1. Study Scope

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Spinal Cord injuries are the most devastating traumatic injuries causing numerous complications in individuals (May et al., 2006). These injuries initiate with a blow fracture and progressively dislocate the vertebrae (bone disks which make up the spine). Injuries of this type does not sever the spinal cord, but instead cause damage when vertebrae pieces tear into cord tissue and press down on the signal carrying nerve parts. Spinal cord injuries are the medical emergency conditions costing immense financial leverage on the community. Immediate treatment through effective patient education measures can help in minimising the long term complications. In many of the cases, treatment to spinal cord injuries initiate with the restraining of spine and regulating inflammation to minimise further damage (May et al., 2007). The usual treatment to spinal cord injuries differs completely depending on the exact location and the level of injury. Most of them need substantial physical therapy and rehabilitation, more particularly if the injury of the patient involves day to day activities (Bennett et al., 2004).

Patients with spinal cord injuries possess a life time threat for clinical complications and other health related conditions secondary to their injury, involving pain, spasticity, shoulder ache, infections in the urinary tract, breathing complications, pressure ulcers, cognitive impairments and other depressive episodes. Secondary complications amongst these patients contribute to considerable morbidity, medical costs, and increased rates of re-hospitalisation in the initial year following the injury. Presence of these secondary conditions has been linked with deleterious quality of life and well-being (May et al., 2007).

Patients with severe spinal cord injuries need to be educated to a significant level for managing the consequences of the neurological disability and impairment. The complexities associated to post spinal cord injuries usually influence the individual’s life in a negative manner. They impact on the physical, psychological and social well-being of the person. Many of the secondary complications can be minimised or optimised through appropriate levels of self-care and self-management (Aveyard et al., 2011). However, the present scenario of shorter rehabilitation stays, owing to limitations in the insurance and complexity of accessing the specialists on spinal cord injuries needs patients and family members to absorb information on self-care while staying in the hospital. They even necessitate being proactive in exploring health information as soon as they get discharged. To allow individuals in managing their own care and long term implications, it is important to provide with more than simply information on their clinical situation. Nonetheless, most of the complications can be minimised through the delivery of effective (but challenging) patient education measures. These measures are crucial to promotion of independence, efficacy, self regulation and measurement (Bennett et al., 2004).

Patient education is the crucial segment of rehabilitation and it encompasses the ultimate target of preparing patients to meet the day to day challenges. Various patient education programmes developed in the recent years enable the spinal cord injured patient in understanding and monitoring their own physical, emotional, cognitive and psychological well-being. However, improvements in knowledge may not completely translate the problem solving competencies even for the crucial issues. Many of the studies have then suggested the need to include the more active learning or contextually based interventions within the patient education programmes. Incorporation of these measures will necessarily increase the transfer of knowledge in the situations associated to life (May et al., 2007).

The value of patient education in the spinal cord injured patient includes the following (May et al., 2006):

* Enhanced understanding of clinical situation, disease and disability.

* Enhanced knowledge on the various methods and forms to control different aspects of clinical situation.

* Increased self-advocacy in choosing to function independently from the health care practitioners and in interdependence with them.

* Improved acceptability, flexibility and compliance (This can be due to the fact that effective communication and patient education amongst spinal cord injured patients enhances their motivation to comply).

* Informed consent (due to the fact that patients perceive the practitioners in best information providers).

* Usage-Increased use of safe and effective medical services with minimal phone calls and visit.

* Referrals and Satisfaction-the probability of patients staying in the practice of general practitioner and referring to other patients is immense.

* Management of risks or threats (if any)-due to minimal likelihood of malpractices when working with patients possessing realistic expectations.

Effective delivery of patient education necessitates presence of certain competencies amongst the health care providers. The below-mentioned attributes amongst the health care professionals influence the success of patient education in rehabilitation of spinal cord injured patients (May et al., 2006).

* Encompass the perspectives related to personal ethics in the context to social responsibilities and services over others.

* Offer accurate, competent and evidence-based care.

* Gain sufficient experience in the field of preventative health care.

* Developing focus on the relationship centred care by combining with individuals and their respective families.

* Include different multiple determinants associated to health when offering care and support for spinal cord injured patient.

* Ability to be culturally sensitive and open to the issues surrounding the clinical situations and diverse society.

* Utilise technology in most appropriate and effective manner.

* Developing knowledge on the current treatment methods in the fields of practice and

* Ability to continue to improve measures and strategies in patient education.

There is considerable level of research evidence signifying the fact that information overload from minimal rehabilitation stays involves with the patient’s and family’s ability to completely master the skills and information to prevent secondary complications after leaving the hospital. Numerous research studies (like for instance May et al in 2006, Cortez and Levi, 2000, Rimmer, 2000, Grant and Booth, 2009 and others) that outlined the role of patient education have ascertained its role in improving quality of living, well-being. According to these studies, patient education is one of the valuable information tools that can help individuals with spinal cord injuries in minimising hospitalisations and practitioner consultations. More than ever, patients with severe spinal cord injuries require timely and high quality information on the issues related to health and medicine following their discharge and all throughout the lifetime to prevent the symptoms, stay healthy and promote quality of life (Cortez and Levi, 2000).

Although, a significant proportion of patients are educated at the time of their stay in the rehabilitation unit, many of them still experience complexities in identifying its importance. To overcome such issues, it is highly important to bear in mind the below mentioned fundamental aims of patient education programme. The prime targets of patient education programme identified through ground breaking research by Rimmer (1999) comprise of:

* Enhancing safe and effective healthy and sustaining environment for well-being.

* Minimising and preventing the underlying secondary complications (such as pressure ulcers, obesity, and bladder and bowel complications) of spinal cord injuries.

* Preparing patients who are suffering with spinal cord injuries to regulate and manage their own physical and health complications.

* Controlling and keeping in place the functional independence and

* Increasing freedom and independence to enjoy and increase the quality of life.

Achieving the above mentioned targets necessitates individuals to consider the best ways of implementing the best ways of patient education measures. The readiness, agreement and characteristic nature of patient form the crucial parts of patient education. Many of the studies have even indicated that the absence of compliance and readiness of the patient in gaining information are the usual reasons for failure.

