PATIENT COUNSELING and education are key components for effective self-management and monitoring required with many acute and chronic conditions. Current evidence-based guidelines for complex conditions, such as asthma and diabetes, include patient education as an expected aspect of care (Canadian Asthma Consensus Group, 1999; Taskforce on Community Preventative Services, 2002). Patient education is provided in a variety of settings across the continuum of care. In ambulatory care and outpatient settings, health education has been shown to improve outcomes for patients (Deakin, McShane, Cade, & Williams, 2005; Gibson et al., 2007). Although not always recognized, emergency departments (EDs) offer an important opportunity for educational interventions. However, on the basis of studies utilizing chart audit and patient recall, the ED appears to be underutilized as a setting for delivery of health education (Demorest, Posner, Osterhoudt, & Henretig, 2004; Dunn et al., 1993).
EDs have become major access points for healthcare in many jurisdictions, where a large proportion of visits are for nonurgent problems (Canadian Institute for Health Information, 2006). In part, presentation to the ED for nonurgent conditions is due to poor access to primary care (Drummond, 2002) and for some, it may be the only point of contact with the healthcare system (Partridge, Latouche, Trako, & Thurston, 1997). Because of this shift in healthcare utilization, there is an increasing need to consider delivery of patient education and counseling in EDs. However, there are many barriers to providing adequate patient education in this setting. Overcrowded conditions and the length of time required to provide the necessary information may affect ED staffs' ability to provide teaching (Drummond, 2002). While some believe that the ED is not an appropriate venue for education (Masters, Hall, Phillips, & Boldy, 2001), others believe that it offers a unique "teachable moment" during which time patients may be motivated to learn from healthcare providers (Bowling, 1993; Todd, 1996). In some cases, moderate stress enhances an individual's ability to learn, particularly if the information provided is not too complex (Shors, 2004). Considering all opportunities for patient counseling and self-management support including the ED seems prudent in today's healthcare environment.
Bloom's Taxonomy of Learning Domains is a widely used framework in education that identifies learning outcomes or domains (Redman, 1988). According to Bloom's theory, learning can be divided into three main domains: cognitive, affective, and psychomotor. Each domain includes levels of increasing mastery. Cognitive learning involves the acquisition of knowledge. Simple cognitive goals can be measured by evaluation of recall, understanding, or comprehension, whereas more complex goals may measure the application of knowledge or development of a model or framework. Affective learning involves the internalizing of values, attitudes, or beliefs. In its simplest form, affective learning goals can include being willing to hear information or actively participating in learning. Complex learning goals in the affective domain require the participant to adopt a new value or belief system. The psychomotor domain is a learning process that involves the mastery of skills. These learning goals can range from simply copying a demonstration to automated mastery of the technique. Weston and Cranton (1986) utilized Bloom's taxonomy and identified optimal teaching methods for each level of the three domains (Table 1). Although Weston and Cranton's framework was created for use in the design and evaluation of education in traditional classroom settings and not healthcare settings, some of the methods suggested may be useful in the ED. The challenge is to effectively provide the optimal education using the time and resources available in a setting such as the ED.
Currently, we know little about the effectiveness of providing education in the ED. In a 2000 review, Wei and Camargo (2000) synthesized the research on patient education in the ED identifying studies related to populations with asthma, myocardial infarction, psychiatric conditions, and injury and trauma. Because so few studies focused on education done exclusively in the ED (n = 5), the authors included studies with interventions that continued after discharge from the ED (n = 4) as well as interventions conducted in the coronary care unit and acute care wards (n = 6). The authors concluded that educational interventions in these settings, including the ED, improved patient outcomes. Although similarities may exist between the ED and other acute care settings, key differences across settings may impact on important factors related to educational effectiveness, such as time available for teaching and the anxiety of patients. In addition, although ongoing counseling and education is ideal, encouraging patients to attend education sessions may be challenging. In a study evaluating an asthma education program, only 31% of the 164 eligible participants recruited from the ED attended the program (Yoon, McKenzie, Miles, & Bauman, 1991). If individuals are not utilizing primary care for follow-up, it is important that we understand what can reasonably be delivered in the ED and determine the effectiveness of interventions provided only during the ED visit.
We undertook this review to more fully understand the educational approaches used in the ED and the potential benefits of these programs and to update and expand on the review by Wei and Camargo. Weston and Cranton's framework was used to guide the analysis of interventions in the ED. The objectives of this integrative study were to:
1. describe educational approaches currently being tested in the ED (type of teaching methods used, delivery time, and how the intervention is delivered);
2. catalog the research literature on the outcomes being used to evaluate educational approaches the emergency setting; and
3. evaluate the effectiveness of educational interventions delivered in the ED.
