Objectives

The overall objective of patient education is to effect a durable cognitive improvement that results in a positive change in an individual’s or group’s health behavior. In most cases the physical therapist must embark on a process to meet this objective in the course of procedural interventions. The education process consists of assessing the learning needs of the patient, identifying measurable, realistic objectives, planning and implementing the patient education program, and finally, evaluating its effectiveness. Specific examples of patient education learning objectives are listed in Box 28-1.

Achieving these objectives will lead to the achievement of a host of documented benefits of patient education. These include reduced length of hospital stay,⁶ reduced patient anxiety,⁷ improved health-related knowledge,⁸ increased quality of life,⁹ and improved response and adherence to medical treatment.¹⁰ Patient education has also been shown to empower patients to take more active roles in their health care.¹¹ Patients who are educated partners in their care are able to be smart consumers in the health-care system and adapt more readily to the changes in their lifestyles that result from illness. Educated patients learn and understand the health consequences of their behaviors and choices.

Learning Theory: Concepts Pertinent to Cardiopulmonary Patient Education

Behavioral scientists of the 20th century developed a variety of learning theories and models that attempt to explain the complexities of human behavior. Subsequent models have emerged that specifically address health behavior. Although a comprehensive discussion of these models is beyond the scope of this chapter, a list of references for further reading may be found at the end of this chapter (see Bibliography). The discussion of the three theoretical concepts that follows is designed to provide the clinician with a rationale for patient education practice in terms of its basis in learning theory. The concepts are social-cognitive theory, the health-belief model, and the behavior-modification approach.

The social-cognitive theory as developed by Bandura (1986)¹² posits that human behavior can be explained and predicted using the following key regulators: incentives, outcome expectations, and efficacy expectations. For example, a myocardial infarction patient perceives value in following the exercise program (incentive). Patients with this incentive will attempt to exercise if they believe that their current sedentary lifestyle poses a threat to health. These patients also believe exercise will reduce that threat (outcome expectation) and that they are personally capable of performing the exercise program (efficacy expectation). Outcome and efficacy expectations directly relate to patients’ beliefs about their capabilities and the relationship of their behaviors to successful outcomes. In essence, then, behavior is influenced by perceptions that create expectations for similar outcomes over time.

To function competently in a given environment requires a belief in one’s ability to attain a certain level of performance. Bandura terms this self-efficacy.¹³ He argues that perceived self-efficacy influences all aspects of behavior, including learning new skills and inhibiting or stopping current behaviors. Self-efficacy has the following four primary determinants:

For example, a pulmonary rehabilitation program increases a patient’s self-efficacy when the patient successfully completes multiple exercise sessions (performance accomplishments), learns how to deal with dyspnea by consulting fellow program graduates (vicarious experience), receives counseling on energy conservation techniques from the staff (verbal persuasion), and notes that oxygen saturation measured 95% before exercising (physiological state).

The health-belief model, developed in the early 1950s, theorizes that patients are likely to take a health action in the following situations: they believe they are at risk for illness; they believe that the disease poses a serious threat to their lives should they contract it; they desire to avoid illness and believe that certain actions will prevent or reduce the severity of the illness; and they believe that taking the health action is less threatening than the illness itself.¹⁴ This model was originally developed in an attempt to understand why large numbers of people failed to accept preventative care or screening tests for early disease detection. Subsequent studies have used the model to analyze compliance with regimes for hypertension, asthma, and diabetes.¹⁵ The health-belief model conveys that in the context of health behavior some stimulus or “cue to action” is necessary to initiate the decision-making process. These cues can be internal (i.e., a productive cough) or external (i.e., instructional video on pulmonary hygiene techniques). Once the behavior commences, it is understood that many demographic, structural, personal, and social elements are capable of influencing the behavior. In addition, perceived barriers (i.e., unpleasant side effects) may limit or prevent undertaking the recommended behavior.

The behavior-modification approach has its roots in operant-learning theory and consists of techniques that manipulate environmental rewards and punishments in relationship to a specified behavior.¹⁶ The theme of this approach is that an individual’s behavior can gradually be shaped to meet a set objective. According to Becker (1990),¹⁷ the behavior-modification approach frequently follows a general plan: “identify the problem; describe the problem in behavioral terms; select a target behavior that is measurable; identify the antecedents and consequences of the behavior; set behavioral objectives; devise and implement a behavior change program; and evaluate the program.”¹⁷ This plan is similar to the patient/client management model¹ that physical therapists use to achieve optimal patient care outcomes. The physical therapist examines the patient, describes the problem(s) in functional terms (evaluation and diagnosis), sets short-term and long-term functional goals, designs a plan of care to meet those goals (prognosis), implements the plan (intervention), and reevaluates the patient. These similarities may facilitate the use of the behavioral-modification approach by physical therapists.

