Most patient education involves helping patients return to the best possible state of health after an acute illness. If a full return to wellness is not possible, patients may need help learning to live with chronic conditions. However, much of our effort in health care should be directed at keeping patients well before illnesses have a chance to develop. In Chapter 5, “Communicating Wellness,” we will learn health care factors our patients need to know to restore or maintain health. Your clinical manuals cover information regarding performance skills that you and your patient need to correct or manage the outcome of many illnesses and will be the basis of much of your teaching. You will find, though, that all of this information and all of your skills combined will not benefit the patient once he is home and no longer under your care if he does not understand his part in correcting or maintaining health. One of our major health care duties is to educate patients and caregivers in the proper means of retaining or restoring health. To that purpose, this chapter covers how to transmit information to a variety of patients in a manner best suited to their individual needs.

To help control the increasing cost of health care, hospitals discharge patients earlier and with greater medical needs now than in years past. As much as 90% of post-hospital care will be self-care or home care, involving ongoing treatments, medications, and lifestyle changes monitored by the patient or his caregivers, frequently with only occasional oversight by medical professionals. These sick patients and their caregivers need more help from health educators and more direction from their health care providers to ensure that health maintenance plans are understood and followed. This requires that the patient and caregivers understand as fully as possible what must be done to achieve health care goals.

The purposes of educating the patient in self-care are as follows:

• To promote, maintain, and restore health.

• To raise the standard of health.

• To help the patient cope with the lasting effects of illness.

LEGAL EAGLE

It is very important to work within your scope of practice guidelines. Exceeding your scope of practice or level of responsibility can put your career in jeopardy and can endanger your patients. In certain cases, you may lose your license or certificate, be fined, or even terminated from your position. If you are unsure of your scope of practice and responsibility in patient education or other tasks, communicate your concerns to your supervisor for clarification.

Many agencies employ health educators to oversee and coordinate patient teaching, but every member of the team is responsible for reinforcing the patient’s understanding of how to maintain or regain a reasonable level of health. Changing a dressing, assisting with procedures, and administering medications have a more visible effect, and may be more immediately rewarding to you and the patient, but patient education has a longer lasting effect on overall health. Patient education is as important as any clinical responsibility that you perform. Each member of the team is expected to treat patient teaching as seriously as any other clinical duty and must never miss an opportunity to reinforce good health habits (see the Legal Eagle box).

MAKING SURE YOUR PATIENT LEARNS

Education and compliance work best if the approach centers on the patient’s holistic needs. These include spiritual, physical, emotional, social, and economic needs, not just medical needs. For example, consider how disruptive an illness and its treatments will be to all areas of the patient’s life. How expensive is the treatment, and at what sacrifice? Will he be able to work at his chosen career? Can she continue to care for her family? Will the illness become debilitating, or is it manageable with lifestyle changes? What is this patient’s cultural concepts of the illness, its cause, and traditional medicine’s cures? Patients must trust health care providers to know these things, to have their best interests at heart, and to involve them in decisions about the direction of care that may profoundly affect the rest of their lives.

We will find as we work toward educating patients that we value the “good” patient, one who complies with all we suggest, who does not question, who does not complain, and who passively follows any health care plan set for him, either for correction or prevention. Unfortunately, we frequently resent the “difficult” patient who makes independent health care choices. This does not include patients who will not follow health care plans and then wonder why their health does not improve. These “difficult” patients ask questions regarding their care, make suggestions that differ from ours, and make logical and healthful changes that work better for them than those we suggest. Although this may annoy those of us who presume we know best, this is actually the goal of health care and more likely leads to a healthy lifestyle than the behavior of a patient who blindly follows directions without questions or understanding. The “difficult” patient may be the most compliant, because he feels he has an active part in his care. He understands and agrees to the needed treatment, asks questions, and monitors his treatment to be sure it has the expected results. He knows that most of his wellness is under his control.

As you work toward determining your patient’s health education needs, also consider your feelings about the patient and the illness. If you are uncomfortable talking with the patient about some factor in health care prevention or treatment, discuss this with the physician. You may need someone to take your place on the health care team. It is unrealistic to presume that you will never come across situations that make you uncomfortable or that are offensive to you. If this happens, and you cannot set aside or overcome your discomfort, you owe it to your patients to turn over their care to someone else. If you are prejudiced against the patient or the illness, or simply uncomfortable in the situation, you may find it difficult to keep the patient’s best interest foremost in the interaction. If your patient senses your discomfort, effective communication may not be possible.

