The Organization and Distribution of Patient Education Materials in Family Medicine Practices

Sampling

A total of 18 family practices were purposefully selected³⁸ from across Nebraska. Based on results of a previous study,³⁹ practices known to deliver both high and low levels of tobacco prevention services were included. The sites were chosen to include a wide variety of practice types, with maximum variation with respect to rural/urban, small/large, and privately owned/part of a larger health system. After preliminary analyses of the initial 10 practices, 8 additional practices were selected to search for confirming or challenging cases using replication logic.⁴⁰Table 1 summarizes the characteristics of the practices and physicians studied.

Study participation was solicited by sending an invitation letter, followed by a phone call to one of the physicians within the practice. Later, the consent of all clinicians to conduct research in the practice was obtained. Only 5 practices declined to participate. Three individual physicians subsequently declined participation after their practice was enrolled in the study (2 family physicians who were on the verge of retirement and one gynecologist who saw patients part-time in one family practice). Data collection proceeded for the other clinicians enrolled in the study for those sites.

Data Collection

A research nurse trained in qualitative methods was sent to each practice where she used a variety of data collection methods to produce a comprehensive picture of the practice as a functioning organization. It took 4 to 12 weeks for the nurse to complete the data collection in each practice depending on its size.

Field Notes. The research nurse observed the physical environment and functioning of the practice and dictated extensive field notes at the end of each day.⁴¹ These notes contained detailed descriptions of the clinic location and environment, patient characteristics, nursing station, examination rooms, the waiting area, bulletin boards, posters, and patient education materials. Photographs were taken of each room. The nurse specifically noted the location and organization of patient education materials and their accessibility to both providers and patients. She inventoried the available patient education materials, noting the number of brochures available, the topics covered, and who produced them. Samples of each patient education handout were obtained whenever possible. She also noted who was responsible for maintaining and organizing patient education supplies.

Checklist of Office Environment. Structured checklists of the office environment facilitated quantification of specific areas of interest and served as a template for standardized field note descriptions of the practice.⁴² Items on this 5-page instrument included the number of patients scheduled and seen per day, the number of personnel in the office, and the percentage of patients covered by managed care plans. The accessibility, quality, and patient use of education materials were also specifically recorded.

Patient Encounters. Approximately 30 patient encounters for each provider were observed. After obtaining written informed consent from the patient, the research nurse shadowed the provider and took notes for later dictation. The patient encounter field notes contained descriptions of any verbal patient teaching and the context of that education, including the reason for the visit, how the visit unfolded, and how the provider and patient interacted. The patient encounter structured checklist captured the number of times patient education materials were used.⁴³ Thus it was possible to quantify how frequently patient education handouts were used during the observed patient visits, as well as to describe the context of their use.

Patient Pathways. The research nurse also followed 2 of each clinician’s patients from the time they entered the practice until they left. These patient pathways provided a minute by minute recording of events from the time of entry into the health center, encounter with the receptionist, nurse, physician, checkout, and until the patient left.⁴⁴ To collect this data, the research nurse followed patients during their clinic visit, noting the places they visited, how long they waited and what happened to them during each stage. Opportunities for patients to select patient education materials intended for self-service were noted.

Interviews. Depth interviews with each provider in the practice explored themes related to the delivery of preventive services.^45,46 Patient education materials were sometimes discussed during the interviews, but specific questions about their use were not included on the interview guide.

Data Analysis and Interpretation

All quantitative and qualitative data were checked for accuracy and entered into Folioviews, an infobase software package.^47,48 This software program facilitates the organization of text documents and allows computerized searches and coding of the qualitative database.

The first phase of data analysis was an immersion/crystallization process^49,50 that lead to the development of a code book—an organizational scheme for understanding the qualitative data—that could be applied to the entire data set. Initially, one of the authors (MV) immersed herself in all the data from 5 purposefully selected practices to understand the functioning, organization, and dynamics of the practice. She read the field notes on the computer and made written notes on each practice, then reviewed patient encounter checklists to see how often handouts were used by each provider. Using this approach, she worked with the other authors to crystallize hypotheses and form an initial organizational scheme. Group discussions among all of the authors led to the development of our code book.⁵¹