Patient Education

If we think of patient care as customer service—which it indeed is—then we cannot ignore education as a crucial component of that service. Whether we buy a car or a television set, we expect the salesperson to educate us about the essential aspects of our purchase. We also expect this information to be provided in writing. Likewise, education is an essential component of patient care. For patients to assume or resume control of their health, they must be educated. Because they rely on the health care practitioner to provide this education, every respiratory care education program should include instruction regarding patient education.

Performance Objectives

Initially it is helpful for the RT to develop learning objectives that are appropriate for the specific patient education topic to be addressed. These learning objectives will help to clarify the teaching strategies that are needed for patient education sessions. Objectives should be stated in measurable terms so that the RT and the patient can recognize when the objective has been accomplished. Clear objectives describe what is to be accomplished and how evaluation will occur.

The format for writing an objective is as follows:

1. Begin with the phrase, “At the end of the lesson, the patient will … .”

2. Write the action verb (e.g., “list,” “describe,” “demonstrate”).

3. Write a condition, if needed (e.g., with or without the use of notes).

4. Write a standard, if needed (e.g., how fast, how accurate).

For example: At the end of the session, the patient will be given a metered-dose inhaler and spacer and be able to demonstrate the correct technique for using the metered-dose inhaler in 5 minutes or less.

Action verb: “demonstrate” (from the psychomotor domain; the relevant domains are discussed later in this chapter)

Condition: “given a metered-dose inhaler and spacer”

Standard: “in 5 minutes or less”

Learning Domains

Learning occurs in three domains: cognitive, psychomotor, and affective. Some learning sessions will involve only one domain, whereas others may involve all three. The cognitive domain is very important, because it will address the knowledge that a patient needs regarding his or her illness and how to manage it. The psychomotor domain addresses the skills that the patient will need to acquire to perform specific treatment modalities (e.g., the use of metered-dose inhalers). The affective domain involves teaching patients about the necessary attitudes and motivations for successfully living with their diseases.

Mini Clini

Developing Learning Objectives for the Use of an Albuterol Metered-Dose Inhaler

 Problem

Your 31-year-old patient is newly diagnosed with asthma, and she is being discharged tomorrow. She requires instruction regarding how to properly use her albuterol metered-dose inhaler. Develop learning objectives for her, and address each learning domain.

Solution

Use a variety of learning objectives, including the following:

Cognitive domain: Describe the action of albuterol on the bronchial smooth muscle; recognize when it is necessary to seek medical attention.

Affective domain: Agree that it is important not to skip a dose; verbalize willingness to use the metered-dose inhaler; feel satisfaction by controlling the disease.

Psychomotor domain: Demonstrate the ability to assemble the metered-dose inhaler and spacer; inhale slowly and deeply with an inspiratory hold.

Cognitive Domain

The cognitive domain is probably the easiest to translate into learning objectives because it involves the facts and concepts that the RT wants the patient to know and apply by the end of the education session. Objectives for the cognitive domain might include the following:

1. List the indications for oxygen therapy.

2. Discuss the importance of using the prescribed liter flow.

3. Explain the relationship between oxygen and combustion.

Any factual information that you expect the patient to understand and apply falls under the cognitive domain. Action verbs for the cognitive domain are included in Table 49-1.²

TABLE 49-1

Verbs for the Cognitive Domain

Purpose	Example Verbs
1. Knowledge	Cite, define, read, identify, list, label, name, outline, recognize, select, state
2. Comprehension	Convert, describe, defend, explain, illustrate, interpret, give examples of, predict, paraphrase, summarize, translate
3. Application	Apply, compute, construct, demonstrate, change, calculate, use, estimate, modify, present, prepare, solve, proceed, relate, utilize
4. Analysis	Analyze, associate, compare, contrast, determine, diagram, differentiate, discriminate, distinguish, outline, illustrate, separate
5. Synthesis	Categorize, combine, compile, compose, create, design, develop, devise, integrate, modify, organize, plan, propose, rearrange, reorganize, revise, rewrite, translate, write
6. Evaluation	Appraise, assess, compare, conclude, contrast, critique, discriminate, make a decision, support, evaluate, judge, weigh

Modified from French D, Olrech N, Hale C, et al: Blended learning: an ongoing process for Internet integration, Victoria, Canada, 2003, Trafford Publishing.

