PATIENT EDCUCATION -CHAP 9

ADULT LEARNERS- 1

*People who prefer to be given information they can use immediately, to be actively involved in the learning process, to connect their life experiences with the new information they learn, to know how the new information is relevant to their busy lives, to know how the information will solve a problem, and to receive information that is relevant to their needs. ***Adult learners must believe that they need to learn before they become willing to learn.

Teaching Methods and Instructional Materials

A teaching method is the way information is taught that brings the learner into contact with what is to be learned. Instructional materials are the objects or vehicles used to communicate information that supplements the teaching method. TEACHING METHODS: No one method is right for teaching all learners in all settings, nor is one method more effective for changing behavior in any of the three domains.Combine methods or use one method with one or more instructional materials to meet the needs of the learner. Choose methods depending on your familiarity with the method, the availability of educational resources, and the characteristics of individual patient or audience including age-appropriate methods.

Adherence and Compliance

Adherence and Compliance are often used interchangeably to refer to a patient's efforts to follow health care advice. Both terms refer to the ability to maintain health-promoting regimens determined by or in conjunction with the health care provider, respectively. Compliance refers to the extent to which a patient's behavior coincides with the clinical advice, implying the health care provider is viewed as the authority and the patient passively follows recommendations, a paternalistic attitude toward patients Adherence refers to the extent to which a person's behavior corresponds with the agreed-upon recommendations from a health care provider. The term adherence supports a more inclusive and active patient role, emphasizing agreement between the patient and health care provider, and is seen as more patient centered than compliance. Use of the term adherence reflects the patient's right to choose whether or not to follow treatment recommendations (Hurlow & Hensley). Therefore, the term adherence will be used in this discussion.

Additional Implementation Considerations Promote patient learning by using a warm and accepting approach.Your attitude has more effect on the patient than any other factor Avoid taking a condescending attitude and using technical and medical terms (unless the patient has a background in this area). A nonthreatening teaching-learning atmosphere allows learning to occur. Consider the physical environment when implementing the teaching plan. Some planning may be needed to ensure adequate space and lighting, comfortable chairs, and good ventilation. Privacy is alsoimportant, as is freedom from distractions and interruptions. Review the patient's expectations and role functions as a learner. To avoid any misunderstandings, review the contractual agreement beforeimplementing the teaching plan. The patient is expected to listen, observe, and attempt to understand what is being taught.

Assess the patient's comfort level. Some people are uncomfortable in the role of learner. You need to recognize this problem in order to assist the patient to assume the role more easily. If the patient must learn special techniques or procedures (e.g., colostomy care, selfinjections, eye medication instillation), assure the patient that it takes time and practice before anyone can perform new skills confidently. Be prepared and organized before implementing the teaching plan.Gather and organize all teaching aids (e.g., posters, films, printed materials) before the teaching session. A disorganized teacher distracts the learner and hinders learning. Also, a procedure or skill must be taught in the correct sequence so that the patient does not become confused. Make each learning session interesting and enjoyable for the patient. Have an enthusiastic and positive attitude, and make learning fun by creative use of planned teaching strategies. When you approach teaching positively, the patient is more likely to approach learning in a similar way.

NURSING PROCESS FOR PATIENT AND CAREGIVER TEACHING

Assessing: Patients themselves are the best source of assessment information. Patients are considered primary sources of information. By using effective interviewing techniques. you can obtain the data needed to identify learning needs.

LEARNING DOMAINS People learn in three domains: cognitive, psychomotor, and affective

COGNITIVE: learning involves the storing and recalling of new knowledge in the brain. PSYCHOMOTOR: Cognitive learning includes intellectual behaviors such as the acquisition of knowledge, comprehension, application (using abstract ideas in concrete situations), analysis (relating ideas in an organized way), synthesis (assimilating parts of information as a whole), and evaluation (judging the worth of a body of information). AFFECTIVE: includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence after physical therapy).

EVALUATING TEACHING: REVISING THE PLAN/THE NURSE AS COUNSELOR

Documenting: The nurse is legally responsible for documenting teaching in the patient's health record. Documentation of the teaching-learning process includes a summary of the learning need, the plan, the implementationof the plan, and the evaluation results. THE NURSE AS A COUNSELOR: Counseling is the interpersonal process of helping patients to make decisions that promote their overall well-being. Counseling focuses on improving coping abilities, reinforcing healthy behaviors, fostering positive interactions, or preventing illness and disability.