1. Study Background

The underpinning necessity for choosing the current topic –“A critical review of the factors that influence the success of effective patient education in a rehabilitation unit for individuals with spinal cord injuries”, emerged after the continuous meetings with the professionals associated with this clinical condition. The meeting emerged in response to numerous complaints made by the patients, who failed to receive sufficient levels of information during their stay. Very recently, the numbers related to re-hospitalisation owing to secondary complications following the spinal cord injury have increased to a significant level. In addition, the department and individuals concerning the outpatients have been overwhelmed through telephone conversations and sudden visits from the already encountered patients (May et al., 2006).

Although there is a patient education programme in my unit, the desired results of its effectiveness are not met. This may be because of the low profile of the subject in the department despite spending significant amount of time and resources to educate patients, families and carers. Nevertheless the process of patient education is not documented systematically to verify its effectiveness. The numbers of re-admissions of former patients are increasing and the post injury complications are growing. On the other hand many patients and care agencies benefit from the existing patient education programme. The question of why some patients are benefiting and others returning with complications is crucial (Cortez and Levi, 2000).

1. Study Purpose

This project explores the topic – “A critical review of the factors that influence the success of effective patient education in a rehabilitation unit for individuals with spinal cord injuries” and aims to integrate the research findings to obtain knowledge with regard to the context. The wide range of developments, innovations and technological advancements in the patient education measures for spinal cord injuries together with their individual effectiveness in offering best results have inspired me to gain an interest on this topic

However, the prime aims for this study include:

* To critically explore the underpinning literature governing the research topic.

* To develop an evidence base for supporting the best available strategies for effective patient education.

* To investigate the barriers and facilitators for implementing effective patient education.

Besides, the presence of a relative gap in the literature concerning treatment procedures of spinal cord injuries and the significance of such measures in the field of scientific research are some of the other reasons. This study uses the critical review and literature search methodology for information collection. These methodologies evaluate the article or an essay combining a summary and critical commentary presentation. By moving much beyond the usual explanation of resources, this methodology enables individuals to include a wide variety of degrees of analysis and conceptual innovation methods (Grant and Booth, 2009). It also aims at collecting needed information for the development and implementation of prospective education programmes at the spinal cord injury unit in Sheffield Teaching Hospitals.

1. Aims and Objectives

Within this study, the information needs of patients with spinal cord injuries and how their necessities correlate to the well-being and promotion of life quality were explored. By considering information on the best available approaches for delivering spinal cord injury, this study addresses different research-related questions. This study aims at critically exploring and identifying the literature related to:

* Available interventions for the effective implementation of patient education in rehabilitation centre for spinal cord injured patients.

* Investigating the influence of personal leadership in disseminating the findings through patient education strategies in the care associated to spinal cord injuries.

* Utilising available research evidence from the literature to propose a revised patient education programme and strategies for implementation.

To achieve the above mentioned research aims, the study aims to fulfil the below mentioned objectives:

* Examining the obstacles and facilitators for implementing effective patient education.

* Framing prospective recommendations, suggestions and implications for practice using gap analysis.

* Suggest recommendations to inform a future strategy for patient education in spinal injuries care.

1. Key definitions

Since the topic under study does not encompass any complex terms, the definitions of simple terms-“Patient education”, “Rehabilitation” and “Spinal cord injuries” were considered and the following definitions are offered:

Patient education is a process through which professionals in health care and other related fields impart information to the patients. This process aims at altering the health behaviours of patients, besides improving their status. With the crucial elements of skill building and responsibility, patient education aims at improved understanding of clinical situation, diagnosis and disability (May et al., 2006).

Rehabilitation or treatment is a specialised field of medicine that aims in enhancing and restoring the functional ability, quality of life and well-being of patients with disabilities and physical impairments. More specifically, it involves management of disorders that change the function and performance of the patient. In rehabilitation, increased emphasis is usually placed on the functional optimisation through the integrated utilisation of medications, physical modalities, and training with clinical exercise, modifications in movement and activities, assistive devices and experiential training methodologies (Cortez and Levi, 2000).

Spinal cord injuries are the highly devastating and traumatic injuries usually caused through accidents of motor vehicles, falls and other activities related to violence. More commonly, sports related spinal cord injuries persist in children and teenagers, whilst the work related types (such as construction work) predominate amongst adults (May et al., 2007).

1. Summary

This chapter has outlined certain introductory points in relevance to spinal cord injuries, patient education and associated issues surrounding rehabilitation. It even outlined the research aims and objectives, key definitions and reasons for choosing the topic. Further chapters will explore the methodology used for data collection, together with the data analysis, inclusion and exclusion criteria, data presentation and development of information. It also accounts the analytical viewpoints associated with the present research project.


This chapter outlines the, search strategies, key words, inclusion and exclusion criteria, data presentation, gap analysis and critical appraisal tools along with the synthesis of relevant conclusions. The current research project forms a part of critical literature search methodology of considering the effectiveness of patient education in attaining success in spinal cord injury. The outcomes associated to the study were potentially limited to make sure of clinical applicability and acceptability. Drawing on my tacit knowledge as a nurse, I will be working in an empathetic patient centred way to undertake this study. However as my main focus is to critically review the literature this will require me to take an ‘objective’ epistemological standpoint when undertaking a review of the referred articles and the grey literature. I will resolve this tension between aiming to be ‘patient centred’ and taking an ‘objectivism’ standpoint by ensuring that I critically reflect on the process of inquiry and ensure I strike a balance between representing literature from a patient’s knowledge perspective and an observational professional perspective.

Based on work by Grant and Booth (2009) this will be performed by critically reviewing the literature and by evaluating its quality, encompassing:

* Reading and understand the main points in an article.

* Analysing findings of an article.

* Choosing suitable criteria which to evaluate the article.

* Providing a critical evaluation of the article based on the criteria selected.

