Basic learning principles
Understanding each learning domain prepares the nurse to apply the basic principles of learning to any teaching method. The client’s willingness to become involved in learning is influenced by previous knowledge, attitudes and sociocultural factors.
If a learning ability is impaired, such as when a client is in pain, the nurse should postpone teaching activities or modify teaching strategies to better meet the needs of the learner. The nurse might also need to manipulate environmental conditions to facilitate learning. This can be particularly challenging for a nurse in a busy healthcare setting where the environment is noisy; the nurse might need to modify conditions by shutting the door, turning off the television or even finding an office or a quiet area in which to enhance learning.
Motivation to learn
Attentional set
An attentional set is the mental state that allows the learner to focus on and comprehend the material. Before learning anything, clients must be able to give attention to, or concentrate on, the information that is to be learned.
Physical discomfort, anxiety and environmental distractions can influence this ability to attend and concentrate on the information or skill to be learned. The nurse therefore must determine the client’s level of comfort and energy before beginning a teaching plan, and ensure that the client’s anxiety is alleviated.
Anxiety may increase or decrease the ability of a person to pay attention. Anxiety is uneasiness or uncertainty resulting from anticipating a threat or danger. When faced with change or the need to act differently, a person feels anxious. Learning might require a change in behaviour and thus produce anxiety. A mild level of anxiety may motivate learning; however, a high level of anxiety prevents learning from occurring. It incapacitates a person, creating an inability to attend to anything other than efforts to relieve the anxiety. Non-verbal cues can also reveal that a client is not ready to learn.
Motivation
Motivation is a force that acts on or within a person (e.g. an idea, an emotion or a physical need) which causes the person to behave in a particular way (Redman, 2007). If a person does not want to learn, it is unlikely that learning will occur. The client’s motivation to learn must therefore be assessed before an educative process begins, to ensure the client is ready to learn.
Motivation may result from a social, task mastery or physical motive; such motives stimulate a person to learn. Social motives are a need for connection, social approval or self-esteem. People normally seek out others with whom they can compare opinions, abilities and emotions. For example, new parents often seek validation of ideas and parenting techniques from others whom they have identified as role models.
Task mastery motives are based on needs such as achievement and competence. For example, for a high school student with diabetes wanting to establish their independence, the ability to successfully manage their own diabetes provides the motivation to master the task or skill. After a person succeeds at a task, the person is usually motivated to achieve more.
Often, motives are physical; a client with a physical change in function may be motivated to learn to regain or accept and modify their life according to that loss of function.
Unless there are motivating factors, not all people will be receptive to health promotion education. An obese client may continue to refuse to follow dietary advice to reduce their weight, or a smoker may continue to smoke even though they are aware of the potential dangers to their health. Likewise, no therapy will have an effect unless a person is motivated by the belief that following the treatment regimen is important to their health. When discussing a client’s conformity to a prescribed course of therapy, the term ‘compliance’ is often used. This term has often been criticised in the past as seeming paternalistic or coercive. The term adherence is a more positive descriptor to use, as it implies choice on the part of the client (Bennett and others, 2011). The nurse must therefore assess the client’s motivation to learn, and then what the client needs to know in order to assist them to adhere to the prescribed therapy. The nurse must also determine and apply interventions that might stimulate learning and positive behaviour changes.
Use of theory to enhance motivation and learning
Nurses employ various interventions, based on theory, when developing client education plans. For a plan to be successful, the client’s ideals, beliefs and motivating factors must be assessed and integrated into the plan.
Client education is a complex process and is supported by a variety of theoretical paradigms. Applying a theory that matches the client’s need helps the nurse provide effective client education. Bandura (1997) remains the principal author on social learning theory. Social learning theory provides one of the most useful approaches to client education because it explains the characteristics of the learner and guides the educator in developing effective teaching interventions that result in enhanced learning and improved motivation (Bandura, 1997).
According to social learning theory, people continuously attempt to control events that affect their lives. This allows people to attain desired outcomes and avoid undesired outcomes, resulting in improved motivation. Self-efficacy, a concept included in social learning theory, refers to a person’s perceived ability to successfully complete a task. When people believe that they can execute a particular behaviour, they are more likely to actually perform the behaviour consistently and correctly. Personal efficacy beliefs influence how much effort is expended in controlling a situation, how long people will try to overcome obstacles in the face of adversity, how people cope with demands, and the outcomes people attain (Bandura, 1997).
Self-efficacy beliefs arise from four sources: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states (Bandura, 1997). Enactive mastery experiences refer to the client’s perceived ability to successfully complete a desired behaviour. For example, the confidence of an older adult client learning to prepare low-fat meals is enhanced as the client successfully prepares meals that are low in fat and taste good. Actually performing a behaviour provides the greatest source of efficacy beliefs.
