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Take the patient education challenge

Gattullo, Barbara Ann APRN-BC, CDE; McDevitt, Diane ANP, CNS-BC

Nursing Made Incredibly Easy!: May/June 2013 - Volume 11 - Issue 3 - p 8–11
doi: 10.1097/01.NME.0000428439.77156.da
Department: On the Horizon

Associate Professor • Kingsborough Community College • Brooklyn, N.Y.

Assistant Professor • Kingsborough Community College • Brooklyn, N.Y.

The authors have disclosed that they have no financial relationships related to this article.

As our world population grows and moves, we're caring for a much less homogeneous patient population than in the past. Our patients are now from other countries and cultures, and speak other languages. Their underlying beliefs about health, illness, and healthcare aren't always the same as ours. So, as nurses, we ask, how do we provide patient education when our basic understanding may not be the same?

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The challenges

Most nurses recognize the importance of patient education, but are frustrated by the lack of time and resources to support it. We know that the limited time we have with patients can restore health to some degree, but the patient and family are ultimately responsible for continuing the gains and maintaining health through self-care.

Socioeconomic pressures also pose challenges. Some of our patients may have grown up in poverty; others may simply be new to patient education. Some may not have had access to medical care or medications and may be living without electricity or running water. Some patients can't read at all, others can't read well, and still others don't have any background in science to help them understand what we're saying.

Nurses are realizing the impact of poor health literacy on patient outcomes. But how do we change our expectations to meet all of our patients' needs? We often respond to the pressures placed on us by hospital administration, patients and families, and our peers by saying that we have “no time to teach,” and then we ask “How can I get more time to teach?” In light of a tough economy and its impact on healthcare delivery, the response is frustrating: “no money, no staff, no time.”

However, we must change the question to “How can I most effectively and efficiently teach in the time I do have?” By asking this question, we open up a world of options and can invest in resources to improve health outcomes. Investigate your personal teaching challenges, decide what frustrates you most, and discover how to best teach your patients by utilizing evidence-based research and communicating with other professional nurses.

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Stick to the plan

Patient education is a multifaceted process that involves promoting, protecting, and maintaining health. But where do you begin? Ask your patient how he or she wants to learn, and then identify priority needs. Evaluate your assessment, along with the patient's thoughts about what's most important to learn. After your patient's priorities have been addressed, he or she may be more motivated to concentrate on other identified learning needs. Meeting the most important needs first can help the patient to see that he or she can do it, making additional goal accomplishment seem more realistic.

During the short period of time allotted for teaching, patient strengths and weaknesses need to be examined. Reflect on observable, measurable activities, such as preparing and injecting insulin. By doing this, you can assist your patient to be more accurate and comfortable with the task at hand. But handling the equipment may be problematic for your patient. What if a patient has arthritis? Are there any devices that can assist this patient to safely prepare a dose? What resources might be available for a patient who has a sensory deprivation? Utilize specialists who can help patients adapt more comfortably, as necessary. And remember that patient confidence will come from comfort with performing the activity.

The teaching-learning process must involve dynamic interaction between you and your patient. Collect data, analyze them, make educated diagnoses, and develop and implement a teaching plan. After it's developed, the plan must also be made available to the patient. Teaching plans may be likened to the traditional nursing process. Just as the nursing process begins with patient assessment, the teaching process must focus on the patient and significant others' needs if outcomes are to be successful.

Remember that documentation of the teaching process is vital. It provides a legal record that teaching took place, and the written teaching plan is a resource to all who care for the patient. The teaching plan also ensures continuity in the healthcare team's approach, which means less repetition and frustration for the patient.

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Be a patient advocate

When patients are ill, they're frequently unable to assert their rights as they would if they were healthy. The healthcare system is far too complex for a patient to navigate when they're too sick to deal with it. An advocate supports patients in their decision making, giving them full or at least mutual responsibility in the process. The ability to make wise decisions about healthcare issues is part of a partnership that requires patient involvement. Without an understanding of what your patient wants or expects from a teaching plan, advocacy becomes hollow.

Motivation to learn is the desire to learn. When a patient is motivated, how much he or she learns is greatly influenced. An assortment of practical skills can influence how much and what a patient learns. Ascertain patient needs, identify barriers to learning, and incorporate education into each visit (see Watch for barriers!). Demonstrate attitudes that help your patient recognize education is essential and integral, which will assist him or her with successfully navigating the experience. The goal of any patient teaching encounter is for learning to take place.

Consider some of the following limitations and their impact on a teaching plan:

* current physiologic status (Is your patient in pain?)

* financial considerations (Can your patient afford supplies, medications, or certain foods for a prescribed diet?)

* misconceptions about the disease and its treatments

* language barriers, low literacy, or poor comprehension skills (Your patient may be ashamed to let you know that he or she has these problems.)

* lack of motivation

* psychological barriers, such as fear, anger, and depression

* impaired psychomotor skills or inability to handle necessary equipment

* sensory deficits

* negative past experiences with the healthcare system.

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Make the most of your time

Research has shown that learning helps patients feel more confident and become more effective in their self-care management. Some helpful suggestions to enhance teaching opportunities include:

* Respect any potential cultural barriers and evaluate your patient's comfort zone.

* Determine your patient's readiness to learn and establish a contract for learning the specific actions that he or she will need to know.

* Ask your patient how he or she learns best. What's most comfortable: Watching a skill performed, reading about how to do it, or listening to an explanation?

* Keep your patient's family or other caregivers involved. Consider asking your patient questions such as, “Would you like a family member or friend to help you learn the skills you'll need to know?” Having another person available to serve as a backup if the need arises may help enhance your patient's self-confidence and comfort level.

