ; Abdi, A., Izadi, A., Vafaeei, K., & Lorestani, E. 2014 ; Abbasi, M., Rabiei, L., & Masoudi, R. 2018; Ghorbani et al., 2014; ). Moreover, alternating between patients, not knowing who to provide patient education, difficulty in communication and disrupted confidence and work rhythm were some of the factors which hindered delivery of patient education (Hui-Lian Che et al., 2016). The patient related factors were illiteracy and language barriers, non-receptive patients and attendants. This is also in line with the studies conducted among nurses and nursing student in Iran which showed that patient’s related factors such a lack of demand to receive education, severe illness, lower educational levels, inability to communicate with the nurse, patients’ attitudes and length of hospital stay, and patient’s lack of interest in provided knowledge were few of the barriers to patient education .(Abbasi, M., Rabiei, L., & Masoudi, R. 2018; Ghorbani, R., Soleimani, M., Zeinali, M. R., & Davaji, M. 2014; Karimi Moonaghi, H., Emami Zeydi, A., & Mirhaghi, A. 2016). The other factor which hindered education delivery was lack of infrastructure. This is in line with the study conducted by Ghorbani and the colleagues. It was found out that lack of educational materials and environmental factors such as overcrowded patient rooms and lack of educational facilities were also few of the factors hindering patient education (Ghorbani et al., 2014). CONCLUSION Perceptions on Health education delivery Health education which requires the cooperation of the patient when carrying out a procedure and education at the time of discharge regarding medication usage and follow ups are usually imparted to the patients. However, health education on disease condition of the patients is not usually imparted. Perceptions on health education delivery among nurses during Covid pandemic The policy related to Covid pandemic has influenced the health education delivery to the patients by the nurses. The Covid related health topics were introduced and health education https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.221-229 229 was delivered more on these topics than ever before. Due to the restriction of visitors/attendants in the hospital during the time of pandemic in order to keep the health facility free of covid cases, this has resulted in less crowding and favorable environment for the nurses to provide health education to their patients as it is less noisy. As per the author’s knowledge there is no study which has explored the health education delivery to the patients during the covid pandemic. At the same time delivering of health education was still a challenge during the pandemic as the number of nurses working per shift was reduced during lock down and nurses used to maintain distance from patient admitted in the ward as they feared of contracting Covid. REFERENCES Abbasi, M., Rabiei, L., & Masoudi, R. (2018). Experience of nursing students about the barriers to patient education: a qualitative study in Iran. Korean journal of medical education, 30(4), 327. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288616/. 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