METHODS
An explicit search strategy, as well as retrieval procedures and appraisal process, was undertaken with this systematic review. Table 2 provides details of the data sources, search strategy, key words, and limitations used. Articles were included if they were an evaluative research study (randomized control trials [RCTs], quasi-experimental, or observational designs) involving an educational intervention delivered to adult participants (18 years or older) who presented to the ED for treatment or an adult who was accompanying a minor child, and who were subsequently discharged home.
RESULTS
The search strategy yielded 437 potentially relevant unique citations of which 19 met the inclusion criteria and comprised the final set for this review (Figure 1). Although many studies included in this review were also present in the Wei and Camargo's (2000) review, there were a number of new ones (n = 10) and the scope and focus of the new articles were different. Four other studies that included interventions initiated and largely carried out in the ED but continued after discharge were also identified. These studies have been addressed after presentation of the 19 studies focusing on interventions in the ED only. Synthesis of the 19 articles from the primary set and the 4 additional articles are summarized in Table 3.
The primary set of 19 studies that focused on ED educational interventions was published between 1990 and 2005, and was characterized by a range of populations and research methodologies. Ten studies were RCTs and nine were quasi-experimental. Sample size ranged from 59 to 635 participants for the RCTs and 52 to 464 for the quasi-experimental studies. The focus of education was wide ranging and included asthma, injury prevention, whiplash associated disorders, smoking cessation, general health promotion, chest pain, alcohol abuse, AIDS awareness, and medications.
Type of Educational of Interventions
All of the studies included detailed descriptions of the interventions. Two of the 19 studies included multiple interventions for a total of 21 unique interventions. Instructional tools such as written information were the most commonly used in 15 of 21 interventions. Didactic lecture style was used in 9 of 21 whereas discussion was used in 7 of 21 interventions, with demonstration included in 4 of 21 interventions. Three of the four studies that used demonstration also asked participants to practice the skills learned. Most interventions (13/21) used multiple teaching methods.
Many interventions (15/21) used instructional tools that included provision of pamphlets, discharge instructions, and/or information sheets. These instructions were in the form of written or cartoon illustration to be reviewed by the participant following discharge (Barzargan-Hejazi et al., 2005; Berger et al., 1998; Blank et al., 1998; Blank & Smithline, 2002; Clarke et al., 2005; Delp & Jones, 1996; Ferrari et al., 2005; Hayes, 1998; Jolly, 1993; Jolly et al., 1995; Magid et al., 1990; O'Malley et al., 2003; Posner et al., 2004; Richman et al., 2000). In addition, some interventions also provided supplies for the participants to use, such as condoms (Magid et al., 1990), home safety kits (Posner et al., 2004), or pocket electrocardiograms (Blank et al., 1998). Although in some cases, the written information was meant to supplement information provided through other methods such as lecture or discussion, six studies utilized written-only instruction to identify the readability and effectiveness of this kind of intervention (Berger et al., 1998; Clarke et al., 2005; Ferrari et al., 2005; Hayes, 1998; Jolly, 1993; Jolly et al., 1995). In some cases, interventions included modified written materials such as instruction in cartoon form (Delp & Jones, 1996), simplified versions of standard discharge instruction (Jolly, 1995), or information in easy-to-read, large-font format (Hayes, 1998).
Some interventions (9/21) involved the use of brief didactic or lecture components to disseminate information (Blank et al., 1998; Blank & Smithline, 2002; Delp & Jones, 1996; Lyons et al., 2004; Magid et al., 1990; Posner et al., 2004; Richman et al., 2000). Lecture is defined as dissemination of information by the healthcare provider while the patient remains passive (Weston, & Cranton, 1986). For the purpose of this review, interventions were considered to be lecture if they described the interaction as "scripted," or if the instruction was done by means of video or audiotape. Of the nine interventions using lecture, four of the interventions were reported in three separate studies where video was used as the medium for providing the lecture (Blank et al., 1998; Blank & Smithline, 2002; Magid et al., 1990). Videos ranged in length from 5 min (Blank et al., 1998; Blank & Smithline, 2002) to 15 min (Magid et al., 1990). Verbal instruction was used in five of the nine lecture interventions (Blank et al., 1998; Delp & Jones, 1996; Lyons et al., 2004; Posner et al., 2004; Richman et al., 2000), and one-on-one instruction was offered to participants in all interventions.
