Journal of Psychiatric and Mental Health Nursing, 2010, 17, 335–341

Patients’ perceptions of patient education on

psychiatric inpatient wards: a qualitative study jpm_1530 335..341

H . H Ä T Ö N E N 1 r n m n s c , R . S U H O N E N 2 r n p h d , H . WA R R O 3 r n m n s c ,
A. PITKÄNEN4 rn mnsc & M. VÄLIMÄKI5 rn phd
1
Doctoral student, University of Turku, Department of Nursing Science/Municipality of Imatra, Hospital District
of South Carelia, 2Professor (acting), 3Ward manager, University of Turku, Department of Nursing Science,
4
Doctoral student, University of Turku, Department of Nursing Science/Pirkanmaa Hospital District, and
5
Professor, University of Turku, Department of Nursing Science/Hospital District of South-West Finland,
Turku, Finland

Keywords: patient education, Accessible summary

psychiatric hospital, qualitative
study • A number of patient education programmes have been developed and implemented
in psychiatric nursing care to support patients’ information receiving. There is still
Correspondence:
a lack of knowledge about how patients themselves perceive patient education
H. Hätönen
programmes when they have been used on psychiatric inpatient wards.
University of Turku
Department of Nursing Science • In this study, patients with schizophrenia or related disorders described how they
Municipality of Imatra perceived IT-based patient education, conventional patient education with leaflets or
Hospital District of South Carelia patient education according to standard care during their hospital stay. In addition,
Sinivuokonkatu 10 areas for improvement were identified.
55100 Imatra • Patients’ perceptions of patient education varied depending on which patient
Finland education group they had participated in.
E-mail: heli.hatonen@utu.fi • Structured and systematically conducted patient education programmes on psychi-
Accepted for publication: 9 November atric wards were reportedly useful. However, no simple educational method suits
2009 every patient and therefore a combination of different education methods should be
used to meet patients’ individual needs. Moreover, nurse–patient interaction is still
doi: 10.1111/j.1365-2850.2009.01530.x
an essential element of patient education whatever educational methods are used.

Abstract

This study describes patients’ perceptions of different types of patient education

interventions and areas where patient education should be improved on psychiatric
wards. Thematic interviews were conducted with 16 patients who had completed the
information technology (IT)-based patient education, conventional patient education
with leaflets or patient education according to ward standards during their hospital
stay. Data were analysed using inductive content analysis. Patients’ perceptions of
patient education varied depending on which patient education group they had par-
ticipated in. Patients participating in IT-based or conventional patient education per-
ceived education as a systematic and planned process. However, especially patients
in the patient education group applying ward standard education perceived patient
education as occasional information dissemination situations. To improve patient
education, patients suggested that it should be based on their individual needs and
offered with different methods systematically to all patients. The results indicate that
patients find structured and systematic patient education programmes useful. Different
educational methods should be used, not forgetting interaction between patient and
nurse, which was reportedly as an essential element of patient education.

