PATIENT EDUCATION AND ITS IMPORTANCE IN TERMS OF PATIENT SAFETY

Patient safety and prevention of medical errors in every stage of health services is among the priorities of health system. Measures taken for prevention of medical errors in patient safety, one of the most important in care quality for health services, are the basis of patient safety. Information, skill and behavior increasing the degree of patient safety and making learning from errors easier can be gained through both training of health professionals and patient. Today, patient education focused on accurate application of treatment aims firstly for providing patient and patient family with accurate decision ability on care and taking responsibilities. Patient education helps patient with learning and understanding of his/her diagnosis and treatment, gaining active self-care attitude, and getting rid of feeling “weakness” due to illness. This process, in which effective and observable changes in patient behaviors are aimed, is not limited to inpatient treatment, but continuous. Patient education is not limited to patient health, but also includes increasing health care quality. Patient’s healthcare expense get less and less proportionally as hospitalization time gets closer to end. Importance of patient education, financing of which is so profitable, increases more and more today.


Introduction
"The first claim of education is actually to manage the person who is trained as pointed out by Descartes. To manage is to lead, to show the way, to impress... It is to interfere with someone else's development to comply with certain norms." Charles Hadji (Lacroix, Assal, 2003) The World Health Organization (WHO) is defined as a permanent system organized nationwide to provide health care services and to realize objectives varying as per needs and desires of the society by taking advantage of different types of health personnel in certain health institutions, and Http://www.granthaalayah.com ©International Journal of Research -GRANTHAALAYAH [110] thus to provide healthcare of individuals and society with all kinds of preventive and therapeutic activities (WHO, 1981).
Today, there are rapid developments in healthcare, and many factors are becoming increasingly prominent in the health service presentation. During provision of healthcare services with their critical function that focusing on human life, medical errors are likely to be seen from time to time due to lack of training and lack of skills among healthcare personnel serving in this field, as well as due to deficiencies in infrastructure or processes. These errors can lead to increased morbidity and mortality in patients, as well as financial cost increases, and shake confidence in the healthcare institution.
Patient safety that must be ensured at every stage of service delivery as one of the most important elements in provision of quality in healthcare services, and prevention of medical errors that constitute the basis of patient safety are among the priorities of healthcare system.
The "safe" term included among the characteristics of healthcare services refers to prevention of any harms from offered service rather than benefits, and prevention of injuring, causing disability and death (Akgün, Al-Assaf, 2007: 42-47).
The development of health services into a more complex structure, changing and evolving health needs and rapid developments in health technology bring along risk factors from the point of both service providers and service takers, and thus, the subject of employee safety occupies an important place in health agenda of all countries recently (Sezgin, 2007:13). While defining characteristics of contemporary health service, it is commonly accepted as provision of safe, effective, patientoriented, efficient and equally distributed delivery in time. Providing a safer healthcare service to patients and all healthy people has become the first priority. Therefore, the right to choose a physician, as well as rights to be informed and the right to receive safe health services are gaining more importance (Onganer et al.,2014:171-174).
The U.S. Institute of Medicine (IOM) has put the subject of patient safety among the priorities of the 21st century health presentation and listed subjects that are aimed to be improved in the healthcare system: 1) Safe Health Service (patient safety): To avoid harming patients while helping them, 2) An effective healthcare service: The provision of services including scientific information and evidence-based medicine practices, and the prevention of low or unnecessary use of health care, 3) Patient-oriented health service: A health service provided in accordance with patient's needs, value judgments and preferences and by combining the clinical decision-making mechanisms, 4) Health service given on time: A system in which the waits are prevented from damaging health (health attainment), 5) Efficient provision of health service: A cost-effective healthcare delivery, where the waste is prevented (IOM, 1999).
Patient safety is the complete measures taken by healthcare institutions and employees in these organizations to prevent damage that individuals may be exposed to during provision of healthcare services. Healthcare services do not harm people. The damages specified here are those that may arise due to the risks arising in the presentation processes of the service (Çakır, 2007: 128). It is possible to define elements that threaten patient safety as negativity that can affect the success of the treatment in all of the service processes given to the patient (Duman, Kitiş, 2013:72-79) According to the definition by National Patient Safety Foundation, patient safety is the prevention of errors related to health care and reduction of patient damages caused by health-related failures (NPSF, 2003).
Ethically, the principle of "nonmaleficence" is used as base in the definition and implementation of patient safety; in line with this principle, patients are tried to be protected from the factors in the presentation of health services in all applications.
Improvement quality of care, reducing and prevention of adverse events and control of health status with accountable and value based viewpoint are three basic goals of patient safety efforts (Aslan, Ulutaş, 2015:445-464 While patients' safety-related events provide harmful consequences for patients who come to health institutions with an expectation of benefit, these events also lead to an additional cost to the hospital. Damage done to patient may cause serious injuries, prolonged hospitalization, disability and even death of patient (Karaca, Aslan, 2014:9-18).
Knowledge, skills and attitudes that enhance patient safety and facilitate learning from mistakes can be earned by both health professionals and patient education (Cozens, 2001:26-31;Henderson et al., 2006:275-280). The awareness of individual, family and society through education can be ensured when they undertake more responsibility for their health/illness.
WHO aims to ensure that thoughts of patients and healthcare consumers are taken to the center of the patient safety movement. To increase the leadership and participation of patients with the idea of patient safety for patients, encouraging studies are carried out towards establishing close cooperation with patients and their families. The partnership is the key theme, and the realization of partnership can be carried out through education (WHO, 2013).
The health system is prone to major changes. The main points of this change are related to service delivery and expenses. There is a movement towards preventive medicine from therapeutic medicine. Protection against diseases is the most important work of both patients and healthcare professionals and is only possible with training. In addition to patient satisfaction and expectations for physicians and other healthcare professionals, many reasons require patient education. The most important one is to increase the quality of service and to establish a better relationship. This will increase compliance with the service and treatments provided. Compliance with the treatment will increase success and training harmony, better healthcare level will be achieved, and morbidity will be reduced.

