Ch 25 Flashcards
Importance of a teaching plan
A well-designed, comprehensive teaching plan provides a good fit with each patient’s unique learning needs and ultimately changes behaviors to improve patient outcomes. In due course the information gained helps patients make informed decisions about their care and become healthier and more independent
The primary goal of patient education is
-to help individuals, families, or communities achieve optimal levels of health to help individuals, families, or communities achieve optimal levels of health
Comprehensive patient education includes three important purposes , each involving a separate phase of health care:
health promotion and illness preven- tion, health restoration, and coping.
Teaching
the concept of imparting knowledge through a series of directed activities. It consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills
Learning
defined as a “conscious or unconscious permanent change in behavior as a result of a lifelong, dynamic process by which individuals acquire new knowledge, skills, and/or attitudes that can be measured and can occur at any time or in any place through exposure to environmental stimuli”
It is a process of both un- derstanding and applying newly acquired concepts. For example, an adult exhibits learning when he demonstrates how to set up his weekly pillbox correctly. He shows transfer of learning when he demonstrates how to set up his wife’s pillbox. Teaching and learning begin when a person identifies a need for knowing or acquiring an ability to do something. Teaching is most effective when it responds to a learner’s needs. An educator assesses these needs by asking questions and deter- mining a learner’s interests. Interpersonal communication is essential for successful teaching
The Joint Commission’s (TJC’s) Speak Up campaign helps patients understand their rights when receiving medical care and supports them to become more active participants in their care by asking ques- tions
• Speak up if you have questions or concerns. If you still do not under- stand, ask again. It is your body, and you have a right to know.
• Pay attention to the care you get. Always make sure that you are getting the right treatments and medicines from the right health care professionals. Do not assume anything.
• Educate yourself about your illness. Learn about the medical tests that are prescribed and your treatment plan so you can make informed decisions.
• Ask a trusted family member or friend to be your advocate (adviser or supporter).
• Know about your new medicine(s) and why you take them.
• Use a hospital, clinic, surgery center, or other type of health care organization that you have researched or checked carefully.
• Participate in all decisions about your care. You are the center of the health care team. Medication errors are the most common health care mistakes.
Not using the teach-back method can lead to gaps in u
learning objectives
The steps of the teaching process are similar to those of the commu- nication process.
You use patient requests for information or identify a need for information because of a patient’s health restrictions, recent diagnosis of an illness, or a recent injury.
Then you identify specific learning objectives to describe the behaviors the learner will exhibit as a result of successful instruction (The steps of the teaching process are similar to those of the commu- nication process.
You use patient requests for information or identify a need for information because of a patient’s health restrictions, recent diagnosis of an illness, or a recent injury.
Then you identify specific learning objectives to describe the behaviors the learner will exhibit as a result of successful instruction.
Those objectives serve the same role as outcomes when delivering physical and psychological care.
DOMAINS OF LEARNING
Learning occurs in three domains: cognitive (understanding), affective (attitudes), and psychomotor (motor skills) \
The most effective learning takes place when all three of these domains are used
Cognitive learning
Cognitive learning occurs when an individual gains information to further develop intellectual abilities, mental capacities, understanding,
and thinking processes
The revised taxonomy
for cognitive learning includes:
• Remember (formerly Knowledge): Recognizing or recalling knowledge from memory
-Understand (formerly Comprehension): Constructing meaning from different types of messages or activities, such as interpreting, exemplifying, classifying, summarizing, inferring, comparing, or explaining
-Apply: Carrying out or using a procedure through executing or implementing
-Analyze: Breaking materials or concepts into parts, then determining how the parts relate to one another or how they interrelate, or how the parts relate to an overall structure or purpose
-Evaluate: Making judgments based on criteria and standards through checking and critiquing
• Create (formerly Synthesis): Putting elements together to form a coherent or functional whole; reorganizing elements into a new pattern or structure through generating, planning, or producing
Affective learning
Affective learning deals with learning how to express feelings and emotions and to develop values, attitudes, and beliefs needed toward improving health
The simplest behavior in affective learning is receiving, and the most complex is characterizing. Affective learning includes the following:
• Receiving: Learner is passive (not engaged) but is alert and willing to receive information.
