SCENARIO A 78-year-old man is living in an assisted living facility. He is able
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Question
SCENARIO A 78-year-old man is living in an assisted living facility. He is able to walk very short distances and uses a wheelchair to transport himself to the communal dining room. He administers his own medications independently and bathes himself. Over the last year he prefers to remain in the wheelchair even when in his room. He has a history of CHF, hypertension, hyperlipidemia and lower extremity weakness. He is able to state his current medications include metoprolol (Lopressor) 50 mg once daily by mouth, furosemide (Lasix) 20 mg once daily by mouth, Quinapril (Acupril) 20 mg once daily by mouth, atorvastatin (Lipitor) 20 mg once daily by mouth. During a routine examination, his physician noted a pressure ulcer over the ischium on the right buttocks. The wound is oval about 10mm x 8 mm, with red and yellow areas in the middle and black areas on some surrounding tissue. It has a foul odor. The patient had been padding the area so “it doesn’t get my pants wet”. The physician arranged for him to be admitted to the hospital in order for intravenous antibiotic therapy and wound care to be initiated. After being admitted to the hospital his medications are: metoprolol (Lopressor )50 mg orally every 12 hours, furosemide (Lasix ) 40mg once daily by mouth, quinapril HCl (Accupril) 40 mg once daily by mouth, cefazolin (Ancef)1.5 Grams in 50 mL 0.9 % Normal Saline intravenously three times a day. The result of the wound culture identified Methicilin-resistant staphylococcus aureus. After a surgical debridement of the black tissue a SilvaSorb® (antimicrobial gel) dressing was ordered daily.
QUESTION: To assist the patient in preventing a recurrence of a similar incident once he returns to the assisted living environment, the RN needs to develop a teaching plan. Use the nursing process to consider the information the RN would need prior to development of the plan. Respond to the following and be able to support your answers.
You will not be developing a teaching-learning plan but demonstrating using the teaching-learning process to prepare for an individualized plan.
How does the RN decide the format of the teaching plan, i.e., written, verbal, or other?
How does the RN know which information needs to be included?
When does the RN determine how and when to evaluate the teaching-learning process?
Explanation / Answer
Learning how to be an effective teacher is an important part of your professional development. Effective patient teaching requires the same analytical and problem-solving skills as other clinical interventions. The purpose of this chapter is to improve your abilities as a patient teacher by outlining the steps of the teaching-learning process; to suggest ways of assessing learning needs and readiness for learning; to discuss methods of developing learning objectives, planning, implementing, and evaluating teaching; to review principles for documenting patient teaching; and to recognize common teaching mistakes and ways of avoiding them.
The teaching-learning process
The process of patient teaching refers to the steps you follow to provide teaching and to measure learning. The five steps involved in the teaching-learning process are:
The teaching-learning process is very similar to the nursing process steps of assessment, diagnosis, care planning, care implementation, and evaluation. Your first step in the process of patient teaching is to assess what the patient and family already know, what they want and need to learn, and what will be the best way to teach them.
Start the process by talking with patients to determine what they see as their health care goals, what their priorities for learning are, how ready they are to learn, and what their preferred learning style is. To assess learning style, ask patients about something they recently learned and how they learned it- by reading about it, listening to information, or by actual hands-on learning. Determining learning readiness is a crucial part of your assessment.
This part of the process begins when someone- the patient, a family member, or you- identify the need to learn a new skill or to know more information. If the patient identifies the need-“What exactly will this operation involve?” or “How will I manage this when I go home?”- he or she is demonstrating learning readiness. 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 incorporating your teaching plan into a written critical pathway that spans care delivery setting from hospital to home, teaching and learning can be spread out over time to take advantage of optimum learning readiness.
After you’ve talked with the patient, interview the family members. 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 You can also use questionnaires and checklists to obtain information about learning needs, learning styles, and learning readiness. Written materials can also help you assess the patient’s literacy level and ability to understand written information.
Developing learning objectives
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 example, for a newly diagnosed diabetic patient, a goal will be to learn how to maintain blood glucose levels between 70 and 150 mg/dl. Reaching this goal may be overwhelming unless it’s broken down into specific objectives that lead up to the overall goal. 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.
Decide which domain of learning is involved. There are three separate learning domains-cognitive, psychomotor, and affective-each of which is described in a classification of “taxonomy” that proceeds from simple to complex learning. 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. An example of teaching in the cognitive domain is teaching a diabetic patient how to recognize the signs and symptoms of high and low blood sugar and what actions to take if these conditions occur.
Learning how to take a blood pressure, change a dressing, or walk with crutches is an example of psychomotor learning. Learning to accept altered activity levels due to a chronic disease or to quit smoking are examples of learning in the affective domain. 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.
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. Many existing patient education programs are not useful, because patients are not in hospital long enough to participate in complex or ambitious learning activities. Instead of starting with an anatomy lesson, focus on survival skills. Table 1 shows critical learning needs that are an essential part of discharge preparation.
TABLE 1: Critical Learning Needs for Discharge
Plan when you will teach, taking the length of hospital stay or number of clinic or home visits available 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 precious “teachable moments” when the patient is ready to learn-even 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. Table 2 shows examples of teaching methods and materials.
TABLE 2 Examples of Teaching Methods and Materials
Teaching Methods
Teaching Materials
Follow these principles to increase your teaching effectiveness.
In order to teach, the nurse must first have an understanding of the patient education process. The following are part of this process:
In the hospital, it is especially important for nurses to begin patient teaching at the time of admission. It is equally important to document this teaching for evaluation and reimbursement purposes. However, in the acute care setting, nurses often report feeling that they do not have enough time for it.
The following is a list of strategies that promote the incorporation of teaching into daily nursing practice:
Patient education requires that the nurse think critically. No longer are we simply responsible for administering medications and communicating with physicians. We also play a dynamic role in assuring that the patient is able to be independent in managing his disease.
In essence, we are nurse educators. After all, teaching is a vital component of the nursing process. However, the process is not uniform in nature. In order to promote learning, it is valuable to keep these proposed strategies in mind. And as part of our nursing education about the values of patient teaching, we have to remember that the patient population is indeed heterogeneous.
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