Patient Education Targets and Objectives
According to WHO, patient education allows patients to have the skills they need to sustain their lives and to manage their illnesses, assists them in this respect, improves individual's health level to an upper level and ensures that patient develops correct health behaviors (WHO,1998).
Patient education is a term that includes patient teaching, advice and information-giving, behavior modification techniques, and involves two-way communication between the nurse/physician and the patient aimed at maintaining or improving health or learning to cope with their condition (Crawford et al.,2017:495-500).
The objectives of patient education required by WHO to ensure patient safety includes; • Developing information about the disease, related risks and prevention.
• Development of technical skills for pharmaceutical, self-monitoring, maintenance management. • Adoption of healthy living, self-management and treatment-integrated behaviors (WHO,1998 Planned patient training given to each patient in consideration of individual and requirements aims at; • Teaching healthy living knowledge, attitudes, behaviors and habits to healthy/sick individuals, • Ensuring that the patient and his family regain their health, • Supporting behaviors that the patient will make the right decisions about health and form a healthy lifestyle, • Contributing to the recovery of the patient in less time, • Supporting individual's gaining health and independence in an optimum/best way, • Maintaining the care of patient at home, • Making the patient feel better and independently in psychological terms, • Reducing the cost of health care services by shorting the patient's hospitalization time, • Increasing the quality of health care services and increasing patient individuals' level of satisfaction (WHO,1998).

Characteristics of Patient Education
To correct the course of diseases in a society, to ensure that physical, social and psychological self-sufficiency in line with the potential of individual and improve the quality of life can only be realized with patient education.  Kaya, 2009:19-23). In this context, it is possible to sort the characteristics of patient education as follows: • Patient education covers patient, his/her family, other relatives and friends.
• Patient education is a complementary part of treatment and care. It is a systematic process with continuity and integrated with healthcare. • Patient education is a patient-centered learning process. It is an individualized education.
It contains patient-specific differences. This education must comply with patients' lifestyle and his/her disease. • Patient education covers knowledge, attitudes and behaviors related to health and disease, patient's attitudes towards adaptation process (coping with disease, health beliefs and socio-cultural perceptions), requirements, ability to maintain self-care, disease-related treatment, care, psychosocial support, information about hospital and other healthcare institutions. Patient education is planned, organized learning experiences designed to facilitate voluntary adoption of behaviors or beliefs conducive to health. It is a set of planned educational activities that are separate from clinical patient care. The activities of a patient education program must be designed to attain goals the patient has participated in formulating. The primary focus of these activities includes acquisition of information, skills, beliefs and attitudes which impact on health status, quality of life, and possibly health care utilization (Coates, 1999