• Responding: Requires active participation. This refers to a learner’s active attention to stimuli, verbal and nonverbal responses, and motivation to learn.
• Valuing: Attaching worth and value to the acquired knowledge (e.g., new coping skills) as demonstrated by the learner’s behavior through acceptance, preference, or commitment.
• Organizing: Developing a value system. Learner internalizes values and beliefs involving (1) the conceptualization of values and (2) the organization of a value system.
• Characterizing: Highest level of internalization. Acting and re- sponding with a consistent value system; requires introspection and self-examination of one’s own values in relation to an ethical issue or particular experience.
Psychomotor learning
Psychomotor learning involves the development of manual or physi- cal skills, such as learning how to walk or how to type on a computer
The simplest behavior in the hierarchy is fundamental (depending on the hierarchical model), whereas the most complex is origination. Psychomotor learning includes the following:
• Fundamental: Skills, movements, or behaviors related to walking, running, jumping, pushing, pulling, and manipulating. They are often components for more complex actions.
• Perception: Skills related to kinesthetic (bodily movements), vi- sual, auditory, tactile (touch), or coordination abilities as they are related to the ability to take in information from the environment and react.
• Guided response: Early stages of learning a particular skill under the guidance of an instructor that involves imitation and practice of a demonstrated act.
• Mechanism: Higher level of behavior in which a person gains con- fidence and proficiency in performing a skill that is more complex or involves several more steps than a guided response.
• Complex overt response: Smoothly and accurately performing a motor skill that requires complex movement patterns.
• Adaptation: Motor skills are well developed and movements can be modified when unexpected problems occur.
• Origination: Using existing psychomotor skills to create new movement patterns and perform them as needed in response to a particular situation or problem.
Motivation
Motivation is an internal state (e.g., an idea, emotion, or a physical need) that helps arouse, direct, and sustain human behavior
A patient’s motivation to learn is influenced by a belief in the need to know something. Patients who need knowledge for survival have a stronger motivation to learn than patients who need it for promoting health
Motivational interviewing (MI) is a counseling and educational tech- nique that focuses on a patient’s perceived goals and helps people resolve insecurities and ambivalent feelings (e.g., nonadherence) to find the internal motivation needed to change their behavior (
social learning theory
-Among the various theories, social learning theory is one of the most useful approaches to patient education. It considers the personal characteristics of the learner, behavioral patterns, and the environment and guides the educator in developing effective teaching interventions that motivate and enhance learning
-according to social learning theory, a person’s state of mind and intrinsic motiva- tional factors (i.e., sense of accomplishment, pride, or confidence) reinforce behaviors and influence learning This type of internal reward system allows a person to attain desired outcomes and avoid undesired outcomes, resulting in improved moti- vation.
Self-efficacy
a concept included in social learning theory, refers to a person’s perceived ability to successfully complete a task. When people believe that they can achieve a particular behavior, they are more likely to perform the behavior consistently and correctly. Motivational interviewing techniques incorporate self-efficacy principles.
Self-efficacy beliefs come from four sources: verbal persuasion, vicarious experience, enactive mastery experience, and psychological and affective states
- Assessment of a patient’s lifestyle, health beliefs, cultural traditions, and health practices
- Communication with an awareness of the many variations in verbal and nonverbal responses
- Cultural negotiation and compromise that encourages awareness of characteristics of a patient’s culture and one’s own biases
- Establishment of respect for a patient’s cultural beliefs and values; creating a caring rapport
- Sensitivity to how patients from diverse backgrounds perceive their care needs and the patterns of communication they use
- Safety that enables patients to feel culturally secure and avoids disempowerment of their cultural identity
attentional set
he mental state that allows a learner to focus on and comprehend a learning activity. Before learning anything, patients must be able to pay attention to or concentrate on the informa- tion to be learned. Physical discomfort, anxiety, confusion, and envi- ronmental distractions influence the ability to concentrate. Therefore determine a patient’s level of comfort before beginning a teaching plan, and ensure that the patient is able to focus on the information. As anxiety increases, a patient’s ability to pay attention often decreases. A mild level of anxiety can be conducive to learning. However, a high level of anxiety prevents learning from occurring. At times when a patient is unable to attend, a family caregiver often becomes the recipient of edu- cation. Simple facts, rather than detailed teaching strategies, are most important during these times. For example, a patient in pain is receptive to learning about how to use a patient-controlled analgesia pump but not how to use crutches.
health literacy
-the cognitive and social skills that determine the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.
