Health Promotion Model

Patient Education in Home Care: Strategies for Success

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Home Healthcare Now

May 2014, Volume :32 Number 5 , page 288 – 294  [Free]

Authors 

• Ashton, Kathleen PhD, RN
• Oermann, Marilyn H. PhD, RN, ANEF, FAAN

Abstract

This article describes principles for patient education, beginning with assessment of learning needs through evaluation. Strategies for effective teaching in the home care setting are presented, including use of educational resources.

 

Article Content

1. P. is a 56-year-old male being discharged to home with a diagnosis of osteomyelitis of the right lower extremity, requiring long-term antibiotics via a recently placed peripherally inserted central catheter (PICC) in his right upper arm. J. P.’s comorbidities include Type 2 diabetes mellitus, chronic kidney disease, and depression. He lives with his wife and adult son in a one-story home. J. P. is unable to work at his regular job providing security at a local university because it requires him to ambulate for long hours. J. P. and his family need education about administering the antibiotics and the PICC line.

 

Figure. No caption available.

1. J. is a 64-year-old female with a recent diagnosis of heart failure (HF). She was discharged home with a new regimen of medications and requires education about those medications and living with HF.

 

Both patients have been referred to a local home healthcare agency for ongoing nursing care. They received some information about their illness and treatment from healthcare providers before discharge, but neither of these patients is able to manage their healthcare needs independently. Although patient education is a nursing competency (National Research Council, 2011), there are barriers to effective patient teaching in acute care settings. Nurses in acute care are challenged by their limited time for teaching. Education is typically delivered based on the patient’s medical condition rather than individualized learning needs, and patients are expected to retain a great deal of complicated and new information in a short amount of time (McBride & Andrews, 2013). In addition, patients may not be physically or psychologically ready to learn. These real challenges limit the effectiveness of patient education in the acute care setting and transfer the responsibility for teaching patients and their caregivers to clinicians who provide home nursing care.

 

Clinicians who provide care in the home setting also face challenges to effective patient education. Many patients have complex illnesses. A clinician may spend a lot of time providing direct hands-on care, reducing time for teaching. When a patient is experiencing pain and other symptoms, his or her ability to take in new information and learn is hindered. Clinicians have to build in time to support and educate caregivers as well. Despite their best intentions, patients with poor health literacy face numerous barriers in their attempt to follow a treatment plan. Limited health literacy can manifest itself as nonadherence (Bastable, 2008).

 

There may be cultural influences in the home that affect teaching and learning. Home care clinicians may not have easy access to interpreters when patients and caregivers speak a different language. Patients may have specific beliefs about illness and treatment options, relationships within the family and with healthcare providers, privacy, and diet. These factors can affect patient attitudes toward learning new information (Bastable, 2008).

 

Clinicians need to develop the skill set that will allow them to be effective teachers. They should understand the principles of adult learning and be educated about cultural influences on teaching and learning (McBride & Andrews, 2013; Rice, 2006). Effective patient education requires that clinicians provide the information patients need to know in a manner that reflects their readiness or capacity to learn (Bastable, 2008). Clinicians should understand the educational process and strategies for promoting patient learning, be aware of teaching methods, be able to direct patients and caregivers to quality and credible patient education materials and other resources, and have an understanding of the content. Although providing patient education is a fundamental nursing activity, effectively teaching patients is a complex process.

 

Despite the challenges, clinicians who provide care to patients in their homes are uniquely positioned to deliver patient education. They understand they are “guests” in the patient’s home (Rice, 2006, p. 32). Patients have more autonomy regarding their healthcare practices in their home than they do in acute care (Ellenbecker et al., 2008). Clinicians’ humility allows patients to participate in their care by leveling the power in the relationship. The teacher is seen as the “facilitator of information” and not as the “authoritative” figure (McBride & Andrews, 2012, p. 20). The purposes of this article are to describe principles for patient education, beginning with assessment of learning needs, and share strategies clinicians can use to be effective teachers in the home care setting.

 

Assessment

The nursing process provides a framework for the clinician to use for patient education (Pearson, 2011). Teaching begins with an assessment of learning needs and other characteristics such as readiness to learn. What do patients know currently about their conditions, treatments, and self care? The assessment indicates gaps in knowledge and skills and where to begin with the education. Because of limited time for teaching, the clinician should focus instruction on essential information for the patient to understand the health problem and manage his or her own care independently or with caregiver assistance. An important component of assessment is determining the patient’s readiness to learn. Readiness is evident when patients demonstrate an interest in learning and can engage in the instructional process (Bastable, 2008). Assessment is the first step in patient education (Bastable, 2008; McBride & Andrews, 2013; Pearson, 2011; Rice, 2006). In a survey, patient educators reported that the most important strategy for effective patient teaching was assessing the patient and adjusting education to those needs (Smith & Zsohar, 2013). Developing, implementing, and evaluating the teaching all follow assessment.

 

Factors to Assess Before Teaching

Assessing learning needs, or the gap between what patients know and need to learn, is a priority. Asking about patients’ or caregivers’ level of formal education is important but may not in and of itself describe their capacity to learn new information at the point the clinician encounters them (Pearson, 2011). Patients with higher education may be less motivated to learn, and conversely patients with limited formal education can be successful learners (Pearson, 2011). Questions from a patient or caregiver can demonstrate motivation to learn (Bastable, 2008). Assessing cognitive abilities and motivation are essential to effective teaching.

