PATIENT & FAMILY EDUCATION for A Diverse Population

Transcription

1 PATIENT & FAMILY EDUCATION for A Diverse Population Objectives: 1. Describe the unique characteristics of the adult learner and significance in healthcare. 2. Examine the steps of the teaching-learning process and their incorporation into daily practice. 3. Determine effective methods to assess learning needs and readiness for learning. 4. Summarize how to plan, implement, and evaluate patient teaching. 5. Reflect on how to utilize the eight Kleinman questions to learn about a patient's culture. Description: The education of our patients and their families is fundamental to the delivery of safe, highquality, cost-effective health care. This module will facilitate professional development in terms of learning how to be an effective teacher as well as incorporate patient education into the healthcare provider's daily routine. 1

2 Introduction Why Commit to Patient Education? The education of our patients and their families is fundamental to the delivery of safe, highquality, cost-effective, compassionate health care. Besides being a requirement for Joint Commission accreditation, sending patients home unprepared to take care of themselves safely is legally and ethically unacceptable. Learning how to be an effective teacher is an important part of your professional development, as is learning how to incorporate patient education into your daily routine. When everyone works together to plan and deliver patient education, patients get to safely walk out the door knowledgeable about their health care needs. Whatever role you play; dietitian, nurse, physician, pharmacist, physical therapist, social worker, patient care technician, or respiratory therapist, the education of patients is one of your major professional responsibilities. Other compelling reasons to learn how to effectively teach patients and their families include: Increased Patient Satisfaction The personal attention you give while educating a patient can convey a sense of caring that benefits both educator and learner. Time spent with a patient discussing their diagnosis and treatment greatly influences the patient's sense of receiving quality health care and improves patient satisfaction. Learning is a way for patients to gain some control of their situation and thereby decrease anxiety. Armed with facts, they can benefit by developing a healthier lifestyle. Increased Compliance You may not be surprised to learn that approximately half the patients with chronic conditions are taking less than their prescribed medication, not taking their medication, or even failing to fill their prescriptions. The issue of noncompliance can be traced back to the patient's confusion, disappointment, misunderstanding, fear, or finances, all of which can be alleviated through interaction with you, their caregiver. When a patient thoroughly understands their diagnosis, the reason for treatment, the effects of the medications, and the positive outcomes they could achieve, they are more likely to comply. Cost Effectiveness The financial burden on healthcare because of repeated emergency room visits, unnecessary procedures and testing, and continued poor health as a result of inadequate patient education is largely avoidable. 2

3 What Are the Joint Commission Requirements? Education is coordinated among the disciplines providing care, treatment, and services. Education provided is appropriate to the patient s needs and abilities. The assessment of learning needs addresses cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication. 1. The content is presented in an understandable manner. 2. Teaching methods accommodate various learning styles and comprehension is evaluated. The patient is educated about the following: The plan for care, treatment, and services Basic health practices and safety The safe and effective use of medications Nutrition interventions, modified diets, or oral health Safe and effective use of medical equipment or supplies All aspects of pain management Rehabilitation techniques for maximum independence The Adult Learner The American adult educator Malcolm Shepherd Knowles (born 1913) led the development and application of principles of adult learning throughout the world. When Knowles began his earliest work in adult education, adult learners were almost universally taught with the methods of pedagogy, the education of children. Knowles was viewed as the person most responsible for achieving wide acceptance by adult educators of such concepts as the following: 1. Adults will pursue learning that they believe they need. 2. Instructors of adults should approach their role as facilitators, catalysts, and guides. 3. Adults should have control over their learning in an adult-oriented, cooperative, non-authoritarian setting and climate. 4. Learner involvement approaches to learning should be followed. 5. The adult should be viewed as a responsible, independent individual responsive to interdependent learning opportunities. 6. In addition to shared control and relevance, adult education should be based on authenticity of participants, instructors, procedures, and goals. 3