The Centers for Disease Control and Prevention (CDC) define personal health literacy as the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others
Health literacy pertains not only to a patient’s ability to read and comprehend health-related information but also to having the skills to problem solve, articulate, and make appropriate health care decisions
-Research shows that not only is health literacy a strong predictor of a person’s health status, but it is also a stronger predictor compared with several other factors, includ- ing age, income, employment status, educational level, and race
Health literacy pertains not only to a patient’s ability to read and comprehend health-related information but also to having the skills to problem solve, articulate, and make appropriate health care decisions
Because health status is dynamic, assessment is an ongoing activity. Assess the following:
• Information or skills needed by a patient to perform self-care and
to understand the implications of a specific health problem. For example, you teach a young man who has just entered high school how to prevent sexually transmitted infections (STIs).
• Patient experiences (e.g., new or recurring problem, past hospital- ization) that influence the motivation and need to learn.
• Information that family caregivers require to support the patient’s needs. The amount of information needed depends on the patient’s health status and extent of a family member’s role in helping the patient.
Motivation to Learn. Ask questions to identify and define a patient’s motivation. These questions determine whether a patient is prepared and willing to learn. Assess the following factors:
• Behavior (e.g., attention span, tendency to ask questions, memory,
and ability to concentrate during the teaching session).
• Health beliefs and sociocultural background: Norms, values, expe- riences, and traditions all influence a patient’s beliefs and values about health and various therapies, communication patterns, and
perceptions of time (see Chapter 9).
• Perception of the severity and susceptibility of a health problem
and the benefits and barriers to treatment.
• Identification of patient outcomes for learning, which must origi-
nate from the patient and not be imposed from outside by health care providers.
• Perceived ability to perform needed health behaviors.
• Desire to learn.
• Attitudes about health care providers (e.g., role of patient and
nurse in making decisions).
• Learning style preference: As the nurse, any educational effort will
be more effective if the chosen method of instruction aligns with your patient’s preferred learning style
Examples of nursing diagnoses that indicate a need for education include the following:
•Decisional Conflict
• Lack of Knowledge (Affective, Cognitive, Psychomotor)
• Impaired Health Maintenance
• Impaired Ability to Manage Dietary/Exercise Regimen
• Self-Care Deficit
Organizing Teaching Material.
An effective educator carefully con- siders the order of information to present. When a nurse has an ongoing relationship with a patient, as in the case of home health or case manage- ment, an outline of content helps organize information into a logical sequence. Material needs to progress from simple to complex because a person must learn the simple facts and concepts before learning how to make associations or complex interpretations of ideas.
-Staff nurses in acute care settings often focus on the simpler, more essential concepts, whereas home health nurses can better address complex issues.
-Begin instruction with essential content because patients are more likely to remember information that you teach early in a teaching ses- sion.
-A concise summary of key content helps the learner remem- ber the most important information (Bastable, 2019). Using instruc- tional materials that contain the same summaries is very helpful.
Reinforcement
Reinforcement requires the use of a stimulus to in- crease the probability of a desired response. A learner who receives reinforcement before or after a desired learning behavior is more likely to repeat that behavior. Reinforcers are positive or negative. Positive reinforcement such as a smile or verbal praise promotes desired behav- iors. Although negative reinforcement such as frowning or criticizing can decrease an undesired response, it may also discourage participa- tion and cause the learner to withdraw. The effects of negative reinforcement are less predictable and often undesirable.
The Brigham and Women’s Faulkner Hospital (BWFH) Patient/Family Education Committee reviewed research on verbal instruction and developed the EDUCATE Model, which includes the following elements
• Enhance comprehension and retention—Collaborate with a patient to create a question list so that the patient can ask questions and you can answer them. Follow the teaching strategies in Box 25.6.
