CHAPTER 3. Patient and Family Education
Valerie S. Watkins
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define the education process and use the nursing process to provide patient and family education (assessment, nursing diagnosis, planning, implementation, and evaluation).
2. Define The Joint Commission (TJC) standards for patient and family education.
3. Identify the developmental stages of learner.
4. List patient education that addresses the five teaching domains.
5. List components of patient teaching using the three domains of learning.
6. Describe teaching strategies that meet the needs of patients with different learning styles.
7. Describe methods for evaluation of patient education.
8. Identify documentation and information obtained from evaluations to improve the education process.
I. TJC STANDARDS FOR PATIENT AND FAMILY EDUCATION
A. TJC’s rationale for patient and family education is to provide patients sufficient information to make decisions and take responsibility for self-management and activities related to their needs.
B. Expectations (Box 3-1)
BOX 3-1
THE JOINT COMMISSION 2009 STANDARD
Provision of Care
The hospital provides patient education and training based on each patient’s needs and abilities.
Elements of Performance
▪ The hospital performs a learning needs assessment for each patient, which includes the patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.
▪ The hospital provides education and training to the patient based on his or her assessed needs.
▪ The hospital coordinates the patient education and training provided by all disciplines involved in the patient’s care, treatment, and services.
▪ Based on the patient’s condition and assessed needs, the education and training provided to the patient by the hospital include any of the following:
▪ An explanation of the plan for care, treatment, and services
▪ Basic health practices and safety
▪ Information on the safe and effective use of medications
▪ Nutrition interventions (for example, supplements) and modified diets
▪ Discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management
▪ Information on oral health
▪ Information on the safe and effective use of medical equipment or supplies provided by the hospital
▪ Habilitation or rehabilitation techniques to help the patient reach maximum independence
▪ The hospital evaluates the patient’s understanding of the education and training it provided
From The Joint Commission: Comprehensive accreditation manual for ambulatory care (CAMAC), Oakbrook Terrace, IL, 2009, The Joint Commission.
C. TJC is not looking for evidence of what is taught but what the patient knows.
II. ASSESSMENT
A. Assessing learning needs
1. Defined as gaps in knowledge that exist between desired level of performance and actual level of performance
a. Gaps exist because of a lack of knowledge, attitude, or skills.
b. Identify the learner.
c. Choose the right setting.
d. Collect data about the learner.
e. Collect data from the learner.
f. Involve members of the health care team.
g. Prioritize needs.
h. Determine the availability of educational resources.
i. Access demands of the organization.
j. Take time-management issues into account.
B. Readiness to learn: willingness or ability to accept information
1. Assessment of readiness to learn
a. Physical readiness
(1) Measures of ability
(2) Complexity of task
(3) Environmental effects
(4) Health status
(5) Gender
(6) Primary language
b. Emotional readiness
(1) Anxiety level
(2) Support system
(3) Motivation
(4) Risk-taking behavior
(5) Frame of mind
(6) Developmental stage
c. Experimental readiness
(1) Level of aspiration
(2) Past coping mechanism
(3) Cultural background
(4) Locus of control
(5) Orientation
d. Knowledge readiness
(1) Present knowledge base
(2) Cognitive ability
(3) Learning disabilities
(4) Learning styles
C. Assessing learning styles
1. Visual: learn through seeing.
a. Like to see the big picture or diagrams
b. To coincide with the verbal instructions, prefer
(1) Demonstrations
(2) Watching videos
(3) Written material
2. Auditory: Learn through hearing.
a. Like to listen to
(1) Audio tapes
(2) Lectures
(3) Debates
(4) Discussion
(5) Verbal instructions
3. Kinesthetic: learn through physical activities and through direct involvement.
a. Like to be “hands-on,” moving, touching, experiencing
b. Will respond well to hands-on learning with equipment and return demonstration of skills
4. Determine learning style (way that individual processes information).
a. Adults
(1) Use more than one method of learning
(2) Have a primary learning preference
b. Children have a more defined preference for one of the learning styles.
c. May need to use more than one method to provide information
D. Developmental stages of learner: specific patient population requirements will have bearing on ability to learn and interact
1. Age-specific—infant, child, adolescent, adult, and geriatric
a. Emotional, cognitive, communication, educational
b. Developmental age—not just age of patient
2. Are there any developmental delays or injuries that may have impacted the ability to learn?
a. Family’s, significant other’s, or guardian’s expectations for and involvement in care
b. Emotional or behavioral disorders
c. Alcoholism or drug dependency
d. Possible victims of abuse or neglect
e. Patients with history of posttraumatic stress disorder or previous unpleasant experiences
f. Cultural preferences
g. Past and present health care practices
h. Language barriers
(1) Legislation requires the use of qualified interpreters for limited English proficiency patients representing the largest minority group in the area.
