Fundamentals Lecture-Patient Education
Barriers for the teacher
Barriers for the TEACHER: -Limited time -Limited opportunity to prepare for teaching -Lack of space and privacy -Teaching not seen as a priority -No reimbursement for teaching -Frustration with amount of documentation needed -Lack of coordination with other healthcare providers
What Challenges might older adults have?
Cognitive Challenges-Aging results in normal changes in cognition. Three specific changes occur: reduced processing speed, greater tendency to be distracted, and reduced capacity to process and remember new information (working memory). Visual Challenges-Many older adults have problems with vision. About 2/3 of adults with vision problems are older than 65. Hearing Challenges-Hearing loss is common in older adults, affecting 1 in 3 people older than 60 and half of those older than 85.
Evaluation
Evaluate: •TEACH BACK Method •Test & written exercises •Oral questions •Interviews •Questionnaires •Checklists •Direct observation of performance •Client report •Client records
Learning Environment
Ideal for most = •PRIVATE •QUIET •COMFORTABLE •FREE FROM DISTRACTIONS
Complexity of Content
More complex = more challenging -Newborn: •Profound immune disorder vs •Healthy learning about immunization schedule -Stoke - varying degrees: •Relearning to use utensils, dressing, and using adaptive equipment vs •Learning new meds
Teaching Strategies: PRINTED MATERIAL
PRINTED MATERIAL -ADVANTAGES: •Standardized information to be presented •Good for reinforcement of lecture/demo/one-to-one •Can read when convenient •Teacher can cover highlights and learner can read more later -LIMITATIONS: •Assumes literacy •Motivation to read the content •Need to keep track of the material •Those with visual problems
What is health literacy?
The Patient Protection and Affordable Care Act of 2010, Title V, defines health literacy as: The degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.
the 3 domains of learning are:
cognitive, affective, psychomotor
Stratagies for visual challenges
•Make information easy to see and read •Contrast: Text should be printed with the highest possible contrast. Very high contrast is done best using black text on a white background. •Font Size: 16 to 18 point size font or larger is best to use when developing materials for older adults •Spacing Between Lines of Text: People with low vision may have difficulty finding the beginning of the next line when reading, so it is preferable for space between lines of text to be at least 25 percent of the point size •Paper Finish: If printing materials for older adults, do not use paper with a glossy finish because it can cause problems with glare. •Consider providing audio information whenever necessary •Reduce the amount of text
National Action Plan to Improve Health Literacy is based on the principles that:
•(1) everyone has the right to health information that helps them make informed decisions and •(2) health services are delivered in ways that are understandable and beneficial to health, longevity, and quality of life.
Promoting Health Literacy
•Ask questions that involve "how" and "what" instead of "yes or no" •Assist pt in completing forms/health histories •Organize information - most important stands out (highlight!) •Avoid medical jargon/technical terms •Speak using simple words, short sentences... direct instructions •Use drawings and photographs http://www.vizhealth.org/gallery/ •Provide information in primary language •Watch for low literacy levels/illiteracy -May fail to ask questions over content -With-drawl -"too tired" -Repeated non-compliance
Cultural Factors
•Be aware of norms, values communication, social structure, time orientation, cultural identification •If English not primary language... need interpreter? Need material written in primary language?
Communication
•Central to the teacher/learner relationship •Sit at eye level with patient •Barriers include: -Pain -Anxiety -Fatigue - Illness -Hunger -Dysfunctional relationships -Language differences -Vision and hearing impairment -Cultural factors •Pay attention to the verbal and nonverbal feedback
Why do nurses need teaching skills?
•Clients/families need information for decision making •Shorter hospital stays increase need for teaching about home-care needs •Teaching facilitates compliance and shortens hospital stays and medical complications •Teaching empowers clients and families
Cultural Factors
•Cultural sensitivity involves respect for the pts identity and needs. -Observe interactions among family..... Who is decision maker? -Assess for customs and taboos -Observe verbal and nonverbal communication -Determine if any same-sex preferences in care givers -Find resources/information to educate yourself -Admit unfamiliarity - but willingness to learn -Speak slow & clear... not LOUDER -Caution with jokes/sarcasm/slang -Encourage questions
Patient Teaching Topics
•Disease information • Information about medications • Procedures/psychomotor skills • Disease prevention and health promotion • Clinical processes •ADL's •Preventative self-care
Anyone who needs health information and services also needs health literacy skills to:
•Find information and services •Communicate their needs and preferences and respond to information and services •Process the meaning and usefulness of the information and services •Understand the choices, consequences and context of the information and services •Decide which information and services match their needs and preferences so they can act
Teaching Strategies: Group Discussion
GROUP DISCUSSION -ADVANTAGES: •Learner centered •Uses cognitive and affective domains •Interaction with peers •Social aspects -LIMITATIONS: •More difficult with large groups •Less structure •Not good for psychomotor •Social pressure to "agree" with group •Can get off topic •Dominate participants can take over
Special Populations: Older Adults
Health Literacy Skills: The National Assessment of Adult Literacy (NAAL) indicates the following about older adults' health literacy skills: •71% of adults older than age 60 had difficulty in using print materials •80% had difficulty using documents such as forms or charts •68% had difficulty with interpreting numbers and doing calculations •We can improve how we communicate with older adults and create materials and messages that match their health literacy skills.
