One of the basic parts of the nursing role is teaching patients. If patients are to have successful results with medications, they must learn all they can about the drugs and how to take them properly. The nurse must learn how to speak clearly as they teach. This can be very difficult when patients do not speak English or have poor reading or writing abilities. It is also hard if patients are not ready to learn.

The reason we teach patients about their diseases, their drugs, and what to expect when they take the drugs is to help them improve their health. Patients who do not clearly understand basic health information have less ability to carry out the treatment plan. Patients who are unable to carry out the treatment plan, for whatever reason, are at greater risk for having problems or not getting well.

Compliance, Noncompliance, and Concordance

Often a patient is said to be compliant when a plan of care is followed and noncompliant when it is not. A better term to use, one that does not judge the patient, is concordance. Concordance or agreement might be defined as the nurse, patient, family, physician, and pharmacist working together as a team to implement the treatment plan.

There are two basic reasons a patient has difficulty meeting treatment goals:

1. The patient does not understand what to do.

2. The patient understands what should be done but fails to do it, because he or she:

• may not believe the plan needs to be carried out.

• may believe something should be done but fails to carry out the plan.

• may believe something should be done but does not have money, time, or ability to do it.

In teaching the patient, focus on helping the patient make informed decisions about taking medications. (See Chapter 5 for other factors that might make it difficult for patients to follow treatment plans, including cultural and life span considerations.)

Communicating With the Patient

In the busy health care setting, it may be difficult to find time to talk with patients. In addition, many of our patients are from different countries or cultures and have different languages and beliefs that affect their ability to understand or talk about their health. Many nurses also are from different countries and cultures. This means that beliefs about what is important or harmful may not be the same. Even words used by both patient and nurse might have different meanings to each. A growing number of patients are older adults, with their own challenges to hearing, understanding, and acceptance of suggestions.

Although speaking clearly to patients is important, much of the teaching that patients need will be given in writing. Thus what is written and how it is written is very important if we wish to send the right message.

In the U.S. (per house style), we say that people are literate when they have the ability to read, write, and speak in English, to do math, and to solve problems at the level necessary to function on the job and in society. During the last 20 years, research has shown that many people in the United States do not have the basic level of literacy to allow them to do these tasks. In 2003, the latest National Assessment of Adult Literacy reported that 30 million Americans scored at Below Basic level of literacy, the lowest of four levels, and another 63 million were at Basic level of literacy, the second lowest level. People are placed in these two lowest levels if they have trouble finding pieces of information or numbers in a long text, putting many pieces of information together into one story, or finding two or more numbers in a chart and doing a math problem. These levels are roughly equal to being able to read at about the fifth-grade level.

While general literacy is a problem, we have also learned that many patients do not have high levels of health literacy—the ability to understand and use information that is important in keeping them healthy. Low literacy limits a person’s ability to deal with the health care setting, which has become more complex and uses written materials even more difficult to understand than those used in everyday life. This may mean patients cannot read a prescription to learn how many pills they should take, cannot figure out when their next appointment is, or cannot read a map to help them find a pharmacy or get where they need to go for their appointment. It often means they cannot read the information nurses or physicians send home with them explaining their disease, the medicines they are taking, and important things they need to know. Thus they often do not have the information they need to help them get well or stay well.

Even patients who read at college level have been found to prefer medical information written at the seventh-grade level. Recent research suggests that written information given to most patients should be written at a fifth- to seventh-grade level if we wish to make it more likely patients will understand it. This will be a challenge.

Although there may be large numbers of people in the United States with low literacy, research has documented that certain groups may have more problems than others. People who are older, are from minority races or ethnic backgrounds where English is not the dominant language, live in certain areas of the country, have a low income level, or are in prison tend to have lower literacy levels. Research about the reasons for these disparities has shown that frequently these individuals have not been able to stay in school and get an education.

It makes sense that people who have low literacy levels often have poor health outcomes. Because they cannot read or write they are at higher risk for disease and disability. This situation is called health disparity. Unfortunately, such individuals often die from a disease several years earlier than someone with higher literacy simply because of this difference in ability to read and write.

Because of these factors, there is no more important teaching than that given by the nurse to the patient about the patient’s disease and its drug treatment. This teaching is a big factor in whether the drug therapy ordered will be effective. When patients don’t understand and so cannot follow the treatment plan, there are often limitations in what the patient can do to take care of themselves. Accurate, careful teaching of the patient by the nurses involved in their care should help reduce such problems. This is very true when medications are involved, because drug information is usually complex and thus is often given in writing.

The Process Of Patient Education

Assessment Of Patient Education Needs

The fact that a nurse knows a patient should have information does not mean the patient is aware of that need or, in fact, expects to learn from the nurse. Patient education has to involve both teacher and learner and cannot be forced. Patients may show one of four types of behavior when seeking drug information, as shown in Table 2-1. Patients will go to the person they feel is the best source of information or with whom they feel most comfortable.

Table 2-1

Behaviors of People Seeking Drug Information

CLASSIFICATION	PERCENTAGE	CHARACTERISTICS
Uninformed	34%	This group tended to be older, was less likely to have received written or verbal counseling from a provider or pharmacist, and did not seem to recognize the results of improper drug use.
Rely on physician	40%	This group took information as given from the physician and was most likely to get prescriptions filled at chain pharmacies.
Rely on pharmacist	19%	This was the youngest group; they got information at the pharmacy and saw few barriers to getting information.
Questioners	7%	This group included those who were more likely to receive information from books or magazines. They required clear information about specific questions and appeared to be the most difficult group to satisfy.

Modified from Morris LA, et al: A segmentational analysis of prescription drug information seeking, Med Care 25:953-64, 1987.

There may be some differences between the information clinicians see as important and the information patients want. For example, it may be hard to discuss some of the serious side effects that might be caused by a drug. Nurses may not want to talk about some of these problems for fear of scaring patients to the point they won’t take the drugs. However, research has shown just the opposite result with many patients. Patients who are given more information feel more comfortable taking their drugs and can correctly recognize side effects, should they occur.

More emphasis is being placed on the use of computers, both in learning the needs of patients and in meeting those needs. In some situations, computers are even helpful in teaching patients with low literacy skills. Computers may be used for health surveys and have been shown to result in more honest reports of certain health behaviors. A few years ago, a study found that patients might actually be more comfortable revealing personal information on a computer than to a human being—even though they know the information will be seen later by health care workers.

The registered nurse has primary responsibility for patient teaching, but all nurses caring for the patient play a role. The important items to include in the patient-teaching process are the following:

1. Assess the patient’s specific needs to learn. Often the nurse may wish to provide information about a new treatment plan or medication, or the patient may ask direct questions. Teaching materials should then be written that take into account the specific needs of the patient, including knowledge, reading ability, beliefs, and experiences.

2. Assess the patient’s willingness to learn. This requires getting to know patients and talking with them about their interest in learning. Patients must see a need for the patient education they receive.

3. Decide what needs to be taught. The patient and nurse decide this together. This information should be written down as objectives that can be measured (that is, you can determine when they are met). For example, the objective “Learn about adverse reactions of the medication” is not measurable. The objective “List five possible adverse reactions” is measurable.

4. Select a teaching method. This may include verbal instructions, written materials, audiovisual materials, or a combination of methods. The method and pace of the teaching must be designed for each patient, recognizing differences in the ways people learn and the rate at which they learn. Plan for repetition. Different teaching skills may be needed at different times for the same patient. Teaching should be provided in small amounts over several meetings.

5. Determine how well the material has been learned.

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