(2) The patient has the option of declining the interpreter and using a family member or friend, but this must be documented on the patient record.
(3) Qualified interpreters must be used for all “life-threatening” information (unless declined by the patient) such as
(a) Diagnosis
(b) Patient histories
(c) Surgical procedures
(d) Medical procedure
(e) Procedural consents
(f) Discharge instructions
(4) Information can be taken and given over the phone via an authorized interpreter if the interpreter is not available to come to the hospital or facility site.
E. Stress
1. Can be physiological, psychological, or emotional
2. Some individuals are more vulnerable than others.
3. Responses can be behavioral, psychological, or physiological.
4. Children are more vulnerable when a number of stressors are present.
5. Identify behaviors indicative of stress.
6. Must listen to children—be aware of fears and concerns.
7. Physical comforting and reassuring are beneficial to children.
F. Coping: individual reactions to stressors
1. Strategies are specific to the person.
2. Styles are relatively unchanging personality characteristics or outcomes of coping.
3. Children have a more internal center of control.
4. Strategies that use relaxation are effective in reducing stress.
G. Pediatric concerns when addressing educational needs (see Chapter 10)
1. Pediatric stages of growth and development
2. Psychosocial development (Erikson)
a. Experiences can be favorable or unfavorable.
b. Birth to 1 year (trust vs mistrust)
(1) Establishment of trust dominates.
(2) Trust exists in relationship to someone or something.
c. One to 3 years (autonomy vs shame and doubt)
(1) Autonomy is centered on the children’s increased ability to control their bodies, themselves, and their environments.
(2) Children want to do things for themselves by using newly acquired motor skills.
(a) Walking
(b) Climbing
(c) Mental powers of selection and decision-making
(3) Much of learning is acquired through imitation of activities and behavior.
(4) Negative feelings arise when
(a) Made to feel small and self-conscious
(b) Consequences of behavior and choices are negative
(c) Shamed by others
(d) Forced to be dependent in areas where independence has been demonstrated
d. Three to 6 years (initiative vs guilt)
(1) Characterized by energetic and intrusive behavior and a strong imagination; explore the world with all of their senses and abilities.
(2) No longer guided by outsiders; develop a conscience that warns and protects or threatens them.
(3) A sense of guilt occurs when in conflict with others or made to feel that their behaviors are bad.
(4) Must learn to maintain initiative without encroaching on the rights of others.
e. Six to 12 years (industry vs inferiority)
(1) Want to engage in activities and behaviors that they can complete. They need a sense of achievement.
(2) They learn to compete and cooperate with others, and learn the rules.
(3) Important for learning to develop relationships with others.
(4) May feel inadequate and inferior if too much is expected of them or they believe they cannot measure up to standards set for them by others.
f. Twelve to 18 years (identity vs role confusion)
(1) Adolescent-development is characterized by rapid and marked physical changes.
(2) Adolescents’ perception of their bodies changes and diminishes.
(3) They become overly preoccupied with others’ perceptions of themselves.
(4) Adolescents face difficulty in dealing with concepts that others expect of them and the values of society.
3. Cognitive development (Piaget)
a. Consists of age-related changes that occur in mental activities.
b. Intelligence enables individuals to make adaptations to the environment that increase the probability of survival.
c. Three stages of reasoning
(1) Intuitive
(2) Concrete operational
(3) Formal operational
d. Concrete reasoning for children begins at about 7 years of age.
e. Birth to 2 years (sensorimotor)
(1) Six substages that are governed by sensations
(2) Progress from simple reflex activity to simple repetitive behaviors to imitative behavior
(3) Develop a sense of cause and effect
(4) Display a high level of curiosity, experimentation, and enjoyment of new things
(5) Begin to develop a sense of self; become aware of a sense of permanence
(6) Begin to use language and thought
f. Two to 7 years (preoperational)
(1) Interpret objects in sense of relationships or the use to themselves. Unable to see things from any perspective but their own
(2) See things in sense of concrete and tangible; lack the ability to use deductive reasoning
(3) Use imaginative play, questioning, and other interactions to develop the ability to make associations between ideas
(4) Thought is dominated by what children see, hear, or experience. Have increasing use of language and symbols to represent objects in their environment
g. Seven to 11 years (concrete operations)
(1) Become increasingly logical and articulate
(2) Able to sort, classify, order, and organize information to use in problem solving
(3) Develop a new concept of permanence
(4) Able to deal with multiple aspects of a situation simultaneously
(5) Do not have the ability to deal with abstract concepts
(6) Problems are solved in concrete systematic methods based on what children recognize.