• Deliver patient-centered education—Talk with, and not at, a patient. Learn patients’ values and preferences for education about their health. Practice empathetic skills, especially when the view of the patient is different from that of the provider.
• Understand the learner—Build instruction based on what the patient already knows and wants to learn. Attend to nonverbal messages as you instruct the patient and gather feedback.
• Communicate clearly and effectively—Follow the teaching strategies in Box 25.6.
• Address health literacy.
• Measure outcomes of Teaching and Education—Know what is ef-
fective, adapt the approach based on the patient’s ability to learn. Use teach-back.
A cognitive regulation technique called “reappraisal”
-can be effective
in reducing anticipatory anxiety. This cognitive change strategy involves changing the meaning of a stimulus in a way that alters its emotional impact
- It allows people to change an underly- ing appraisal that contributes to negative emotions (Troy et al., 2018). For example, rather than saying to a patient during the insertion of an intravenous catheter, “You are going to feel a stick,” say instead, “The catheter I am about to place in your arm will be our way of giving you the fluids and medications you need.”
-Reappraisal typically includes reconsideration or reframing of an emotional event in less emotional terms
return demonstration
Demonstrations are most effective when learners first observe the educator and during a return demonstration have the chance to prac- tice the skill. Combine a demonstration with discussion to clarify concepts and feelings. An effective demonstration requires advanced planning:
- Position the learner to provide a clear view of the skill being per-
formed so the learner can see each step of the demonstration easily. - Assemble and organize the equipment. Make sure that all equipment works.
- Perform each step slowly and accurately in sequence while analyzing the knowledge and skills involved, and allow the patient to handle the equipment.
- Review the rationale and steps of the procedure.
- Encourage the patient to ask questions to ensure understanding of
each step. - Judge proper speed and timing of the demonstration on the basis
of the patient’s cognitive abilities and anxiety level. - Demonstrate mastery of the skill by having the patient perform a return demonstration under the same conditions that will be expe- rienced at home or in the place where the skill is to be performed. For example, when a patient needs to learn to walk with crutches, simulate the home environment. If the patient’s home has stairs, the patient would practice going up and down a staircase in the hospital.
Analogies
Learning occurs when an educator translates complex
language or ideas into words or concepts that a patient understands. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water
through a hose. Follow these general principles when using analogies:
• Be familiar with the concept.
• Know the patient’s background, experience, and culture so that you
can make an analogy relevant.
• Keep the analogy simple and clear.
Teach-back
a closed-loop communication technique that assesses patient retention of the information given during a teaching session. To perform teach-back, ask the patient to explain material that was dis- cussed, such as the role of diet and exercise in managing blood glucose levels, or to demonstrate a skill, such as self-monitoring blood glucose. The response allows you to determine the degree to which the patient remembers and understands what was taught or demonstrated. Use nonjudgmental language so that patients do not feel tested
-For example, say, “I want to be certain that I taught this well.
Can you please describe some symptoms of a stroke?” Examples of teach-back prompts and questions include:
1. “Tell me in your own words how you will take this medication at
home.”
2. “Tell me some of the side effects that you should watch for.”
3. “When will you call the office regarding your blood pressure?”
4. “Please show me how to request a refill of this medication online.”
If the patient has difficulty recalling the material or demonstrating
a skill, modify and repeat the content and reassess retention. Also, take ownership of the teaching experience by responding, “I must not have explained stroke symptoms very well. Let me try again.” Patient under- standing is confirmed when the patient can accurately restate the information in own words
Summary
• The three purposes of patient education are health promotion and illness prevention, health restoration, and coping with impaired function.
• The Joint Commission’s (TJC’s) Speak Up initiatives help patients understand their rights when receiving medical care and support them to become more active participants in their care by asking questions of health care providers.
• Steps of the teaching process are similar to those of the communi- cation process.
• Just as effective communication involves feedback from the sender and receiver, an effective educator delivers instruction and then provides a mechanism (e.g., teach-back) for evaluating the success of a teaching plan by gaining feedback from the receiver.
