Health Science Journal

Keywords

Need, hospitalized patients, confidence, information, education, self-care, support

Introduction

During the last decades, the interest of health professionals increases continuously towards the assessment of the fulfillment of the patients’ needs. Given that each disease requires significant and sometimes abrupt changes, especially after the diagnosis in the patients’ lives, assessment of their needs should be an integral part of treatment as it may lead to beneficial results for the management and treatment of disease. Also, given that the hospital is a place where the patients’ psychological strength is usually reduced, it is widely accepted that the dimension of the problem is not limited to the treatment of disease as such but to other problems that emerge or deeper needs of the patients. [1-8]

According to the literature, the needs of hospitalized patients are: confidence/ communication, information, education, self-care, and support. The "patients’ need" is a dynamic complex concept that changes with time and disease progression, while it is also dependent on the spiritual cultivation and cultural traditions of the patients.

The collection of information from the health professionals regarding the patients’ needs, taken either from them directly or their relatives is essential, and the health professionals should record, evaluate, and most importantly meet fulfill needs.

The detection, evaluation, and meeting of the patients’ needs have many benefits both for patients and the NHS in each country. The most important benefits are: the improvement of the provided health care, the evaluation of the quality of the service offered, the effective management of the health funding sources, the development of the health care system and social support, and the effective usage of the health professionals’ qualifications. However, in the Modern Greek health system, systematic measurements of patients’ needs as well as comparative studies regarding this subject are lacking. [1-8]

The main factors that undermine the assessment of the patients’ needs is the lack of time, as far as the health professionals are concerned, while as far as the patients are concerned, is the kind and severity of the disease, and demographic factors such as personality, age, sex, marital status, educational level, etc. [1-8]

Need for trust / communication

Fulfillment of the need for trust is essential for the harmonious relationship between patients and health professionals and is largely important for their good cooperation. More specifically, accomplishment of an effective communication, starting from taking the medical history of the patient to implementation of any medical / nursing practice helps to reduce the patients’ anxiety and ensures their cooperation. Therefore, the clinical practice is performed with higher precision. According to the literature, an effective therapeutic intervention can affect the outcome of the disease. [9-15]

The communication between health professionals and patients is a dynamic and interacting relationship. For example, the health professionals need accurate information from the patients in order to assess the disease state, to provide an accurate diagnosis, and to choose the appropriate treatment. On the other hand, through an effective communication, the patients are able to understand the medical instructions in detail, to accept their medical condition, and to comply with the treatment. [9-15]

However, although this relationship is supposed to be interactive in order for the best therapeutic result to be achieved, there are times when this condition is violated. An example is when the patient demands more time or attention from the health professional than what is actually required. Many times, the long duration of the disease requires long-term relationship between the patient and the health professional, which sometimes tends to become a dependent relationship as the stage and the severity of the disease are increasing. Therefore, it is mainly the health professionals’ responsibility to keep the relationship within safe limits by both trying to understand the psychology of the patients and at the same time acting as professionally as possible. [9-15]

The main factors that undermine an effective communication is the stress experienced by the patients during hospitalization, as well as the degree of stress and fatigue experienced by the health professionals due to high workload. According to the literature, other factors that lead to non-effective communication is the patients’ low educational level, their ability of perception and their past experiences. There are reports in the literature suggesting that failure to achieve good communication leads to loss of information regarding the disease and compliance with the treatment, to missed signs and symptoms, to failure of behavior modification in the concept of secondary prevention. Thus, all these factors affect negatively the outcome of the disease. [9-15]

Need for information

The need for information was developed several decades ago when, according to the literature, in the late 1960's and early 1970’s, a moral shift towards the health sector was suggested according to paternalism. Thus, the doctor was the person to decide for the patient’s treatment therapy, and the degree and the kind of information given to the patient, always taking into account what is ‘best’ for the patient. This was done in order to promote autonomy and for recognition of the patients’ right to be informed clearly about their health condition. [16-19]