 

Several other factors are equally important for clinicians to assess, including the patient’s age, goals of treatment, and financial well-being (Pearson, 2011; Rice, 2006). Many patients who receive home care services are elderly and have limited resources. Patients with adequate financial resources may be more likely to adhere to medication treatment plans and have access to needed medical equipment and supplies (Ellenbecker et al., 2008; Rice, 2006).

 

Clinicians also should assess readiness to learn. Being ready to learn means the patient is ready physically, psychologically, and cognitively to engage in learning. Health status and limitations because of the patient’s condition, pain, medications, and other conditions affect physical readiness to learn and the energy of the patient to engage in learning. J. P.’s multiple conditions combined with his depression may influence his learning about his antibiotics and PICC line, and the clinician may decide to teach the wife and son and recommend educational resources J. P. can access at a later time. In addition to the medical problems, knowing the patient’s vision acuity or ability to hear the spoken word will influence teaching.

 

Psychological readiness is the degree of acceptance or denial of the condition, and is influenced by anxiety and stress, ability to concentrate, and developmental stage. These influence motivation to learn and the ability of the patient to retain the information. Other areas that affect readiness to learn are cultural values (what are the patient’s perceptions of illness and health beliefs?), current health practices (what are they, and do they promote or hinder care?), learning styles (do patients prefer to learn visually, by listening to instructions, by reading materials, or by experiencing?), literacy (can patients read and at what level?), and use of the Internet (do patients search the Web for health information?) (Inott & Kennedy, 2011; Orlowski et al., 2013; Wright, 2011).

 

Assessment Strategies

Clinicians can use several strategies to obtain data for this assessment, including informal and targeted conversations and observations during the delivery of care. Developing a relationship with the patient, though, is essential to this process (Bastable, 2008; McBride & Andrews, 2013). One of the best strategies for assessment of learning needs and readiness to learn is by questioning patients about their understanding of their conditions and treatments and what they want to learn. These questions should be open ended and probing. Asking M. J., “Do you have any questions about your new medications?” is of limited value in assessing her understanding. A more effective line of questioning would be, “Tell me about the medications you are taking for your heart failure and whether they are helping. What problems are you still having, and what are you doing about them?” By using open-ended questions geared to the essential content to be learned, the clinician can identify the actual learning needs and use wisely the limited time available for teaching.

 

Asking the right questions and observing the patient’s responses provide information about readiness to learn. In addition, this enables the clinician to identify misconceptions about the health problem and treatments. Assessment not only provides a foundation for teaching but also reflects principles of patient-centered care (McBride & Andrews, 2013). Assessment engages patients in learning and keeps the teaching focused on them.

 

Planning and Implementation

Once the assessment data are gathered and summarized, the clinician can begin to develop the teaching plan. Formal teaching plans may be developed with goals and objectives created for specific content, which will be used to evaluate progress, or available teaching plans may be adapted for the patient. Validating goals and objectives with the patient and caregiver reinforces that the clinician’s plan is aligned with the patient’s needs and will likely contribute to a successful learning activity.

 

Teaching Strategies

The choice of the teaching strategy will depend on the topic. If the patient or caregiver needs to learn a psychomotor skill, the clinician may begin with an explanation and follow with a demonstration and return demonstration. Although time consuming, this strategy provides an opportunity for the patient or caregiver to practice the new skill under the watchful eye of the clinician and for the clinician to provide specific feedback to guide performance. J. P. and his wife and son will need guided practice for administering antibiotics via the PICC line.

 

Use Your Conversation for Teaching

Patient teaching should not be viewed as a one-time occurrence. Instead it should be integrated in the clinicians’ interactions with the patient and caregiver. No matter how brief the interaction, the clinician should be teaching as part of that dialog. Adopting a conversational tone creates a more informal teaching situation, can foster discussion and asking questions by the patient and caregiver, and takes advantage of teachable moments (McBride & Andrews, 2013). Breaking down information into smaller, manageable segments can facilitate the transfer of information (Rice, 2006). An important principle regardless of the information to be taught is to “keep it simple.”

 

Use the Teach-Back Method

By integrating teaching within conversations with the patient and caregiver, the clinician can more easily reinforce the health information. Patients can be asked to explain in their own words what they learned and why that information is needed for their care. This is the teach-back method, explicitly asking patients to repeat back key points of instruction, and it is an effective strategy for assessing patient understanding and if the information needs to be explained again (Jager & Wynia, 2012). Asking patients “do you understand?” may be answered with a “yes” response and not reveal their lack of comprehension about the health information. White et al. (2013) found that the teach-back method was effective for retaining information about care among hospitalized HF patients and post discharge. The teach-back method would be relevant for MJ as the focus of her education is on learning about medications and living with HF.

 

Teach-back provides an opportunity for patients to think about the information and explain it in their own words to the clinician, which serves as a review to help retention. It also reveals gaps in learning. In later interactions with the patient or through use of educational resources, the information can be reviewed again, promoting retention. Box 1 summarizes strategies for learning.