4 In practical terms, andragogy means that instruction for adults needs to focus more on the process and less on the content being taught. Strategies such as case studies, role playing, simulations, and self-evaluation are most useful. Instructors adopt a role of facilitator or resource rather than lecturer or grader. Andragogy's Assumptions of Learning The need to know Adult learners need to know why they need to learn something before undertaking to learn it. Learner self-concept Adults need to be responsible for their own decisions and to be treated as capable of self-direction. Role of learners' experience Adults need to learn experientially, which includes making mistakes. Adult learners have a variety of experiences of life which represent the richest resource for learning. Readiness to learn Adults learn best when the topic is of immediate value. Adults are ready to learn those things they need to know in order to cope effectively with life situations. Orientation to learning Adults approach learning as problem-solving rather than as the assimilation of content. Adults are motivated to learn to the extent that they perceive that it will help them perform tasks they confront in their life situations. The Teaching-Learning Process Based on Malcolm Shepherd Knowles 1990:57 Effective patient teaching requires the same analytical and problem-solving skills as other clinical interventions. The process of patient teaching refers to the steps you follow to provide teaching and for measuring learning, and is very similar to the nursing process steps of assessment, diagnosis, care planning, care implementation, and evaluation. The five steps involved in the teaching-learning process are: I. Assessing learning needs and learning readiness II. III. IV. Developing learning objectives Planning and implementing patient teaching Evaluating patient learning V. Documenting patient teaching and learning 4

5 Assess Learning Needs Patient education does not begin when the patient is discharged; it begins when the patient is admitted. Many patient education programs are not useful because patients are not in hospital long enough to participate in long, detailed learning activities. The biggest mistake health care providers make is in trying to teach patients everything they themselves know. It is impossible to teach years of learning in a few minutes, and it can be overwhelming for someone who has just been diagnosed with a chronic illness. When time and energy are limited, (in other words, every day!), think about what they really need to learn. Focus on survival skills. In order to engage and motivate the patient, you need to let them know what self-care activities are most important in their individual situations. The following are the critical learning needs that are an essential part of discharge preparation: What potential problems are likely to cause complications or readmissions? What prior knowledge or experience do this patient and family have with this illness? What skills and equipment are needed to manage this problem at home? What problems must patients and families be able to recognize? Who should patients and families contact for help to handle problems? To begin, review the patient's admission assessment to identify the challenges that have to be overcome to effectively teach. This assessment should include the evaluation of the patient and family's knowledge, beliefs, attitudes, and skills for self-care. Appropriate information to collect would include: What the patient already knows and what they want to know What skills or abilities will be needed What change the patient is willing to make What health care competencies and strengths are present How teaching will be applied at home 5

6 Barriers to Patient Learning When the patient indicates little interest in the area posing the greatest health threat, the provider best supports the patient by offering a simple statement of genuine concern for the individual's health and indicating a willingness to provide help when the patient is ready. An important part of the planning for education includes identifying barriers and determining ways to minimize them. Scare tactics are best avoided. Once the patient and provider have established agreement on goals, other areas to address include cultural differences, values, beliefs, and attitudes that influence the proposed change; previous history and how it colors the present experience; what the patient believes will and won't work; quality of the support system; financial concerns; lifestyle issues; issues of language, cognitive or psychomotor skills; and level of self-confidence. Thus, with the barriers known, the healthcare provider can then help the patient formulate strategies to deal with those obstacles and decide where efforts should be concentrated. Physical Disabilities The patient may have physical disabilities such as vision or hearing impairments that would interfere with reception of information. Another physical disability is pain. If patients are experiencing pain, they are distracted from learning Cognitive Disabilities Individuals with cognitive disabilities such as developmental delay may be so anxious about the procedure and/or the outcome that they are not able to concentrate on what the nurse may be saying. Others may not experience these levels of anxiety. Cultural Diversity Cultural diversity may inhibit a person from accepting new knowledge. In various regions in the United States, there has been an influx of refugees from other countries. Their orientation to this country has been relatively brief, and it is difficult for some of them to integrate the "new" culture into their lives. They sometimes are confused or angry about being in a new country. Often, there is a reluctance to accept the Western culture. There is a sense of security in "clinging to the old ways." Preconceived Notions The patient may have preconceived notions that keep him or her from learning. There may be a distrust of medical personnel, and the patient may not believe the information that the nurse will present. 6