© 2010 Blackwell Publishing 335

H. Hätönen et al.
Introduction
Schizophrenia is characterized by impaired ability to cope
in daily life (Rossler et al. 2005). Together with medical
treatment, patient education in addition to other psy-
chosocial interventions is an essential method to support
patients’ capacity to manage their illness (Pekkala & Mer-
inder 2002, Zygmunt et al. 2002). However, patients with
schizophrenia in particular are dissatisfied with informa-
tion provided during their treatment (Alexius et al. 2000,
Ascher-Svanum et al. 2001).
A number of explanations have been proposed for
patients’ dissatisfaction with information provided. It has
been assumed that the information offered by staff does not
take account of patients’ individual needs (Feldmann et al.
2002, Sung et al. 2004). Moreover, there is a gap in the
evidence supporting the benefits of tailored information for
people with psychotic illness, because cognitive deficits due
to schizophrenia and psychopharmaceutical medication
may impair patients’ capacity to receive and process new
information (Medalia & Lim 2004). In addition, various
other factors such as lack of insight (Aleman et al. 2006),
motivation (Hill & Laugharne 2006) and support from
family members (Pharoah et al. 2006) have affected
patients’ information reception.
In general, patients desire information through diverse
methods together with discussions with staff (Proudfoot
et al. 2003). Patients themselves appreciate information on
illness and care in written format (Jorm et al. 2003).
However, written information alone with no chance to ask
questions may confuse patients with cognitive deficits
(Strydom & Hall 2001). Thus, personal communication
between patient and staff seems to be an important element
of patient education (Crowe et al. 2001).
More recently, patient education interventions using
information technology (IT) have been used in mental
health care (Lewis 2003) and patients have found them
useful and convenient (Zabinski et al. 2004). IT-based
interventions offer patients self-paced learning, shorter-
time involvement and more concise information com-
pared with face-to-face interventions (Jones et al. 2001,
Chou et al. 2004). They may also help compensate for
cognitive deficits and enhance communication between
patients and professionals (Bellucci et al. 2003, Ahmed &
Boisvert 2006). On the other hand, some patients have
reported deficiencies related to the individuality and cred-
ibility of information received by computer (Jones et al.
2001).
This qualitative study is one part of a large research
project intended to generate information on IT use in
mental health care. In this project, we implemented patient
education programmes in a randomized controlled trial
336
study (RCT) with 311 patients randomly allocated to one
of the three groups: (1) IT-based patient education; (2)
conventional patient education using standard leaflets; and
(3) standard care. In the IT-based patient education group
and conventional patient education group, five sessions
with staff were organized. In both groups, the sessions
focused on specific themes such as mental illness, treat-
ment, well-being, support and patients’ rights (Välimäki
et al. 2008).
No patient education intervention itself is likely to
achieve positive outcomes if the education does not
respond to patients’ individual needs (Bodenheimer et al.
2002). The key question that remains to be answered is
how patients themselves perceive the patient education
methods used on psychiatric wards. The aim of this quali-
tative study to be reported here was to describe patients’
perceptions of different educational interventions and to
identify areas where patient education should be improved.
Method
A descriptive qualitative approach was used to explore
patients’ individual perceptions of what patient education
contributes to patients (Clarke 2001, Grypdonck 2006).
Qualitative research methods are appropriate when explor-
ing social phenomena as perceived by individuals them-
selves (Malterud 2001).
Setting and sample
The data were collected at two psychiatric hospitals (nine
study wards) in Southern Finland. The study population of
this qualitative study consisted of patients who had com-
pleted the RCT study described above and its intervention
(IT-based patient education, conventional patient educa-
tion or standard care) while in hospital. Because the study
sample consisted of patients from the RCT study, they
fulfilled the following inclusion criteria: age 18–65 years,
able to speak Finnish and competent to give written
informed consent to participate in the study. All patients
had schizophrenia, schizotypal disorders or delusional dis-
orders (International Classification of Diseases – 10 criteria
F20–29; WHO 1992).
Convenience sampling was used to recruit patients dis-
charged from psychiatric hospital during the middle period
of the RCT study (between August 2006 and January
2007). All eligible patients (n = 32) were systematically
invited to participate in the study during data collection
period. They were contacted by letter and telephone and
invited to participate in the interview about 3 months after
the patient education interventions.
© 2010 Blackwell Publishing