 

Provide Educational Resources

Because of limited time for teaching and need for repetition and practice, patients should be given or directed to resources for further learning about their conditions. These resources can include brochures, handouts, and other written materials; video recordings, DVDs, and YouTube videos; and Web sites, depending on their appropriateness for the patient. However, those resources need to be evaluated for their quality and readability (ease with which materials can be read and understood) before use with patients. Studies of the readability of patient education materials have found that many materials are written at too high a level for most patients to read and understand. Wilson (2009) analyzed the readability of 35 patient education materials, developed by government agencies, other professional sources, or providers, used in community settings. The reading levels were all above the recommended level of sixth grade or lower (U.S. National Library of Medicine, 2013). Most patients, even those with higher literacy skills, prefer the readability of their health-related educational materials to fall below their usual reading level (Bastable, 2008). Clinicians can improve the readability of patient education materials by using visuals to communicate the content and less text requiring reading.

 

Clinicians should assess the readability or grade level of the educational materials they will be using for their teaching. If they are working in Microsoft Office, they can check the readability score in Microsoft Word or Outlook according to two tests: the Flesch Reading Ease and Flesch-Kincaid Grade Level. The instructions can be found by “clicking” on the question mark in the upper right area of the tool bar. There also are several Internet sites that provide the clinician with the readability level of patient education materials. They can be found by doing an Internet search for “readability scores.”

 

With more people searching online for health information, the Internet has become a valuable resource for patient education as long as patients are guided to reputable Web sites. A survey by the Pew Research Center’s Internet & American Life Project indicated that as of September 2012, 81% of U.S. adults used the Internet, and among those, 72% have searched online for health information (Fox & Duggan, 2013). However, not all health Web sites provide accurate, up-to-date, and unbiased information, and it may be too high a reading level for many patients and consumers to understand. Health information on the Internet needs to be evaluated for quality and readability before use by patients similar to written materials. Schmitt and Prestigiacomo (2013) assessed the readability of patient education materials provided by the American Association of Neurologic Surgeons, U.S. National Library of Medicine (NLM), and U.S. National Institutes of Health (NIH). None of the documents were at or below the recommended sixth-grade reading level. Even the patient education materials from the NLM and NIH were above the recommended level.

 

Not only are patients finding information on various Web sites, but they are increasingly using YouTube to learn about medical conditions (Desai et al., 2013). However, most YouTube videos are not peer reviewed; they may not communicate balanced information; and similar to Web sites the information may not be accurate or from a credible source (Stamelou et al., 2011; Steinberg et al., 2010). Sorensen et al. (2014) assessed 55 videos on YouTube related to pediatric adenotonsillectomy and ear tube surgery. Most of the videos presented low-quality information and testimonials. Clinicians cannot control the quality of health information on the Web, but they can evaluate and then recommend quality Web sites and YouTube videos for patient education. JP and his family would benefit from these to provide a review about administering antibiotics via his PICC line.

 

A quick and reliable method of evaluating the quality of patient education resources for clinicians to use is the suitability assessment of materials (SAM) checklist (Doak et al., 1996). Six factors are examined and rated as superior, adequate, or not suitable (see Box 2). Hoffmann and Ladner (2012) recommended use of SAM to identify specific elements of materials that should be modified before given to patients. Although developed originally for written materials, the SAM also has been used successfully to evaluate health information on the Web (Rhee et al., 2013).

 

Evaluation of Learning

Evaluation is an integral part of any teaching, and the clinician should continually assess how well patients are understanding the information and developing their ability to perform skills. This can be done by asking questions to assess the extent of learning, through the teach-back method, and by observing performance of skills. Using this information, the clinician can modify the teaching, for example, explaining the content again and in a different way, suggesting other resources, or teaching a family member or caregiver.

 

Summary

Patient education begins with an assessment of learning needs and other characteristics because the teaching should be based on those needs and individualized for each patient. Clinicians use several strategies for this assessment, including asking the right questions during informal and targeted conversations and observing the patient. Although the choice of teaching strategy depends on the topic and patient needs, the information presented needs to be provided in small, manageable parts to facilitate learning: keeping it simple is critical. There are many educational materials and resources clinicians can recommend to patients including Web sites if appropriate, but they need to be evaluated for their quality and readability. This article presented some key principles for teaching patients and meeting their learning needs.

 

Box 1. Strategies for Effective Learning

Assessment

 

* Current knowledge and understanding

 

* Readiness to learn

 

* Barriers to learning or to disease management

 

* Health literacy

 

* Cultural issues that may affect acceptance to what is being taught

 

Teaching

 

* Teach-back

 

* Keep it simple

 

* Reinforce with appropriate educational materials

 

Box 2. Factors Examined in Suitability Assessment of Materials Checklist

 

* Content

 

* Literacy demand

 

* Graphics

 

* Layout and type

 

* Learning stimulation and motivation

 

* Cultural appropriateness

 

Source: Data from Doak et al., 1996.

 

Teaching and Learning StylesBy Stacey Whitney

Essential Questions

• How does the awareness of social norms, values, beliefs, and lived experiences influence health care delivery and health outcomes?
• How does individual learning style shape individual understanding of education and behavior change?
• How can nurses help individuals, families, and communities overcome barriers to teaching?