7 Language Barriers If a language barrier exists, an interpreter must be called in to assist. During the patient assessment for patient education, the healthcare provider should be setting goals dependent on the learning capabilities of the patient. Although there are educational plans already formulated, the nurse needs to individualize a plan of teaching for each person. Reduced Ability to Speak, Understand, and/or Read English Depending on the specific patient population, it is important that healthcare workers understand how to adjust their educating and training styles. If your patient is illiterate or speaks a foreign language, giving them written materials will only increase their confusion. Asking someone who has reduced literacy whether they understand what you just gave them to read may make them too embarrassed to admit their difficulty. Another issue is the problem experienced by clinicians for whom English is a second language. Another staff member in the unit should help them communicate more clearly. Patients should be encouraged to say, "I don't understand what you're saying. Can you explain?" Helping patients understand their illness is instrumental in bringing about a more positive outcome for the patient, and cannot be overlooked for any reason. Written educational materials must be appropriate for the individual patient, and the Patient Bill of Rights states that patients have the right to educational materials that they can understand. The grade completed during formal education may not be a reliable indicator of the patient's ability to read. If you discover that your patient has low literacy, you may want to consider using the following guidelines: Use printed materials with lots of pictures, drawings, or cartoons. Actual step by step photographs offer the most accuracy, and patients are better able to retain the information. Make sure that sentences are brief, concise, and do not use jargon. Limit instructions to "need to know" information only. Illustrate your teaching with drawings when feasible. Teach the smallest amount possible. Make your points vivid. Use the 'demonstrate, practice, return demonstrate' method whenever possible. 7

8 The Core Skills of Cultural Competence Starting with an open attitude, cultural competence can be learned through your experience at the bedside, during normal care activities. You may not have a working knowledge of your patient's culture, but you can find out specifically how that culture affects your patient's understanding of their symptoms and illness. Key questions developed in the 70's by Kleinman, Eisenberg and Good illustrate the wealth of important information that can be gathered by listening, observing, and empathizing with the patient and/or their family. Assessment Dimensions Biophysical Age Visual acuity Manual dexterity hearing Pain, fatigue Medications Psychological Mild Anxiety Defensiveness S/S of stress response Adaptation to illness Outlook on life Environmental Learning Styles Learning environment Sociocultural Perception of hospital setting Perception of learning experiences Lifestyle (occupation, education, income, housing, diet, sleep, exercise, sexuality) Coping mechanisms Cultural Issues Language and communication barriers Time Religious beliefs Cultural remedies and healers The Kleinman Questions Kleinman et al. (1978) proposed eight questions that a healthcare provider could comfortably ask a patient of a different culture. This means that the healthcare provider does not have to know about the patient's culture but can specifically find out how that culture is reflected in the expression of his or her perspective regarding health. The Eight Kleinman Questions 1. What do you think caused the problem? 2. Why do you think it happened when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short course\ 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 8

9 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your sickness? These are open-ended questions. Incorporate them into conversation into the admission interview and early in the admission, as appropriate. You do not have to ask them all. You do not have to ask them all at one time. These questions are appropriate for all patients, not only for members of minority groups. If English is not the patient's primary language, even if he or she speaks English, consider using an interpreter. The patient's cultural views may best be expressed and communicated in the language of the culture. Deeply listen to the responses without judgment. Remember that you are asking these questions to learn the patient's view. If the patient comes from a different culture, religion, or socioeconomic group than you, you may not accurately anticipate what you will hear. Some of the answers may be surprising, shocking, or confusing. Ask for clarification or detail as necessary and appropriate. Remember that this is the assessment conversation, so at this time, do not correct what you perceive as wrong answers or misperceptions. If you do, it could prevent the patient from being willing to reveal more of his or her point of view, and you need that information to better individualize care. You may answer questions, but do not actively teach at this stage. Accept that some of Kleinman's questions may not work for all patients. For example, when a patient is asked, "What kind of treatment do you think you should receive?" he or she may respond, "Why are you asking me? That's up to the doctor! Doesn't he know what he's doing?" A way to handle this reaction is to explain that some people come to the physician already believing that they need a specific medicine or surgery. This question is meant to elicit those beliefs. Learning Readiness Learning readiness varies greatly from patient to patient and even from hour to hour. Learning readiness becomes apparent when a patient or their family member asks What exactly will this operation involve? or How will I manage this when I go home?. If you, rather than the patient, identify the need, your job will not only be to teach the information in a way that the patient is able to understand and use, but also to convince the patient that the information is important to his health and well being. Pain, fatigue, or physical or emotional stress may be barriers to learning readiness. By documenting your teaching plan to include the patient's care throughout hospitalization to home, teaching and learning can be spread out over time to take advantage of optimum learning readiness. 9