1. Strategies for literature search

1. Electronic modes of search

MEDLINE, The Cochrane Library, EMBASE, CINAHL Plus, EBSCO Nursing Source, Pub Med, Web of Science, Science Direct, British Medical Journals Online, Wiley Interscience Journals, Cochrane Library, Google Scholar, The King’s Fund and the International Pharmaceutical Abstracts were explored to identify the needed articles relating to the topic. The keywords for the disease (spinal cord injuries) were combined and the complexities associated with such condition were even indicated. At certain instances, medical side-headings (MeSH) were even used as search strategies wherever needed and relevant. As this dissertation is completely linked with the development of leadership for the implementation of revised patient education programme, the grey literature was searched in addition to the databases. This eventually enabled in recognising other relevant examples throughout the country where in various hospitals have developed innovative models and approaches with their patient education programmes on spinal cord injury units. Boolean operators (and, or, not) were even applied during the search mechanism (Hart, 2010).

The critical literature reviews falling within the years of 2000 to 2012 were explored and referred to compare and contrast the studies in relevance to scope of the current topic (Hart, 2010). Various research studies, conference abstracts and reviews that are completely applicable to the present study were included, despite of their journal of publication. Use of this process enabled in effectively averting the complexities of search and assisted in attaining highly organised data for analysis. Exploration of different websites with regard to the health technology assessments and clinical trial registries has allowed in the assessment of non-published information. At the time of exploring the research study, the key words correlating in an effective manner to the study were used. This assisted in the recognition of studies that are completely related to the research question. It also aided in underscoring of much useful and needed information. Assessment of research aim, objectives, study strategies and outcomes (which are the crucial segments of effective exploration reviews) helped in attaining the needed information for the topic (Greenhalgh, 2010).

1. Citation Tracking

The reference and bibliographic lists associated to various related research papers and journals assisted in gathering needed research evidence for the present topic (Parahoo, 2006). To recognise the highly relevant and suitable research study, the bibliographic information published in each and every study was accounted. Once suitable inclusion and exclusion criteria had been established, those studies that appeared to be completely appropriate for inclusion within the study were added and analysed accordingly. Before including the research article, thorough check was made to make sure that the information published was related to the review. Making of these checks even enabled in ensuring that the data did not seemed to be ineffective as a result of not being witnessed in the relevant databases. Many of the available research studies and review articles identified through suitable search phrases were being utilised to include the relevant study. The use of electronic search methodology for the present project appeared to be best; however, it consumed considerable levels of time (Hart, 2010).

1. Methods

For exploring different ways of implementing successful patient education for the spinal cord injured patients, the methodology of critical literature search enabled in obtaining useful information. This methodology encompassed a comprehensive investigation of different available literature, reading books, research articles, journals and other related materials. Grey literature together with the discussions made with senior colleagues and other staff were included in the study. Different forms of advice, recommendations and practical implications were accounted for together with the individual, personal and field experiences. Contact with other spinal cord injury centres in and around the country (the United Kingdom) enabled in collecting possible and concrete evidence suiting the practicality of the study (Parahoo, 2006).

The tactics and knowledge gained from being a professional nurse were used to work in a patient centred way to carry out the study. The tension existing between the concepts associated to “patient centred” and undertaking an “objective” standpoint was resolved by making sure of critical reflection on the process of inquiry. In addition, ensuring of balance between representing literature from a patient’s knowledge perspective and an observational professional perspective also helped in minimising research related complexities. The suggestions provided by Grant and Booth in 2009, on critical review of literature – reading and assessing the crucial points of an article, examining the findings of the research study, considering the appropriate criterion for analysing the article and offering critical assessment of the research review depending on the selected criteria, helped in effectively assessing the research study quality.

1. Inclusion and Exclusion Criteria

Research studies published in English and from the period of 2000 to 2012 were included in the literature review. Various double blind randomised controlled trials, systematic review studies, critical literature reviews were accounted for the inclusion. Research studies that utilised experimental, survey and observational methodologies and confining to the research question were included for synthesising effective information. The pre-established exclusion criteria for the present study-irrelevant study design, longer study periods, different research aims, interventions and outcomes were used to filter the study collection.

The research studies related to traumatic spinal cord injuries (to obtain information needing long term rehabilitation), patient education (for comparison of patient education strategies amongst individuals with spinal cord injuries), teaching and learning in the settings related to health care were accounted for inclusion. Research studies focusing on the rehabilitation of spinal cord injuries (only base for comparing the patients with spinal cord injuries), patients gaining education during spinal cord injury, from year 2000 to till date (to compare and contrast the information related to the subject and make an up-date on the patient education) and multidisciplinary methodologies to patient education were included. In addition, studies encompassing spinal patients (to record and understand their personal experiences), implementation of measures related to patient education and international research (for gaining culturally rich information from various countries and use them for making trials on the multi-disciplinary populations of the United Kingdom) were considered for inclusion. But, the specialist literature considering spinal cord and sustained head injury (head injury with spinal cord injury is more complex and need different approach for dealing), minor spine surgeries (as they need minimal hospitalisation), learning complexities, back pain (as it is not associated to the research aim of the present study), spinal cord injuries in children (since the spinal unit I work doesn’t deal with children), and studies older than 2000 (explore more up to date information) were excluded.

Following tables clearly tabulate the inclusion and exclusion criteria followed for the study:

Inclusion criteria:

1. Literature with traumatic spinal cord injuries. This usually lead to spinal injuries requiring long term rehabilitation

2. Literature with patient education. To compare general patient education strategies with spinal injuries.

3. Literature with teaching and learning in health care settings.

4. Literature with spinal cord rehabilitation. As the study is only base on the patient with spinal cord injuries.

5. Literature with patient educating in spinal cord injury.

6. Literature from 2000 to present. To get more up-to-date and latest information on the subject.

7. Literature with multidisciplinary approach to patient education

8. Literature about the implementation of patient education.

9. Literature including spinal patients about their experience.

10. Literature including international research worldwide from developed as well as the non-developed countries. This will help to get culturally rich information from different countries; in return the information can be used for the multi cultural population of the UK.

Exclusion criteria:

1. Literature including spinal cord injury with sustained head injury.

Head injury with spinal cord injury is more complex and need different approach altogether to deal with.

1. Literature with minor spine surgeries. Because this usually doesn’t need long

term hospitalisation.

3. Literature with back pain.

4. Literature with learning difficulty. To make the process comparatively easy as

this can be challenging dealing with spinal patients with learning difficulties.