In addition, determine how well you know the information or how skilled you are at performing a required procedure. If you are unsure of anything you are responsible for teaching, ask someone to walk you through the steps or read all available information before you begin. Patients count on you to know as much as you can about factors affecting their health, and you owe it to yourself and your professionalism to present a credible presence to your patients. If your patient asks you a question that you cannot answer, be honest and explain, “I don’t know the answer, but I will find out and will let you know.” If you create an answer that is wrong, not only will you lose your professional credibility, the misinformation may actually harm the patient.

When you have your information in place, begin the education process. Patient education involves these five steps:

Each of these steps is equally important in effective patient teaching.

Determining Your Patient’s Learning Style

Looking at all factors in any situation is called assessment and is the first step in most health care interaction. Consider points such as these when determining, or assessing, the patient’s current educational needs: Is she emotionally and physically able to absorb possibly complex concepts? Is she too nauseated or sedated to listen and learn? How acute are his senses? Can he see you? Can he hear you? If English is his second language, can he understand you? Are you speaking beyond her level of education? Is he motivated to learn? Is she emotionally ready to learn, or is she still in denial? Has he accepted his illness and the consequences? Is she ready to assume responsibility for her own care and return to health? How much does he understand about his health care issues? How does she feel about the effects of this illness on her future? How much experience has he had with the health care system to this point? What is her medical and surgical history? Is it extensive, implying long-term involvement in health care, or is it brief, alerting you that she may not understand how to work through the medical system? The process is easier and more productive if you understand the patient’s physical and emotional needs before deciding how to approach health care education.

Determining how much the patient already knows and understands about the illness can direct how much and what type of information is needed in each situation. For example, diabetics who do not understand the fundamentals of nutrition will not understand or retain information as well as those already actively involved in good dietary habits. Patients with a poor nutritional background may require a referral to a nutritionist or dietitian to help establish a working foundation. Likewise, a patient who understands exercise physiology will more likely continue a physical therapy routine than one who is set in an inactive lifestyle. Learning is easier when we already have an established knowledge base for adding new information.

You may know most of the patient’s background information, such as sensory barriers, education and comprehension levels, and so forth, from previous interaction with the patient or from the record. Consult other staff members and the patient’s caregivers for additional information that will make education easier.

Next, determine the patient’s best style of learning. These include the following:

• Cognitive—processing facts, forming conclusions, and making decisions by listening to or reading instructions or information. Most literate adults do well with self-directed, independent learning when they understand how important it is, especially if they feel that the learning experience is under their control. Most patients quickly and easily understand that learning how to handle an illness will help improve their health or, at the very least, help them cope with the changes they are experiencing. For example, many well-educated, assertive patients research their illnesses and will approach you with stacks of information from many sources, some more reliable than others. They may even challenge you with information they find that contradicts what you are trying to teach. If the information gathered by patients disagrees with agency policy, let the physician know so that more time can be set aside to explain the purpose of the individual treatment plan.

• Affective—appealing to emotions or feelings to change someone’s beliefs or attitude and reinforce the importance of the change in concepts. It is more difficult to learn new information if it goes against firmly held beliefs. However, once adults are convinced it is important to their health, most will adapt to new concepts. The new way of thinking and believing may need to be explained or approached from different viewpoints and by various means until the patient accepts the information. This may include recruiting family members to help convince the patient of its importance, or introducing patients to support groups of those who have experienced the same type of health problem with a positive outcome. For example, a woman who believes that she will no longer be a desirable mate if she has a hysterectomy or mastectomy may need to speak with someone from a support group who has experienced her same doubts and fears. If she can believe that she will still be desirable, she will more likely change her mind and her beliefs. She may not agree to the surgery until she can accept that the changes in her body image will not interfere with forming and maintaining relationships.

• Psychomotor—learning by doing, as in demonstration of a skill. If the new knowledge can be taught by active participation in a skill, understanding is more likely for those who learn best by doing. For example, your patient may accept the need to learn how to self-inject his insulin and may have read what he needs to know, but until he has practiced the steps with you, you cannot be sure that he understands not only how to do it right, but what may happen if he does it wrong.

Most people have one learning method they prefer, but we all learn best by combining all three methods. This helps store information in more areas of our brain for better recall. The more places we store information (seeing, hearing, reading, reasoning, doing), the better we remember. To retain information, we must receive data, compare it to what we already know, store it in accessible memory banks, and value the information enough to keep it for future reference, much as a computer does for future use. We remember best those things we know are important. And we remember most easily those things that relate to something we already know and can add to our knowledge base.

When you have gathered all you need to know and to relay to the patient, start the next step of the education process.