Patients interviewed
Out of the 32 eligible patients, seven were not reached and
nine refused to participate in the study. Thus, 16 individu-
als were willing to share their perceptions of patient edu-
cation. Six patients had participated in IT-based patient
education, six in conventional patient education and four
in standard care. The patients interviewed were 11 men
and 5 women, in the age range from 20 to 64 years (mean
35.7, SD 11.92). Half of the patients were on pension. The
duration of disorders varied between 1 month and 32 years
(mean 12.3, SD 9.26).
Data collection
The interviews were carried out by one researcher. Patients
were interviewed at psychiatric outpatient clinics or public
libraries. The individual interviews were conducted using
an open-ended thematic interview guide piloted with two
interviews and not changed thereafter. The main themes
discussed were: (1) patients’ description of how education
sessions were conducted and (2) suggestions for improving
patient education on the psychiatric ward. Each theme was
followed up in the dialogue between patient and inter-
viewer (Silverman 2001). Interviews were tape-recorded
with patients’ permission. The duration of the interviews
ranged between 8 and 29 min.
Analysis
The data were analysed in two phases using inductive
qualitative content analysis (Denzin & Lincoln 2000). In
the first phase, the aim was to explore how patients
described patient education. The transcribed interviews
were read through to get a general picture of the material as
a whole. Primary observations from the whole data set
were then coded. Where the primary observations shared
the same properties they were allocated to the same cat-
egory (Silverman 2001). This served to reveal the following
five key elements describing patient education identified
from the data: (1) procedure; (2) interaction; (3) educa-
tional method; (4) environment; and (5) benefits. These
elements were used as a framework for second analysis
phase.
In the second analysis phase, the aim was to describe
patients’ perceptions in different educational groups (IT-
based patient education, conventional patient education,
standard care) and to explore patients’ suggestions for
improvements in patient education. The analysis was per-
formed separately for each patient education group to
examine how each of the five key elements of patient
education was described in the data. For example, when a
© 2010 Blackwell Publishing
Patients’ perceptions of patient education
patient’s descriptions concerning ‘interaction’ were found
in the data set, a sentence or part of a sentence was coded
with a description of the thematic content characterizing
the sentence. Subcategories were developed for these coded
phrases by grouping together those with similar connota-
tions. The set of main categories was established by group-
ing together subcategories with similar meaning (Silverman
2001). The analysis was carried out by the first author.
Ethical considerations
The study procedure was evaluated by the local hospital
district’s ethics committee. Permission to conduct the study
was obtained from the organization’s directors. Written
informed consent was obtained from each participant.
They received oral and written information about the
purpose of the study and their rights as participants. It was
emphasized that participation in the study was voluntary
and refusal would not affect their care. To ensure partici-
pants’ anonymity, the data were treated in confidence by
changing all identification data into numerical form during
the analysis (ETENE 2001, Declaration of Helsinki 2004).
Findings
The key elements of patient education
The analysis of patients’ perceptions of patient education
formed five key elements identifying patient education:
(1) procedure; (2) interaction; (3) educational method; (4)
environment; and (5) benefits.
Procedure for patient education described the structure
and content of how patient education was conducted on
psychiatric wards. Interaction of patient education was
described through perceptions of communication and the
nurse–patient relationship. Educational method included
descriptions of using educational methods as a part of
patient education and possible additional support for
receiving information. Environment was described in terms
of physical environment possibly affecting patients’ infor-
mation receiving. Further, benefits described patients’ per-
ceptions of the advantages of the patient education for
everyday coping with their illness.
Patients’ perceptions of patient education methods
The five key elements of patient education were used as a
framework to describe patients’ perceptions of IT-based
patient education, conventional patient education and
patient education according to the standard care.
337
H. Hätönen et al.
IT-based patient education
The procedure for IT-based patient education was
described by patients in terms of systematic patient educa-