Vicarious experiences are gained through modelling someone else’s behaviour. For example, the older adult client learning how to prepare low-fat meals models techniques learned from the nurse during the cooking class. This is especially important for those who are learning new skills or behaviours.
Verbal persuasion occurs when significant others express faith in one’s capabilities. Providing verbal encouragement often improves a client’s self-efficacy. For example, the nurse provides positive reinforcement as the client describes low-fat ingredients used when preparing meals.
Finally, physiological and affective states also affect self-efficacy. If a client perceives physiological and/or emotional improvement as a result of a desired behaviour, perceived levels of self-efficacy will improve. For example, the client who believes that a diet low in fat will lead to a healthier life will be more likely to change behaviours than one who does not believe in the benefits of such a diet.
Understanding the four sources of self-efficacy allows nurses to develop interventions that will improve clients’ abilities to adopt healthy behaviours. For example, a nurse wishing to teach a child recently diagnosed with asthma to correctly use an inhaler expresses personal belief in the child’s ability to use the inhaler (verbal persuasion). Then the nurse demonstrates how to use the inhaler (vicarious experience). Once the demonstration is complete, the child uses the inhaler (enactive mastery experience). As the child’s wheezing and anxiety decrease after the correct use of the inhaler, the child experiences positive feedback, further enhancing the child’s confidence to use the inhaler (physiological and affective states). Interventions such as these enhance perceived self-efficacy, which in turn improves the achievement of desired outcomes. As a result of the positive outcomes associated with self-efficacy, other health behaviour theorists have included self-efficacy in their theories. Health behaviour theories that do not include self-efficacy as a concept often have difficulty predicting the adoption of healthy behaviours (Bandura, 1997).
Psychosocial adaptation to illness
A temporary or permanent loss of health may be difficult for a client to accept. The process of grieving provides clients with the time to adapt psychologically to the emotional and physical implications of illness. The stages of grieving (see Chapter 25) encompass a series of responses that a client may experience during an illness. Individuals experience each stage differently depending on their self-concept before the illness, the severity of their illness and the changes in lifestyle that the illness creates. Nursing care should be implemented to support the client through the grieving process.
Readiness to learn is significantly related to the stage of grieving (see Table 13-2). Clients cannot learn when they are unwilling or unable to accept the reality of illness. Teaching therefore needs to be properly timed to help facilitate a client’s adjustment to illness or disability.
When the nurse identifies that the client enters the stage of acceptance—the stage compatible with learning—the nurse introduces a teaching plan. Ongoing assessment of the client determines whether the client remains in a stage conducive to learning.
Active participation
A client’s involvement in learning implies an eagerness to acquire knowledge or skills. Active participation also improves the opportunity for the client to make informed decisions following teaching sessions. For example, to manage their chronic condition, a client with a diagnosis of asthma learns to monitor their peak expiry flows and the effect of their salbutamol when used. The nurse can assist the client by providing education on peak flow technique, managing and administering their salbutamol inhaler and lifestyle modifications, to reduce the risk of an asthma attack.
Ability to learn
Developmental capability
Cognitive development influences the client’s ability to learn. A nurse must therefore incorporate an assessment of the client’s intellectual abilities to ensure that the teaching plan is realistic and the goals achievable. Assessing the client’s literacy and numeracy skills is also important if the nurse is going to rely on providing written material as an educational tool. Understanding and following the directions on a medication label or in a teaching booklet, for example, require clients to have adequate reading and comprehension skills to prevent them not adhering to the regimen properly or, worse, harming themselves.
A requisite level of maturation and cognitive development must exist before an individual is capable of learning new information. It is wrong to assume that a client has a certain level of knowledge; instead, the nurse assesses the client’s level of knowledge. Learning occurs more readily when new information complements existing knowledge.
Learning in children
The capability for learning and the type of learning behaviours that can be acquired depend on the child’s maturation level. Without proper biological, motor, language and personal–social development, many types of learning cannot take place. Learning can occur in children of all ages, and as the child matures intellectual growth moves from the concrete to the abstract. Information presented to children therefore must be understandable, and the expected outcomes must be realistic, based on the child’s developmental stage (see Table 13-3). Teaching aids that are developmentally appropriate should also be used to assist in their learning (see Figure 13-1).