Psychomotor Domain

Repetition and active involvement are important when teaching a psychomotor skill. RTs who teach new skills to patients need to provide plenty of opportunity for the patient to practice the activity. Simple demonstration of the skill to the patient is not enough. To confirm performance in the psychomotor domain, have your patients provide a return demonstration. Be sure to provide help and encouragement as needed. Be patient; not everyone develops skills at the same rate.

Examples of action verbs for the psychomotor domain are included in Table 49-2.²

TABLE 49-2

Verbs for the Psychomotor Domain

Purpose	Example Verbs
1. Perception: prepares and recognizes sensory cues to want to respond	Detect, distinguish, differentiate, identify, isolate, relate, recognize, observe, perceive, see, watch
2. Ready to act and respond	Begin, explain, move, react, show, state, establish a body position, place, posture, assume a stance, sit, stand, position
3. Guided response: imitate and practice; rough sequencing of events	Copy, duplicate, imitate, manipulate, operate, try, practice, dismantle
4. Efficiency: smooth sequencing of events	Assemble, calibrate, construct, display, fasten, fix, grind, manipulate, measure, mix, sketch, demonstrate, execute, increase speed, improve, make, show dexterity, pace, produce
5. Perform alone: modifies, responds as needed	Act habitually, advance confidently, control, excel, guide, manage, master, organize, perform quickly and more accurately
6. Creates a new or original model	Adapt, alter, rearrange, reorganize, revise

Modified from French D, Olrech N, Hale C, et al: Blended learning: an ongoing process for Internet integration, Victoria, Canada, 2003, Trafford Publishing.

 Rule of Thumb

People learn by doing. Get the learner involved.

Affective Domain

The patient’s attitudes and motivations influence his or her ability to learn. It is important to remember that, with patient education, timing is everything. Patients who have recently been given a poor prognosis or who are in pain are not in an optimal position to learn. Maslow suggested a hierarchy of needs, and he identified physiologic needs as the most basic of human needs, followed by safety, love, esteem, and self-actualization.³ Lower-level needs must first be satisfied before moving on to higher-level needs. For example, if a patient is dyspneic or in pain, he or she will probably not be receptive to learning the steps that are involved in cleaning a small-volume nebulizer. It is important for RTs to assess a patient’s readiness to learn by talking with the patient and his or her family and by listening to the patient’s concerns. It is important to develop a relationship of trust and to be empathetic with the patient.

The RT should begin with easy-to-master facts and skills. After the patient conquers these, motivation should increase, and the patient will have a feeling of accomplishment. Motivation is also enhanced by presenting material clearly with the use of a variety of teaching methods and by relating the facts and skills to practical applications. Getting patients to see how these skills will benefit them is the key to motivation. Communicating to the patient that there is something that he or she can do to maintain or improve his or her health and sense of well-being is important.

Objectives in the affective domain—using the oxygen therapy example mentioned earlier—might include the following:

1. Demonstrate genuine concern for yourself by using your oxygen therapy correctly.

2. Demonstrate a willingness to learn by being an active participant in the program.

Affective domain action verbs are included in Table 49-3.²

TABLE 49-3

Verbs for the Affective Domain

Purpose	Example Verbs
1. Receive: becoming aware of	Accept, acknowledge, alert, choose, give, attend, notice, perceive, tolerate, select
2. Respond: interested in or doing something about something	Agree, assist with, aid, answer, assist, comply, conform, communicate, consent, label, obey, cooperate, follow, read, report, visit, volunteer, study
3. Value: concerned about, developing an attitude	Adopt, assume, behave, choose, demonstrate, commit, desire, initiate, join, exhibit, express, prefer, seek, share
4. Organize: arranging systematically, confirming	Adapt, adjust, arrange, classify, conceptualize, group, rank, validate, verify, strengthen, substantiate, corroborate, confirm
5. Characterize: internalizing a set of values, championing	Demonstrate a change in lifestyle, discriminate, defend, influence, invite, listen, preach, qualify, question, serve, act upon, advocate, devote, expose, justify, support

Modified from French D, Olrech N, Hale C, et al: Blended learning: an ongoing process for Internet integration, Victoria, Canada, 2003, Trafford Publishing.