Later, in the 70's and 80's, the need for more active participation of the patients in decisions concerning their treatment started to rise. The patients adopted a more critical attitude towards health care provision and there was a significant change in the way and type of information provided by the physicians. The method of honest, detailed and analytical information was applied widely in the United States of America, where the doctor-patient relationship is governed by the ethical principle of the patients’ autonomy. [16-19]

Since then, many countries around the world have recognized the importance of information; however it is not applied in the everyday clinical practice. In the Modern Greek society, probably unconsciously, the paternalistic model is the one that still takes place. Accordingly, the provided information is filtered, and usually the whole truth is hidden from the patient, like in the cancer patients, who therefore become suspicious and question the need for treatment, or feel insecurity, fear, and resentment of the care provided. [16-19]

Usually, patients require information not only regarding the disease and the treatment, the prevention of complications or side effects of medication, but also for other more practical problems associated with everyday activities or even with economic issues.

Finally, it is worth mentioning that often the differences in the information need not necessarily mean that the needs vary, but may reflect the ability of acceptance and understanding of information. People fail to understand the information provided should be recognized by health professionals and to take care after hospital discharge. In these cases it has been proven it is very constructive to provide information to the supportive environment, as the family. [16-19]

Need for education

Education is defined as the process of acquiring knowledge and skills that can lead to changes in human behavior, necessary for the maintenance or improvement of health. Recently, the interest of the health sciences has focused on the design and effectiveness of individual education programs. The idea behind an effective educational program is the change of the patient’s behavior towards more self-control, more active participation n decision making, development of self-care, assessment of personal risk factors, the implementation of realistic goals and expectations, and generally more efficient managing of their health and quality of life. [20-29]

The design of an educational program should also focus on the individual needs of each patient (patient-centered approach). The learning process, and more specifically the way and the duration, differ among individuals, and depend on the attitude, the personal beliefs, the goals, and the patients’ ability of understanding. Given that this approach investigates and fulfills the needs of each patient and particularly their perception of the severity of the disease, is considered the most effective. According to the literature, the need for education was defined as the gap between knowledge adequacy and the present level of ‘students’’ development of knowledge. The most essential step in assessing this gap is the personal opinion of the ‘students’ on the difference between the point they are now the point should be reached. Previous work has shown that the educational program that focuses on the patient is associated with increased patient satisfaction, lower levels of anxiety and depression, high levels of compliance to treatment, as well as improved quality of life not only for the patients but for their supporting environment as well. [20-29]

Researchers who studied the factors affecting the education of patients concluded that health professionals pay more attention to issues relating to the anatomy, psychology, medication and even sexual lives of the patients, whereas the patients need to be educated about more practical issues regarding their health condition and prevalence of complications. Therefore, the educational programs that are designed based only on the health professionals’ opinion are less efficient compared to those based on the patients’ needs as perceived by them including their expectations and feelings. In addition, the literature suggests that the health professionals should not transmit knowledge passively, but they should instead encourage the active participation of patients. [20-29]

Finally, the effectiveness of an educational intervention program is not only the relevance of knowledge acquired, but whether and how knowledge is maintained over time. Therefore, for the long-term ensure and maintenance of the benefits of the education program, the last one should be continuous.

Continuous education is associated with a statistically significant reduction in mortality, morbidity, re-hospitalizations and healthcare costs.