• The most effective teaching plan often includes all three domains of learning: cognitive (understanding), affective (attitudes), and psy- chomotor (motor skills). Nurses consider the patient’s needs and learning preferences and the content of what the patient needs to know to select the appropriate domain.
• Motivation to learn is influenced by an individual’s belief in the need to know something; the more important people believe information to be, the stronger their motivation is to learn.
• An adult’s readiness to learn is affected by health status, attentional set, and acceptance of the illness experience.
• The ability to learn depends on physical and cognitive attributes, developmental level, physical wellness, and intellectual thought processes. A person’s learning style affects preferences for learning.
• The ideal environment for learning is well lit and has good ventilation, appropriate furniture, and a comfortable temperature.
• Self-efficacy is a concept included in many health promotion theo- ries because it often is a strong predictor of motivation to learn healthy behaviors. People who have self-efficacy for health-promoting behaviors believe they can accurately complete a particular health behavior and are more likely to perform the behavior consistently and correctly.
• Knowledge of a patient’s health condition and the patient informa- tion you gain from assessment during the nursing process allows you to critically select the topic and level of instruction required and allows you to determine the best time for teaching and how to engage the patient.
• A nurse assesses a patient’s current level within a learning domain and then selects approaches to use to aid the patient in achieving a higher level of performance in that domain.
• The characteristics of learning within each domain influence your teaching and evaluation methods.
• Understanding each learning domain prepares you to select proper teaching techniques and
apply the basic principles of learning.
• The nursing and teaching processes differ in that the nursing process
requires assessment of all sources of data to determine a patient’s total health care needs. The teaching plan focuses on a patient’s learning needs as they relate to the patient’s health status, as well as on a patient’s motivation, ability, and readiness to learn.
• Health literacy is one of the most important predictors of health outcomes because it influences whether an individual has the skills needed to manage health and prevent disease.
• A nurse bases educational priorities on a patient’s nursing diagnoses, outcomes established for the patient and the patient’s perception of what information is most important, anxiety or physical comfort level, and the amount of time available to teach.
• When planning a teaching session, remember that patients need to learn essential content first. Learning progresses from simple to complex; thus learners need to acquire simpler knowledge and skills within a learning domain before they can master more complex knowledge and skills.
• Nurses promote learning in patients with limited health literacy by creating a safe, shame-free environment, communicating clearly, using visual aids to reinforce spoken information, and carefully evaluating the patient and family caregivers’ understanding of the content.
• At the end of a teaching session, a nurse uses the teach-back technique to evaluate learning by asking the patient to explain the material that was discussed or demonstrate a skill.
REFLECTIVE LEARNING
Consider a member of your family or a friend who has some type of health issue. Review what you would assess about the individual to determine learning needs, and then summarize your conclusion about the person’s ability and motivation to learn.
• After you complete a clinical assignment with a recent patient, reflect on how you determined if the patient understood the care you pro- vided and any information you shared.
• Select a student colleague, and together develop a case study of a patient requiring health instruction. Using the case study, describe the learning domains relevant to what the patient’s educational needs are. Then identify three approaches for instructing the patient.
A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient’s first clinic visit. The nurse reviews the patient’s medical record and sees a note about the patient receiving instruction on how chemotherapy treats can- cer, but the note does not summarize the patient’s response. The doctor makes a quick visit and tells the patient, “We will get your treatment started today and we will be checking your blood each week for any problems.” The doctor leaves and the patient asks the nurse, “What are the blood tests for?” To determine this patient’s learning needs, what should the nurse assess? (Select all that apply.) 1. Medicalrecordsummaryofthestageofthecancer
2. Thepatient’sbehaviorasthenurseinteractswithhim
3. Thepatient’slevelofknowledgeaboutchemotherapyeffects
4. Thenumberoftreatmentsthepatientwillbereceiving
5. Thepatient’shealthliteracy
6. Thepatient’sself-descriptionofseverityofhiscancer
7. The date of the medical record note describing patient instruction
2.,3.,5.,6.,
A nurse who works in an outpatient chemotherapy infusion center is assigned to the care of a 56-year-old male patient who is receiving chemotherapy for colon cancer. This is the patient’s first clinic visit. The nurse reviews the patient’s medical record and sees a note about the patient receiving instruction on how chemotherapy treats cancer; the note does not summarize the patient’s response. The nurse’s assessment reveals that the patient is motivated to learn more about his chemotherapy and is alert and currently feeling well. The nurse has prepared the first infusion, regulated it, and now takes time to begin instruction. Which teaching approaches are best suited for this situation?