Teaching Tips

Following is a list of time-honored suggestions for improving patient education:

• Address the patient’s immediate concerns first.

• Create an optimal learning environment. Teach in a quiet and relaxed setting.

• Have patients use as many of their senses as possible during their learning session. Whenever possible, include hearing, seeing, smelling, speaking, touching, and doing.

• Keep sessions short. If the material is complex, break it down into brief segments.

• Repeat, repeat, repeat!

• Provide many opportunities for the patient to practice psychomotor skills.

• Be prepared.

• Be organized. People learn more quickly when they are presented with information that is well organized.

• Demonstrate enthusiasm for what you are doing. The learner can always sense your level of motivation.

• Evaluate in a nonthreatening manner, and provide helpful feedback. Use evaluation as a learning tool.

Teaching Children As Compared With Teaching Adults

Teaching children is often very different than teaching adults. Children are more motivated by external factors (e.g., prizes) as compared with adults, who tend to have internal motivating factors. This suggests that adults will learn quicker if they can easily see the intrinsic value of knowing more about their illness. Alternatively, children may need a more obvious reward system in place before learning can take place. They have no problem taking instruction from adults, because they are often dependent on such instruction. Adults, however, are more independent, and they do not like being dependent on others. This suggests that adults should be more involved in setting program goals and that they will readily learn skills that make them more independent. Other important issues related to differences between children and adult learners are listed in Box 49-1, and allocated time for teaching is given by age in Box 49-2.⁴

Box 49-1   Learning Differences Between Children and Adults

Child

• Motivated by external factors like grades

• Directed by others

• Learning is a big part of his or her life

• Trusts teacher

• Has limited experience

• Learns for the future

• Learns quickly

• Tends to learn in accordance with his or her developmental stage

• Has no problem with a slow pace of learning

• Subject oriented

Adult

• Motivated internally

• Is self-directed

• Learning is only one part of his or her life

• Questions the teacher

• Has rich life experiences

• Learns for the present

• May learn more slowly

• Varies with regard to learning ability

• Dislikes a slow pace of learning

• Problem oriented

Box 49-2   Attention Spans for Different Ages

• Toddlers: about 2 to 3 minutes

• School-aged children: about 10 to 15 minutes

• Adolescents and adults: about 20 to 30 minutes

Evaluation of Patient Education

The critical question that remains when all of the patient education sessions are complete is, “Has the patient learned?” Evaluation is the process that answers that question. The method used to evaluate learning is determined by the measurable learning objectives (i.e., cognitive, affective, or psychomotor). Cognitive objectives are often evaluated with the use of a written examination. Objectives in the affective and psychomotor domains are evaluated with the use of performance checklists.

Informal evaluation should occur during the educational process. The RT can ask simple questions along the way to identify whether the patient has comprehended the information. If the patient provides an answer that is not correct, the RT should view this as an opportunity to repeat previous discussions or to present the material with a new approach. The RT must never convey disappointment or frustration when patients are having trouble learning new material.

Mini Clini

Metered-Dose Inhaler Instruction for a Pediatric Patient

 Problem

How would you change the approach to the metered-dose inhaler situation described in the previous Mini Clini if your patient was a 7-year-old boy with asthma?

Solution

Although the learning objectives may remain the same, the methods may be different. You may compare the slow, deep inspiration to getting ready to blow out the candles on a birthday cake. You may use swimming under water as an image to encourage breath holding. Use simple diagrams to show how the medication will act on the patient’s lungs. If he likes sports, tell him about athletes who compete well despite having asthma (you may also use this illustration to stress the importance of controlling asthma). An abundance of resource materials are available for children with asthma; make use of them. Many local, state, and national lung associations (www.ala.org) offer such learning aids as age-appropriate books, coloring books, and puppets to make the learning process more fun for children.

49-1   Providing Patient and Caregiver Training

AARC Clinical Practice Guideline (Excerpts)*

American Association for Respiratory Care Clinical Practice Guideline (Excerpts)* updated June of 2010.

www.rcjournal.com/cpgs/pdf/06.10.0765.pdf

Indications

Patients who need to increase knowledge and understanding of health status and therapy; improve skills needed for safe and effective health care; and develop a positive attitude, strong motivation, and increased compliance. Patients need to know the answers to “Ask Me 3”: What is my main problem? What do I need to do? Why is it important for me to do this?