tion sessions. This meant that the timing and content of
patient education were planned in advance and it was a
step-by-step process as stated in following quotation:
We had a schedule and in each session a specific topic
was discussed.
The nurse–patient interaction was described in terms of
individual discussions when the content of patient educa-
tion was integrated into the patient’s life situation through
cooperative discussions. By contrast, interaction was
described as mechanical information dissemination when
it was perceived as delivery of information from nurse to
patient rather than a process responding to patients’ needs.
The use of a computer was perceived to give additional
support to patients’ information receiving, but some
patients were concerned if the use of computer affected the
confidentiality. Patients described an environment that was
peaceful and suitable for the purpose as supportive for
information receiving while an environment with interrup-
tions and disturbances was perceived to hinder patients’
information receiving. Considering the benefits of patient
education, some patients thought that the focus was on
patients’ independent coping with illness. However, some
patients considered the information received to be impor-
tant, but useless for everyday coping.
Conventional patient education
Patients who participated in the conventional patient
education described the procedure of patient education
in terms of planned patient education sessions with the
content based on leaflets as described by one patient:
We had several sessions where we had certain time to go
through those leaflets.
The nurse–patient interaction was described by some
patients as helpful. This meant open and confidential dis-
cussions. By contrast, some patients in this group reported
that interaction was rather passive, a one-way informing
situation. The use of the leaflets was perceived to give
additional support to patients’ information receiving.
Patients reported that it was useful to recap information
received independently from leaflets. The patients did not
mention any effect of the environment on receiving infor-
mation. Regarding the benefits of patient education, some
patients thought that the information received was useful
for their independent coping with illness, while some
patients reported that the information seemed rather super-
ficial to them.
Standard care
The procedure of patient education was described as occa-
sional informing sessions as one patient put it:
338
Yes there was it [patient education] sometimes. I do not
remember details right now.
Some patients reported that they did not receive any
information at all.
The nurse–patient interaction reportedly lacked discus-
sions on patients’ situation. Some patients reported that the
interaction lacked appropriate respect and individuality.
They felt that their information receiving was not sup-
ported with any educational method and the patients did
not mention if the environment had any effect on how they
received information. Considering the benefits of patient
education, patients reported that the information received
was mainly meaningless to them.
Suggestions for the further development of
patient education
The key elements of patient education were used as a
framework to describe patients’ suggestions for improving
IT-based patient education, conventional patient education
and patient education according to the standard care.
IT-based patient education
Patients’ suggestions related to the development of pro-
cedure were described in terms of individual planning
and more extensive content of patient education. Patients
reported that their individual situation should be consid-
ered in planning patient education as described in the fol-
lowing quotation:
In what situation someone is, it is important. If someone
is very tired or something, there should be a change to
rest before those sessions.
More extensive content meant including more examples
of patients descriptions in the content.
To develop the educational method, patients suggested
that the options of IT should be utilized more widely. This
meant using more pictures, voice clips and interactive tasks
in the portal. Environment for patient education should be
peaceful and undisturbed. Moreover, having computers on
the ward was suggested to support patients’ independent
information seeking. No suggestions on interaction or
benefits were mentioned by patients in this group.
Conventional patient education
Regarding procedure, patients’ suggestions included
involving patients in planning, recapping of content and
detailed information. Patients reported that involving them
in the planning of the patient education integrates this into
their life situations.
Nurses should actively offer this [patient education] and
ask if the patient is ready for it. Then it is easier to
participate and think about those different topics.
© 2010 Blackwell Publishing