Discussion between provider and the individual was used in 6 of the 21 interventions (Barzargan-Hejazi et al., 2005; Esler et al., 2003; Kelso et al., 1995; Lyons et al., 2004; Magid et al., 1990; O'Malley et al., 2003). Five of the discussion interventions were described as "counseling" (Barzargan-Hejazi et al., 2005; Esler et al., 2003; Kelso et al., 1995; Lyons et al., 2004; O'Malley et al., 2003), and one was in the form of a 5-min question and answer period following a video lecture (Magid et al., 1990). Time required to deliver the counseling intervention was not specified in two studies (Lyons et al., 2004; O'Malley et al., 2003), whereas one discussion intervention was 15 to 20 min in duration (Magid et al., 1990) and the other was 60 min long (Esler et al., 2003).
Demonstration was used in 5 of the 21 interventions and involved a visualization of a skill to be learned (Blank & Smithline, 2002; Esler et al., 2003; Kelso et al., 1995; Numata et al., 2002; Shrestha et al., 1996). Following demonstration, four of the five interventions asked participants to practice the techniques that were taught (Esler et al., 2003; Kelso et al., 1995; Numata et al., 2002; Shrestha et al., 1996). The demonstration was visual-only or both verbal and visual. Two interventions used only demonstration and practice to teach proper inhaler technique (Numata et al., 2002; Shrestha et al., 1996). Time reported to teach proper inhaler technique ranged from 6.2 to 8.5 min. The remaining studies provided demonstration as part of a larger intervention. Time to complete these interventions ranged from 5 to 60 min.
Outcomes
The 19 studies included in the review incorporated outcomes that cover the three main domains (psychomotor, cognitive, and affective) identified by Bloom. The outcome measures reported in these studies were cognitive (n = 12) and affective (n = 11), with psychomotor measures used much less often (n = 3). Nearly one third (6/19) of the studies measured outcomes in more than one domain.
Cognitive learning was measured in a number of different ways (Blank et al., 1998; Blank & Smithline, 2002; Clarke et al., 2005; Delp & Jones, 1996; Ferrari et al., 2005; Hayes, 1998; Jolly, 1993; Jolly et al., 1995; Kelso et al., 1995; Lyons et al., 2004; Magid et al., 1990; Posner et al., 2004). Nine of the 12 studies measured basic cognitive domain outcomes including recall of information and comprehension (Blank et al., 1998; Clarke et al., 2005; Delp & Jones, 1996; Hayes, 1998; Jolly, 1993; Jolly et al., 1995; Lyons et al., 2004; Magid et al., 1990; Posner et al., 2004). These outcomes were evaluated using open-ended interview and knowledge tests. Four studies measured higher-level cognitive domains such as the application of information taught (Blank & Smithline, 2002; Ferrari et al., 1998; Kelso et al., 1995; Posner et al., 2004). Three intervention studies reporting psychomotor outcomes measured inhaler technique in asthma and/or chronic obstructive pulmonary disease (COPD) populations (Kelso et al., 1995; Numata et al., 2002; Shrestha et al., 1996). Of the 11 studies reporting affective domain outcomes (Barzargan-Hejazi et al., 2005; Berger et al., 1998; Clarke et al., 2005; Delp & Jones, 1996; Esler et al., 2003; Ferrari et al., 2005; Kelso et al., 1995; Magid et al., 1990; Numata et al., 2002; O'Malley et al., 2003; Richman et al., 2000), three measured change in high-risk behaviors such as drinking (Barzargan-Hejazi et al., 2005), smoking (Richman et al., 2000), and sexual activity or intravenous drug use (Magid et al., 1990). Each outcome was measured by self-report from participants. One study measured self-management of asthma as seen by a decrease in hospital readmissions over a 1-year period (Kelso et al., 1995). Two studies measured satisfaction with instructions (Delp & Jones, 1996; Numata et al., 2002) reported by participants. In two studies where counseling was provided to seek advice from other agencies, participants were asked on follow-up whether they had contacted these agencies (O'Malley et al., 2003; Richman et al., 2000). Four studies measured self-reported compliance with instructions (Berger et al., 1998; Clarke et al., 2005; Delp & Jones, 1996; Ferrari et al., 2005), and one measured use of a home safety kit (Posner et al., 2004). One study measured change in frequency and severity of symptoms (noncardiac chest pain) and anxiety scores, pre-and postintervention (Esler et al., 2003).