Need for self-care

Participation and self-care is defined as the extent to which the patient is involved in the treatment and in decisions concerning it. Providing quality care requires apart from meeting the patients’ needs, to investigate and improve the extent to which they can participate in their treatment therapy with the ultimate aim to be the improvement of the prognosis and their quality of life. [30-36]

The degree of involvement of patients in their treatment therapy varies. Sometimes patients are reluctant to participate actively because of lack of knowledge or even lack interest for the progress of the disease, and sometimes they question the treatment and its effectiveness. According to the literature, enhancement of patients for participation and self-care requires strategies that motivate, empower and encourage patients to take responsibly of their own care. It also depends largely on the patient’s ability and willingness to carry out complex and diverse self-care activities. In addition, participation in the changes imposed by the disease on the patients’ daily routine should be continuous in order to achieve the best possible therapeutic effect. [30-36]

An increasing number of relevant researches stress out the necessity of strengthening the participation/self-care to all patients with poor compliance, including those with cognitive and physical impairment or of a low educational level. As mentioned earlier, according to the paternalistic model of care, the physician is the person who takes the decision regarding treatment therapies, regardless of participation or consent of the patient. However, nowadays in many countries including Greece, this type of care is decreasing and the active participation of patients in the therapeutic process is enhanced through enhancement of the patients’ information and education. However, an accurate estimate of the patients’ abilities, clear and detailed guidance and further encouragement for active participation and reassessment of the result is required in order to achieve the best possible outcome. [30-36]

Meeting the need for active participation in the therapeutic process is not always possible, like in case of a sudden heart attack, in which the patient does not have a choice but of course still reserves the right to be informed. On the contrary, this principle can be applied during the process of deciding the appropriate therapeutic approach or during the recovery process. For example, the aim of health care for patients who suffered myocardial infarction is the development of self-care, the ability to handle the consequences of the disease, as well as the participation in rehabilitation programs. All the above are also important for achieving secondary prevention, where the modification of risk factors depends to a considerable extent on the patients themselves. It is worth mentioning that many of the studies have focused on the needs of the hospitalized patients. However, there is little information regarding the needs of patients after discharge from the hospital, during the recovery period. [30-35]

Need for support

Regarding the need for support, it is widely accepted that both the sudden hospitalization and the frequent rehospitalizations are stressful conditions where the patients need support from their family and the health professionals in order to cope with the disease. Also, most patients experience various problems mainly after discharge from the hospital, and need help and support. Recent research findings have shown that the magnitude of these problems is associated with the degree of adaptation to physical, emotional and psychological impact of the disease, as well as the patients’ unwillingness to accept the new lifestyle restrictions imposed by their disease, and loss of self-care. Often, when the patients realize their inability to maintain activities, past relationships, and functional roles, are gradually leaded to social isolation. This, in conjunction with the change of their self image and the low selfesteem that they usually have, undermines their emotional balance and mental health. An increasing number of studies confirms the importance of preventing social isolation by maintaining communication and providing support, which thereby has a beneficial impact on the treatment process and the outcome of the disease. [36-40]

During the last decades, the term "support" for patients with chronic diseases has been the subject of several investigations. It usually refers to the mechanisms through which interpersonal relationships and relations with other family members and the society protect patients from the adverse effects of the disease and promote their mental health. Moreover, emphasis is continuously given on the importance of social support, provided through the social support systems, which operate as a direct source of support for the individual and as a basic network with other resources and forms of help. [36-40]

Although historically there is no universally accepted definition of social support, most researchers agree on the division of the social support term to the two following broader areas: the structural and functional support. More specifically, the structural support refers to the size, type, intensity, frequency and particularly the quality of contact of the supportive network of people surrounding the patient. The functional support is provided by the social carriers and includes the financial and emotional support, information provision, assessment of the condition, and in general a more systematic assistance provided to achieve specific goals for each patient. [36-40]

Many theories emphasize the difference of the provided support (received functional support) and the personal assessment of satisfaction from the support or the belief that support is always available when needed (perceived functional support). In addition, the patients’ belief regarding the social support is affected by other factors such as gender, ethnicity, personality, or even from social-economic or psychological factors such as anxiety and depression.