5. Spinal cord injuries in children. The spinal unit I work doesn’t deal with kids.

6. Literature older than 2000. To explore more up to date information.

1. Search Terms or Keywords

For the collection of data, in relevance to the research topic, various key words and related combinations were used. The search phrases of-“Patient education”, “education in health care setting”, “factor affecting education”, “learning in hospital”, “hinderance in education after spinal injury”, “failing factors in patient education”, “learning after loss”, “un effective education”, and “adult learning” assisted in gaining needed information. At certain instances, use of key words related to “Leaning theories”, “spinal cord injuries”, “spinal cord rehabilitation”, “effective rehabilitation”, “health promotion for people with disabilities”, “effective patient education”, “rehabilitation of the spinal cord injured patients”, “goal planning for spinal patients”, “long term rehabilitation”, “complications after spinal injuries”, “implementation of health education”, “the need of rehabilitation”, “effectiveness of education”, “the right time for education in rehabilitation”, “the experience of spinal cord injury”, “cost of readmission after spinal injury”, and “Spinal Cord Injury Interdisciplinary education” enabled in gathering much information for developing well-defined conclusions. Boolean operators (AND, OR and NOT) were even used for this project to explore the research reviews related to the topic. Use of these operators assisted in collecting the research studies that considered spinal cord injuries and patient education.

1. Critical Appraisal Tool

Carrying out the literature search for the present topic is guided through well-established set of principles and procedures. For this purpose, a relevant and much effective critical appraisal tool was used and this aided in systematically critiquing the articles explored in the literature. The use of critical appraisal tool developed by Aveyard and Sharp in 2011 helped in investigating the answers for questions such as-“who is the author of the paper?”, “In which journal the relevant article for appraisal have been published?”, “has review been carried out in a systematic manner?”, “what are the crucial methods utilised by the researchers to meet the aims underlined in the review?”, “Does researchers completely demonstrated the facts that they carried out every thing?”, “what are the benefits and limitations governing the research?”, and “what are the future implications for the research?”. I have rated overall usefulness within table 4.2 (page 35) where * equate to some part of the study meet the criteria **equates to partially met usefulness criteria with very few weaknesses while *** meaning fully met.

Besides, the questions linked to senstivity of the research context (does the research design possess considerable flexibility in making changes?”), primary marker (does the chosen research sampling method (does study sample purposefully shaped the theoretical perspectives and levied focus on the diverse contexts and meanings?”), quality of information (what different knowledge sources were used for understanding about the issues being explored or compared?”, theoretical appropriateness, generalisability (does the study enable in making generalisations in a logical and theoretical way?), validity and applicability.

1. Theoretical Frameworks

This framework includes methods and processes for exploring the future implications and suggestions for practice. The theoretical framework or gap analysis model developed by Parasuraman (1985) was used to obtain the needed information. This model aims at exploring differences between standards and their delivery. The underlying reason for choosing this model is to explore the gaps and limitations existing in the current practice. It is important to keep up the service package, since the expectations and assumptions of patients and service users are rising. Use of this gap analysis model has enabled exploration of the patients’ expectations, service providers, and users together with the staff.

This gap analysis model also helped in investigating on possible reasons as why the associated expectations are not met in an effective manner. Since the gap analysis tool was found to be considerably cohesive with the research findings, it is even used to explore the gaps in offering effective patient education in the unit related to spinal cord injuries. The process of current patient education and its associated implications were analysed thoroughly and any possible gaps (that existed if any) were identified by using gap analysis theory (A diagram is attached for reference in figure 1).This model was even applied to the patients’ education process in the present study to look for the possible gaps and weaknesses.


(Figure. 1)

1. Assessment of Validity

The internal validity pertaining to each of the selected research studies was analysed depending on the pre-defined set of criteria developed by the Aveyard and Sharp in 2011. . At certain points, the external validity, applicability and generalisability was even assessed, however, this not effectively influenced the quality ratings. Each and every selected study was rated as per the fatal limitations and benefits and studies failing to meet the criteria were excluded.

In the present project, a considerable number of studies attained fair ratings. The information collected through literature search methodology was pooled by assessing the relative risks and sizes. Different tests were used to assess the publication bias, though the validity of methods was minimal. All the research studies that effectively satisfied the inclusion criteria were analysed through the utilisation of quality assessment tool. Assessment of each of the found pieces of research work was made in terms of quality to ensure about the incorporation of best quality of studies. Since the appraisal of the study is important as indicated by Parahoo (2006), each of the studies was assessed for validity, reliability and precision before making a conformity and inclusion in the report. This type of quality assessment through the use of above questions outlined in the critical appraisal tool has helped in efficient reflection of internal validity of various research studies (Greenhalgh, 2010).

1. Summary

This chapter has outlined the search terms, strategies, study design, inclusion and exclusion criteria and quality assessment tools used for the research. Further chapters will consider the relevant research studies and outline the illustrations that form a basis for well-defined conclusions.


Spinal cord injuries can be considered as insult to the spinal cord resulting into traumatic implications instead of disease. The symptoms of Spinal Cord Injuries and its associated factors influencing patient education vary widely from pain to paralysis and even to incontinence (Yunchen and Boore, 2006). More particularly, these involve if the injuries associated to the patient interfere with their daily activities of living (Bennett et al., 2004). A critical exploration of factors influencing the success of effective patient education in the rehabilitation unit for individuals with spinal cord injuries is important for diagnosing the condition and this chapter makes an effort in outlining such illustrations. A systematic overview on different statements outlined in different research reviews, conference abstracts and articles will be provided in the further sections.

In general, spinal cord injuries enhance the physical and psychologic declines and cause changes within musculoskeletal, cardiovascular, gastro-intestinal, pulmonary and other integumentary systems (Valliant and Loghin, 2009). A considerable proportion of long term follow-up studies have been carried out and numerous researchers have documented the inherent ability of patients with spinal cord injuries to age at a faster rate than the potentially bodied population does. Individuals with spinal cord injuries inherit characteristics and medical complexities more usually related with the process of ageing at a very younger age (Tranfield et al., 2003).