Issues to be Considered in Patient Education
Healthcare professionals who are training patients should be aware of patient's requirements. These professionals should consider patient's emotional state, experiences, thoughts on the disease and treatment, and establish empathy with the patient. The appropriate methods and tools for patient education should be selected together with the patient. The therapeutic effects of patient education (clinical, psychological, social and economic), educational, psychological and social aspects of long-term care should be evaluated (WHO, 1998).
Individuals who have any acute or chronic diseases or are healthy are becoming more responsible for maintaining their own treatment or healthy condition. The qualification required to carry this responsibility can be earned through education that becomes more programmed. Multidisciplinary teams can provide the application of therapeutic procedures and patients' learning through education. In this way, specific training objectives for each patient can be determined according to therapeutic objectives. This approach should ensure the suitability of the training objectives or at least increase it. That is because patient education relates to treatment as a necessity.
The correct behavior of patients after education is not only based on intellectual level and functions. Patients' behaviors are also affected by their illness and their perception of disease and their anxiety levels. Sometimes, patients may not be able to handle the actions they learned during training because they do not recognize the stimulants or act fast and appropriately enough to overcome the situation. As such situations may arise, educators should assess the success of education by observing patient. Therefore, determining the individual rules without adequate consideration of the patient's actual condition by using the educational objectives of the healthcare service providers may prevent the prospect of therapeutic success. The main advantage of using targets is that they mainly focus on movements and behaviors of the patient. Targets do not contradict methods that help patients develop better adaptation to their chronic condition (Lacroix, Assal, 2003).
Key points to be considered when training patients can be summarized as follows: • Targets and objectives of the training should be created together with patients and their relatives, and these points should be focused during the training period. Education should be more oriented towards behaviors and skills rather than giving information. • Education must be individualized.
• The assumptions about the patient and its relatives should be avoided, their knowledge and skills before/after education should be assessed. Beliefs of learners should be respected. • Active involvement of patients and their relatives in all phases of education process should be supported. • Benefits of teachable moments (when patient asks questions, such as when applying care and treatment to the patient) should be used. Patient's curiosity should be eliminated immediately, and his/her interest in the subject should be kept alive. • The effect of education must be evaluated and monitored, and the results should be shared with other team members. • All the records related to education should be documented in writing (Ulupınar, 2016:37-39). Patient education is the responsibility of all health professionals involved in treatment and care of patients (physician, nurse, psychiatrist, psychologist, nutritionist, physiotherapist, social work expert, clinical pharmacist, hospital managers, health insurance specialists etc.). However, nurses have more responsibility in coordinating the training activities of employees in patient education and in focusing on patient's needs since they are in constant communication with the patient and provide service to patients 24 hours (Kaya, 2009:19-23;Lacroix, Assal, 2003). It is a legal responsibility for health professionals to educate the patient by informing them. Because both the law and health care quality standards require training for all patients (Hasta Hakları Yönetmeliği, 2014; Ergün, Çiftçi, 2004:63-70). With JCAHO (Joint Commission on Accreditation of Healthcare Organization) standards, patient education standards are determined as follows: • Establishing a training plan to provide the necessary knowledge and skills to patients and their families to ensure the recovery and regulate functions, • The participation of patient in the decision-making process and inclusion of family in the education process, • Emphasizing a training program that starts with diagnostics and that is suitable for specified preferences and information requirements, • Training of patients regarding safe and effective drug use, • Training of patients on safe and effective use of the instruments and support of the patients, • Explaining nutritional-drug interactions, dietary recommendations that are appropriate for the disease, • Providing information about health controls and the social resources that patients can reach (Ergün, Çiftçi, 2004:63-70).