Health-care contracts can be useful in implementing the behavior-modification approach. An example of such a contract may be seen in Box 28-2. The contract should be realistic, measurable, and renewable.¹⁸ Specific goals, time frames, behaviors, and contingencies are written in the contract. The clinician and patient discuss and then sign the contract. Positive and negative reinforcements are used to facilitate the desired behaviors in the patient. Ideally, once the contract expires, the patient feels competent and is able to continue the desired behaviors without the external reinforcements.

Areas to Assess

The learning needs assessment encompasses the following five major areas: perceptual, cognitive, motor, affective, and environmental (Box 28-3). By addressing these five areas, the physical therapist will obtain an accurate picture of the patient’s learning abilities, knowledge level, performance skills, attitudes, and cultural influences.

The perceptual area encompasses the learner’s ability to receive information via the senses. If the learner’s sight, hearing, or sense of touch is impaired, the instructor may need to make modifications so that the information can be received by the learner. The comprehension of symbols, such as numbers, words, or pictures, also needs to be assessed in the perceptual area. The instructor needs to know what meaning the learner attributes to the symbols that will be used in the education program to ensure clarity.

The cognitive area addresses the learner’s knowledge and problem-solving skills. The instructor needs to know how much the learner already knows and what needs to be learned. The instructor also needs to know if the learner has any problems with memory. Short- or long-term memory deficits may require that the instructor integrate a prompting system into the education plan.

The patient’s fine- and gross-motor skills and functional mobility are covered in the motor area. The instructor needs to be aware of the physiological changes in the patient that affect abilities to perform activities necessary for a given education program. For example, if patients who are wheelchair users are interested in attending a support group, the physical therapist would ensure that it is being held in a room that is wheelchair accessible.

The affective area comprises the learner’s attitudes, beliefs, and readiness to learn. Identifying the learner’s value-belief system will assist the instructor in determining what is important to the learner and facilitating motivation. The patient’s perception of wellness may vary from the absence of disease to an enhanced healthy state. What the instructor feels is important to learn may not be what the patient feels is important to learn. Identifying what the patient values early on will prevent instructor (and patient) frustration later.

Cultural influences and personal and societal resources are included in the environmental area. It is important for the instructor to be aware of the patient’s lifestyle, religion, traditions, roles, and primary language in order to individualize the patient’s learning experience. Presence or absence of the patient’s resources may affect consistency in, and access to, patient education.

All five of these areas can be addressed with the use of a learning needs assessment survey (Box 28-4). By using a survey in combination with the physical therapy patient evaluation, the therapist can gather all the necessary information to create an optimal patient education experience. The survey in Box 28-4 consists of three parts, which can be adapted to any patient care setting. In the pediatric setting, some of the questions could be asked of the parent(s) or rephrased to address school-age children. Part I primarily assesses the patient’s perception of the illness or disability and its impact on the patient’s life. Part II lists a wide variety of teaching methods and asks the patient to indicate which methods he or she personally feels are most useful. Part III identifies specific topics about which the patient would like to know more. This part is also helpful in alerting the therapist that referrals to other members of the interprofessional health-care team may be required. For example, if the patient selects “I would like to know more about what I should eat,” the therapist would make a referral to the dietitian. Patients’ answers provide clues to learning style preferences that work best for them and can often provide clues to health literacy issues.

Health Literacy

Certain barriers, such as limited health literacy, can alter the effectiveness of patient education and rehabilitation interventions, such as promoting lifestyle behavior changes.22,23 Health literacy can be described as a person’s ability to comprehend health information and use that information to make informed decisions about his or her health and medical care.²⁴ Specifically, the patient needs these skills when reading consent forms, prescription drug information, food labels, rehabilitation instructions, and appointment slips or when filling out a health insurance form or reviewing a health care bill.^25–27 Health literacy is required to read a peak flow meter, to understand body mass index (BMI), and to recognize whethera blood pressure reading is considered high.²⁸ Signs of limited health literacy can be found in Box 28-5. Limited health literacy increases the risk for hospitalization, the overall cost of health care, and mortality rates. Studies have shown that patients with limited health literacy are more likely to report difficulties with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as a result of poor or diminished physical health and pain that interferes with normal work activities.²⁹ Those with limited health literacy also have higher rates of diabetes, hypertension, obesity, depressive symptoms, and physical limitations. Older adults with limited health literacy also may demonstrate a higher incidence of heart failure, arthritis, and multiple health conditions, and they tend to have a greater need for complex medical management.^29,30 Patients with limited health literacy have less knowledge about hypertension, diabetes, and asthma.²⁵ Inadequate health literacy skills are key factors in the exacerbation of heart failure.³¹