Communication Example
"you are scheduled for surgery tomorrow. You need to be NPO after 2400. I'll be in to prep the op site at about 8. you'll need to void before your pre-med. After that we'll move you to a gurney and transfer you to the holding area" VS " your surgery will be tomorrow morning. You will not be able to eat or drink anything after midnight. I'll come in about 8 in the morning to clean your hip and get it ready for the operation.. Then you'll need to urinate before I give you some medicine to relax you. After that, we'll put you on a cart and roll you up to the operating area"
Health Literacy
- The ability to understand basic health information and services needed to make appropriate healthcare decisions •Interferences: -Using medical terminology that is unfamiliar or misunderstood by the patient •Gets misinterpreted •Creates "meaningless" information -More common in medically underserved, minority populations, and older adults -May have trouble with: taking meds as prescribed and managing complex/chronic health problems -Reading literacy - can be a barrier if low level... how to identify????
motivation
- a desire from within -Without it - little learning can occur -Greatest when: •pt recognize the need for learning •Believes it is possible to improve their health •Are interested in the information -To help motivate: •Convey you interest in/ respect for the learner •Warm friendly environment •Enthusiasm •Help understand need •Allow for opportunities for success - steps/stages
Feedback
- giving information back about the learner's performance -Identifies area to focus on/reinforce -Positive feedback encourages learners/boosts morale -"coach" -Increases motivation -Point out errors in a positive way -Be careful of being judgmental or creating fear of failure
Repitition
- more likely to retain information and incorporate it into life if the content is repeated. -"M" in the Box
ACTIVE INVOLVEMENT
- more meaningful when the pt is actively engaged in the planning and learning activities -Retain 10% of what read -Retain 90% of what speak and do -TEACH BACK
TIMING
- present the information at a time the patient is open to learning... similar to readiness -Retain info more when can use it soon after -Sometimes need more time to absorb information - break it up... especially complex information
Teaching Strategies: Additional
-Audio-Visual -Simulation -Role-Playing -Role-Modeling -Self-instruction -Distance learning -Online sources of information -Computer-Assisted instruction/online coursework -Gaming -Concept Mapping
Readiness
-indication the learner is both motivated and able to learn at a specific time -Includes physical and emotional capacity to take in, process, and recall information -Physical: •Pain - interferes with concentration •Strength/coordination/energy - for psychomotor •May need to adapt for impaired hearing/vision -Emotional: •Anxiety, stress, emotional pain - interfere •Idea of learning/behavior change can create anxiety •NOTE: Mild anxiety - can help motivate!
The plan is dependent on achieving the following seven goals:
1. Develop and disseminate health and safety information that is accurate, accessible, and actionable 2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services 3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child- care and education through the university level 4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community 5. Build partnerships, develop guidance, and change policies 6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy 7. Increase the dissemination and use of evidence-based health literacy practices and interventions
The nurse is teaching a patient newly diagnosed with type 1 diabetes mellitus about how to best manage his blood sugar. Which outcome in the patient's plan of care is associated with the cognitive domain of learning? The patient: A.identifies signs and symptoms of hypoglycemia. B.nods affirmatively with direct eye contact. C.demonstrates fingerstick glucose monitoring. D.independently self-administers insulin.
Answer = A Cognitive behavior includes recall and comprehension, which is demonstrated by stating information, such as indicators of hypoglycemia. Nodding with eye contact is an action that exhibits the listener is dealing with the information with emotion (respect), which shows affective domain. Affective learning is the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes. Willingness to hear and showing attention falls within the affective domain. Demonstration of skills depicts the psychomotor domain, such as performing a test to check blood sugar or injecting insulin.
Barriers for the LEARNER:
Barriers for the LEARNER: -Personal stress -Illness -Physical condition -Anxiety -Low literacy -Negative environmental influence -Lack of time -Overwhelming amount of behavioral change needed -Lack of support and positive reinforcement -Lack of willingness to take responsibility -Communication gap/language barrier -Too much "technical jargon" -Teaching not adapted to the learner's preferences/learning style
The client is given a pamphlet to read about how to manage his newly inserted central venous access device. It will be most important for the nurse to assess the client's: A. Health beliefs B. Literacy level C. Fine motor abilities D. Ability to see
Correct answer: B
The client needs to be taught how to find and check his own radial pulse. The nurse will complete this teaching A.Only if the client asks her to do so to avoid causing stress B.When the client recognizes the need to learn the skill C.Before pain medication is administered when the client is alert D.Right before the client is discharged so he can remember the skill
Correct answer: B ...The client will be most motivated to learn when he recognizes why this skill is important to the success of his overall treatment plan (e.g., medication effectiveness).