Various research studies (Valliant and Loghin, 2009, Tranfield et al., 2003, Loghin, 2009, Bloeman et al., 2003, and Yunchen and Boore, 2006) have indicated the fact that patients with spinal cord injuries of fifteen years or more experience 93% decline in the functional status. Rehabilitation of different spinal cord injuries has an increasingly important role. Prevention of secondary complications, enhancement of physical functioning and reintegration into the community are the prime goals of rehabilitation (Bloeman et al., 2007). In line with the enhanced demand for the patient education over the past few years, there was been a dramatic shift from the paternalistic intervention by health care professionals to an increasing identification of patient independence with regard to their personal health care (Krassioukov, 2009). Much emphasis was laid on patient rights to evidence-based, customer oriented, precise and balanced information to enlighten patients to be actively involved in their care. To enable efficient and optimal use of medications during spinal cord injuries, there is a need for research that focus on the assessment on how patients use their available education (Loghin, 2009).

Various secondary conditions related to spinal cord injuries can be minimised by relevant self-care or self-management. But, the present scenario of minimal rehabilitation stays for spinal cord injuries illustrate difficulties in accessing the information. The specialists associated to spinal cord injuries need patient and their family members to absorb information on self-care more quickly whilst in hospital. As per the study of Loghin (2009) study, patients need to be much proactive in exploring information about health care once they get discharged from the hospital.

There is still evidence that information overload on minimal rehabilitation stays involve with the patients and their family’s ability to completely master the skills and information needed to avoid secondary complexities subsequent to leaving of hospital. Much more than before, patients with spinal cord injuries require more timely and high quality information on health and medical issues following discharge and all throughout their lifetime to decrease secondary conditions, remain healthy, promote well-being and quality of life (Matter et al., 2006). The injuries associated to spinal cord are explained at different levels of incomplete, varying from no significant effect on the patient to a “full” injury reflecting a complete loss of functional abilities. Diagnosing various spinal cord injuries initiate with restraining the spine and regulating the inflammation to minimise further damage (Zemper et al., 2003). The usual treatment can differ widely relying on the location to the level of injury. In most of the cases, the injuries associated to spinal cord need substantial physical therapy and rehabilitation (Williams, 2007).

Research on the spinal cord injuries has been carried out, but minimal information prevailed on the impact of ineffective patient education in spinal cord injuries. An effective and efficient understanding on different factors impacting patient education will allow health care professionals to shape the design and delivery of care to spinal cord injured patients in meeting their needs (May et al., 2007). Various patients actively seek a wide range of health related information. Nevertheless, as the information can be passively collected, there are certain individuals who even fail in looking for information. With regard to patient education, the factors that influence patients to undertake an interest can be active or even passive and much of it is largely unknown. Possible factors exerting impact on successful patient education can be arbitrarily divided into those that are related to the patient and even the environment (Cortez and Levi, 2007).

In the research study by Loghin (2009) patients with spinal cord injuries indicate significant utilisation of the Internet for health information. But in contrary, the studies of Burkell and co-workers have found that about one third of populations utilised Internet for spinal cord injury information. On the other hand, the general and specialist health care professionals used three fourth’s of the sample. Internet was the prime source rated to be as the most accessible and least reliable. Interpersonal resources, like the spinal cord injured patients and other health care professionals use, was rated to be as the reliable source for enhancing patient knowledge. Quite a close examination of the studies indicate the fact that the findings are inconsistent regarding the use of Internet and suggest the need of more research to determine the Internet application of individuals with spinal cord injuries. Hart et al (2010) carried out a survey of patients with spinal cord injuries residing in the community to recognise the information and education needs. Topics were completely limited to three prime domains (sexuality, wellness and medical).

Significant proportion of patients indicated “increased interest” in various exercise programmes (53.25), nerve testing (51.4%), bladder and kidney complexities, pain, sexuality issues, and spasticity and stress reduction issues. Another small study by Hart et al (2010) have found that patients most identified information needs persisted in the areas of aging, research, financial aid and recognition. Research study by Matter et al in 2009 have explored the information needs and effective measures to be undertaken to improve patient education during rehabilitation of spinal cord injuries. As indicated in the study, patients with spinal cord injuries possess enhanced life time risk for clinical complexities and other health implications secondary to their injury. Various secondary conditions can be minimised or mitigated with the use of effective patient education, relevant self-care and self-management.

To enable effective and successful patient education, patients with spinal cord injuries require timely and high quality information on health and medical issues. But, this needs to be prevailed following discharge and all through the lifetime to enhance self-care and quality of life. Results of this study confirm the fact that, though patients with spinal cord injury obtain information from experts, the Internet is most and effective source for reliable information. Level of education and race- the most influential factors hinder the implementation of successful patient education (Potter et al., 2004).

Through a rapid communication with the relevant health care provider, on medical status, healthcare concerns and personal medical information, patients with spinal cord complexities would potentially gain benefit. In addition, exploring about the vital signs, information about blood sugar and use of medication could also assist in gaining considerable benefits (Cortex and Levi, 2009). Patients suffering with spinal cord injuries possess complex, medical, social and discharge planning needs. According to Cortez and Levi (2007), Krassioukov (2009) and Loghin (2009), spinal cord injuries expose the individual towards deleterious consequences. The financial costs associated to this type of injury are immense and its associated injury complications following the disease can even boost up the costs (Matis and Birbilis, 2009; Drigotaite and Krisciūnas, 2006). The consequences subsequent to the spinal cord injury usually influence the life of an individual in a negative manner. The associated spinal cord complexities can be resolved through the access to effective and efficient patient education. But, this delivery can be a challenging process (Potter et al. 2004).

The study by Potter et al (2004) has examined factors inhibiting learning in the health care settings. As per this study, presence of symptom and absence of knowledge, medical awareness, high pressure and work load as well as waiting are the prime barriers to efficient and effective patient discharge education for spinal cord injured patients (Potter et al., 2004). The presence of continual care and support, detention and inclusion of pharmacological interventions prevailing in the setting of spinal cord injury rehabilitation will definitely contribute in the need for health care practitioners to ensure that they do not violate patient rights (legal and ethical). Certain inpatients experience more complexities while reading the patient education materials in the rehabilitation and hospital settings. This can be attributed to the noise and activity. The modification in the maintenance of information immediately subsequently to learning and two weeks following the study was effective for patients who were not completely distracted by their children. The previous studies offered insight to a wide variety of factors that contributed to decrease in the patient education (Matis and Birbilis, 2009; Drigotaite and Krisciūnas, 2006). Although the studies included the significance of controlled measure of inhibitor, the dose of Midazolam, what still remains unclear is the level of distraction influencing patient education under similar conditions.

