Efficacy of educational strategies in patient involvement for safety in care: a systematic review

Luiz, Raíssa Bianca; Estevam, Layara Oliveira; Raponi, Maria Beatriz Guimarães; Felix, Márcia Marques dos Santos; Barbosa, Maria Helena

doi:10.1590/1983-1447.2022.20210198.en

Raíssa Bianca Luiz

Universidade Federal do Triângulo Mineiro (UFTM), Instituto de Ciências da Saúde, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

http://orcid.org/0000-0003-0921-0082

Layara Oliveira Estevam

Universidade Federal do Triângulo Mineiro (UFTM), Curso de Graduação em Enfermagem. Uberaba, Minas Gerais, Brasil.

http://orcid.org/0000-0001-8503-9833

Maria Beatriz Guimarães Raponi

Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Curso de Graduação em Enfermagem. Uberlândia, Minas Gerais, Brasil.

http://orcid.org/0000-0003-4487-9232

Márcia Marques dos Santos Felix

Universidade Federal do Triângulo Mineiro (UFTM), Instituto de Ciências da Saúde, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

http://orcid.org/0000-0001-8431-6712

Maria Helena Barbosa

Universidade Federal do Triângulo Mineiro (UFTM), Instituto de Ciências da Saúde, Programa de Pós-Graduação em Atenção à Saúde. Uberaba, Minas Gerais, Brasil.

http://orcid.org/0000-0003-2749-2802

Corresponding author
Maria Helena Barbosa E-mail: mhelena331@hotmail.com

Authorship contribution

Project administration: Maria Helena Barbosa. Formal analysis: Raíssa Bianca Luiz, Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Conceptualization: Raíssa Bianca Luiz, Layara Oliveira Estevam, Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Data curation: Raíssa Bianca Luiz, Layara Oliveira Estevam, Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Writing-original draft: Raíssa Bianca Luiz, Layara Oliveira Estevam, Maria Beatriz Guimarães Raponi. Writing-review & editing: Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Investigation: Raíssa Bianca Luiz, Layara Oliveira Estevam, Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Methodology: Raíssa Bianca Luiz, Maria Beatriz Guimarães Raponi, Márcia Marques dos Santos Felix, Maria Helena Barbosa. Supervision: Maria Helena Barbosa.

The authors declare that there is no conflict of interest.

Associate editor

João Lucas Campos de Oliveira

Editor-in-chief

Maria da Graça Oliveira Crossetti

Description	Abbreviation	Question Components
Population	P	Adult patients hospitalized
Intervention	I	Educational interventions to involve the patient in safe care practices
Comparison	C	Conventional guidance or no intervention
Outcome	O	Participation of the hospitalized patient in safe care practices.
Study design	S	Experimental design studies