(7) Become less self-centered through interactions with others; thinking becomes socialized
(8) Can consider points of view outside their own
h. Eleven to 15 years (formal operations)
(1) Able to be adaptable and flexible
(2) Can think in abstract terms and symbols, and are able to draw logical conclusions from observations
(3) Can make hypotheses and test them
(4) Consider abstract, theoretical, and philosophical matters
(5) May confuse the ideal with the practical, but in most cases can deal with the contradictions and resolve issues
(6) Nonsocial stimulating experience that starts outside the child
(7) Attention attracted by objects in the environment
(a) Light
(b) Color
(c) Taste
(d) Odors
(e) Textures
(f) Consistencies
(8) Use of body senses to experience
H. Fears
1. Vary with age
a. Infants
(1) Birth to 6 months: loss of support, loud noise, bright lights, sudden movement
(2) Seven to 12 months: strangers, sudden appearance of unexpected and looming objects, animals, or heights
b. Toddlers (1–3 years): separation from parents, the dark, loud or sudden noise, injury, strangers, certain persons (e.g., the physician), certain situations (e.g., trip to the dentist), animals, large objects or machines, change in environment
c. Preschoolers (3–5 years): separation from parent, supernatural beings (e.g., monsters or ghosts), animals, the dark, noises, “bad” people, injury, death
d. School-age children (6–12 years): supernatural beings, injury, storms, the dark, staying alone, separation from parent, things seen on television or in movies, injury, tests and failure in school, consequences related to unattractive physical appearance, death
e. Adolescents: inept social performance, social isolation, sexuality, drugs, war, divorce, crowds, gossip, public speaking, plane and car crashes, death
I. Adult concerns when addressing educational needs
1. Early adulthood: 20 to 40 years (intimacy vs isolation)
a. Have a commitment to work and relationships
(1) Have they planned appropriately for the impact that surgery may have on their work, social, and personal life?
b. Concerned with emancipation from parents and in building an independent lifestyle
c. Concerned with forming an intimate bond with another and choosing a mate
(1) The adult seeks love, commitment, and industry of an intense, lasting relationship.
(2) Relationships include mutual trust, cooperation, acceptance, sharing of feelings and goals.
(3) Without secure personal identity, the adult cannot form a love relationship; may result in a lonely, isolated, withdrawn person.
d. Has reached maximum potential for growth and development
e. All body systems operate at peak efficiency.
f. Nutritional needs depend on maintenance and repair requirements and on activity levels.
g. Sensible nutrition is a major problem for many adults.
h. Cognitive function has reached a new level of formal operations and the capacity for abstract thinking.
i. Less egocentric, operates in a more realistic and objective manner
j. Is close to the maximum ability to acquire and use knowledge
k. Work is an important factor in the young adult and is tied closely with ego identity.
l. Begins to self-reflect in the late 20s to early 30s:
(1) “Where am I going?”
(2) “Why am I doing these things in my life?”
m. The 30s are characterized by settling down.
n. Strives to establish a niche in society and to build a better life
o. Risk for stress is increased since there are many situations that require choices to be made.
p. Single parents often have additional stress of decreased financial resources for themselves and/or children.
2. Middle adulthood: 40 to 64 years (generativity vs stagnation)
a. Realization that life is half over
b. Accepting and adjusting to the physical changes of middle age
(1) Effects of aging are becoming more apparent—wrinkles, graying or thinning hair, changes in body function, redistribution of fat deposits, decreased physical stamina and abilities.
(2) Decreased respiratory capacity and cardiac function, visual changes
(3) Sensory function remains intact except for some visual changes (e.g., decreased accommodation for near vision or presbyopia)
(4) Women—menopause:
(a) Decrease in estrogen and progesterone
(b) Attendant symptoms of
(i) Atrophy of reproductive organs
(ii) Hot flashes
(iii) Mood swings
(5) Men: decrease in testosterone, which causes
(a) Decreased sperm and semen production
(b) Less intense orgasms
c. Adjusting to aging parents
d. Reviewing and redirecting career goals
e. Helping adolescent children in their search for identity
(1) Often feel caught in a “squeeze” between simultaneously changing needs of adolescent children and aging parents
f. Accepting and relating to the spouse as a person
g. Coping with an empty nest at home
h. Aware of occasional death of peers—reminder of own mortality
i. Leading causes of death: cardiovascular disease, cancer, and stroke
j. Morbidity increased
(1) Often related to increase in obesity
(2) Resulting hypertension, cardiovascular disease, diabetes, mobility dysfunction, and arthritis
(3) Chronic smoking leads to health problems.
k. Intelligence levels remain generally constant.
(1) Is further enhanced by knowledge that comes with
(a) Life experiences
(b) Self-confidence
(c) A sense of humor
(d) Flexibility
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