1. Use an entrusting approach in explaining how to monitor for side effects of chemotherapy.
2. Bring the patient together with two other patients in the clinic and conduct a group discussion.
3. Provide verbal one-on-one instruction, with the patient partici- pating in selection of content.
4. Presentthepatientwithaproblemsituationinvolvingaserious side effect and have the patient decide what to do.
3.,
A 26-year-old patient visits a medical clinic and asks a nurse to provide instruction on how to perform a breast self-examination. “My mom had cancer so I want to learn how.” Which domains are required to learn this skill? (Select all that apply.)
1. Affectivedomain
2. Sensorydomain
3. Cognitivedomain
4. Attentionaldomain 5. Psychomotordomain
3.,5.,
A patient suddenly experienced a severe headache with numbness and decreased movement in the left arm. An emergency brain scan confirmed a cerebral vessel clot. With a stroke confirmed, the emer- gency room physician consults with a neurosurgeon to schedule an emergent angiogram to remove the clot. Which teaching approach is most appropriate for explaining to the patient what to expect from the procedure?
1. Sellingapproach
2. Tellingapproach
3. Entrustingapproach
4. Participatingapproach
2
A nurse is teaching an older-adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.)
1. Speak in a low tone.
2. Begin and end the session with the most important information regarding melanoma.
3. Provide a pamphlet about melanoma with large font in blues and greens.
4. Use basic one- or two-syllable medical terms.
5. Provide specific information in frequent, small amounts.
6. Speak quickly so that you do not take up much of the patient’s time.
1.,2.,,5.,
A 55-year-old man has been in the hospital for over a week follow- ing surgical complications. The patient has had limited activity but is now ordered to begin a mobility program. The patient just re- turned from several diagnostic tests and tells the nurse he is feeling fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient’s condition?
1. Motivation to learn
2. Developmentalstage
3. Stage of grief
4. Readiness to learn
4
A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the fol- lowing is the best way for the nurse to evaluate whether learning has taken place?
1. Verbalization of steps to use in splinting
2. Selecting from a series of flash cards the images showing the
correct technique
3. Return demonstration
4. REALM test
3
A patient’s cultural background affects the motivation for learn- ing. Using the ACCESS model, match the nursing approach with the correct model component.
ACCESS Model Component
__1. Assessment
__2. Communication
__3. Cultural
__4. Establishment
__5. Sensitivity
__6. Safety
Nursing Approach
A. Helppatientsfeelculturally
secure and able to maintain
their cultural identity.
B. Remainawareofverbaland
nonverbal responses.
C. Beawareofhowpatientsfrom
diverse backgrounds perceive
their care needs.
D. Becomeawareofyourpatient’s
culture and your own cultural
biases.
E. Learnaboutthepatient’s
health beliefs and practices. F. Showrespectbycreatinga
caring rapport.
1e
2b
3d
4f
5c
6a
A nurse is preparing to teach a patient who has sleep apnea how to use a continuous positive airway pressure (CPAP) machine at night. Which action is most appropriate for the nurse to perform first?
1.Allowpatienttomanipulatemachineandlookatparts.
2. Provideateach-backsession.
3.Setmutualgoalsfortheeducationsession.
4. Discuss the purpose of the machine and how it works.
3
Which of the following scenarios demonstrate that patient learning has taken place? (Select all that apply.)
1. A patient listens to a nurse’s review of the warning signs of a stroke.
2. A patient describes how to set up a pill organizer for newly ordered medicines.
3. A patient attends a spinal cord injury support group.
4. A patient demonstrates how to take his blood pressure at
home.
5. A patient reviews written information about resources for
cancer survivors.
2.,4.,