Contraindications

None.

Complications

Omission of essential steps concerning care, presentation of inconsistent information, or failure to validate the learning process can lead to unfavorable results. Lack of cultural competence, and information appropriate in the language other than English will result in less than desirable outcomes. Lack of trust.

Limitations

• For the patient: Lack of motivation; impairment (physical, mental, or emotional); inability to understand instruction; illiteracy; language barriers; religious and/or cultural beliefs that are at odds with the material presented. Lack of health literacy, despite educational completed and conflicts of religious and/or cultural practices.

• For the RT: Lack of a positive attitude or flexibility; limited knowledge of skill being taught; inadequate assessment of patient’s readiness to learn; cultural or religious practices that may affect learning; inability to personalize the material; insufficient time; inadequate communication skills, and inadequate knowledge of cultural or religious practice.

• For the system: Hospital stay too brief; lack of interdisciplinary communication and/or cooperation; inconsistent information presented; lack of an interpreter.

• Other factors: Lack of support system for the patient; reimbursement issues; interruptions, distractions, or noise; inadequate lighting, heat, or space; poorly chosen resources including inappropriate reading level and vocabulary.

Assessment of Need

Determine the knowledge gap between what the patient knows and what he or she needs to know. Apply this to cognitive, psychomotor, and affective domains.

Assessment of Outcome

Evaluate knowledge gained, skills mastered, patient should return demonstration without assistance, reassess patient outlook, attitude and life style changes.

Resources

Access trained interpreters, ensure the written materials are readable at a fifth or sixth grade level, materials should be available in variety of formats (audio and visual), use demonstration models, reevaluate the skills.

Monitoring

The monitoring of the training processes should include awareness of the patient’s verbal and nonverbal responses, including eye contact, listening skills, and participation in discussion.

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^*For the complete guideline, see the American Association for Respiratory Care: AARC Clinical Practice Guidelines. Providing patient and caregiver training 2010. Respir Care 55(6):765-769, 2010.

 Rule of Thumb

Evaluation results reflect the quality of instruction as much as the degree of learning.

Health Education

Health education may have been the earliest form of organized health promotion in the United States. Health programs in schools may be the result of Lemuel Shattuck’s report in 1850 to the Sanitary Commission of Massachusetts, which described the value of schools helping to contain communicable diseases. However, it was not until 1875 that health education became widespread. During that year, the Women’s Christian Temperance Union lobbied for alcohol education in the schools. As a result of these efforts, 38 states passed legislation to require this education, which later turned into tobacco, alcohol, and drug education. From that time, health education has been enhanced and expanded in schools. There are public health agencies at the local, state, national, and international levels that provide health education and care for those who would otherwise have none.

Health education is a process of planned learning that is designed to enable individuals to make informed decisions and to take responsible actions regarding their health. The primary goal of health education is behavior change, and it is designed to promote, maintain, and improve both individual and community health. Health education covers the continuum between health and disease and between prevention and treatment.

Health promotion helps people change their lifestyles in a variety of settings, from the home or school to the workplace or the health care agency or institution. To be effective, health education must be combined with strategies for health promotion; the two are strongly linked. The American Association for Respiratory Care has created a statement for health promotion and disease prevention (Box 49-3).⁵

Although individuals must ultimately assume responsibility for their own health, promoting healthy behaviors through education is an important part of being an RT. In this capacity, the RT should serve as a role model for the public. Unless health care professionals model healthy behaviors, successful health outcomes cannot be expected from the public. To this end, the American Association for Respiratory Care has created a role-model statement to encourage RTs to set a positive example for the public (Box 49-4).⁶

Providing a good example is not enough to ensure successful health education programming. For the desired outcomes to be achieved, certain conditions must first be met. The components are remarkably similar to patient education requirements. The essential components of effective health education are as follows:

For RTs to assist patients, caregivers, or the public with regard to the development healthier lifestyles, greater emphasis must be placed on health promotion and disease prevention strategies.

