According to the Guide to Physical Therapist Practice, patient/client-related instruction is one of the three major components of physical therapist intervention.¹In cardiovascular and pulmonary physical therapy, choosing an effective procedural intervention is based on the physiological evaluation of the patient. Similarly, choosing effective patient instruction or education methods is based on the learning needs assessment of the patient.² The overall goal of patient education is for the patient to practice health behaviors that promote health, well-being, and independence in self-care. Cardiovascular and pulmonary patient education can pose a significant challenge to the physical therapist. Patient education interventions can range from teaching a hospitalized patient about cardiac risk factor modification to designing a series of community-based exercise classes for children with asthma. Meeting this challenge is important because the benefits of patient education include reduced health-care costs, reduced disability, enhanced patient decision making, improved patient knowledge, and increased quality of life. In addition, physical therapists share with other health-care providers the responsibility of ensuring that patients have the opportunity to make informed choices in their care. Unless effective patient education is implemented, this opportunity will be lost.

The overall objective of this chapter is to provide the clinician with an understanding of the principles and practice of effective patient education. To meet this objective, patient education is defined and pertinent learning theories are presented, supported by examples of how they relate to cardiovascular and pulmonary patient education. The learning needs assessment of the patient is explained, followed by a description of patient education methods and materials. Because the effectiveness of patient education efforts is important to evaluate, methods to determine effectiveness are addressed. Finally, interprofessional considerations and educational resources are discussed.

Defining Patient Education

Physical therapists believe that patient education is an important part of patient care.³ The teaching role of the physical therapist has been reported as highly valued by patients as well.⁴ According to the Consumer and Patient Health Information Section of the Medical Library Association (1996),⁵ patient education is “a planned activity, initiated by a health professional, whose aim is to impart knowledge, attitudes and skills with the specific goal of changing behavior, increasing compliance with therapy and, thereby, improving health.”⁵

Several factors make patient education unique when compared with other types of teaching. The patient may have limited or no access to teaching because of financial and/or geographical barriers to health care. The learner may lack a sense of well-being because of signs and symptoms of an acute illness, making learning more difficult. The relationship between the teacher and the learner in patient education may be perceived as hierarchical—a medical authority figure instructing a lay person. The learner’s emotional status may be fearful or anxious, depending on the medical situation. Superimposed time constraints, such as length of hospital stay or length of clinic appointment, may have a direct impact on patient education. The physical therapist and the patient may be from different cultures. Furthermore, the learner may have limited health literacy. Any of these factors may pose barriers to learning. In addition, the patient’s family dynamics may be altered as family members try to cope with the patient’s illness or disability. The physical therapist’s responsibility extends to determining readiness and ability to learn and including the family in the education process.

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.

Box 28-1 Patient Education Objectives

1. Enhanced patient-clinician rapport

2. Increased knowledge of health disorder/condition

3. Increased adherence to physical therapy treatment plan

4. Decreased health-care costs

5. Increased self-efficacy

6. Increased ability to make informed health-care choices

7. Improved patient outcomes (such as quality of life, mobility, etc.)

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:

1. Performance accomplishments, which is the strongest determinant and refers to “acting out” the desired behavior and mastering the task, resulting in increased self-efficacy

2. Vicarious experience, which involves learning through observing the actions of others, especially actions with clear, rewarding outcomes

3. Verbal persuasion

4. One’s physiological state as it relates to the perceived ability to perform a given task

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.

Box 28-2

Health Care Contract

Date:

Contract goal: [specific outcome to be attained]

I, [Client’s Name], agree to [Detailed description of required behaviors, time, and frequency limitations] in return for [Positive reinforcements contingent on completion of required behaviors; timing and mode of delivery of reinforcements].

I, [Provider’s Name], agree to [Detailed description of required behaviors, time, and frequency limitations].

(Optional) I, [Significant Other’s Name], agree to [Detailed description of required behaviors, time, and frequency limitations].

(Optional) Aversive consequences: [Negative reinforcements for failure to meet minimum contract requirements].

We will review the terms of this agreement and will make desired modifications, on [date]. We hereby agree to abide by the terms of the contract describe above.

Signed: [Client]

Signed: [Significant Other, if relevant]

Signed: [Provider]

Contract effective from [Date] to [Date].

From Janz NK, Becker MH, Hartman PE: Contingency contracting to enhance patient compliance: A review, Patient Education Counseling 5:165–178, 1984.

Needs-Based Approach to Patient Education

The most important aspect of planning for patient education is assessing the learner. The process of patient education requires assessment of the total patient and family, including an understanding of the psychosocial, socioeconomic, educational, vocational, and cultural qualities of the patient and family unit.¹⁹ Assessing educational needs of the patient allows the physical therapist to determine what the patient needs to know to meet the desired cognitive and behavioral teaching objectives. This assessment also increases patient-teacher rapport and allows the physical therapist to individualize the learning experience.

Learning Needs Assessment

Tools

The American Physical Therapy Association’s Commission on Accreditation of Physical Therapy Education in their Normative Model of Physical Therapist Professional Education: Version 2004 ²⁰ requires that the graduate physical therapist be able to “effectively educate others using culturally appropriate teaching methods that are commensurate with the needs of the learner.”²⁰ Learning needs can be assessed in a variety of ways. These include patient and family interviews, questionnaires and surveys, written tests, and observation of patient performance.²¹ Interviews allow the physical therapist to ask questions directed at determining the patient’s view of the illness, including associated beliefs and attitudes. Questionnaires and surveys can be used in conjunction with the interview to document the patient’s responses to specific questions about his or her condition. Open-ended questions such as “What are the major problems your illness has caused for you and your family?” elicit more information than a multiple-choice format. Written tests can be helpful in determining what patients already know when the tests are given, before any teaching. These tests can also identify problems with reading, comprehension skill, and health literacy. Observing patients as they perform a skill, such as diaphragmatic breathing, reveals whether the patient can demonstrate the correct technique. The physical therapist can also pose questions to the patient during the demonstration to determine whether the patient knows the rationale for the exercise.

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.

Box 28-4 Learning Needs Assessment Survey

Your physical therapist would like to help you learn what you need to know to function as independently as possible and manage your illness/disability. Please answer the following questions.

Part I

Name:

Please describe your illness and/or disability here:

1. Do you have any problems seeing or hearing?

2. Do you have any body areas that are numb (can’t feel)?

3. How long have you had this illness/disability?

4. What problems has it caused you?

5. Are you able to care for yourself at home?

6. Are you responsible for the care of any others at home?

7. Do you have someone at home to help you? If so, whom?