EVALUATING / METHODS OF EVALUATION

Evaluating: The nurse and the patient together measure how well the patient has achieved the outcomes specified in the care plan. METHODS OF EVALUATION:There are several methods of evaluation of learning. For instance,cognitive domain learning may be evaluated through oral questioning, affective domain learning through the patient's response, and psychomotor domain learning by a return demonstration. Asking direct questions is often an efficient method of evaluating learner outcomes. Simply ask the patient a question, and the answer reflects the patient's level of knowledge about a topic. Direct questions can also be used to evaluate the patient's affective learning. Sometimes observational skills can help determine whether the patient is using the material learned. A nurse also uses observation when evaluating the patient's psychomotor skills. A return demonstration is an excellent way of evaluating psychomotor domain learning

GROUP VS INDIVIDUAL/Formal Versus Informal Teaching/

Group Versus Individual Teaching:Several factors are important when choosing the teaching setting. Some learner outcomes are met more readily in a one-to-one encounter, whereas others are achieved more easily in a group. FORMAL VS INFORMAL TEACHING: Many nurse-patient interactions can include informal teaching. Theseunplanned teaching sessions are often effective because they deal withthe patient's immediate learning needs and concerns. Discussion as simple as reinforcing the correct technique for postoperative deep breathing exercises or explaining or clarifying information about a scheduled procedure is actually teaching. Informal teaching may also lead to additional planned, formal sessions. Formal teaching is the planned teaching done to fulfill learner outcomes. Both forms are effective when used appropriately.

Diagnosing

If the patient lacks the required knowledge, attitudes, or skills to support health promotion, you should diagnose the deficiency. If you believe that a patient's knowledge deficit is the primary problem, write a nursing diagnosis identifying a specific learning need as the problem, followed by the defining characteristics and the related factors—for example, "Deficient knowledge: Breastfeeding related to inexperience, as evidenced by anxiety, multiple questions, and inability to demonstrate." A knowledge deficit may contribute to other actual or potential problems; if that is the case, it is written as the etiology (second part of the diagnostic statement). For example, the lack of knowledge contributes to the nursing diagnosis of "Imbalanced nutrition: less than body requirements related to mother's lack of knowledge about infant feeding and deficient learning readiness, as evidenced by mother's quick frustration when breastfeeding, inability to identify appropriate actions to encourage the infant to suck, and infant's weight loss."

BREASTFEEDING NURSING DIAGNOSIS

If you identify that a pregnant woman plans to breastfeed but knows nothing about breastfeeding, "Deficient knowledge: Breastfeeding" is the problem statement. The goal is to increase the mother's knowledge. If, on the other hand, you observe a newborn failing to gain weight appropriately, and it is reasonable to suspect that the mother's lack of knowledge about how to breastfeed is interfering with the infant's nutritional intake, a lack of knowledge about breastfeeding is the etiology of the problem (Imbalanced nutrition). The goal is to ensure the infant's proper nutrition. Related nursing diagnoses include the following: Ineffective health management Noncompliance (specify) Self-care deficit (specify).

EFFECTIVE COMUNICATION TECHNIQUE

Key points of effective communication associated with patient teaching include the following: 1. Be sincere and honest; show genuine interest and respect. 2. Avoid giving too much detail; stick to the basics. 3. Ask if the patient has any questions. 4.Be a "cheerleader" for the patient. Avoid lecturing. 5.Use simple words. 6.Vary your tone of voice. 7. Keep the content clear and concise. 8. Listen and do not interrupt when the patient speaks. 9. Ensure that the environment is conducive to learning and free of interruptions. 10.Be sensitive to the timing of teaching sessions. A shorter session is best for a younger child, and an adult may need to choose an opportune time to learn new information.

MOTIVATION

Motivation: iIs enhanced When: Assessing a patient's learning readiness, consider the patient's motivation. Patients who are ready to learn are able and motivated toprocess new information, develop new skills, and explore new attitudes and behaviors. Motivation is an internal impulse (such as emotion or physical pain) that encourages the patient to take action or change behavior. Examples of motivational triggers include personal crisis and loss of social role due to disease symptoms. You can use the health belief model when developing teaching plans, evaluating the ideas or beliefs that motivate a patient, and applying these to the teaching plan.

MOTIVATIONAL INTERVIEWING

Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. Nurses often become frustrated because their patients do not seem to want to get better or to learn how to care for themselves. GOOD FOR or an issue such as the childhood obesity epidemic. Instead, a collaborative, family-centered model that includes motivational interviewing may help the family identify health goals. Instead of focusing on solutions to the obesity issue, the nurse attempts to gain a better understanding of the barriers that exist to changing family behaviors. With this technique, families gain the self-confidence needed to promote better health outcomes. This is not the traditional approach, and it requires time to establish relationships and explore family perspectives.