Introduction

The likelihood of successful patient teaching depends upon the health care provider’s understanding of the learning process and the barriers that impact the patient’s ability to grasp new ideas. This chapter will review various patient learning styles and the inclusion of family and friends in patient education. Teaching is not limited to patients alone, as it can and should include the patients’ family as well. Barriers to education will be explored, including language, culture, and environment. Psychosocial issues, level of literacy, and life experiences all impact patients’ ability to learn. In fact, the connection of successful patient teaching and patient quality of life should be considered. Understanding the lived experiences of others helps the nurse to develop individualized teaching plans. Patient understanding can be assessed for understanding using several methods of evaluation such as:

• Are they able to teach back what they have learned by return demonstration?
• Can they apply what they have learned?
• Have health outcomes shown improvement?

Nurses in the in the Bachelor of Science in Nursing (BSN) program are taking part in the learning role as a student. Continuing education is important for currency in nursing practice. It is just as important for nurses to understand their own learning style as it is for them to know their patients’ learning preferences. Self-reflection, personal knowing, and the development of a personal self-care plan are all relevant practices for the professional nurse.

This chapter will explore self-examination of varied learning styles, providing a greater understanding of the varied modes of learning, which will prove useful when educating patients. Educating patients requires the establishment of learning and behavioral objectives aimed at moving patients toward their health-related goals. This chapter explores writing objectives, the theoretical basis for health promotion, and the models used to explain and initiate behavior changes.

Examination of Learning Types

A person’s learning style can be defined as the way he or she chooses to approach a learning situation. It is the method of organizing, interpreting, and processing information. Throughout life, learners become aware of what learning preferences are most useful based on their learning style. Styles of learning can be identified by four distinct categories: visual, auditory, kinesthetic, and read/write. Ideally, the nurse should incorporate teaching methods and materials based on the preferred learning style once it is established; however, including all learning patterns should be considered best practice when instructing a group. Because of multiple patient learning styles, the nurse should be aware of a variety of strategies to meet the educational needs of all patients. Being mindful of varying learning styles and preferences will enhance learning outcomes (Beagley, 2011).

Fleming and Mills (1992) identified learning preferences to recognize the four sensory modalities applied in learning. The VARK acronym—visual, auditory, read/write, and kinesthetic—was created by Neil D. Fleming in 1987 as part of a questionnaire that allows learners to identify their own personal learning preferences. A learning preference relates to the most effective and efficient way by which a learner prefers to understand, process, and retain information (Prithishkumar & Michael, 2014). By accessing the questionnaire available on the VARK website, learners are able to complete a series of multiple-choice questions that identify a learning preference. The VARK visual modality indicates that the learner prefers graphics in the form of maps, outlines, diagrams, graphs, charts, or videos to understand information, ideas, or concepts. Auditory (or aural) learners learn best from lecture-style formats or group discussions. Those with the auditory preference prefer the spoken word to convey thoughts or messages. The read/write modality identifies a learner preference of the written word in all forms, such as books, reports, written lectures, and essays. Kinesthetic style refers to those who learn best through movement or by performing the skill or task. Most people identify as kinesthetic learners who benefit from personal experiences, either simulated or real, that generate the experience of actually doing something. Learners seldom identify with only one mode of learning preference, but rather a mix of styles, which Fleming calls multimodal. Multimodal preference allows for varying preference of learning style based on the current learning task. Interestingly, the learner can change modality to accommodate learning based on attitude or motivation (Introduction to VARK, n.d.).

Figure 1.1

VARK Learning Styles

Note. Adapted from “The VARK Modalities,” by VARK Learn Limited, n.d. Copyright by VARK Learn Limited.

Psychologist David Kolb identified learning as “the process whereby knowledge is created through the transformation of experience” (Kolb as cited in McLeod, 2017a, para. 4). In 1984, Kolb’s experiential learning model (see Figure 1.2) was published based on the learners’ inner cognitive processes. Kolb identifies learning types based on how the learners perceive and process information. The experiential learning model depicts learning as a four-stage process (Cavanagh, Hogan, & Ramgopal, 1994).

1. Concrete experience
2. Observation and reflection
3. Formation of abstract concepts and generalizations
4. Hypotheses to be tested by future actions that lead to new experiences

Kolb’s belief is that through a learning situation, the learner reflects on the experience and forms a concept that is then used for problem solving and decision making. Each stage of the cycle is dependent upon the previous stage and is not effective as a learning style on its own. Kolb’s model reflects the assumption that effective learning happens when the learner cycles through these four stages (McLeod, 2017a).

Figure 1.2

Experiential Learning Model

Note. Adapted from “Kolb – Learning Styles,” by S. McLeod, 2017, SimplyPsychology.com. Copyright 2017 by SimplyPsychology.com.

This learning model defines four learning styles identified through the completion of Kolb’s learning style inventory. The inventory is a series of 12 partial sentences requiring participant completion based on four possible predetermined endings. Each completed sentence is ranked according to learning style. The combination of scores then determines the learning style of the participant. These four learning styles are converger, diverger, assimilator, and accommodator(DeCoux, 1990) (see Figure 1.3).

Figure 1.3

Learning Style Inventory

Note. Adapted from “Kolb – Learning Styles,” by S. McLeod, 2017, SimplyPsychology.com. Copyright 2017 by SimplyPsychology.com.