Title/ Country Authors/Year	Sample	Study design	Objective	Intervention Group (IG)	Control Group (CG)	Main Results and Conclusion
The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Australia Chaboyer, et al., 201620. Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): a cluster randomised trial. Int J Nurs Stud. 2016;64:63-71. doi: https://doi.org/10.1016/j.ijnurstu.2016.09.015. https://doi.org/10.1016/j.ijnurstu.2016.... (2020. Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): a cluster randomised trial. Int J Nurs Stud. 2016;64:63-71. doi: https://doi.org/10.1016/j.ijnurstu.2016.09.015. https://doi.org/10.1016/j.ijnurstu.2016.... )	1,600	Randomized clinical trial	To evaluate the efficacy of a set of care on pressure ulcer prevention (PUP), in reducing the incidence of PU, and increasing the active participation of patients in the process of preventing PU.	They received information on pressure ulcer prevention through posters, leaflets and DVD. The incidence of PU in the participants and the use of a scale to measure the patient's participation in the prevention of PU were evaluated.	They received standard care based on regional guidelines.	There was a reduction in the incidence of PU in the IG (p<0.0001). The hazard ratio indicated a 52% reduction in the risk of developing PU associated with the intervention compared to standard care, however this difference was not statistically significant. There was no difference between the groups regarding patient participation in the prevention of PU (p=0.124)).
A randomized controlled trial to improve engagement of hospitalized patients with their patient portals. USA Greysen, et al., 201821. Greysen SR, Harrison JD, Rareshide C, Magan Y, Seghal N, Rosenthal J, et al. A randomized controlled trial to improve engagement of hospitalized patients with their patient portals. J Am Med Inform Assoc. 2018;25(12):e1626-33. doi: https://doi.org/10.1093/jamia/ocy125. https://doi.org/10.1093/jamia/ocy125... (2121. Greysen SR, Harrison JD, Rareshide C, Magan Y, Seghal N, Rosenthal J, et al. A randomized controlled trial to improve engagement of hospitalized patients with their patient portals. J Am Med Inform Assoc. 2018;25(12):e1626-33. doi: https://doi.org/10.1093/jamia/ocy125. https://doi.org/10.1093/jamia/ocy125... )	97	Randomized clinical trial	To evaluate the efficacy of educational guidance to increase patient involvement in the use of their apps, during hospitalization and after discharge.	They received verbal guidance at the bedside, through structured educational material, addressing the relevance of using the application, the importance of post-discharge use and its main functions. Participants were evaluated by the number of accesses to the application’s functions.	Guidance for beginners only for app login registration. No other assistance on how to use the application was offered.	The IG had higher means in terms of involvement and use of the application, compared to the CG, with statistical significance only in the access to the outpatient messaging function (p=0.04).
Facilitating Inpatients’ Family Members to Learn: A Learning Engagement Promoting Model to Develop Interactive E-Book Systems for Patient Education. China Huang; Hwang, 201922. Huang H, Hwang GJ. Facilitating inpatients’ family members to learn: a learning engagement-promoting model to develop interactive e-book systems for patient education. J Educ Techno Soc. 2019 [cited 2021 Mar 12];22(3):74-87. Available from: https://www.jstor.org/stable/pdf/26896711.pdf . https://www.jstor.org/stable/pdf/2689671... (2222. Huang H, Hwang GJ. Facilitating inpatients’ family members to learn: a learning engagement-promoting model to develop interactive e-book systems for patient education. J Educ Techno Soc. 2019 [cited 2021 Mar 12];22(3):74-87. Available from: https://www.jstor.org/stable/pdf/26896711.pdf . https://www.jstor.org/stable/pdf/2689671... )	74	Randomized clinical trial	To evaluate whether the use of an interactive e-book is able of improving cognition, learning, motivation and patient and family satisfaction about patient safety.	They received information on patient safety using an e-book. An adapted questionnaire was used to measure the participants’ cognition, motivation and satisfaction and an interview was used to assess the perception and opinion about the e-book.	They received information about patient safety through written and verbal instructions.	The use of the intervention was significant for the cognition of the patient and their families regarding patient safety. IG (p<0.01). In addition, it improved learning attitudes (p<0.05), motivation to learn (p<0.01) and satisfaction with the use of technology (p<0.05).
Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. United Kingdom Lawton, et al., 2016(2323. Lawton R, O'Hara JK, Sheard L, Armitage G, Cocks K, Buckley H, et al. Can patient involvement improve patient safety? a cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. BMJ Qual Saf. 2017;26(8):622-31. doi: https://doi.org/10.1136/bmjqs-2016-005570. https://doi.org/10.1136/bmjqs-2016-00557... )	2,115	Randomized clinical trial	To evaluate the efficacy of an intervention, based on patient feedback on safe care, to improve patient safety by decreasing damage to patient.	Patients provided feedback from a questionnaire about their perception of safe care and reported experiences related to adverse events they had already had. The researchers evaluated the patient's feedback and developed a plan of action together. Afterwards, they compared whether the action plan reduced the incidence of damage to the patient.	Patients provided feedback, but no action plan was designed.	The action plan developed together with the patient in the IG did not reduce damage to patients.
Effects of an educational patient safety campaign on patients’ safety behaviours and adverse events. Switzerland Schwappach, et al., 2011(2424. Schwappach DLB, Frank O, Buschmann U, Babst R. Effects of an educational patient safety campaign on patients' safety behaviours and adverse events. J Eval Clin Pract. 2013;19(2):285-91. doi: https://doi.org/10.1111/j.1365-2753.2012.01820.x. https://doi.org/10.1111/j.1365-2753.2012... )	420	Randomized clinical trial	To investigate the effects of a patient safety warning on risk perceptions, behavioral control and performance of safety behaviors and adverse event experiences.	Guidance through a booklet with recommendations on safe practices during hospital admission. A questionnaire was built to assess the participants’ perception of their involvement in safety in care.	Care/ standard guidance	IG showed better perception and behavior regarding their safety (p=0.010) and reported less experiences with adverse events and unsafe practices compared to CG (p=0.009).
Patients’ and health care professionals’ attitudes towards the PINK patient safety video. United Kingdom Davis, et al., 201225. Davis RE, Pinto A, Sevdalis N, Vincent C, Massey R, Darzi A. Patients' and health care professionals' attitudes towards the PINK patient safety video. J Eval Clin Pract. 2012;18(4):e848-53. doi: https://doi.org/10.1111/j.1365-2753.2011.01688.x. https://doi.org/10.1111/j.1365-2753.2011... (2525. Davis RE, Pinto A, Sevdalis N, Vincent C, Massey R, Darzi A. Patients' and health care professionals' attitudes towards the PINK patient safety video. J Eval Clin Pract. 2012;18(4):e848-53. doi: https://doi.org/10.1111/j.1365-2753.2011.01688.x. https://doi.org/10.1111/j.1365-2753.2011... )	296	Quasi-experimental	To evaluate patients’ attitude and health care professionals regarding an educational video to promote patient involvement in safety-related behaviors.	Patients watched an animated video about their contribution to preventing errors during care provided. They answered a questionnaire about their attitudes towards being involved with safety issues, before and after the video.	NA	The video increased the patient's perception of the importance of involvement in safety issues, being significant for the domains of professional hand hygiene and personal hygiene (p<0.05).
Patients’ attitudes towards patient involvement in safety interventions: results of two exploratory studies. United Kingdom Davis, et al., 201326. Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164-76. doi: https://doi.org/10.1111/j.1369-7625.2011.00725.x. https://doi.org/10.1111/j.1369-7625.2011... (2626. Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164-76. doi: https://doi.org/10.1111/j.1369-7625.2011.00725.x. https://doi.org/10.1111/j.1369-7625.2011... )	80	Quasi-experimental	To evaluate patients’ attitude towards a video and a leaflet to encourage patient involvement in behaviors related to safe practices.	Patients watched an animated video encouraging them to participate in safe care management. The leaflet addressed patient participation in safety-related behaviors. Patients responded to a scale on how comfortable they were with participating in some safety-oriented behaviors.	NA	The video and leaflet increased the patient’s perception on issues related to hand hygiene and error reporting (p<0.05). However, behaviors related to medication errors were not significant (p>0.05) to improve patient perception.
Engaging hospital patients in the medication reconciliation process using tablet computers. USA Prey, et al., 201827. Prey JE, Polubriaginof F, Grossman LV, Creber RM, Tsapepas D, Perotte R, et al. Engaging hospital patients in the medication reconciliation process using tablet computers. J Am Med Inform Assoc. 2018;25(11):1460-9. doi: https://doi.org/10.1093/jamia/ocy115. https://doi.org/10.1093/jamia/ocy115... (2727. Prey JE, Polubriaginof F, Grossman LV, Creber RM, Tsapepas D, Perotte R, et al. Engaging hospital patients in the medication reconciliation process using tablet computers. J Am Med Inform Assoc. 2018;25(11):1460-9. doi: https://doi.org/10.1093/jamia/ocy115. https://doi.org/10.1093/jamia/ocy115... )	65	Quasi-experimental	To determine whether an electronic tool of medication review can improve medication safety during hospitalization.	They used an electronic application, after hospital admission, to select the medications they used at home. Afterwards, the medication list was printed, and the responsible researcher encouraged the patients to compare it with the medication list prepared by the medication reconciliation team.	NA	Patients were more engaged with medication reconciliation after using the electronic application. Only the item of recognition of the discrepant medications between the list they completed and the one prepared by the reconciliation team showed significant results (p=0.021).