MOTOR SKILLS/ AGE AND TEACHING

Motor development is also a concern in the teaching-learning process. A 4-year-old girl diagnosed with diabetes may not be able to administer her own insulin shots if she lacks the fine motor skills needed to manipulate the equipment, but a 13-year-old patient could probably master the technique quickly.

REFERRALS

Offer to refer the patient to the appropriate professional (e.g., psychiatric or mental health nurse, psychologist or psychiatrist, social worker, clergy, financial counselor, sex therapist, or occupational therapist). In other cases, a simple referral to a community resource, such as a neighborhood support group, may be all the patient needs.

ADULT LEARNERS 2

PEDAGOGY generally refers to the teaching of children and adolescents. In recent years, however, the study of teaching adults ANDRAGOGY has gained more attention. Adults need to be taught differently than children. Four assumptions about adult learners: 1. As people mature, their self-concept is likely to move from dependence to independence. 2. The previous experience of the adult is a rich resource for learning. 3. An adult's readiness to learn is often related to a developmental task or a social role. 4. Most adults' orientation to learning is that material should be useful immediately, rather than at some time in the future.

PANEL DISCUSSION / DEMONSTRATION&RETURN DEMONSTARTION/DISCOVERY LEARNING

Panel Discussion: A panel discussion involves a presentation of information by two or more people.can be used to impart factual material but are also effective for sharing experiences and emotions. Debates are a form of panel discussion that includes multiple sides of a controversial topic.Demonstration and Return Demonstration Demonstration of techniques, procedures, exercises, and the use of special equipment, combined with a lecture and discussion, is an effective strategy. Evaluate patient's learning using a return demonstration, as with the teach-back technique described earlier. Practice sessions are often included for the learner. Models of body parts or practice models, such as a resuscitation model, are frequently used. Childbirth educators usually demonstrate the birth of a baby by using a pelvic model, knitted uterus, and baby doll.Discovery In discovery learning, a problem or situation is presented to the patientor group of patients, who are then guided to discover the solution or approach. Discussion of other possible approaches and solutions can follow the patient's own solutions. This is a good method for teaching problem-solving techniques and independent thinking. you could give a group of diabetic patients a short description of a situation that includes signs and symptoms, asking them to decide whether they indicate hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and what measures to take.

ROLE PLAYING/INSTRUCTIONAL MATERIALS/ AUDIOVISUAL/WRITTEN MATERIALS/

Role playing gives the learner a chance to experience, relive, or anticipate an event. You explain a scenario and allow the patient to play out the scene with you or with one or more other learners. Role playing can be used to work through emotional traumas or to plan for possible traumas.Role playing is a good strategy for children as well as adults. Puppets and dolls can be used as part of the process to help young children express negative feelings about hospitalization and traumatic procedures. INSTRUCTIONAL MATERIALS AND LEARNINGACTIVITIES: While planning teaching methods, also decide what instructional materials will be used to communicate the information, and any learning activities the patient should do independently. There are many ways that the patient can preview new material or reinforce what has already been taught. Printed materials, audiovisual materials, and programmed instruction materials are often assigned as part of the teaching plan.Audiovisual materials such as computer programs, online courses, technology-driven learning tools, presentations using presentation tools such as PowerPoint or Prezi, films, television programs, flip charts, posters, and diagrams are popular and effective teaching strategies when combined with a lecture or discussion.Written Materials: The first consideration with printed material is availability. Many brochures, fact sheets, and pamphlets are available at no cost from online sources. Many nurses have also written materials for distribution to patients. Writing instruction sheets, books, and comic books for health teaching can be rewarding as well as useful. Like audiovisual materials, printed materials are generally used in conjunction with other strategies.

Outcome Identification and Planning

Specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions

THE ROLE OF THE NURSE AS A COACH

The Role of the Nurse as a Coach: With the implementation of the 2010 Affordable Care Act and the goals outlined in the Healthy People 2020 initiative, there is a clear need to address the direction of health care in the future. The IOM's report, The Future of Nursing: Leading Change, Advancing Health (2011), emphasizes the need for nurses to assume a leadership role that includes collaborating and coordinating care across teams of health professionals. The nurse coach role is an integral component of this partnership and assists patients and families to make changes that promote healthier lifestyles. Nurses who incorporate coaching into their professional practice can improve the quality and effectiveness of care. A nurse coach is a"registered nurse who integrates coaching competencies into any setting or specialty area of practice to facilitate a process of change or development that assists individuals or groups to realize their potential

THE NURSE COACH ROLE The role of nurse coach is evolving and should not be confused withthat of a preceptor or mentor. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session,supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

The nurse coach role is supported by coaching education, training, and experience and is influenced by the population served. The nurse coaching process includes the following: Establishing relationships and identifying readiness for change. Identifying opportunities, issues, and concerns. Establishing patient-centered goals. Creating the structure of the coaching interaction Empowering and motivating patients to reach goals Assisting the patient to determine progress toward goals.