The theories related to social support are developed continuously and recent research data indicate the need of inclusion of other factors: a) factors referred to the disease, such as the stage and the severity of the disease, b) factors referred to the patient, such as the degree of loss of the self-care, and the compliance to the treatment and c) factors referred to the patient’s wish to seek help and to show to others the areas where they need support. [36-40]

Summarizing social support is a multifaceted concept which is not explained by a single concise definition. The main attributes of all definitions of social support is the provider, the recipient, the support and the environment in which all these attributes occur and interact. Although the concept of social support is not always accurate as to how is defined and measured, however, addressing these limitations is an important step in designing effective intervention rehabilitation programs. [36-40]

Conclusions

The assessment of needs for hospitalized patients should be an integral part of the treatment process and part of the training program for the nurses. In addition, this process should start very early, from the diagnosis stage until the discharge from hospital.

References

1. Stevens A., Gillam S. Needs assessment: from theory to practice. BMJ. 1998;316(7142):1448-52.
2. James M. Towards an integrated needs and outcome framework. Health Policy. 1999;46(3):165?177. doi: 10.1016/S0168- 8510(98)00064-5.
3. Robinson J., Elkan R. Health needs assessment, theory and practice. New York, Churchill Livingstone, 1996.
4. Davidson PM., Macdonald P., Moser DK., Ang E., Paull G., Choucair S., et al. Cultural diversity in heart failure management: findings from the DISCOVER study (Part 2). Contemp Nurse. 2007;25(1-2):50-61.
5. Davidson PM., Macdonald P., Ang E., Paull G., Choucair S., Daly J., et al. A case for consideration of cultural diversity in heart failure management-- Part 1: Rationale for the DISCOVER Study. Contemp Nurse. 2004;17(3):204-10.
6. Davidson JE., Boyer ML., Casey D., Matzel SC., Walden CD. Gap analysis of cultural and religious needs of hospitalized patients. Crit Care Nurs Q. 2008;31(2):119-26.
7. Seddon ME., Marshall MN., Campbell SM., Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care. 2001;10(3):152-8.
8. Sofaer S., Crofton C., Goldstein E., Hoy E., Crabb J. What do consumers want to know about the quality of care in hospitals? Health Serv Res. 2005;40(6 Pt 2):2018-36.
9. Asadi-Lari M., Packham C., Gray D. Need for redefining needs. Health Qual Life Outcomes. 2003;1:34.
10. Asadi-Lari M., Packham C., Gray D. Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services. Health Quality Life Outcomes. 2003;1: 26.
11. Ridd M., Shaw A., Lewis G., Salisbury C. The patient-doctor relationship: a synthesis of the qualitative literature on patients' perspectives. Br J Gen Pract. 2009;59(561):e116-33.
12. Beck RS., Daughtridge R., Sloane PD. Physician?patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002;15(1):25?38.
13. Unger J-P., Ghilbert P., Fisher JP. Doctor-patient communication in developing countries. BMJ2003 ; 327 14. Lings P., Evans P., Seamark D., Seamark C., Sweeney K., Dixon M., Gray DP. The doctor-patient relationship in US primary care. J R Soc Med. 2003;96(4):180-4.
14. Lings P., Evans P., Seamark D., Seamark C., Sweeney K., Dixon M., Gray DP. The doctor-patient relationship in US primary care. J R Soc Med.  003;96(4):180-4.
15. Teutsch C. Patient-doctor communication . Med Clin North Am. 2003;87(5):1115-45.
16. Scott JT., Thompson DR. Assessing the information needs of post-myocardial infarction patients: a systematic review. Patient Educ Couns. 2003;50(2):167-77.
17. Timmins F. A review of the information needs of patients with acute coronary syndromes. Nurs Crit Care. 2005;10(4):174-83.