Innovating fall safety. Engaging patients as experts. USA Radecki et al., 202028. Radecki B, Keen A, Miller J, McClure JK, Kara A. Innovating fall safety: engaging patients as expert. J Nurs Care Qual. 2020;35(3):220-6. doi: https://doi.org/10.1097/NCQ.0000000000000447. https://doi.org/10.1097/NCQ.000000000000... (2828. Radecki B, Keen A, Miller J, McClure JK, Kara A. Innovating fall safety: engaging patients as expert. J Nurs Care Qual. 2020;35(3):220-6. doi: https://doi.org/10.1097/NCQ.0000000000000447. https://doi.org/10.1097/NCQ.000000000000... )	203	Quasi-experimental	To evaluate patient involvement in developing a fall prevention action plan.	Verbal guidance and folders on fall prevention and development of an individualized action plan. A questionnaire was used to assess patient participation in fall prevention of and the incidence of falls.	NA	The intervention improved patient involvement in fall prevention (p=0.0007) and decreased the incidence of falls.
Effects of self-education on patient safety via smartphone application for self-efficacy and safety behaviors of inpatients in korea. South Korea Cho; Lee, 202129. Cho S, Lee E. Effects of self-education on patient safety via smartphone application for self-efficacy and safety behaviors of inpatients in Korea. Healthc Inform Res. 2021;27(1):48-56. doi: https://doi.org/10.4258/hir.2021.27.1.48. https://doi.org/10.4258/hir.2021.27.1.48... (2929. Cho S, Lee E. Effects of self-education on patient safety via smartphone application for self-efficacy and safety behaviors of inpatients in Korea. Healthc Inform Res. 2021;27(1):48-56. doi: https://doi.org/10.4258/hir.2021.27.1.48. https://doi.org/10.4258/hir.2021.27.1.48... )	94	Quasi-experimental	To determine whether self-educational intervention on patient safety via smartphone app can improve patient self-efficacy and safety behaviors.	Patients received a smartphone with content (text, images and videos) about the importance of patient safety, main adverse events and tips to improve safety in care. A scale was used to measure patient safety behavior.	NA	There was a significant improvement in safety behavior after the intervention (p<0.001).
An education intervention care bundle to improve hospitalised patients' pressure injury prevention knowledge: a before and after study. Australia Deakin et al., 202030. Deakin J, Gillespie BM, Chaboyer W, Nieuwenhoven P, Latimer S. An education intervention care bundle to improve hospitalised patients’ pressure injury prevention knowledge: a before and after study. Wound Pract Res. 2020;28(4):154-62. doi: https://doi.org/10.33235/wpr.28.4.154-162. https://doi.org/10.33235/wpr.28.4.154-16... (3030. Deakin J, Gillespie BM, Chaboyer W, Nieuwenhoven P, Latimer S. An education intervention care bundle to improve hospitalised patients’ pressure injury prevention knowledge: a before and after study. Wound Pract Res. 2020;28(4):154-62. doi: https://doi.org/10.33235/wpr.28.4.154-162. https://doi.org/10.33235/wpr.28.4.154-16... )	80	Quasi-experimental	To evaluate patient participation in pressure ulcer prevention before and after the educational strategy.	It was used a care bundle for the prevention of pressure ulcers through a poster, leaflet and video to encourage patient involvement. A validated scale was used to assess patient’s involvement.	NA	After the intervention, there was an improvement in the patient’s participation in care for the prevention of pressure ulcer (p<0.001)
Development and effectiveness of a patient safety education program for inpatients. South Korea Shin et al., 202131. Shin SH, Kim MJ, Moon HJ, Lee EH. Development and effectiveness of a patient safety education program for inpatients. Int J Environ Res Public Health. 2021;18(6):3262. doi: https://doi.org/10.3390/ijerph18063262. https://doi.org/10.3390/ijerph18063262... (3131. Shin SH, Kim MJ, Moon HJ, Lee EH. Development and effectiveness of a patient safety education program for inpatients. Int J Environ Res Public Health. 2021;18(6):3262. doi: https://doi.org/10.3390/ijerph18063262. https://doi.org/10.3390/ijerph18063262... )	69	Quasi-experimental	To evaluate a patient safety education program among hospitalized patients about knowledge, perception and participation in safe practices.	Educational videos on general patient safety issues and fall prevention measures, infection, PU and patient participation. It was used a questionnaire to assess knowledge, perception and intention to participate in safety issues.	Guidance according to institutional routine	IG had better scores in knowledge (p<0.001) and perception (p=0.04) regarding patient safety. There was no significant difference between IG and CG regarding the intention to participate in safety issues (p=0.478).