POPULATIONS AFFECTED BY LOW HEALTH LITERACY

This population is more likely to avoid medical screenings and require emergency department attention. Awareness of the health literacy issue gives health care professionals the opportunity to support patients and families in overcoming barriers to health and empowering patients to take control of their health care needs. health care information and directions have traditionally been written at a 10th-grade level or higher, while educational material is generally more easily understood when written at a 5th-grade level. Low health literacy affects all segments of our population and threatens the quality and safety of our health care.

WEB BASED INSTRUCTION AND TECHNOLOGY/ CONTRACTUAL AGREEMENT

Web-Based Instruction and Technology Websites appropriate to the patient's disease process, wellness interests, or health promotion focus can be valuable teaching and learning resources. Access to the Internet is common, and many websites can support instruction. These sites provide consumer information that is formatted for easy reading and access. Programmed instruction or webbased instruction can be particularly useful for patients in isolated areas, especially when it is interspersed with opportunities to see the nurse or health care provider in person.A contractual agreement is a pact between two people setting out mutually agreed-on goals. Contracts between nurses and patients are common in many health care settings. The contracts are usually informal and not legally binding. When teaching a patient, such an agreement can serve to motivate both the patient and you as the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment

Piaget Formal Operational and Concrete Operations

When teaching a sexually active 16-year-old girl about contraceptive methods, you would assess whether the young patient has reached the stage Piaget : Formal Operations (the ability to use logical reasoning to solve hypothetical problems). If the patient's intellectual development is delayed and she is still in the period of Concrete Operations (use of logical reasoning to solve concrete problems), she may be less skilled in thinking abstractly— she may not perceive pregnancy as a real possibility, and therefore may not fully understand the need for contraception.

FINANCIAL ASSISTANCE

iF NEEDED, Evaluate the family's financial resources, because the patient may be unable to afford to follow a new treatment regimen. If needed, refer patients and families to community-based support groups and funding sources.

Motivation is enhanced when:

1. Patients view themselves as susceptible to the health problem in question 2. Patients view the health problem as a serious threat 3. Patients believe there are actions they can take to reduce the probability of acquiring the health problem 4. Patients believe the threat related to taking these actions is not as great as the health problem itself

OLDER ADULT LEARNERS

First identify any learning barriers such as sensory loss, limited physical mobility, or inability to comply with the recommended therapeutic regimen. Sensory deficits that can affect learning in older adults include the presence of cataracts that can cloud vision; a decrease in lens accommodation that necessitates adequate lighting; a decrease in peripheral vision that requires that teaching materials be kept immediately in front of the learner; or a hearing loss that make it imperative for the teacher to speak slowly and clearly.

SUCCESSFUL TEACHING PLANS FOR OLDER ADULTS

Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information.

POSITIVE REINFORCEMENT / NEGATIVE REINFORCEMENT

To make the most of this dynamic, use positive reinforcement to affirm the efforts of patients who have mastered new knowledge, attitudes, or skills. Reinforcement may be as simple as a few words of acknowledgment ("You've mastered this diet quickly"), as spontaneous as a warm hug, or as planned as the entire staff joining to celebrate a patient's independent ambulation. Negative reinforcement—criticism or punishment—is generally ineffective; undesirable behavior is usually best ignored.

FACTORS AFFECTING PATIENT LEARNING

Consider: Age and Developmental level, family support networks and financial resources, cultural influences and language deficits, and health literacy level, you can individualize the teaching plan and maximize learning. Three critical developmental areas to consider when developing a teaching plan are the patient's physical maturation and abilities, psychosocial development, and cognitive capacity. Compared to adults, children have shorter attention spans and a greater need for nurturing, support, and creative participation in learning activities. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible. Teaching strategies that include clear explanations and reasons for procedures, stated in a simple and logical manner, are most successful.