Effectiveness of Education Interventions in the ED
In reviewing the 19 studies, a mix of experimental and quasi-experimental designs were used to evaluate interventions. Ten studies were RCT designs. On the whole, the trials were well described with detail of the randomization procedures provided in 8 of the 10 RCTs (Barzargan-Hejazi et al., 2005; Blank & Smithline, 2002; Delp & Jones, 1996; Esler et al., 2003; Ferrari et al., 2005; Hayes, 1998; Numata et al., 2002; Richman et al., 2000) and baseline comparisons between intervention and control groups provided for 9 of the RCTs (Barzargan-Hejazi et al., 2005; Blank & Smithline, 2002; Delp & Jones, 1996; Esler et al., 2003; Ferrari et al., 2005; Hayes, 1998; Magid et al., 1990; Posner et al., 2004; Richman et al., 2000). Nine other studies included cohort and case-controlled designs. Of these studies, three included a control group (Kelso et al., 1995; Lyons et al., 2004; O'Malley et al., 2003) and one included two intervention groups (Lyons et al., 2004).
Of the 10 RCTs, six reported statistically significant improvements in the intervention in comparison with the control group, whereas two reported improvements in some of the learning goals and two found no improvements. One study that reported significant results did not describe the control group (Numata et al., 2002), but the remaining studies all described intervention and control groups that were similar with respect to baseline characteristics and sample size. One RCT included multiple interventions for a total of 11 unique interventions. Teaching methods used included instructional tools (n = 9), lecture (n = 6), discussion (n = 3), and demonstration (n = 3). Most interventions (9/11) used multiple teaching methods. The outcome measures reported in the 10 RCTs were cognitive (n = 6), affective (n = 7), and psychomotor (n = 1). Four of the studies measured outcomes in more than one domain.
One study was able to effectively meet psychomotor learning goals by teaching proper inhaler technique to patients with asthma and COPD (Numata et al., 2002). This was done using demonstration and practice. Four of the six studies reporting improvements included cognitive domain outcomes (Delp & Jones, 1996; Hayes, 1998; Magid et al., 1990; Posner et al., 2004). All were simple cognitive outcomes such as recall of information and comprehension measured using knowledge tests. These interventions used lecture and instructional tools (Delp & Jones, 1996; Magid et al., 1990; Posner et al., 2004) and instructional tools only (Hayes, 1998). One of the studies that provided an intervention using lecture and instructional tools provided a home safety kit along with a lecture about home safety (Posner et al., 2004). One study included an intervention arm that used discussion and found no difference with the addition of discussion for simple cognitive outcomes (Magid et al., 1990). Two studies failed to meet some or all of the higher-level cognitive outcomes that required individuals to use information at a later time. One intervention used lecture, demonstration, and instructional tools; however, the participants did not meet all of the learning goals (Blank & Smithline, 2002). The second study measuring higher learning goals had no success in getting participants to apply the information received. This study used only instructional tools in the form of an information pamphlet (Ferrari et al., 2005).
Four studies evaluated affective learning goals (Barzargan-Hejazi et al., 2005; Delp & Jones, 1996; Magid et al., 1990; Numata et al., 2002). Two of these studies met simple affective outcomes including satisfaction with instructions and compliance (Delp & Jones, 1996; Numata et al., 2002). These two studies used lecture and instructional tools (Delp & Jones, 1996) and demonstration and practice (Numata et al., 2002). Two studies also met all higher-level affective outcomes in the form of change in high-risk behavior using lecture and instructional tools (Magid et al., 1990) and discussion and instructional tools (Barzargan-Hejazi et al., 2005). In studies where the participants failed to meet some or all of the learning goals, three measured outcomes in the affective domain using discussion, demonstration, and practice (Esler et al., 2003), lecture and instructional tools (Richman et al., 2000), and instructional tools only (Ferrari et al., 2005).
In looking at the entire set of experimental and quasi-experimental designed intervention studies, the majority (13/19) reported statistically significant improvements in learning in the intervention groups (Barzargan-Hejazi et al., 2005; Blank et al., 1998; Clarke et al., 2005; Delp & Jones, 1996; Hayes, 1998; Jolly, 1993; Jolly et al., 1995; Kelso et al., 1995; Lyons et al., 2004; Magid et al., 1990; Numata et al., 2002; O'Malley et al., 2003; Posner et al., 2004; Shrestha et al., 1996). Three studies reported improved outcomes for some of the learning objectives (Berger et al., 1998; Blank & Smithline, 2002; Esler et al., 2003), and three studies reported no improvement in learning (Ferrari et al., 2005; Jolly, 1993; Richman et al., 2000).