18. Clark JC., Lan VM. Heart failure patient learning needs after hospital discharge. Appl Nurs Res. 2004;17(3):150-7.
19. Czar ML., Engler MM. Perceived learning needs of patients with coronary artery disease using a questionnaire assessment tool. Heart Lung. 1997;26(2):109-17.
20. Johanssona Κ., Leino-Kilpia Η., Salantera S., Lehtikunnasa T., Ahonenb P., Elomaac L., et al. Need for change in patient education: a Finnish survey from the patient’s perspective Patient Education and Counseling. 2003; 51 (3): 239–245.
21. Ojanlatva A. Patient education in Finland. Patient Educ Couns. 2001;44(1):49?54.
22. Rees CE., Bath PA. The information needs and source preferences of women with breast cancer and their family members: a review of the literature published between 1988 and 1998. J Adv Nurs 2000;31:833?41.
23. Timminsa F., Kaliszerb M. Information needs of myocardial infarction patients European Journal of Cardiovascular Nursing.2003; 2(1): 57?65.
24. Chan AD., Reid GJ., Farvolden P., Deane ML., Bisaillon S. Learning needs of patients with congestive heart failure. Can J Cardiol. 2003;19(4):413-7.
25. Johnson A., Sandford J., Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev. 2003;(4):CD003716.
26. Chien WT., Chiu YL., Lam LW., Ip WY. Effects of a needs-based education programme for family carers with a relative in an intensive care unit: a quasiexperimental study. Int J Nurs Stud. 2006;43(1):39-50.
27. Visser A., Wysmans M. Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation. Patient Educ Couns. 2010;78(3):402-8.
28. Johansson K., Leino-Kilpi H., Salanterä S., Lehtikunnas T., Ahonen P., Elomaa L., et al. Need for change in patient education: a Finnish survey from the patient's perspective. Patient Educ Couns. 2003;51(3):239-45.
29. Cebeci F., Celik SS. Discharge training and counseling increase self-care ability and reduce postdischarge problems in CABG patients. J Clin Nurs. 2008;17(3):412-20.
30. Ivarsson B., Larsson S., Lührs C., Sjöberg T. Extended written pre-operative information about possible complications at cardiac surgery--do the patients want to know? Eur J Cardiothorac Surg. 2005;28(3):407-14.
31. Suter PM., Suter WN. Patient education. Timeless principles of learning: a solid foundation for enhancing chronic disease self-management. Home Healthc Nurse. 2008;26(2):82-8; quiz 89-90.
32. Knowles MS. The adult learner: a neglected species. 3rd ed. Houston: Gulf Publishing Company, 1989.
33. Goodlin SJ., Trupp R., Bernhardt P., Grady KL., Dracup K. Development and evaluation of the "Advanced Heart Failure Clinical Competence Survey": a tool to assess knowledge of heart failure care and self-assessed competence. Patient Educ Couns. 2007;67(1-2):3-10.
34. Welstand J., Carson A., Rutherford P. Living with heart failure: an integrative review. Int J Nurs Stud. 2009;46(10):1374-85.
35. Johnson VD. Promoting behavior change: making healthy choices in wellness and healing choices in illness - use of selfdetermination theory in nursing practice. Nurs Clin North Am. 2007;42(2):229-41.
36. Ryan P. Integrated Theory of Health Behavior Change: background and intervention development. Clin Nurse Spec. 2009;23(3):161-70.
37. Kristofferzon ML., Löfmark R., Carlsson M. Coping, social support and quality of life over time after myocardial infarction. J Adv Nurs. 2005;52(2):113- 24.
38. Frasure-Smith N., Lespérance F., Gravel G., Masson A., Juneau M., Talajic M., et al. Social support, depression, and mortality during the first year after myocardial infarction. Circulation. 2000;101(16):1919-24.
39. Mookadam F., Arthur HM. Social support and its relationship to morbidity and mortality after acute myocardial infarction: systematic overview. Arch Intern Med. 2004;164(14):1514-8.
40. Worth A., Tierney AJ., Watson NT. Discharged from hospital: should more responsibility for meeting patients and careers’ information needs now be shouldered in the community? Health Soc Care Community 2000;8:398– 405.