Nurses should be considered lifelong learners. The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, offers key messages related to nursing education, encouraging nurses to achieve higher levels of education and training (American Nurses Association [ANA], 2018). The report reinforces the fact that continuing education should be a priority for the professional nurse to increase knowledge related to nursing. Education expands thinking and enhances personal knowing.  Personal knowing occurs by incorporating research into practice over time. The personal knowing process relates to acceptance of relationships between the nurse and his or her patients by developing a more holistic approach to assessing, understanding, and treating patients.

Self-reflection, or caring for self, provides a necessary foundation that aids the nurse in caring for others. It is the process of reviewing personal activities and events, noting areas of strength or weakness. Florence Nightingale’s Notes on Nursing is a perfect example of “masterful reflection” (Lim & Shi, 2013, p. 1) of a meaningful nursing practice. An example of current day reflection occurs at shift change when passing the care of patients. As a means of debriefing events of the prior shift, the nurse can self-reflect on the day’s happenings to improve or encourage professional growth (Lim & Shi, 2013).

Self-reflection can be put into action by developing a personal self-care plan. Through self-reflection, areas of deficit may be noticed, and a plan for improvement can be developed. A plan for self-care and personal wellness are beneficial in avoiding burnout and compassion fatigue, both common phenomena amongst professional nurses (Carlson, 2017).

How Other Variables Affect the Ability to Learn 

As educators, nurses must teach patients according to all learning styles and be aware that other variables are likely present that affect patients’ ability to learn. Because of this, the important task of patient education is often challenging for health care providers. Providers should consider the cultural, socioeconomic, and sociopolitical influences that affect the patient’s experience. Variables such as race, ethnicity, immigration status, disabilities, sex/gender/sexual orientation, environmental threats, poverty, access to health care, and lack of education can have a profound impact on the effectiveness of health education and patient outcomes.

These variables contribute to inequities or an unequal distribution of resources for various populations, otherwise known as health disparities. When assessing the health and illness beliefs of patients, the nurse should be cognizant of any stereotypes, biases, or other forms of discrimination toward individual patients and families based on cultural values, beliefs, attitudes, and practices. The nurse should identify and avoid any type of discrimination toward individuals, families, groups, communities, and populations.

Maslow’s hierarchy of needs lists basic human physiological needs for survival. For those living with health disparities affecting their basic needs for sleep, food, shelter, and safety, efforts toward improving their health status is likely far-reaching (McLeod, 2017b). When there are differences among individuals or groups of people that set them apart from the majority, they become disadvantaged and vulnerable. For example, homeless individuals are at a disadvantage because they are unable to meet their basic needs much less obtain or access wellness services. In many cases such as this, multiple issues come together, including lack of income, housing, access to health care, education, awareness, poor environmental conditions, geography, and trauma from adverse life experiences that place this population at greater health risk.

Figure 1.4

Maslow’s Hierarchy of Needs

Note. Adapted from “Maslow’s Hierarchy of Needs,” by S. McLeod, 2017, SimplyPsychology.com. Copyright 2017 by SimplyPsychology.com.

The Center for Disease Control (CDC) (2013a) states, “Health disparities … are gaps in health outcomes or determinants between segments of the population” (para. 1). The CDC Health Disparities and Inequalities Report (CHDIR)(Centers for Disease Control and Prevention [CDC], 2013b), published as a part of the CDC’s Morbidity and Mortality Weekly Report (MMWR), provides data related to the effect of health disparities on overall health and wellness. This report provides evidence that inequality and health disparity ultimately contribute to death and illness. For example, the prevalence of heart disease is higher for those of African American heritage, and they are more likely to die prematurely from the disease. Those living in poverty and lacking education are more likely to have heart disease as well. The information provided by this report was key in fueling the Healthy People 2020 nationwide objectives for eliminating health disparity and improving health for all population groups in the United States (CDC, 2013b).

Basic skills such as reading and writing are necessary for the patients to comprehend health education provided by their health care provider. In general, the term literacy refers to a person’s reading and writing ability.  Health literacy can be defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health choices” (Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 32). Ideally, the patient and family’s learning needs and/or style should be assessed by the nurse at the time of admission if an inpatient. This proves beneficial by allowing appropriate education to be provided throughout the patient’s stay. In order to identify a patient’s literacy level, specific questions should be asked. The Single Item Literacy Screener (SILS) is a screening tool that specifically asks the patient, “How often do you need to have someone help when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” (Morris, MacLean, Chew, & Littenberg, 2006). The patient’s response can immediately provide information regarding his or her literacy level (Bullen & Young, 2016). Another health literacy tool, Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF), provides professionals with a quick, seven-item word-recognition test to assess health literacy (Agency for Healthcare Research and Quality, 2016).

Keep in mind, a patient can be literate, but not health literate. They may be able to read and write but have difficulty understanding health-related information, such as discharge instructions, reading prescription labels, or scheduling follow-up appointments. An educated patient does not guarantee an ability to manage health care. For example, a patient may be shy about asking questions or obtains health information solely by searching the Internet, from which the patient considers all sources reliable, when quite the opposite may also be true. Uneducated patients may lack formal schooling but can be taught complex health education and have the desire to do what is right for themselves or their loved ones. This type of patient may require the nurse to use creative teaching methods, such as providing interpreters or a schedule using pictures of a clock. Those with literacy barriers may be categorized with low socioeconomic status (SES). SES can be defined as one’s position in the social structure, related to financial well-being and educational achievement. In other words, a person’s SES is reflective of their lifetime access to education, resources, and opportunities (Anderson, Bulatao, & Cohen, 2004).  Immigrants, or those who leave their native country to take up permanent residence in the United States, often struggle with poor health literacy and socioeconomic factors that may impact health status (National Network of Libraries of Medicine, n.d.).