* Move from simple to complex in a logical and organized fashion; be concrete, not abstract, and avoid the use of medical jargon.

* Provide nonjudgmental support.

* Be a reflective listener.

* Repeat the information, as needed, to facilitate reinforcement of newly learned materials.

* Keep the period of time between learning and the active use of learned material as short as possible so your patient doesn't forget what was taught.

* Provide sufficient time for your patient to practice skills and provide return demonstration or “teach-back” sessions.

* Look for outcomes. Does your patient fully understand what you taught?

* Praise your patient for correct behaviors and provide feedback at intervals throughout the learning experience.

* Consider any psychomotor limitations, such as decreased muscle strength or coordination, as well as sensory deficits, and make appropriate adjustments.

* Have multiple teaching materials available. Teaching aids should be written at a level that's appropriate for your patient, have large type with simple pictures, and focus on active not passive learning. Never consider your job done by just handing out printed information. Consider using the Internet or other audiovisuals; these will likely appeal to and hold the attention of many patients. Allow your patient to choose a learning tool that provides the most comfort.

* Make time for questions and answers. If your patient states that he or she doesn't have questions, consider saying “a few frequently asked questions are...” Always allow time for the new material to sink in.

* Note in discharge plans what your patient was taught before transfer or discharge and what remains for him or her to learn; communication with family or significant others is vital at this time.

* Encourage your patient to keep a notepad and pen handy in the event that a question arises after discharge.

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You have an impact!

Once upon a time, physicians did the majority of patient teaching, but now we've assumed most of this role. Patients require nurses who can think critically and help them prepare to problem solve when away from the comfort zone of a hospital. Teaching requires communication skills that begin with a simple hello and end with accomplishing the mutually designed plan and goals. Cooperative planning enhances success and patient adherence. Focus on patient needs and assess the patient's primary health problem, health beliefs, cultural position, learning styles, and support systems.

The teaching-learning experience must be interactive to be effective. Create an environment conducive to learning with trust, respect, and acceptance. Patients need to feel safe and comfortable enough to ask questions and to be an active participant in their healthcare without judgment. We must empower our patients to become the solution for achieving their own optimal health by enabling them to connect effectively to not only the system, but also to other resources around them such as family and community. Our failure to help patients adequately understand their disease and its treatment underlies much of the suboptimal adherence to treatment that leads to otherwise preventable outcomes.

Stay alert to current nursing practices either through formal continuing education, reading, or attending professional programs that address important issues such as the relationship between critical thinking skills, patient education, and safe, knowledgeable care delivery. We must prepare patients to adjust to a shortened hospital stay, along with a quicker discharge, at a time when they may feel apprehensive and alone.

Regardless of the delivery format, patient education and safety across healthcare settings must remain paramount to all nurses. What's vital to satisfactory patient outcomes is that we never stop learning how to be better nurses and patient educators. Keep a positive attitude, identify your responsibility to teach, and capture every teachable moment possible. Pave the road for your patient's successful journey to making promotion and restoration of positive health outcomes a reality.

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key points

Patient education is a major aspect of nursing practice, and it's an important independent nursing function. The Patient's Bill of Rights mandates patient education, and individual state nursing practice acts include teaching as a function of nursing, making it a legal responsibility. The Joint Commission has expanded its standards of patient education to include evidence that patients and significant others participate in care and decision making and understand what they've been taught.

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Watch for barriers!

Barriers to self-care are a patient's own perceptions of the social, personal, environmental, and economic obstacles to achieving or maintaining a specific behavior or a set goal for that behavior. Barriers have many dimensions and can have a major negative impact on outcomes. Unfortunately, many nurses bypass assessing barriers and incorrectly label a patient's behavior as “nonadherent” or “noncompliant.” Healthcare providers can help patients engage in optimal self-care by identifying the source of barriers and taking steps to remove them.

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key points

Ensure that your patient knows that teach-back sessions are meant to assess physical abilities such as muscle strength, motor coordination, and sensory acuity. Emphasize to your patient that the responsibility is on you to decide whether he or she adequately performed a new skill. Remember that trial and error has a place in patient education. Allowing patients to perform a skill more than once helps you be certain that comprehension has taken place. If your patient is struggling, reassess and readdress as appropriate. Ask questions when teaching problem-solving skills. Consider asking your patient, “Why do you think this happened?” Help patients make a plan to use if help isn't readily available. Patients should never feel like they're being tested, but rather given the opportunity to gain confidence in performing new skills.

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key points

In today's healthcare landscape, employers are seeking nurses skilled in critical thinking, leadership, case management, and health promotion. Baccalaureate nursing programs encompass all of the course work taught in associate degree and diploma programs plus a more in-depth study of physical and social services, nursing research, public and community health, nursing management, and the humanities. The increasing complexity of the scope of practice for RNs requires a workforce that has the capacity to undertake research and adapt to change. It also requires critical thinking and problem-solving skills; a sound foundation in a broad range of basic sciences; knowledge of behavioral, social, and management skills; and the ability to socialize and communicate data.

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Learn more about it

Baumann LC, Dang TT.Helping patients with chronic conditions overcome barriers to self-care. Nurse Pract. 2012;37(3):32–38; quiz 38-39.
Berman AJ, Snyder S.Kozier & Erb's Fundamentals of Nursing. 9th ed. Upper Saddle River, NJ: Pearson; 2012.
Grove D.Patient advocacy—pass it on. Nursing made Incredibly Easy! 2012;10(4):4.
London F.No Time To Teach? The Essence of Patient and Family Education for Healthcare Providers. 2nd ed. Atlanta, GA: Pritchett & Hull; 2009.
Overgaard MP.Patient teaching in five easy steps. Nursing made Incredibly Easy! 2009;7(3):56.
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