Presence of background noise and disturbance in teaching patients frequently prevail in health settings. Both of these factors indicate a form of distraction. But, no significant variation in learning was encouraged between patients in the distraction condition to that of the ones not distracted by the spaceship information. Patients who were distracted took considerably more time to understand the implications of spinal cord injuries than the non-distracted individuals.

Time commitment, cost of therapy, income and social support are some of the social and economic factors influencing success of patient education in spinal cord rehabilitation. Cost is one of the crucial issues in patient education, more specifically for patients with the chronic spinal cord injuries. This is because the treatment period appears to be too long and may be even life-threatening. Though, cost and income are interrelated, the health care costs must not become an overburden if the patient possesses relatively more income and health insurances (Harrison, 2006).

Patient compliance and education towards the spinal cord injuries are even dependent on the degree of behaviour and therapeutic outcomes attained. Since an enormous amount of time and energy is spent establishing and reinforcing care routines with SCI individuals as well as their carers, an effective follow-up of different recommendations will definitely help in attaining positive outcomes. Information and philosophies of care must be offered to service users; especially patients and their families according to their needs. This should reflect information with the background of why and how things can go wrong. For instance, to minimise pressure sores, the patients with spinal cord injuries need to be educated to maintain the regular intervals of turning during the periods of enforced bed rest or at night. But if community patients ignore these instructions they often end up with pressure sores which are the major cause of readmission to the hospital (Harrison, 2006). To overcome and avoid secondary complications after SCI there is a need of adhering to a well-structured and effective patient education programme (Gélis et al. 2011; Matter et al, 2009).

Amongst the broad range of factors, the ones related to the patient arguably influence the patient’s education in spinal cord injury rehabilitation. Presence of symptoms in diseased state is considered as one of the main factors impacting the symptoms of patient use of education (Potter et al., 2004). Functional health literacy, termed as the underlying ability to understand and act accordingly to the health information is one the basic requisite influencing the patient education. A minimal level of health literacy is linked to deleterious health condition and enhanced use of health services. Despite of the fact that patients with poor health literacy will possess complexity in getting relieved of the spinal cord injuries, it is still unknown as whether this will limit the patient education (Tooth et al., 2004). Health locus of control relates to the degree at which individuals attributes their personal health outcomes to outsiders and themselves. Internal health locus of control is found to be intricately influencing the behaviour of patients and health care professionals towards education. Besides, it is also known to impact the adherence to medical treatment and screening of diseases (Matter et al., 2009).

Patient education is a crucial part of spinal cord injury rehabilitation. With an underlying objective of preparing individuals with spinal cord injuries to meet their day to day challenges, the study by May et al (2006) evaluated the experiences of patient education programme from the patient’s viewpoint. The qualitative study involved a semi-structured interview format with twenty two patients gathering relevant information on the factors influencing patient education. Learning readiness, learning effects, exploration of complexities, involvement of families were the prime factors that influenced patient education. Besides, partnership learning and individuality were even recognised as some of the implications. Although the study by May et al (2006) offered valuable information from the patient’s viewpoint (used to enhance the patient education programmes), it still needs highlighting of adult learning principles (May et al., 2006).

With the help of in-patient education programmes, the patients with spinal cord injuries learns to assess and control the physical, emotional and social well-being (D’Hondt and Everaert, 2011). Determining the knowledge, problem solving skills with regard to spinal cord injuries at admission, discharge and six months follow-up is crucial and this research was laid forward by May and his co-workers in 2007. This study even determined the perceived important of each context topic included in the education programme (Dahlberg et al., 2004). Knowledge and associated factors influencing patient education were evaluated with the Multiple Choice Questionnaire (MCQ) and perceived significance of each implication was rated on a five point Likert scale (May et al., 2007). Considerable improvements in the MCQ scores were evident from admission to discharge, problem solving ability and improvement from follow-up to bowel care. Bowel, bladder and associated skin care seemed to as the most crucial education topics. The study indicated the fact that improvements in knowledge do not completely translated to problem solving ability improvements. Although the study was effective in outlining the relevant considerations about patient education, it still needs to include more active learning strategies and other contextually dependent interventions within the programmes related to patient education. Use of these will definitely facilitate the transfer of knowledge within the life situations (May et al., 2007).

The retrospective study by Tooth et al in 2004, predicted the satisfaction levels with medical rehabilitation after the spinal cord injury. The study explored the information submitted to the Uniform Data System for Medical Rehabilitation. Different socio-demographic factors, case mix groupings, length of stays, rehospitalisation, and follow- on therapy and maintenance of health were examined (Tooth et al., 2004). The conclusions of study ascertain the fact that satisfaction with medical rehabilitation services following the spinal cord injuries is completely linked to the functional skills, marital status and other hospitalisation measures. Certain levels of different results were even found for whether satisfaction was even rated through the patient and their family. But, quite a close examination of the study indicated the fact that the complex relationships amongst satisfaction, demographic implications and functional levels need persistent investigation (Tooth et al., 2004).

The study by Franks in 2007 indicated the financial implications associated to pressure sores. By outlining its equivalence to the price of diagnosing mental health, the study outlined the requirement of around 2.5 billion Euros. Although, effective patient education helps in resolving the issue, other secondary complications influence the experiences of disability for individuals with spinal cord injuries (Potter et al., 2007). These experiences impact the quality of life, long term health conditions, dignity, mobility and mortality and independence of patients (Franks, 2007). As per the study of Dorsett and Geraghty (2008), the associated social and psychological factors related to patient education even delay the admission of new patients from acute wards to the community level (Roy and Saunders, 1999). Critically speaking, these factors and its underlying implications appear to be frustrating for the unit as it completely hampers the attainment of success and required goals (Dorsett and Geraghty, 2008; Hammell, 2010).