10 After you ve talked with the patient, interview the family members as well. Family members can be included in the assessment when they visit the patient, or by telephone. Conversations with the patient s family can provide missing information, enrich your understanding of what you ve heard from the patient, or alter your view of the patient s home situation Developing Learning Objectives If you develop objectives without consulting your learner, are you really providing quality care? Caring implies a partnership, which implies that the patient's perspective and feelings matter. The key to eliminating frustration in patient and family education is to develop expectations your learner can meet. Set realistic goals and partner with your patient to establish learning objectives. Since the patient and/or family member are the ones responsible for carrying out the behaviors and are ultimately responsible for the success, the objectives must be shared. If your patient does not agree to mutually shared goals and is unwilling to change behaviors, your teaching cannot accomplish any change in outcomes and you will soon feel frustrated. Find out what is important to your learner. What are his or her greatest concerns? What bothers him or her the most? Knowing this information will help you to put your teaching into context, and to individualize your teaching to meet the needs of your learner. The first step in developing learning objectives is determining a simple goal. A goal is a broad statement of what you want to accomplish. It is short, clear and concise. It doesn t say how, by whom, when, or where it will be accomplished. For example, if I want to use this process for a diabetes education program, a goal might be: The patient will learn how to maintain blood glucose levels between 70 and 150 mg/dl. The next step in the patient education process is to develop learning objectives. Unlike goals, which are general and long term, learning objectives are specific, attainable, measurable, and short-term statements. For this patient, an objective such as After this session, you will be able to list 5 symptoms of low blood sugar is a realistic objective. Other sample objectives might be: The patient will be able to count carbohydrates in a sample meal The patient will be able to test their blood sugar using a blood glucose meter. The patient will be able to self-administer their insulin. 10

11 Learning Domains When developing learning objectives, decide which domain is involved. There are three separate learning domains-cognitive, psychomotor, and affective-each of which is described in Bloom s taxonomy classification that proceeds from simple to complex learning. (A taxonomy is a mechanism used to categorize things according to their relationships to one another.) The cognitive domain refers to learning new knowledge, the affective domain refers to adopting new values and attitudes, and the psychomotor domain refers to learning new skills. The cognitive domain relates to knowledge. What does the person know, or need to know, and how do you measure what they know? When you write the objective ask yourself "What does this person have to do to prove that he or she knows this subject? Action verbs such as explain, describe, identify, list, or explain are used in the statement of the objective. The psychomotor domain relates to a physical skill. If you want to find out if the person can achieve a physical skill, have them show you that they can do it. An objective may be "The patient will be able to return demonstrate how to use a lancing device to obtain blood for glucose testing". These simple physical skills are called competency-based skills and they are easy to document. The person can (or cannot) administer insulin. The affective domain relates to attitudes or feelings. This is the hardest domain to deal with, whether it is writing objectives, measuring them or the actual teaching. Learning to accept altered activity levels due to a chronic disease or to quit smoking are examples of learning in the affective domain. Writing a goal and three objectives example: for self-monitoring of blood glucose (SMBG), one for each of the domains. Goal: The person with diabetes will be able to self-monitor blood glucose. Objectives: By discharge, the patient will be able to 1. List the times and reasons for blood glucose testing (cognitive domain). 2. Return demonstrate how to test their blood on their own meter (psychomotor domain) 3. Explain how self-monitoring of blood glucose gives them control to make decisions about how they manage their diabetes (affective domain). Learning how to take a blood pressure, change a dressing, or walk with crutches are examples of psychomotor learning. To help a patient learn a new health care behavior, you may need to teach in all three domains. Your role as a patient teacher is to select content from each domain and use teaching strategies that help the patient to learn simple to complex skills. As you develop objectives, use action words that are measurable such as list, state, explain, and demonstrate. Avoid using terms that cannot be measured or easily observed, such as understand or appreciate. 11