Teaching Strategies: Demo/return demo
DEMONSTRATION/RETURN DEMONSTRATION -ADVANTAGES: •Great for psychomotor skills (equipment use, etc) •Can be used with small groups •Increases self-confidence •Can assess knowledge/skill -LIMITATIONS: •Hard with large groups •Participants may learn at different rates •Time-consuming/labor-intensive •Involves preparation time to set-up
Teaching Strategies: Lecture
LECTURE -ADVANTAGES: •Efficient •Cost effective •Large groups •Can incorporate media •Foundational -LIMITATIONS: •Not individualized •Passive learning •Doesn't address psychomotor or affective domains •Oversaturation (lots of info in limited time) •Can't immediately assess comprehension •Boredom occurs
Scheduling
More than just timing... •Plan for uninterrupted time •Determine time needed - doesn't need to be long •Multiple small sessions vs one long? •Look for teachable moments... Look for the opportunities -Giving meds -Taking BP -Administering insulin -Changing dressing
Teaching Strategies: One to One
ONE-TO-ONE INSTRUCTION -ADVANTAGES: •Establishes a relationship with the learner •Conveys interest in learners needs •Can tailor to the learner's needs •Easier to ask questions •Frequent feedback/evaluation •Good for all 3 domains •Opportunity for supervision/guidance/feedback -LIMITATIONS: •Labor intensive •Time commitment/fewest # learners •Isolation - less support from others •Personality conflicts •Instructor must be a good role model/skills
Developmental Stage
•Guide teaching strategies/content to the level of your learner Stages of Cognitive Development: Preoperational: (age 2-7) - meaning in symbols and pictures Concrete Operation: (age 7-11) - manipulating concrete, tangible objects. Begins to understand logical relationships Formal Operational Stage: (age 11+) - can use abstract thinking and reasoning; can consider alternatives and apply concepts NOT EVERY ADULT reaches the formal operational stage... if not, use examples instead of definitions... be more concrete
teaching examples
•How did you best learn how to do a blood pressure reading? •How would you best learn the appropriate ranges •How would you best learn what causes increases and decreases in blood pressure •How would your patient best learn about blood pressure?
Types of teaching
•INFORMAL: relaxed setting -Education on new meds -How to self-administer insulin •FORMAL: class -Neonatal class -Pre-hip surgery class -Staff education
Cognitive (Thinking) Domain of Learning
•Involves Storing and Recalling information -Memorization, recall, comprehension, ability to analyze, synthesize, apply, and evaluate ideas... "the facts about a disease" •Examples: -Pt can report the names and doses of the 3 meds he is taking -Pt can explain the expected effects of the medication she is prescribed -Pt sets up a schedule for changing the dressing on her leg wound -Pt describes how to distinguish between normal inflammation and signs of infection in his wound •STRATEGIES: lectures, reading materials, audiovisual materials, computer assisted instruction, case studies
Strategies for hearing challenges
•Limit background noise •Speak clearly with more volume •Do not chew gum or eat while speaking •Always talk face to face
Be considerate of limitations
•Literacy •Developmental limitations •Physical limitations •Financial limitations •Language barrier •Culture •Religious beliefs
Factors that affect Patient learning
•Motivation •Readiness •Timing •Active Involvement •Feedback •Repetition •Learning Environment •Scheduling of Session •Complexity •Communication •Developmental Stage •Cultural Factors •Health Literacy •Special Populations
LEARNERS: who are they?
•Patient •Family •Caregivers - caring for pt at home •Healthcare personnel -New employees -Nursing assistants -Peers -Nursing students
Affective (Feelings) domain of learning
•Receiving and responding to new ideas -Changes feelings, beliefs, attitudes, values •Examples: -Adolescent Pt makes eye contact as the nurse explains a procedure -Pt asks questions about what to expect during a procedure he is to undergo -Parent expresses a commitment to stay with hospitalized child after nurse explains impact of hospitalization -Lung cancer survivor volunteers to speak to high school group about the dangers of smoking •STRATEGIES: role model, group work, role playing, panel discussions, mentoring, discussion, counseling
strategies for cognitive changes in older adults:
•Repeat essential information •Focus on the important meaning of the information, that is, the gist •Use plain language •Communicate directions and advice that need to be followed •Use reminders to aid memory i.e. brochures, pamphlets •Include skill building with information activities to reinforce meaning
Psychomotor (skill) Domain of Learning
•Uses sensory awareness for cues & physically performing a skill... "hands on" skills -Must: recognize the value of the skill and know about the skill •Examples: -Pt brings personal equipment to a teaching session -Father demonstrates diapering after watching a demonstration -Patient demonstrates self-administering an insulin injection •STRATEGIES: demonstration/return-demo, simulation models, audiovisual, journaling, self-reflection, pictures/illustrations
Although limited health literacy affects most adults at some point in their lives, there are disparities in prevalence and severity. Some groups are more likely than others to have limited health literacy. Populations most likely to experience limited health literacy:
■ Adults over the age of 65 years ■ Racial and ethnic groups other than White ■ Recent refugees and immigrants ■ People with less than a high school degree or GED ■ People with incomes at or below the poverty level ■ Non-native speakers of English