Four additional studies included interventions initiated in the ED with follow-up education after discharge (Cote et al., 2001; Guttman et al., 2004; Maiman et al., 1979; Mello et al., 2005). Three of the four studies reported improved high-level cognitive and affective outcomes. The interventions included ongoing education following discharge or continued contact with a healthcare professional (Cote et al., 2001; Guttman et al., 2004; Mello et al., 2005). The fourth study reported improved high-level cognitive outcomes using discussion provided by a nurse in the ED who had the condition for which the participant had received treatment (Maiman et al., 1979). Supplemental written information was reported as being successful when adequate verbal instruction was also provided. There was no additional benefit seen after a 6-week telephone follow-up session (Maiman et al., 1979).
DISCUSSION
There is emerging evidence related to the delivery of educational interventions in the ED. On the basis of the results of these studies, health education offered in the ED using a variety of teaching methods may be an effective means of meeting learning goals.
Cognitive and affective learning goals were the most commonly reported outcome measures. A small proportion of interventions focused on teaching psychomotor skills. Most interventions used multiple teaching methods, with the most commonly used method being written instruction, followed by lecture and discussion. Demonstration was used in a minority of interventions. The ED may be an additional venue for education, as most studies were able to meet all or some of the learning objectives and employed a variety of teaching methods.
Bloom's taxonomy was originally developed to assist in the design and evaluation of educational programs (Redman, 1988). Weston and Cranton (1986) built on this taxonomy and suggested teaching methods that work effectively in a variety of scenarios. No articles were found that explicitly utilized Bloom's taxonomy or Weston and Cranton's framework for providing patient education in the ED. Using this framework for health education in the ED may support the use of methods and tools currently employed and provide insight into alternate methods. However, some limitations must be considered when using this framework for patient education. The intent of the framework is to guide teaching in more traditional classroom settings; thus, there is an implicit assumption that time and resources are available to educators. This clearly is one of the major challenges in delivery of patient education in the ED. Currently, many interventions in the ED use written instruction. Weston and Cranton note that written materials and handouts should be considered instructional tools and recommend them as a supplement to teaching. However, the methods they suggest such as field study, laboratory instruction, and group projects require personnel and facilities that may not be possible or appropriate in the ED. Some methods recommended in the framework were not utilized in the ED. These include role-playing, games, and simulations. These techniques might be beneficial, especially when poor literacy is a factor.
When Bloom's taxonomy was initially created, the authors of the taxonomy reported that the distinctions between domains were not clear (Redman, 1988). This is especially true when considering the framework's use with health education where more operational refinement of the domains would contribute to better matching of intervention and outcome assessment. For instance, differentiating between affective domain outcomes and higher cognitive outcomes remains challenging.
Despite this, the framework is promising as an important guide to designing health education programs both in and out of the ED. Teaching methods prescribed by the framework are appropriate for the ED when applied to simple learning outcomes such as recall and comprehension of information and skill mastery. Lecture and instructional tools are relatively fast and effective techniques and are appropriate for improving knowledge and comprehension. In lectures, an individual is assumed to be a passive listener, so either video or verbal interaction can be used. These methods can be used in some cases while treatment is offered. If patients are waiting between treatments, video instruction may be useful. Instructional materials can be provided to support the lecture. Although not as effective when used alone, written instruction can be effective for simple cognitive outcomes when it is provided using simplified language, large font, age- and condition-sensitive formats, and cartoons. Providing supplies (such as condoms or home safety devices) that require for meeting learning goals can be helpful. Skill mastery can be achieved using demonstration and practice techniques.
Higher-level cognitive or affective learning requires more dedicated time and involvement from the participant and educator, and an intervention in the ED may prove insufficient. Discussion can be used to meet these goals; however, this can be time consuming and requires an educator to be knowledgeable enough on the subject to answer any questions. Given the range and scope of what is dealt with in the ED, this specific knowledge may be lacking. Higher-level learning could be enhanced with follow-up education if this is provided after discharge. Follow-up to clinics, education centers, and other outside agencies should be encouraged as further reinforcement of information is possible and time is not as limited. However, given current trends, if patients are unlikely to access healthcare agencies or primary care facilities, interventions in the ED involving discussion should be considered and evaluated. Future research should be theoretically driven and strengthened by designing interventions using novel approaches identified in the framework such as role-playing, games, and simulations. Methodological work is needed to refine outcome assessment for health education generally and in the ED specifically. Lastly, in advancing education for self-management of conditions such as asthma, future research should focus on learning outcomes for higher-level cognitive and affective domains, as these outcomes are more difficult to address in the brief time available in the ED.
Although ED staff do not necessarily view their role as supporting secondary prevention and disease management, the ED is an increasingly important point of contact for populations known to be frequent ED users, that is, those with asthma etc. Despite the challenges of providing health education in the ED, interventions can be effective and this opportunity to disseminate health information should not be missed.
REFERENCES