Language barriers may exist for patients who speak English as a Second Language (ESL). The United States is a very ethnically and racially diverse nation. It becomes a challenge for health care professionals to provide health education to those whose native language is not English. Nurses should be culturally aware by assessing the patient to determine the need for a translator. Translators who are qualified to assist patients and families are available in most health care centers either by telephone or in person. Hospital patient care services may provide various materials such as communication tools or printable discharge instructions in other languages for patients with language barriers.

Environmental and physical barriers play a significant role in the ability to learn. The patient’s readiness to learn should be assessed to determine what barriers may exist. Patients’ physical condition, including limited vision and auditory function, mobility, alertness, mental capacity, or high levels of physical pain, may impede learning capability. Cognitive abilities naturally decline with aging and do so rapidly with disease processes such as dementia or Alzheimer’s disease. The nurse should be aware of environmental conditions of the teaching area, such as temperature of the room, dim or bright lighting, noise levels in the surrounding area, and physical space available for teaching. Length of the patient’s stay has a definite impact on learning, as the nurse has very little time for teaching and discharge planning (Beagley, 2011).

Health Educator: The Nurse’s Role

Patients’ motivation to learn, previous life experiences, level of engagement, and ability to apply what is learned are all critical components that lead to a positive patient outcome related to patient education. “I will instruct you and teach you in the way you should go; I will counsel you with my loving eye on you.” —Psalm 32:8 (New International Version) The nurse can improve patient satisfaction and outcomes by implementing quality educational interventions based on the patients’ specific educational needs. This should be done while weaving cultural competency with health promotion into health teaching. Patient teaching encourages self-care behaviors. Self-care is an important skill for patients with new medical diagnoses and those with complex medical histories. It is a professional and ethical responsibility for nurses to provide patients with evidence-based health education and health counseling (Richard, Evans, & Williams, 2017). Patients’ belief that they can meet their health-related goals, or self-efficacy, is key to meeting desired educational outcomes. Patients can be involved in participatory decision making by setting their own health-related goals.

The Joint Committee on Health Education and Promotion Terminology (2002) defines health education as “Any combination of planned learning experiences based on sound theories that provide individuals, groups, and communities the opportunity to acquire the information and skills needed to make quality health decisions” (p. 6). Health education is a critical role for nurses, one that can impact the health of the nation.

Nurses in all settings teach and counsel patients by promoting behavior change in current lifestyle practices and encouraging them to reduce behaviors that put them at risk and can lead to illness or worsening of chronic diseases. Nursing, along with other health care professionals, can impact rising health care costs, and decrease health care system dependence by promoting positive behavior change in patients (Edelman, Kudzma, & Mandle, 2014). Patients without proper health education can have an increased risk of health complications and more frequent hospital readmissions (Richard et al., 2017).

Assessment is the first process in any teaching plan. The nurse should assess the learning needs of the patient, characteristics of the learner, and any barriers to learning that might exist. Pertinent characteristics of the learner may include age, education level, mental attitude regarding health status, cultural beliefs, motivation, and knowledge of current health status. Barriers to learning, as discussed previously in the chapter, may include health disparities, inequalities, environment, culture, and lack of time for teaching. Once the learning needs of the patient have been identified, a teaching plan can be developed. As a member of the health care team, the nurse should collaborate with other health providers. The plan should list measurable learning objectives that include an action verb to identify the expected change in behavior that will be measured as a result of the learning process. The objectives should be written in behavioral terms, specifying the desired outcome and incorporated into the nursing care plan. Behavioral objectives are the action that describes the behavioral change the patient will learn to promote health.

Table 1.1 

Measurable vs. Unmeasurable Objectives and Action Verb Used

Measurable	Unmeasurable	Action Verb
The patient will list the current medications he is taking.	The patient will increase his knowledge of current medications.	List
The patient will identify how many ounces of fluids she is allowed to drink daily.	The patient will recognize the doctor’s order for a fluid restriction.	Identify
The patient will describe signs and symptoms of fluid overload related to congestive heart failure.	The patient will know signs and symptoms of congestive heart failure and fluid overload.	Describe
The patient will demonstrate insulin administration.	The patient will read about the administration of insulin.	Demonstrate

Nurses’ teaching efforts are not always successful. When nurses create behavioral objectives, it is based on the assumption that the patient is willing to change. Patients have the right to choose not to follow medical advice. Although health professionals naturally want them to choose the recommended path, it is ultimately the patients’ choice to follow medical advice. Scope of practice related to patient education and health promotion should always be considered. The nurse can utilize the transtheoretical model (TTM) to assess the patients’ readiness to create a change in behavior.

The model, formed by psychologists Prochaska and DiClemente in 1984, was originally used to help with smoking cessation. Since then, its application to achieve successful implementation of behavioral objectives has been useful. According to the TTM, behavior change progresses through six stages before change occurs. The stages apply whether the patient is beginning a new behavior or stopping an old one. By assessing the patient’s readiness to change, the nurse can create appropriate behavioral objectives for the patient’s current stage (Edelman et al., 2014).