Planning for Learning

Proper and effective planning for education includes all information gathered during the interview and assessment process and ideally involves the whole health care team. For example, an education plan for a newly diagnosed patient with diabetes may require input from an endocrinologist, a dietitian, a home health service representative, and the coordinating physician. After a stroke, a patient may need assistance from the primary care physician, a neurologist, a physical therapist, and a speech therapist. All of this coordination of services must consider what patients need to know and do, but planning for care should also involve patients in the necessary decisions. We are all more likely to comply with suggestions and directions if we feel involved in making decisions that affect us. Patients have a feeling of control if they are allowed to create schedules, learn new performance skills, or adopt lifestyle changes that consider their likes and dislikes and their preferences and limitations, while still following medical protocol. This makes them participants in the return to health. No one appreciates being told what to do with no input or consideration for personal needs.

Planning should include a definable goal. Learning goals and objectives must be defined with expected short-term and long-term results. Learning goals outline the desired results of the educational program. Learning objectives include procedures or tasks to be discussed or performed at various points in the program. Objectives and goals should be created specifically for each patient and each situation and must include a standard by which learning and achievement can be measured (Teaching Plan box).

For example, consider the patient who must learn to distinguish between angina pectoris and a myocardial infarction. Which of these objectives is more specific and allows a measurement of progress?

• Patient and caregiver will understand how to manage acute angina pectoris.

• Patient and caregiver will demonstrate sufficient knowledge of cardiovascular function and dysfunction to recognize signs of impending myocardial infarction and to identify proper preventive and corrective measures.

The second plan outlines the patient’s and caregiver’s responsibility and, if psychomotor skills are required, ideally should include step-by-step procedures such as those you use in clinical proficiencies. A checklist works well if the patient forgets a step, or wonders what comes next. Just as your proficiency checklist keeps your performance in line, this sort of self-care aid also works for patients.

Patients who receive instructions for physician-approved treatment plans and patient education material (PEM) must sign that they received it and understand it. Copies with the patient’s signature should be kept in the patient’s record. The original is given to the patient. Documenting the education process and the patient’s understanding is covered in the Teaching Plan box.

TEACHING PLAN

FOR A PATIENT WITH ONSET OF ACUTE ANGINA PECTORIS

Learning Objectives: Patient and caregiver will demonstrate sufficient knowledge of cardiovascular function and dysfunction to practice appropriate preventive measures and to recognize signs of impending myocardial infarction and initiate corrective measures.

Learning Goal: Patient and caregiver will understand and practice prudent lifestyle changes for an improvement in cardiovascular functioning and decrease in high-risk cardiovascular factors.

Teaching Plan	Criteria for Evaluation
Evaluate patient and caregiver readiness and motivation to learn	Patient and caregiver will prepare a list of questions regarding cardiovascular functions and dysfunction and the need for prudent living for review with staff
Assess patient and caregiver knowledge base and deficits	Patient and caregiver will discuss their concept of cardiovascular disease, its prevention, and treatment with staff
Determine the preferred learning style and literacy level of patient and caregiver	Health care worker will consult with physician regarding best method for patient education
Provide specific PEM at the appropriate literacy level outlining warning signs of angina pectoris versus myocardial infarction and what to do for both	Patient and caregiver will compile a list of checkpoints for comparison and an algorithm for 911 contact
Review medication regimen and supply written explanations and directions for each	Patient and caregiver will explain benefits and adverse reactions for each medication and list the dosage schedule
Determine understanding of medication regimen by having patient and caregiver restate in own words or demonstrate proficiency	Health care worker will rate understanding of patient and caregiver explanation and demonstration of medication regimen proficiency
Determine that caregiver has completed CPR course	“Friends and Family CPR”course completion card
Review patient and caregiver emergency plan if angina pectoris is not resolved and myocardial infarction is suspected	Review written plan or algorithm for emergency care

This information was explained to me to my understanding.

_____________________ ____________________

(patient) (caregiver)

Comments: _____________________________________________________________________________________________________________________

Implementing the Process

Implementation puts the process in motion and can be carried out in several ways to suit the patient’s needs. You may instruct patients through one-on-one or group discussion, or by teaching aids such as videos and audiocassettes, or take-home references such as booklets, pamphlets, or brochures. Call on other members of the health care team or community support group members to help as needed during this process.

After determining how your patient prefers to learn, you can choose any of the following proven implementation methods.

Lecture and demonstration present the basic information but do not require participation to reinforce or retain the information. In this format, information is relayed and procedures are performed without the patient’s participation. This may be enough for highly motivated patients who you know are generally compliant, but it does not work well for patients who need to participate in learning by psychomotor, or hands-on, reinforcement. Written information should be available for reference if questions come up later, and patients should know they can call to clear up misunderstandings when they have had time to think back over all they have learned.

Role-playing and demonstration require that you perform a medical procedure as the patient watches, then the patient performs it so that you can evaluate his or her understanding. Patients who actively participate in the process of learning are more likely to retain the information.