Patients perceived it as useful that the content of the
previous patient education session should be recapped at
the beginning of the new session, and requested more
detailed information.
Patients noted that interaction could be improved by
creating active interaction through open communication
and clearing up issues about which patients may be con-
cerned. They suggested that different educational materials
should be used to support their information receiving. No
suggestions for improving the environment and benefits
were made.
Standard care
Patients’ suggestions for improving patient education pro-
cedure were described in terms of systematic individual
practices. The patients were of the opinion that patient
education should be offered systematically to all patients
taking into account their individual situation. Development
of interaction included descriptions of individual interac-
tion. Patients considered that nurses should be active in
creating respectful communication based on patients’ indi-
vidual situations.
To develop educational methods, patients wanted to
receive information from different sources such as leaflets
and the Internet as stated by one patient:
And more different leaflets and new technology could
be used.
Patients also wanted to receive information from differ-
ent professionals and from other patients to get different
viewpoints. Patients in this group did not provide sugges-
tions for development of environment and benefits.
Discussion
Patients’ perceptions of the patient education intervention
varied depending on whether they had participated in
IT-based patient education, conventional patient educa-
tion or standard care. Earlier studies have also shown that
patients’ experiences of patient education vary (Feldmann
et al. 2002). In the present study, patients participating
in IT-based or conventional patient education perceived
education as a systematic and planned process. However,
especially patients in the patient education group applying
standard care perceived patient education as occasional
information dissemination situations. These results may be
signs of psychiatric illness and poor insight (Zygmunt et al.
2002). On the other hand, our study showed that patients
with similar psychiatric illness in the same patient educa-
tion group perceived patient education differently. We may
therefore assume that there are aspects, other than the
illness itself, affecting patients’ perceptions of patient edu-
cation. This is also supported by literature mentioning
© 2010 Blackwell Publishing
Patients’ perceptions of patient education
the impact of organizational factors, professional values
and skills on successful patient education (Deccache &
Aujoulat 2001).
In order to support patients to receive information in
psychiatric care, guidelines have been developed to enhance
the integration of patient education into treatment (NICE
2002, APA 2004, Duodecim 2008). However, the use of
standardized treatment procedures has emerged as a
concern about the loss of individuality (Miller & Kearney
2004), which may put patients in a passive role. This is an
important aspect in psychiatric care, where patients often
have problems in actively participating in their own treat-
ment (Hill & Laugharne 2006). In this study, patients
perceived interaction to be passive if information was
delivered to them through one-way mechanical sessions. As
other studies have shown, interaction between patient and
nurse is an essential element of patient education (Crowe
et al. 2001, Pollock et al. 2004). Building a unique, thera-
peutic and trusting relationship with each patient is crucial
in nursing (McQueen 2000). Therefore, staff’s skills in
providing systematic patient education through patient-
centred communication demands attention (Maguire &
Pitcheathly 2002).
In this study, patients mentioned a need to use different
patient education methods to support their information
receiving. This has already been found to be an effective
(Murray et al. 2005, Haynes et al. 2008) and accepted
method among patients (Jorm et al. 2003, Chou et al.
2004). IT especially as a part of patient education is quite
new in the field of psychiatric care (Lewis 2003). In good
hands the use of IT may shift the role of the patient from
that of a passive recipient to that of an active consumer of
health information. Therefore, it is important that health
professionals are ready for this transformation and have
the skills to guide patients to use the health information
available on the Internet safely (Mc Mullan 2006).
Regarding the limitations of this study, the number of
patients who refused to participate in this study was high
(50%). Thus, the patient selection may have been biased
in that less motivated and incompetent patients were
excluded from the study. Participants were also younger
than patients in psychiatric hospitals in general (National
Research and Development Centre for Welfare and Health
2008) and age-related computer literacy might contribute
to the successful realization of IT-based patient education
(Or & Karsh 2009). These results might therefore give too
positive impression of patient education methods used in
this study. Additionally, the length of the interviews varied
a lot, potentially affecting the quality and depth of data.
Patients with schizophrenia may also have severe manifes-
tations of psychiatric illness affecting their responses in the
interviews. However, to ensure the quality of the data, the
339
H. Hätönen et al.
interviews were carried out by one research assistant with
extensive experience in psychiatric nursing and trained in
data collection. The analysis was carried out by the first
author, which may affect the results because of an emphasis
on the researchers’ own perceptions. To overcome this, the
results were read by all members of the research group and
analysis was corroborated with quotations from the origi-
nal data. Because of these limitations, the findings remain
tentative. Despite the limitations, the results still provide
valuable knowledge about the elements and the variations
in patients’ perceptions of patient education carried out on
psychiatric wards.
Conclusions
We can conclude that patients perceive structured and
systematically conducted patient education programmes
useful. Different educational methods should be used not
forgetting interaction between patient and nurse, which
patients perceived to be essential element of patient educa-
tion. However, one educational method alone may not be
sufficient for every patient and therefore different educa-
tion methods should be used according to patients’ indi-
vidual needs.
Acknowledgments
This project was supported by the Academy of Finland
(207384), the Hospital District of South Carelia special
grant-in-aid (EVO 77), the Medical Research Fund of
Tampere University Hospital, the South Carelian Cultural
Foundation and the Finnish Foundation of Nursing Edu-
cation that are gratefully acknowledged.
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