Figure 1.5

Stages of Change

The stages of change toward the goal of behavior change to promote health include:

• Precontemplation – the patient is thinking about a behavior change, but not actively intending to make any changes.
• Contemplation – the patient is considering a change within the next six months.
• Planning or preparation – the patient is seriously considering a change within a month.
• Action – the patient has made a change and it has lasted for six months.
• Maintenance – long-term continued commitment, beyond six months.
• Termination – ideal goal, no temptation to relapse (Edelman et al., 2014; Prochaska & DiClemente, 1984).

Health Promotion

Health promotion is the act of educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care (ANA, 2007). In the United States, health promotion and disease prevention goals and objectives are established by the U.S. Department of Health and Human Services. Every 10 years, goals, objectives, and focus areas are published to guide nationwide health promotion efforts. Specifically, Healthy People 2020 is a tool provided by federal, state, and local governments that provides detailed objectives and target areas used to measure progress for certain populations. Healthy People 2020 is used as a foundation for wellness and prevention efforts and a model for measurement. The provided framework (see Figure 1.6) highlights how the United States can obtain healthier lifestyles by the year 2020. Four foundation health measures (see Table 1.2) are used to assess the progress made toward reaching the four overarching goals.

Figure 1.6 

The Mission, Vision, and Goals of Healthy People 2020

VISION – A society in which all people live long, healthy lives.   MISSION – Healthy People 2020 strives to: Identify nationwide health improvement priorities. Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. Provide measurable objectives and goals that are applicable at the national, state, and local levels. Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge. Identify critical research, evaluation, and data collection needs. OVERARCHING GOALS: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages.

Note. Adapted from “About Healthy People,” by HealthyPeople.gov, 2018.

Table 1.2 

Foundation Health Measures

Overarching Goals of Healthy People 2020	Foundation Measures Category	Measures of Progress
Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.	General Health Status	Life expectancy Healthy life expectancy Physical and mental unhealthy days Self-assessed health status Limitation of activity Chronic disease prevalence International comparisons
Achieve health equity, eliminate disparities, and improve the health of all groups.	Disparities and Inequity	Disparities/Inequities to be assessed by: Race/ethnicity Gender Socioeconomic status Disability status Lesbian, gay, bisexual, and transgender status Geography
Create social and physical environments that promote good health for all.	Social Determinants of Health	Determinants can include: Social and economic factors Natural and built environments Policies and programs
Promote quality of life, healthy development, and healthy behaviors across all life stages.	Health-Related Quality of Life and Well-Being	Well-being/satisfaction Physical, mental, and social health-related quality of life Participation in common activities

Note. Republished from “Healthy People 2020,” by the Office of Disease Prevention and Health Promotion, 2010, p. 3.

Educational and community-based programs play an important role in reaching people outside of typical health care environments. One goal identified with Healthy People 2020 (n.d.) is to “increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health, and enhance quality of life” (para. 1). Nurses should consider nontraditional sources, such as worksites and schools, to reach out to those in need of health education.

Health Promotion Models

Several theories and models aid in explaining and initiating health promotion behavioral changes. The family systems theory relates to the structure and function of the family unit. This theory is based on the idea that the family is interconnected by individual members, and the actions of one family member affect all members of the family. The individuals create a system in which environment, behaviors, and reactions influence values and morals. Over time, change occurs due to introduction of new members and interactions with the environment. Family patterns are established over time. The focus of family systems theory is how one member influences everyone else in the family system (Edelman et al., 2014).

Bandura’s self-efficacy theory of behavior change was formed by Albert Bandura in 1977. He believed that feelings of self-efficacy can lead to competency; in other words, he believed that individuals have the ability to bring about their own outcomes. Three factors influence self-efficacy and include behaviors, environment, and personal/cognitive factors. This conceptual theory explains how learning is influenced by repetition, reinforcement, and symbolic modeling. For example, children likely learn complex applications such as language by watching and listening to others speak (Bandura, 1986).

In health promotion, the aim is improving the health of populations through health education. Pender’s health promotion model, developed in 1982, provides a framework to understand health promotion behaviors by recognizing the family as the unit of assessment and intervention. It was developed as a result of Nola Pender noticing that health care professionals were only treating disease and not recognizing the promotion of healthy lifestyles. Pender offered guidance for interventions that foster resiliency amongst individual family members, identify resources, and promote health amongst the family members (Edelman et al., 2014). This highly accepted, family-based, health promotion model is used in nursing practice, education, and research. The three main components of the model are recognizing experiences and characteristics of the individual, understanding behavior-specific cognition and affect, and implementing behavioral outcomes (Kwong & Kwan, 2007).

The health belief model can be used to predict or explain health behavior and predict readiness for change. By utilizing information regarding individual’s values and expectations, the health care provider can understand why some patients are more compliant to health care instructions than others. This early model was developed in the 1950s by Godfrey Rosenstock and colleagues, as they were trying to understand why individuals were not taking advantage of public health programs offered to identify and prevent disease. As the nurse deciphers contributing factors for an individual’s perceived state of wellness, he or she can also assess the likelihood of the patient following through with an appropriate plan of care (Edelman et al., 2014). The five necessary components for individual change in health behavior modeled in Rosenstock’s model are the perceived:

• Susceptibility toward health threat,
• Severity of health threat,
• Benefits of action to reduce threat of illness,
• Barriers to initiating preventative action, and
• Ability to take preventative action or self-efficacy (Montanaro & Bryan, 2013).