Health literacy is also linked to improved compliance with a physical therapy plan of care and ultimately leads to better health and medical care outcomes.³² Current cardiovascular and pulmonary research demonstrates that patients with adequate health literacy are more likely to keep records of their blood glucose test results³³ and demonstrate improved medication compliance with a diagnosis of cardiovascular disease.³⁴ Patients with chronic obstructive pulmonary disease (COPD) who receive and understand self-management education have decreased hospital admissions.³⁵ Although outside the scope of this chapter, certain formal assessment tools can be used to determine an adult patient’s health literacy level (Table 28-1).

Interpretation of Findings

The next important step after gathering information with the learning needs assessment survey is to interpret the findings. The physical therapist looks at the answer to each item on the survey and uses that information in the process of designing the content and method for teaching that patient. Primary and secondary prevention can be integrated into the content to promote overall wellness. Interpretation of the survey findings means applying the patient’s current health concerns, learning abilities, and knowledge deficits to future learning activities. By identifying the patient’s needs, the physical therapist is able to make informed choices in the planning and implementation of each patient’s education experience.

Formulation and Prioritization of Goals

As physical therapists set intervention goals for their patients, they should include educational goals. Intervention goals usually describe functional outcomes (e.g., “The patient will perform a stand-and-pivot transfer from bed to chair, independently”), and they are written in behavioral terms. Educational goals should also be written in behavioral terms. For example, “Mr. J will safely perform percussion and postural drainage to Mrs. J’s right lower lobe.” The stated behavior must be observable and measurable. Motor skills can be observed, knowledge skills can be tested, and safety can be documented.

Prioritizing the patient’s educational goals in conjunction with other intervention goals enhances the therapist’s efficiency. Referring again to the learning needs assessment survey (see Box 28-4) to determine what knowledge is important to the patient will guide the therapist in creating the most appropriate prioritization of goals. Simplicity is usually best. Overwhelming patients with a huge list of items to be accomplished may discourage them before they even start. If the patient’s learning needs are great, start by breaking down the list of goals into smaller groups. Choose the most important goals and try to accomplish those first. If you run into a series of failures, tackle the next group. Build on each success the patient experiences.

Advantages and Disadvantages

Each education method has its own advantages and disadvantages. Table 28-2 lists the key advantages and disadvantages of 13 education methods. The table is designed to assist the physical therapist in determining the settings and populations in which the methods will be most useful. However, this is not a comprehensive list. In fact, some health education challenges require truly innovative approaches.

In Boston, Massachusetts, for example, community healthcare providers were faced with a dilemma. The incidence of acquired immune deficiency syndrome (AIDS) among women of color was increasing. Latino, African-American, and Haitian women were not receiving vital information about how to prevent the transmission of the human immunodeficiency virus (HIV). These communities were largely distrustful of the healthcare establishment and were not mobilized to stop the spread of HIV. How could they be reached? The Boston Women’s AIDS Information Project (BWAIP) trained lay women to educate other women in the places where they congregate, such as beauty salons. Informational brochures, condoms, and posters were distributed in a number of beauty salons in communities where women were at highest risk for contracting HIV. Lay and professional educators gave presentations, showed videos, and answered questions from the staff and patrons of these establishments, thus empowering them to disarm myths about AIDS, to encourage other women to make appropriate behavior changes, and to make referrals to neighborhood health centers for testing and evaluation.

Another area of education that may require a unique approach is teaching young children about their bodies and health. In 1993, members of the interdisciplinary team caring for children with cystic fibrosis (CF) at Texas Children’s Hospital in Houston held a CF Education Day for the children and their parents. The children ranged in age from 7 to 11 years. To teach them about anatomy, a special anatomy apron was fabricated. The apron had life-sized removable organs made of stuffed fabric. The children took turns wearing the apron and learned to identify and locate the organs by removing and replacing the apron’s heart, lungs, intestines, and pancreas.