Provision of information (and associated philosophies) is the most important measure offered to service users. This information includes patients and their families as per their needs with the background of why and how things can go wrong. Individuals with spinal cord injuries need to be educated to maintain the regular intervals of turning and offered rest at night. However, if the patients (more specifically the ones sustaining in community) ignore these instructions, they completely end up with the serious consequences (such as pressure sores). According to the Makhsoos et al (2007) study, relieving of pressure is the most important step of preventing the influential factors related to patient education. Educating patients during their stay in the rehabilitation unit is important to attain significant benefits. But, numerous patients with spinal cord injuries ignore the significance of pressure relieving procedure and result themselves in getting exposed to pressure ulcers (Makhsoos et al., 2007).

The important elements of patient education-skill building and responsibility help in offering an improved understanding of medical condition, diagnosis and disease. Knowing when, how and why the individuals need to make a lifestyle change is important to increase motivation and self-efficacy. Through the more effective utilisation of medical services, satisfaction and referrals, risk management techniques, informed consent and patient outcomes information, each member of the health care team can make a positive approach. Coping style, levels of literacy in health and occupation, health locus of control and disease state are the main patient related factors influencing their interest and education (Makhsoos et al., 2007). By assessing the utility of medical information and patient education for various patient groups and more specifically meeting the patient needs could help in reducing the effect of factors (Koo et al., 2006). Presence of finances, communication ability of doctor and patient (about the location of medical resources), location and race, gender and ethnicity are some of the factors influencing patient education in spinal cord injury rehabilitation. In addition, factors associated to personal beliefs on medical care and practitioners also exert considerable impact on the health and overall well-being of patients (Makhsoos et al., 2007; Koo et al., 2006).

Certain demographic factors play a crucial role in influencing patient education. In accordance to the literature outlined on the health behaviour, younger age, socio-economic status, level of education are completely associated with the involvement of health promoting behaviours (May et al., 2007). In addition to these, higher socio-economic status and being female are also related with the patient education and seeking of health related information. But, it is completely uncertain whether these factors impact the patient interest and use of treatment strategies for spinal cord injuries (Makhsoos et al., 2007; Koo et al., 2006). Depression after SCI is a common condition (Krause et al. 2010; Kemp and Krause, 1999). This can significantly hinder the understanding and perception process (Kemp and Krause, 1999). The assessment and identifying such hurdles is vital and is a skill in the delivery of patient education (Yuchen and Boore, 2006).

The recovering or coping style of an individual play a crucial role in determining the interest of patients in spinal cord injuries. Whilst some of them cope in an active manner by involving in the treatment, others tackle the spinal cord injuries through avoidance. Offering detailed, clear and concise information would definitely help these patients in future (Tooth et al., 2004).

Patients with sufficient health literacy levels appear to be more interested than the associated counter parts in successful patient education. Health professionals must encourage the utilisation of appropriate information and ensure the access to reliable information sources (May et al., 2006). Assisting patients by referring them to various credible sources and being prepared to solve potential questions arising from the information search could help to a considerable extent. Understanding the underlying reasons about the disinterest in patient education could help the health care professionals in deciding the best way to tailor the information. Relying more on the simple verbal information, keeping in mind that patients with poor health literacy abilities is another strategy (May et al., 2007).

Promoting the ways to attain information and using sufficient time to explain the information could serve as a useful reference for the medication use and successful patient education during spinal cord injuries. Considering the individual as a bio-psycho social being and enhancing adaptation ability to social, mental and psychological change (as a health indicative) could help in promoting well-being. The fundamental aims of patient education for the people with spinal cord injuries-promotion of healthy living and environment, reduction and prevention of secondary conditions (such as pressure ulcers, obesity and bladder complications), managing own physical and health conditions, maintaining functional independence and enhancing quality of life need to be placed in mind (Tooth et al., 2004).

Achieving the goals involve hard and crucial parts. These include choosing the best way of implementing patient education process (Dorsey, 2005). By knowing about the quality improvement measures and adverse effect tests for spinal cord injury rehabilitation, patients can minimise the complications that may occur in future. However, it is much more important even for the health care practitioners to make a check on a timely manner as this may lead to potential complexities (May et al., 2007). Adhering to a well-structured patient education programme and avoiding mistakes help to a considerable extent in minimising complications. Presence of a state of adaptation assists in freeing individual’s energy to respond to various other stimuli. With a multi-disciplinary team based approach involving physical therapists, occupational therapists, rehabilitation nurses, psychologists, speech language pathologists, rehabilitation of spinal cord injuries can be effectively attained (Kemp and Krausse, 1999). In order for the patients to attain more benefits out of their rehabilitation programmes, it is much necessary for them to work hard. High expectations for patient involvement need to be set at the time of admission through discharge. It is important for patients to understand the fact that rehabilitation is different from other types of models, where patients are usually taken care of. Patients need to be encouraged to possess input in to their programme and schedule, comply with the different educational requirements, involve in outings and use the fullest advantage of all possible resources (Makhsoos et al., 2007).

The important implications of patient education-patient behaviour, readiness to learn and compliance and its usual reason for failure should be explored. The concept of readiness in patients with spinal cord injuries is much critical and information linking to these should be a definitive implication (Moullin, 2002). But, as the common acute conditions such as spasticity, pain and urinary tract infections may hamper effective learning process, the readiness for accepting information tend to be more challenging. Sufficient resources and staff, another crucial requirement for thriving learning and maintaining its presence is most important for achieving success. Collecting more culturally sensitive and personally relevant information is one of the crucial strategies. Instead of overlooking the information, patients need to be enabled to discharge to community to face the reality on their own without the expert on site (Harrison, 2006). Investigating and looking into the life of the individual with spinal cord injuries, whilst they are in the communities will appear to be interesting to explore the review studies. This could definitely help in discerning how the individual copes in the community after being discharged from the rehabilitation unit. It is not uncommon for SCI patients to overlook the information once they are discharged to community to face the reality on their own without the expert on site (Harrison, 2006).

Although, the above mentioned research studies have indicated that patients with spinal cord injuries are concerned in exploring health related information and other data linked to spinal cord injuries, data is completely sparse with regard to the specific information needs (Potter et al., 2004). Besides, the data relating to patient education and information seeking behaviours was inconsistent and non-reliable. It is crucial that successful patient education must make the patients as independent as possible and also enable them to act as a part of the society (Parasuraman et al., 2007). Since patients with spinal cord injuries, experience complexities to finish up the daily activities of dressing, cooking, cleaning and working, it is more crucial for them to obtain suggestions on the different ways of using strategies for successful education and other devices. Carrying out more in-depth research to improve the particular activity to be added within the patient education intervention could assist in obtaining useful implications (Pagnotta et al., 2005). More specifically, with regard to the spinal cord injuries, research is still needed to conduct and estimate how benefits from successful patient education and stimulating activities are persuading on the patient performance in overcoming day to day challenges.