When you demonstrate procedures for patients to perform at home, make examples as realistic as possible so that patients can anticipate how to perform them correctly during in-home care. Patients generally do not have homes in any way like the medical setting and have to work through bathrooms, kitchens, or other places not at all like the setting in which they were instructed. Those who do not understand important points, or who cannot translate what they learned into their home environment, may delay recovery or may make the situation worse rather than better.

Psychomotor skills are easier to learn if you demonstrate the skill first, explaining each step as you perform it for the patient, then have the patient perform each step with your support or assistance. Finally, have the patient work through the process without your help until you feel the level of skill is appropriate for self-care. Even with the best of demonstrations, written instructions should be available for reference as needed. Skills checklists work well at this point for reinforcement.

Discussion is a back-and-forth exchange of information and concepts and works best for education regarding lifestyle changes but does not work well for medical procedures. In this format, you present information and patients relay back to you what they understand and how this affects them. This reinforces affective or emotional retention of information.

Discussion can be one-on-one, or may be conducted as a group. A combination of both works best. Patients who are confident and assertive do well in either format but may dominate the discussion and exclude those less able to express themselves; quiet patients may be lost in a group environment. Be alert for cues from any group situation if you suspect that less assertive members are being overlooked and their concerns neglected as the group concentrates on patients who are more vocal. This requires tact and diplomacy on your part to avoid offending any member of the group.

Group dynamics and working with support groups are covered later in this chapter in “The Importance of Support Groups.”

Audio-visual material works well for those who are not motivated to read, but you must have a method for determining how well the patient understands the information contained in the material. Go over the information with the patient and ask appropriate questions to check for understanding. Having patients explain to you in their own terms what they understood is more likely to bring out misunderstandings than simply asking if he or she understands the information. Patients may take the material home to review as needed. Videos to use at home reinforce skills and concepts taught in the medical setting and are reassuring to patients who may have trouble remembering all of the steps in an involved procedure, even with a checklist.

An interesting and very personal aid involves a video of yourself and the patient as you work through the steps of a procedure. If this is possible in your facility, patients find videos of themselves far more interesting than those of anonymous actors performing the same tasks; therefore, they are more likely to review the tape frequently.

Printed material and programmed instructions can be covered with patients to discuss and clarify points and to bring out questions they may have before presuming they understand the information. These materials are available from many sources and are covered in “Choosing and Adapting Teaching Materials” later in this chapter. Physicians must review all material and teaching methods to ensure the information is appropriate for each patient’s needs and that it follows the practices and philosophies of the facility.

Previous chapters alerted you to cues that a patient may have trouble understanding complex concepts. Many evaluation tools are available to determine literacy levels and are covered later in this chapter; however, if you suspect that your patient cannot read well, try using visual and verbal education methods, repeat the instructions as often as needed, use different levels of language skills, and watch for cues indicating the patient understands. Have the patient repeat the instructions back to you. Diagrams and pictures help for nonreading patients. If medical concepts are beyond the patient’s comprehension, ask the patient’s caregiver to work with you. If you suspect that neither the patient nor the caregiver understands what you are trying to teach, alert the physician; a home health agency may need to be involved until everyone feels comfortable with the situation.

After deciding which combination of the formats listed above works best in each situation, use all of the appropriate communication skills you have learned to transmit the information. These suggestions will help reinforce the learning experience:

• Keep up with current medical advances and make sure the information available in your agency is up-to-date. Many of our patients are well informed and appreciate receiving appropriate information from their health care professionals. Patients less involved in their own care and who are unlikely to look for information, such as in journals and on Internet sites, need you to provide and interpret emerging medical technology for them.

• With the physician’s permission, help patients and caregivers contact appropriate support groups. Most support groups provide books, brochures, and videos, and compile lists of local resources for assistance in dealing with Alzheimer’s patients, colostomy care, post-mastectomy recovery, and so on.

• Help patients find community resources to continue complicated at-home care; these include home health agencies, medical supply companies, and so forth. Many pharmaceutical and medical supply companies have well-written information regarding how to use their products and are eager to share this information for patient education.

• Build on the patient’s knowledge base—what does she already know about what you need to teach?—and add new information in a simple-to-complex sequence.

• Allow time for questions and clarification. Patients who feel rushed may not have time to absorb the information and may be too confused and overwhelmed to think of appropriate questions.

• When checking for comprehension, rather than asking, “Did you understand what we just covered?”, ask specific points such as, “Can you tell me when you should use Standard Precautions?” and “How will you dispose of your soiled dressings?” Answers to these open-ended questions are more revealing, since they require more of the patient than “yes” or “no.”

• Offer to call patients in the next day or so to check for additional questions or concerns (Fig. 4-1). Patients who are hesitant and unsure of themselves may be reluctant to call you with what may seem at first a small problem, which then can become a much larger health issue if not corrected in a timely manner.