By evaluating the advantages and disadvantages of available education methods, the physical therapist can choose the methods that are most effective and use them to his or her best advantage. Consideration must be given to cost, equipment, scheduling, labor, time, site, flexibility, and reusability. For example, digitally recorded or videotaped presentations may be easy for the instructor to schedule, present, and reuse, but they can be costly to purchase and they require expensive equipment for viewing.

Content

The specific content of patient education materials and programs should be determined by the needs of the individual or group being taught. There are, however, topics common to many cardiovascular and pulmonary education efforts. These topics are listed in Box 28-8. The physical therapist can use these topics as a checklist to explore the content covered (or to be covered) in a given cardiopulmonary education experience. Although physical therapists may not be responsible for teaching on all these topics, they should be familiar with all the topics taught by the healthcare team. Educational materials on all of these topics have already been developed by a variety of healthcare providers, educators, and organizations and may be available for use by physical therapists (see Interprofessional Considerations and Resources, later in this chapter).

Teacher-Learner Relationship

According to Locke (1986),⁴⁰ the primary step to understanding others is an awareness of one’s self. Acknowledging one’s own personal values, interests, and biases will significantly increase one’s sensitivity toward others. The skilled teacher is aware of his or her own communication style and its limitations and can convey the desire to help despite those limitations.

The teacher-learner relationship that develops between physical therapist and patient is largely the result of communication between the two in the context of culture. Communication is a two-way process consisting of verbal and nonverbal messages. The interpretation of these messages depends on the cultural cues operating in the educational setting. Fairchild (1970)⁴¹ defines culture as all social behavior, such as customs, techniques, beliefs, organizations, and regard for material objects, including behaviors transmitted by way of symbols. According to Locke (1992), “the primary mode of transmission of culture is language, which enables people to learn, experience, and share their traditions and customs.”⁴²In addition, culture can be expressed or experienced via economic and political practices, art, and religion. Health care and medicine have their own cultures. To meet the needs of culturally diverse populations and engage in positive, productive relationships, physical therapists must operate from a framework of cross-cultural understanding. This understanding and knowledge can then be reflected in patient education efforts.

For example, in a large, urban, acute care hospital, two physical therapy staff members were working together to treat an older adult Jewish woman who was critically ill. The clinicians worked carefully to reposition the woman without disturbing the many tubes and lines that were present. Later the woman expressed that she did not want to have two physical therapy clinicians working with her at the same time. She confided to the nurse that it felt it was too much like the Jewish ritual washing of the body after death, which is traditionally performed by two people. This interpretation of the therapy surprised the physical therapy staff members who had treated the woman, because although they were also Jewish, this thought never occurred to them. The next time the clinicians went to see the woman, they explained why it was necessary for both of them to be present during the treatment. They also encouraged the woman to have other supportive people present and to play her favorite recorded music during the therapy session.

Communication

Patients with cardiovascular and pulmonary diseases, such as congestive heart failure, are not always comfortable communicating with health-care professionals or questioning the physician’s decisions. In Circulation (2009),⁴³ the American Heart Association’s publication, health-care professionals are encouraged to avoid using medical jargon and phrases (such as “echo,” “stress test,” and “ECG”), because these terms may confuse patients. Instead, health care providers should explain in plain terms the action steps they want a patient to take.⁴³ In 2011, the Heart Failure Society of America described a five-step process for clinicians working with patients who have heart failure,⁴⁴ culminating in encouraging patients’ use of the “Ask Me 3” questions:⁴⁵

Physical therapists can use the communication strategies outlined in Box 28-9 to create an effective educational experience to fit the individual learner’s needs. These guidelines can be tailored to a variety of patient populations with differing levels of health literacy.

Patient Adherence

The effectiveness of physical therapy treatment, or of any medical treatment, depends on the patient following the health-care provider’s recommendations (adherence). Unfortunately, there is often a gap between what the patient is asked to do and what the patient actually does. This gap, or nonadherence, has an incidence rate estimated to be between 18% and 35%.46,47 Factors affecting patient adherence include knowledge about the illness and its expected course, complexity of the recommendations, convenience, availability of support system, financial resources, the patient’s beliefs, and the effectiveness of patient education, especially for pulmonary patients.⁴⁸

Patient education can improve adherence when the information explains what behaviors are expected, when they should be performed, and what to do if problems arise. Plans for patient education sessions should strive to avoid or remove barriers to patient adherence. These efforts include simplifying and individualizing treatment regimens, fostering collaborative teacher-learner relationships, enlisting family support, making use of interdisciplinary and community resources, and providing continuity of care.⁴⁹ By using an approach that integrates these efforts, the physical therapist can optimize patient adherence to the prescribed physical therapy program.