Health Promotion and Disease Prevention

In 2008, the United States spent $2.3 trillion on health care.⁷ Four of the five major causes of death in the United States are heart disease, cancer, cerebrovascular disease (stroke), and chronic obstructive pulmonary disease (COPD). These diseases have four central causes that, in large part, are preventable: tobacco use, poor diet, physical inactivity, and excessive alcohol use.⁸

Current medical practice is designed to respond to the acute problems of patients; its focus is on diagnosing and treating the presenting symptoms rather than focusing on the prevention of disease by identifying risk factors and providing methods for behavioral changes. Only focusing on the acute or episodic health problems creates a discrepancy when using this model of care to care for chronic conditions that may be prevented or managed. Preventative health care is very different from chronic care.

With this in mind, a quote from Rufus Howe is appropriate: “What a rare privilege it is to be in a position to improve the lives of others.”⁹

A patient with asthma goes to the emergency department and is treated effectively and efficiently. The patient received good quality care, and, in many people’s minds, the patient was “fixed.” However, asthma is manageable to the point that the patient should not have to be in the emergency department. There are excellent national guidelines that outline how to manage asthma, and there are medications that control asthma and keep the patient out of this situation. Usually the reason for the emergency visit is that the patient’s asthma is not in control; this may occur because the patient is not using inhaled steroids, because he or she has a poor understanding of the disease and how to treat it, because the national guidelines are not being used, or because of a combination of all of these issues. Either way, this chronic disease can be self-managed by a patient with the proper multidisciplinary education and follow up.

However, the public health model attempts to reduce disease in the nation as a whole through mass education campaigns. Examples include education about the hazards of drinking and driving, tobacco use (both smokeless and smoking) education, and food labeling to indicate fat and cholesterol content. This is known as health promotion and disease prevention. By participating in public education programs, RTs have the potential to affect the health of individuals and of the population as a whole.

Recent efforts such as Healthy People 2010 have attempted to place the focus on the health of the population rather than on that of the individual.¹⁰ The two broad goals of this plan are as follows: (1) to increase the quality and years of healthy life; and (2) to eliminate health disparities. These goals encompass the essential elements of health promotion and disease prevention, which are the prevention of premature death, disease, and disability as well as the improvement of the quality of life.

The recognition that allied health professionals such as RTs play vital roles in these activities prompted professional organizations to develop policy statements about health promotion and disease prevention. The American Association for Respiratory Care policy statement appears in Box 49-5.⁵

RTs can take an active role in the development of educational materials to assist both the public and other health professionals with regard to health promotion activities. Many medical manufacturers have also developed asthma education kits of various types that include peak flow meters, spacers, and educational materials. These kits are generally developed with input from the medical community and in particular from RTs. An example of an asthma program is given in Table 49-4.¹¹ Respiratory care educational programs need to be diligent when incorporating health promotion and disease prevention activities into all learning domains as part of their curricula.

Monitoring: Component 2: Control of the factors that contribute to asthma Component 3: Pharmacologic therapy: managing asthma for the long term Component 4: Patient education for a partnership in asthma care

Disease Management

The most recent data show that more than 145 million people—which is approximately half of all Americans—live with chronic disease.¹⁵ Half of those with chronic illness have more than one chronic condition or comorbidity. These chronic diseases are extremely expensive and lead to unnecessary admissions. Chronic care models have been used since the 1990s. A chronic care model is patient centered; it encourages multidisciplinary focus on self-management and continuous quality control. Wagner presented the chronic care model that is illustrated in Figure 49-1.¹⁶

Wagner explains the model as follows: “[P]atients and families who struggle with chronic illness require planned, regular interactions with their caregivers, with a focus on function and prevention of exacerbations. This interaction includes systematic assessments, attention to treatment guidelines, and behaviorally sophisticated support for the patient’s role as a self manager. These interactions must be linked through time by clinically relevant information and continuing follow-up.”¹⁶

As with disease management, which is a method of applying the best health care practices to a population with a chronic illness one person at a time,⁹ the goals of this type of program include improving the health of the person, improving patient satisfaction, reducing mortality, improving quality of life, and eliminating unnecessary medical treatment to reduce the cost of health care.⁹ There is no one definition of disease management. However, the Care Continuum Alliance defines disease management as a coordinated system of interventions for people who have conditions that require significant self-care.¹⁷ Disease management is measured by its impact on costs, clinical outcomes, and quality of life. The programs have similar components, including a coordinated comprehensive interdisciplinary care team with a process for measuring improvement. Health insurance companies, pharmaceutical companies, and the federal government all pay for disease management programs.⁹ Most programs have the following attributes:

If you were interested in creating a disease management program, you would want to make sure to include these components. There are many disease management programs offered to patients with chronic diseases such as COPD, asthma, amyotrophic lateral sclerosis, and cystic fibrosis. RTs are ideal members of a disease management program. The patients whom RTs care for have chronic diseases, and these individuals need to be taught about the health risks associated with the disease, the prophylactic measures used to maintain quality health, and disease-specific respiratory therapy. For example, in a disease management program for a patient with COPD, RTs would provide one-on-one counseling for tobacco cessation education (if the patient continued to use these products); discuss pulmonary rehabilitation that included exercise as well as strength and endurance training; and recognize and manage an acute situation and appropriate medication. The RT would work with the patient to establish personal goals, including changing the person’s behaviors and reducing the risks associated with the chronic disease.

Implications for the Respiratory Therapist

Because the RT is able to function as both an individual counselor and a public health advocate, depending on the setting or circumstances, it is useful to examine the most likely settings in which the RT’s health promotion and disease prevention knowledge can be put to good use.

Health Care Institutions

Health care institutions in which RTs provide both health education and promotion include inpatient facilities (e.g., hospitals, skilled nursing facilities) as well as ambulatory care centers (e.g., physicians’ offices, clinics, health insurance organizations). RTs may participate in wellness programs for staff and patients that are aimed at improving cardiopulmonary wellness through exercise (e.g., pulmonary rehabilitation, asthma management education programs).

Work Site

Healthier workers are absent from work less often; they are also more satisfied with their jobs and more productive. This all translates into a more cost-effective workplace. RTs may find themselves involved in work-site wellness by participating in the following: (1) performing pulmonary function or blood pressure screenings; (2) developing and implementing stress management or nicotine intervention programs; and (3) consulting on policies related to smoking and occupational or environmental exposure to foreign dusts (e.g., silica, asbestos) or noxious fumes (e.g., smog).

Home

Home health care continues to be a rapidly growing segment of the health care industry. It has been proved repeatedly to be more cost-effective than hospital care. RTs can perform a wide variety of services in the patient’s home, including oxygen therapy and mechanical ventilation on either a temporary or long-term basis. Generally the focus is on tertiary prevention (i.e., preventing further decline). Patient education is of primary importance in the home in so that the patient may become as self-reliant as possible (see Chapters 50 and 51).

Community

Most of the health promotion activities described earlier pertain to the individual. At the community level, the focus is on the group. Community health promotion activities provided by the RT may include the following: pulmonary function screening at health fairs, smoking cessation programs, family asthma management education programs, and COPD (i.e., better breathing) support groups. RTs, who are certified in basic cardiac life support instruction, may also volunteer to perform certification in this practice for various groups.

Educational Institutions

Because many unhealthy behaviors begin during early childhood or adolescence, elementary, middle, and secondary schools are excellent places to begin health education activities. Education about smoking is one example.

Cigarette smoking is a primary risk factor that is associated with many of today’s leading causes of death. Because most smoking begins during late childhood or early adolescence, schools provide the best setting in which to educate children about the dangers of tobacco. RTs are trained to provide these educational experiences. It is never too early to begin sending the antismoking message.

Summary Checklist

• Patient education and general approaches to health promotion are key issues in health care today.

• Educators should use learning objectives to direct teaching strategies toward individuals or large groups of patients.

• Learning objectives call for the use of an action verb to define the performance that is expected of the patient at the end of instruction.

• Learning occurs in three domains: cognitive (knowledge), psychomotor (skills), and affective (attitudes).

• Patients tend to learn by doing. Passive participation usually does not cause a change in behavior.

• Evaluate the cognitive domain objectives with written tests. Evaluate psychomotor and affective domain objectives with a skills checklist.

• The clinician should evaluate his or her teaching in an effort to improve.

• The RT can have an impact on several areas of health education and health promotion, including tobacco cessation programs, asthma education programs, and community health screenings.

• RTs can be a key player involved in disease management programs because of their understanding of the manifestations of the chronic cardiopulmonary diseases and their abilities to teach patients self-management with the use of the patient education tools discussed in this chapter.