Empowerment Approach in Patient Education
The aim of education given to patients and relatives is to ensure that both the patient and its relatives take informed decisions to participate more in the care process, to develop basic self-care skills, to support them in realizing their problems and solutions. The patient's self-management ability increases by providing information to the patient through education and thus patient's achieving bio-physiological, functional and cognitive dimensions.
There may be a security risk for patients who are not actively trained in the management of selfcare and health problems, and prevention of complications. Therefore, effective communication skills are important to protect patient safety. Empowerment in patient education is a model that has been increasingly noticeable in recent years and is integrated into the service presentation because it affects the self-sufficiency, quality of life and participation of the patients in the decision-making process. (Crawford et al.2017: 495-500).
In patient education, empowerment is conceptualized as an approach that allows patients to undertake health responsibilities by recognizing and promoting their individual strengths, conscious choices and personal objectives. This approach considers patients as experts on their own lives and as equal and active partners in healthcare. It is significantly different from the traditional and didactic patient education forms in which healthcare professionals are represented as specialists. Patient is moved from the passive receiver position to the participant position. The concept of empowerment has become a model for patient education consisting of seven dimensions specified below: 1) Bio-physiological; patients have adequate knowledge of physiological symptoms and symptoms and think they can control these symptoms; 2) Functional; patients can control their own status and their daily activities and function as they wish; 3) Cognitive; patients have adequate knowledge of the health problem and can use this information to improve their health or have the ability to access and evaluate new information; 4) Social; meaningful social contacts and interactions continue despite the health problem, and patients support themselves while trying to control their problems; 3) Experimental; patients can use their past experience to control their health problems; 4) Ethical; patients feel unique, respectable and valuable, and they believe that the service they receive ensures their well-being; 5) Economical; patients can manage their care financially and receive technical assistance and other support (Crawford et al.2017: 495-500).
To provide thorough and appropriate education, each patient requires an ongoing teaching plan. Education isused to empower the patient and is an important aspect of quality improvement given that it has been associated with improved health outcomes (Aghakhani et al.,2012:12-15).

Patient Education -Best Practice Recommendations
The growing imperative that people play an active, effective part in their health care offers researchers and practitioners of patient education the opportunity to provide the theoretical, empirical and professional leadership to support such participation (Gruman et al., 2010:350-356) • Successful patient education programs require staff resources to ensure high quality and consistency. Health systems need to allocate sufficient staff with expertise to these areas to succeed with patient engagement initiatives. • Competing in the risk-bearing reimbursement landscape will require standardization of industry best practices based on the latest evidence. This is true for patient education just as it is for clinical pathways. • Patient education that is integrated into electronic workflows helps streamline processes and ensures greater consistency and standardization. • Choose resources wisely, taking into account long-term needs for compliance and positioning. Consumer-level content is critical to successful patient engagement as are materials that address limited health literacy and the need for language support. • Training staff members to facilitate patient education is essential. Most staff members arrive with a cursory knowledge of how to educate patients and families. To ensure high quality education and patient comprehension, additional training including simulated education sessions are crucial (Neal, 2015).

Conclusion
The rise of consciousness as a society, increased demand for healthcare services, technological developments and risks, increased costs and loads, rise of quality standards, emerging competitive environment, health policies that require progress have made the field of patient safety one of the indispensables of the health field. Safety, as a fundamental concept within the health institutions, should be used functionally, so that reliable behavior in the relationship between healthcare professionals and patients can prevent behavior that may jeopardize patient safety. Technological systems, effective and efficient use of information and also multidisciplinary work ensures the improvement of patient safety system. In patient safety, functional interventions and medical training should be increased to eliminate deficiencies in patient care process.
In order to increase the level of health of individuals, patient education should be discussed comprehensively, it should be placed on a scientific basis, and the training should be carried out by the professionals.
With the introduction of patient education, it is observed that stress developing due to hospitalization and lack of information decreases. It is also indicated that positive attitudes and patient demands increase the effect of all kinds of education. Patient education also decreases health expenditures of patients with decreased hospitalization time. Patient education is of great importance in terms of both finance and health protection and development. Therefore, in all phases, the patient and his family need to be determined and included in the course of the training, and all processes should be recorded. In this way, the patient safety objectives for patients defined by WHO can be achieved in ensuring patient safety by minimizing the errors caused by patients. Ensuring patient safety in health care is an important issue that every country should address. Patient safety is the responsibility of all individuals who serve in the hospital. In order to ensure patient safety in institutions, the perception of patient safety culture should be established in healthcare workers.
A planned and regular training given to individual/community in terms of health and achieving this objective will contribute to the efficient work of healthcare workers and their success in their professions.