12 Planning and Implementing Patient Teaching After you and the patient have agreed on learning objectives, plan how you will implement your teaching plan. You need to plan for what will be taught, when teaching will occur, where teaching will take place, who will teach and learn, and how teaching will occur. Decide what to teach and in what sequence teaching will occur. Plan when you will teach, taking the length of hospital stay into account. Keep teaching sessions relatively short-generally no more than 30 minutes and possibly as short as five minutes. Plan on being able to use those critical teachable moments when the patient is ready to learneven if it means throwing your planned timetable out the window. Plan where you will teach, including both comfort and privacy. Whatever setting you use, make sure that you limit distractions and interruptions. Plan how you will teach. Use data from your assessment about the patient s preferred learning style to select your teaching approach. Remember that global learners like to see the big picture first and work down to the details. Linear learners want the details first and then expect a bigger picture to emerge. For example, when teaching a global learner how to do home blood glucose monitoring, you might start with the overall purpose of monitoring and then go on to the details. If your patient is a linear learner, start with the first thing the patient needs to do to operate the monitor and save the bigger picture for later. If your patient indicated on the assessment that he is a visual learner, selecting teaching materials that emphasize reading, writing, and watching visual media such as videotapes. Auditory learners and patients with low literacy skills benefit from spoken explanations and audiotapes and they may remember information better in pamphlets when they re read aloud. Hands-on or kinesthetic learners learn faster when they can tough and handle equipment. What the patient... Needs to know. What are the survival skills needed to stay safe? What medications, treatments, and/or signs and symptoms to report? Wants to know. They have things they want to know and need to be address before they will listen to what you have to teach. So ask, What questions do you have? Nice to know. These are the fun things but not really necessary at this time. If the patient doesn t need it, don t waste their time. 12

13 Who Has the Time? Time, or the lack of it, should never be an excuse not to teach. To maximize the impact of patient education, every opportunity to teach patients and learn to integrate it into everyday patient care activities must be cultivated. Avoid making it an extra task at all costs! A learning needs assessment which includes the presence of language barriers and cultural differences can be noted by careful observation during the initial assessment, and is usually more effective than using a checklist. Education is part of the end-of-shift report and should include what has been covered with the patient and what needs to be reinforced. For example, when changing a dressing or taking a patient's blood pressure, you might devote an extra five minutes to asking the patient questions and providing information on things the patient needs to know for a safe discharge. Asking patients questions such as how they would take their medication at home or what they would do if they suddenly became short of breath is an easy way to assess learning needs or determine if the patient has learned what has been taught. Other examples: When you take a patient's temperature, teach them about fevers and what the numbers mean. Ask if they have a thermometer at home and if they know how to read it. Tell them to call the doctor if they develop a fever and then teach them what a fever is. Insulin administration should be taught immediately and then demonstrated by the patient each time so you can validate and reinforce that they can actually do it well. When you change a dressing, explain what you are doing and why you do it that way. When you wash your hands before and after a dressing change and mention it to the patient. The bottom line is you can teach patients without adding hours to your day. We all know that we should embrace every teachable moment and make it the time to get our point across. But do we identify that teachable moment? It s often as simple as answering a question. "What is that medication going to do for me" or "Can I shower with that dressing on my hip?" At that point the patient has opened up to you and is ready to learn. Every time you hand a patient a medication or a piece of equipment take time to teach. That is a teachable moment. 13