The findings of this critical review of the literature illustrated in this chapter can provide extensive information for the effective and efficient implementation of strategies as a therapeutic measure for patient education. Many positive findings are presented in the review, indicating the value of patient education as an approach for spinal cord injured patients; however, current research was ineffective in outlining the areas that are under threat. Much research is still needed to develop effective activities and areas prone to immense impact. In relation to spinal cord injury rehabilitation, much research is needed to explore the effective strategies on successful patient education and how its associated factors influence the attainment of positive outcomes. Despite contrasting interpretations, the research reviewed highlighted the strategies for effective patient education.

Patients suffering with spinal cord injuries can use the holistic and problem solving approaches to address the relevant challenges and complexities. The therapists and professionals working with patients are highly accountable for safeguarding that exercise and approaches directed are effective and based on recent evidences. The standards of accountability, awareness, advocacy (carrying out best for patients and their relatives), sensitivity (respecting the patient), objectivity (considering all patients in a similar manner), consideration and respect (ensuring about the patients as whether they are always treated with dignity) enable patients and family in offering relevant information about the clinical condition. In addition, the ethical issues linked to confidentiality, co-operation, protection, development, alertness, accountability, good character and consent succour the health care professionals in moving along with the interests of patients and their families (Doel and Shardlow, 2009).

Implementation of above mentioned strategies for successful patient education can allow patients and their health care workers in overcoming complexities related to the capability, defiance of lifelong learning, functioning policies and guidelines, specialized malpractices and supplementary tasks allied to the work load. With these strategies and above outlined illustrations, the patients need to keep an update with trends, maintain competence, learn new technical and interpersonal skills, develop policies and protocols and safeguard their health and quality of life (Doel and Shardlow, 2009). Through a summary of main provisions with regard to the treatment of spinal cord injuries and patient education, the different frameworks function as support for the care principles developed by rehabilitation settings. It is therefore, crucial for patients to explore in depth on the information about successful patient education that applies to spinal cord injured patients in their professional capacity, along with the responsibilities it aims to protect (Leathard, 2003). Regardless of place, period and age, the spinal cord injuries are causing a foreseeable part of operating practice for health care professionals. In addition, the field of successful patient education can allow in effective team work, improve work environment, and increase mutual respects and share knowledge within different fields (Jackson, 2007). But, the numerous practice based factors such as unrealistic expectations, lack of knowledge, perceived threat, professional jealousies, and impaired autonomy that result in witnessing serious consequences need to be resolved in an efficient and effective manner (Miller and Freeman, 2001).

Despite of above factors, the effect of learning environment need to be explored and tested to implement successful patient education (Koo et al., 2006). Replication of different research studies in the health care environment would definitely assist in clarifying the findings. Furthermore, they also help in making them applicable to health care settings. Testing the role of patients and their interest in patient education will definitely clarify the issues surrounding the inconsistency of information influencing learning (Kemp et al., 1999). By examining different patient outcomes, along with the potential for much effective and efficient learning, avoiding misunderstandings on self-care, patient anxiety could help in enhancing patient satisfaction (Kroll et al., 2007). As patient education empowers patients with sufficient information, greater efforts need to be made to design environments with minimal disturbance, more particularly at times when understanding the information supplemented on health is critical (Mahoney et al., 2007).

Thus, patient education, in developing a more visible activity needs to be effectively established and maintained in terms of quality (Rimmer, 1999). It needs knowledge of the subject and accurate assessment of abilities, motivation and readiness (Saunders et al., 2007). Presence of clear and hands-on presentation using visual and other aids as appropriate is important to minimise the consequences (May et al., 2006). Feedback, as one of the most essential implication enable in gaining rewards and benefits. It is important for the patient to draw attention to areas that necessitate further clarification (Sarhan, 2008). Presence of long term, repetition and flexible approach are crucial, at times of change the lifestyle of patient. Supplementation of text with pictures assists in offering self-care or medication instructions (Miller and Freeman, 2001). By tailoring medication schedules to fit the daily routine of patients, using colour coding medicines and daily events such as reminders help in increasing compliance (Pozgar, 2010).

Use of video-taped patient education materials, podcasts or blogs enable in increasing knowledge and enhance correct self-care. Emphasising on the desired behaviour instead of medical facts could aid in obtaining effective implications as patients find it complex to relate abstract statistics with self-experience (Jackson, 2001). In conclusion, the above mentioned strategies possess the potential to enhance the development of efficient and effective patient education and disease management in caring for complex patients in outpatient setting (Kay et al., 2007). The implemented patient education measures must improve the efficacy of managing patients, improving their overall health and decreasing the complete cost of offering care. Ideally,, a well-designed research studies potentially free from bias need to be conducted to assess the medical and economic influence of factors related to patient education and spinal cord injury management.

1. Summary

This chapter provided a comprehensive review on different research and evidence-based studies linked to patient education and spinal cord injuries. It also outlined strategies for implementing successful patient education. Further chapters will outline the discussions in relevant to the chosen studies and develop a valid conclusion.


1. Process of Screening and Data Extraction

From the initial search, around one hundred peer reviewed research articles on spinal cord injuries and patient education were identified. From this list, the compliance with the inclusion and exclusion criteria, effective exploration of research aims, existed only on 40 papers. Within the process of second screening, around 30 studies were screened owing to their effective compliance with the inclusion and exclusion criteria. The agreement with respect to each individual study seemed to be perfect within the second stage of the screening process. In the third screening, around 10 studies were excluded, especially due to the fact that the researchers seemed to be futile in adhering to the standards. With the studies appearing to be completely appropriate, following the final screening, only 13 eligible studies were included for complete data extraction and critical examination. I have rated overall usefulness within table 4.2 using the critical appraisal tool of Aveyard and Sharp (2011) as discussed on page 17.


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