IMPLEMENTING/ TIME CONSTRAINTS/ SCHEDULING

Implementing the teaching plan requires interpersonal skills and effective communication techniques, as well as organizational and time management skills. Teaching the patient can be a major part of the working phase of the helping relationship. Time Constraints:Nurses often encounter challenges in finding time to meet patients'needs, so consideration of time constraints is important when implementing teaching and learning activities. Set priorities in order to teach essential content thoroughly. Less important content can be taught last so that the more important learner outcomes can be met within the time available. If time permits, the remaining content can be addressed. SCHEDULING:It is better to plan shorter, more frequent teaching sessions than one or two longer sessions. Short sessions allow patients to digest the new material and prevent them from becoming too tired or uncomfortable because of a health problem. Sessions of 15 to 30 minutes are generally well tolerated. Usually, more formal classroom programs last for more than 1 hour; in such cases, provide a break after every 50 minutes ofclass time.

DEMONSTRATION MATERIALS/ PROGRAMMED INSTRUCTION/

Demonstration materials stimulate a learner's senses as well as add variety, realis, and enjoyment to the teaching-learning experience. Models and real equipment and displays, such as posters, flip charts, and bulletin boards are examples of demonstration materials.Programmed Instruction Most programmed instruction books or booklets are prepared so that learners can use them independently of a teacher. However, educators generally agree on the need to spend time with the learner before and after the program to clarify the information, answer questions, and provide the personal touch necessary for a learner's motivation. ITt's a self-paced strategy.

HEALTH LITERACY

Health literacy is the ability to obtain, read, understand, and act on health information. Health literacy skills include performing Internet searches, reading health prevention pamphlets, measuring medication doses, and understanding and complying with verbal or written health care instructions. Over a third of U.S. adults (77 million people) have below basic or basic health literacy and thus would have difficulty with common health tasks. POPULATIONS OF LOW HEALTH LITERACY: The older adult, those with limited education, those with low incomes, racial and ethnic groups other than White, and nonnative speakers of English are most likely to experience low health literacy.

Assessment of Learning Needs

First, identify what the patient considers of importance to learn, as well as new knowledge, attitudes, or skills necessary forpatients and families to learn in order to manage their health care. Second, focus on learning readiness. The patient's anxiety, motivation for learning, willingness to engage in the teaching-learning process, and support system contribute to readiness to learn.

NON ADHERENCE/ NON COMPLIANCE

Nonadherence or noncompliance occurs when patients are resistant to following a predetermined health care regimen (nonadherence) or patients do not follow a predetermined regimen (noncompliance). Patients may ignoreinstructions or not follow them appropriately. These terms are also often used interchangeably and may contribute to situations that threaten the patient's health. Nonadherence and noncompliance can be associated with a lack of learning readiness and motivation, confusion, disappointment, misunderstanding, fear, or inability to learn. Treatment factors such as side effects, lifestyle issues such as transportation, and sociodemographic factors such as inadequate finances may also contribute to nonadherence or noncompliance.

ROLE MODELING /LECTURE/DISCUSSION

Role Modeling: The old saying "actions speak louder than words" explains why role modeling is effective. Patients watch their nurses closely; use this as an opportunity to improve a patient's behavior. Lecture: The term "lecture" means a presentation of information by a teacher to a learner. More effective lectures can include: question-and-answer periods and collaboration with the learner. This strategy can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies.Discussion involves a two-way exchange of information, ideas, and feelings between the teacher and learners. It is an effective method when used by a nurse who is comfortable with leading a group and knowledgeable about group processes. It can also be an effective method for one-on-one instruction.

Types of Counseling Counseling may be situational, developmental, or motivational, as well as short- or long-term.

Short-term counseling focuses on the immediate problem or concern of the patient or family. It can be a relatively minor concern or a major crisis, but in any case, it needs immediate attention. Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life. For example, a patient in the hospital finds out that his wife has been involved in a car accident; she received only a few scratches, but their only car was demolished. Long-term counseling extends over a prolonged period. A patient might need the counsel of the nurse at daily, weekly, or monthly intervals. A patient experiencing a developmental crisis, for example, might need longterm counseling. A developmental crisis can occur when a person is going through a developmental stage or passage. For example, many women going through menopause need help adjusting to the changes they experience. Long-term counseling may occur in nurse-led support groups.

NEWEST VITAL SIGN

The Newest Vital Sign (NVS) is a screening tool to assess health literacy. It was developed by Pfizer to improve communications between patients and providers, and can be administered during initial assessments to assess the patient's literacy skills involving both numbers and words. *NVS has been reported to perform moderately well in identifying limited literacy. NVS uses a nutrition label from an ice cream container and a score sheet for recording the patient's answers to six oral questions that refer to the label. Based on the number of correct responses, the health care provider can then further assess the patient's health literacy level as indicated. The time spent administering this tool more than compensates for the time providers might need clarifying a diagnosis, treatment, or medications if they had not recognized a patient's limited health literacy.