14 How to evaluate learning... Tell me what you know about Show me how you would How would you know if What would you do if Who would you call if Ask the patient how he or she would explain to a spouse or friend. Use follow-up calls to see how the patient and family are doing and answer questions. Documentation Education of patients and significant others should be documented in the patient teaching record by the healthcare professional who provides it. You must document significant findings from the learning needs assessment in the patient's chart to share with the rest of the healthcare team. The better that all the team members understand the patient's point of view, the more likely the team can provide patient-centered care. Documentation must include assessment and identification of learning needs, the intervention to meet those needs, and the understanding by each patient and/or significant other(s) of any instruction or education. Final Points: Teach, Don't Lecture! Do Not Make Assumptions Making assumptions can lead to frustration and wasted time. We each take certain beliefs for granted, assuming they are universally true for everyone. Think about it; not everyone grew up in your house! Often we are not even aware of the assumptions we entertain that can keep us from seeing our patients objectively. As healthcare providers, we must look inward to our values, beliefs and biases. One way to help uncover our assumptions is to pay attention to the process of teaching, and note when we are feeling frustrated. Feeling frustrated is often a sign that you may have made assumptions about the patient that were simply not accurate. 14

15 Top Teaching Tips Assess knowledge and ability before Do not make assumptions Encourage active involvement Evaluate learning Focus on teaching behaviors and skills Help the learner believe Individualize your teaching Partner to establish learning objectives Share your teaching with the team Stay focused on the goals Take advantage of teachable moments Avoid Common Teaching Pitfalls Ineffective: Better: Ineffective: Better: Ineffective: Better: Ineffective: Better: Asking I'm all done. Do you have any questions? Is there anything I didn t say clearly enough? The responsibility now shifts from the patient needing to acknowledge that they did not understand to the willingness of the nurse to take responsibility for not clarifying points. Not allowing the patient to interrupt or distract you. Teaching is most effective when it involves a back-and-forth or interactive dialogue. You repeat the same information over and over because you are not getting through. Partner with your patient to establish learning objectives. You are arguing with your patient and feel frustrated. Acknowledge control as belonging to the patient. 15

16 Ineffective: Better: Ineffective: Better: Treating medical information as if there were only one approach to a problem There is not one right way for the learner to behave. Learners have choices and medical information changes rapidly. Telling patients that they will have dire consequences if they don't do as you teach. Example: "You're going to get really sick and end up back in the hospital if you don't learn how to take care of yourself." Scare tactics are never justified. Often patients know what to do, but choose not to do it. This is not always noncompliance; it may be due to a belief, custom, or other reason. This is where an initial patient assessment saves time and energy and can help reach client-centered goals more efficiently. 16

17 References Douglas, M.K.; Rosenkoetter, M.; Pacquiao, D.F.; Callister, L.C.; Hattar-Pollara, M.; Lauderdale, J.; Milstead, J. & Nardi, D.; Purnell, L. (2015). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2): Hair, M. J. (2011). Nurses utilization of teaching and learning principles in patient education (Order No ). Available from ProQuest Central; ProQuest Dissertations & Theses Full Text. ( ). Retrieved from Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), Knier, S., Stichler, J. F., Ferber, L., & Catterall, K. (2015). Patients' Perceptions of the Quality of Discharge Teaching and Readiness for Discharge. Rehabilitation Nursing, 40(1), doi: /rnj.164 Knowles, M. S. (1989). The making of an adult educator: An autobiographical journey. San Francisco: Jossey-Bass. Knowles, M. S. (1990). The adult learner: A neglected species. Houston: Gulf Publishing Company. McHenry, D. M. (2007). A growing challenge: Patient education in a diverse America. Journal for Nurses in Staff Development, 23(2), Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins. Office of Minority Health. (2007). Think cultural health. Retrieved May 19, 2007, from Pelletier, L.R., & Stichler, J.F. (2013). Action brief: patient engagement and activation: a health reform imperative and improvement opportunity for nursing. Nursing Outlook, 61 (1), Rankin, S.H., Stallings, K.D., & London, F. (2005). Patient education in health and illness (5th ed.). Philadelphia: Lippincott, Williams & Wilkins. 17