Questions for critical analysis of quasi-experimental study	Davis et al., 201225. Davis RE, Pinto A, Sevdalis N, Vincent C, Massey R, Darzi A. Patients' and health care professionals' attitudes towards the PINK patient safety video. J Eval Clin Pract. 2012;18(4):e848-53. doi: https://doi.org/10.1111/j.1365-2753.2011.01688.x. https://doi.org/10.1111/j.1365-2753.2011... 25	Davis et al., 201326. Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164-76. doi: https://doi.org/10.1111/j.1369-7625.2011.00725.x. https://doi.org/10.1111/j.1369-7625.2011... 26	Prey et al., 201827. Prey JE, Polubriaginof F, Grossman LV, Creber RM, Tsapepas D, Perotte R, et al. Engaging hospital patients in the medication reconciliation process using tablet computers. J Am Med Inform Assoc. 2018;25(11):1460-9. doi: https://doi.org/10.1093/jamia/ocy115. https://doi.org/10.1093/jamia/ocy115... 27	Radecki et al., 202028. Radecki B, Keen A, Miller J, McClure JK, Kara A. Innovating fall safety: engaging patients as expert. J Nurs Care Qual. 2020;35(3):220-6. doi: https://doi.org/10.1097/NCQ.0000000000000447. https://doi.org/10.1097/NCQ.000000000000... 28	Cho; Lee, 202129. Cho S, Lee E. Effects of self-education on patient safety via smartphone application for self-efficacy and safety behaviors of inpatients in Korea. Healthc Inform Res. 2021;27(1):48-56. doi: https://doi.org/10.4258/hir.2021.27.1.48. https://doi.org/10.4258/hir.2021.27.1.48... 29	Deakin et al., 202030. Deakin J, Gillespie BM, Chaboyer W, Nieuwenhoven P, Latimer S. An education intervention care bundle to improve hospitalised patients’ pressure injury prevention knowledge: a before and after study. Wound Pract Res. 2020;28(4):154-62. doi: https://doi.org/10.33235/wpr.28.4.154-162. https://doi.org/10.33235/wpr.28.4.154-16... 30	Shin et al., 202131. Shin SH, Kim MJ, Moon HJ, Lee EH. Development and effectiveness of a patient safety education program for inpatients. Int J Environ Res Public Health. 2021;18(6):3262. doi: https://doi.org/10.3390/ijerph18063262. https://doi.org/10.3390/ijerph18063262... 31
Is it clear from the study which is the “cause” and which is the “effect” (i.e., there is no confusion about which variable comes first)?	Y	Y	Y	Y	Y	Y	Y
Were participants included in any similar comparisons?	NA	NA	NA	NA	NA	NA	Y
Were participants included in any comparisons who received similar treatment/care in addition to the exposure or intervention of interest?	NA	NA	NA	NA	NA	NA	Y
Was there a control group?	NA	NA	NA	NA	NA	NA	Y
Were there multiple outcome measures, before and after the intervention/exposure?	Y	Y	Y	Y	Y	Y	Y
Was follow-up complete, and if not, were differences between groups in terms of follow-up adequately described and analyzed?	Y	Y	Y	Y	Y	Y	Y
Were the results of participants included in any comparisons measured in the same way?	Y	Y	Y	Y	Y	Y	Y
Were the results measured reliably?	U	U	Y	Y	Y	Y	Y
Was appropriate statistical analysis used?	Y	Y	Y	Y	Y	Y	Y
Risk of bias (%)	83,33%	83,33%	100%	100%	100%	100%	100%
Final assessment	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk

[1] Corresponding author
Maria Helena Barbosa E-mail: mhelena331@hotmail.com

Brasil

Brasil

Efficacy of educational strategies in patient involvement for safety in care: a systematic review

Eficacia de las estrategias educativas en la participación del paciente para la seguridad em la atención: una revisión sistemática

ABSTRACT

Objective

Method

Results

Conclusion