These theories and models have a common theme in that they promote familial communication and knowledge that is reciprocal amongst its members. The participatory health model has gained attention in recent years. The idea is that incorporating shared decision making into patient-centered medicine can result in improved health care. Shared decision making occurs when health care providers and families discuss treatment options together as a team by including evidence-based practice along with familial values, preferences, and goals. By incorporating respect and open communication, individual family members and health care providers can work together by using the participatory health model to form an effective team (Levy et al., 2016).

Reflective Summary

Successful patient teaching depends upon the health care provider’s understanding of the learning process. Although it may be challenging, patients must be taught according to all learning styles. Nurses must be aware that other variables are likely present that affect patients’ ability to learn. Variables that contribute to inequities or an unequal distribution of resources for various populations must be accounted for when creating patient teaching plans. Understanding that nurses’ teaching efforts are not always successful, awareness of the patients’ motivation to learn, previous life experiences, level of engagement, and ability to apply what is learned are all critical components related to positive patient outcomes through patient education. By utilizing available health promotion theories and models, nurses can positively affect patient outcomes by promoting behavioral changes to improve patient health and wellness.

Key Terms

Accomodator: According to Kolb’s experiential learning model, they are fast learners, use a trial-and-error approach to problem solving, prefer a hands-on approach, use intuition instead of logic, are people-oriented, and like new challenges.

Assimilator: According to Kolb’s experiential learning model, they learn by using a concise logical learning approach, are less people-oriented, less practical than others, and more interested in ideas and concepts than people.

Auditory: A learning modality in which the learner learns best from lecture-style formats or group discussions.

Bandura’s Self-Efficacy Theory of Behavioral Change: Explains how learning is influenced by repetition, reinforcement, and symbolic modeling.

Behavior Change: A change in current lifestyle practices that encourages reduction of risk-taking behaviors that can lead to illness or worsening of chronic diseases.

Converger: According to Kolb’s experiential learning model, they learn by doing. They are common-sense learners who solve problems by finding solutions, are not people-oriented, and prefer technical tasks.

Diverger: According to Kolb’s experiential learning model, they learn by feeling and observation, favor people, empathize toward people, desire harmony, are sensitive, and able to see things from different perspectives.

English as a Second Language (ESL): Persons who primarily speak another language and English as a secondary language.

Family Systems Theory: The theory that holds that each individual or subsystem of a family unit or system influences other parts of the system; therefore, an individual cannot be studied in isolation from the family. Dr. Murray Bowen developed the theory from his studies of family problems and processes.

Health Belief Model: Can be used to predict or explain health behavior and predict readiness for change.

Health Disparities: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.

Health Education: Any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes (WHO, 2018a)

Health Literacy: The level at which an individual can accept, process, and comprehend basic health information.

Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care.

Healthy People 2020: A federal program developed by the U.S. Department of Health and Human Services that sets goals related to prominent health concerns and works to achieve them through health education and health promotion strategies.

Immigrant: Those who leave their native country to take up permanent residence in foreign country.

Kinesthetic: The most common learning style of “hands-on” learners who learn best through movement or by performing the skill or task.

Kolb’s Experiential Learning Model: Identifies learning types based on how the learners perceive and process information.

Kolb’s Learning Style Inventory: A series of 12 partial sentences requiring participant completion based on four possible predetermined endings. Each completed sentence is ranked according to learning style. The combination of scores then determines the learning style of the participant.

Literacy: A person’s reading and writing ability.

Maslow’s Hierarchy of Needs: A model of basic human needs.

Multimodal: A varying preference of learning style based on the current learning task.

Participatory Health Model: A health care model that incorporates shared decision making with patient-centered medicine to improve health care outcomes.

Pender’s Health Promotion Model: Provides a framework to understand health promotion behaviors by recognizing the family as the unit of assessment and intervention.

Personal Knowing: Occurs over time by incorporating research into practice.

Personal Self-Care Plan: A personal improvement plan put into action through self-reflection.

Read/Write: A learning modality that identifies learner preference of the written word in all forms, such as books, reports, written lectures, and essays.

Self-Care: The ability to independently maintain activities of daily living without assistance from others.

Self-Efficacy: The patient’s belief that he or she can meet health-related goals.

Self-Reflection: Caring for self provides a necessary foundation that aids the nurse in caring for others. The process of reviewing personal activities and events, noting areas of strength or weakness.

Socioeconomic Status (SES): One’s position in the social structure, related to financial well-being and educational achievement.

Transtheoretical Model (TTM): Indicates that behavior change progresses through six stages before change occurs.

VARK: A questionnaire created by Neil D. Fleming in 1987 that determines a participant’s learning style of visual, auditory, read/write, or kinesthetic.

Visual: Refers to a learning modality that indicates the learner prefers graphics, such as maps, outlines, diagrams, graphs, charts, or videos, to understand information, ideas, or concepts.

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