TABLE 13-3 DEVELOPMENTAL CAPACITIES FOR LEARNING
| LEARNING CAPACITY | TEACHING METHODS |
|---|---|
| INFANT | |
| TODDLER | |
| PRESCHOOLER | |
| SCHOOL-AGE CHILD | |
| ADOLESCENT | |
| YOUNG OR MIDDLE-AGED ADULT | |
| OLDER ADULT | |
|
Teach when client is alert and rested Involve adult in discussion or activity Focus on wellness and the person’s strength Use approaches that enhance sensorially impaired client’s reception of stimuli (see Chapter 26) |
|
FIGURE 13-1 The nurse uses developmentally appropriate food models to teach healthy eating behaviours to the school-age child.
Image: iStockphoto/Chris Fertnig.
Susan, the manager of a preschool, has noticed that many of the children in the preschool are missing days because of illness. Susan says, ‘These kids always seem to be sick. They seem to get the same thing over and over again.’ The teachers at the preschool have asked Susan to contact you to educate the 3- and 4-year-olds about the need to use tissues and about proper hand-washing, in the hope of keeping the children healthier. What teaching methods would you use with these children?
Adult learning
Teaching adults differs from teaching children: because adults become independent and self-directed as they mature, they are often able to identify their own learning needs. These learning needs arise out of problems or tasks that result from real-life situations. The amount of information that can be provided and learned and the amount of time that can be spent with the adult client varies depending on the client’s personal situation and readiness to learn. Adult learners are self-directed and wish to be viewed as self-directed (McMillan and others, 2007). Needs or issues that are perceived as extremely important to the adult, however, must be resolved before learning can occur.
Adults have a wide variety of personal and life experiences to draw on. This also applies to the nurse, whose experiences in teaching and learning as a student, ongoing reflective practice, and views on health education inform their own nursing practice. Educational topics and goals therefore need to be developed in collaboration with adults, as they are ultimately responsible for changing their own behaviour. For the RN, assessing an adult client’s current knowledge base assists in defining what the client wants to know. In addition, assessing the ways the adult learns helps in the formulation of a teaching strategy for each client.
Physical capability
The ability to learn depends on the client’s level of coordination and sensory acuity, which relates to their physical development and overall physical health. It would be pointless, for example, to teach a client to transfer from a bed to a wheelchair if the client has insufficient upper body strength. The nurse must make an appropriate assessment of the client’s physical capabilities so as not to overestimate the client’s physical development or status. The following physical attributes are required to learn psychomotor skills:
• size—height and weight match the task to perform or the equipment to use, for example crutches
• strength—ability of the client to follow a strenuous exercise program
• coordination—dexterity needed for complicated motor skills, such as using utensils or changing a bandage
• sensory acuity—visual, auditory, tactile, gustatory and olfactory; sensory resources needed to receive and respond to messages taught.
Any condition (e.g. pain) that depletes a person’s energy will also impair their ability to learn. Following a morning undergoing rigorous diagnostic testing, a client is unlikely to be capable of the effort needed to participate in an education session. Teaching sessions should therefore be postponed until the conditions for learning are optimal. The nurse’s ongoing assessment of the client and their ability to continue will also determine whether or not they may need to halt the teaching session temporarily.
Learning environment
The physical environment where teaching takes place should help the client focus on the learning task. The number of people being taught, the need for privacy, room temperature, room lighting, noise, room ventilation and room furniture are important factors when choosing the setting.
The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture and a comfortable temperature (see Figure 13-2). Good light adds to the client’s ability to watch the nurse’s actions, especially when demonstrating a skill or using visual aids such as posters or pamphlets. Comfortable furniture and appropriate room temperature also help eliminate distractions, such as the need to change position or shift bodyweight.
FIGURE 13-2 Choosing comfortable, pleasant environments enhances the learning experience.
Image: Beau Lark/Corbis.
It is also important to choose a quiet setting which offers privacy, whether in the healthcare facility or in the client’s home. The nurse can provide privacy, even in a busy hospital, by closing cubicle curtains or taking the client to a quiet area. If the client so desires, family members or significant others may also share in discussions.
Teaching a group of clients requires a room that allows for everyone to be seated comfortably and within hearing distance of the teacher. The size of the room should not overwhelm the group or tempt participants to sit outside the group along the room’s perimeter. Arranging the seating to allow participants to observe one another can also enhance learning. More-effective communication is possible if participants can observe each others’ verbal and non-verbal interactions.
INTEGRATING THE NURSING AND TEACHING PROCESSES
A relationship exists between the nursing and teaching processes. With the nursing process, a thorough assessment reveals the client’s healthcare needs. The nursing diagnoses identified are individualised to the client’s unique needs. A care plan is individualised, prescribing nursing therapies designed to improve or maintain the client’s level of health. Evaluation determines the level of success in meeting goals of care.
While assessing a client’s nursing care needs, the nurse also identifies the need for education. When education becomes a part of the care plan, the teaching process begins. Like the nursing process, the teaching process requires assessment; in this case, analysing the client’s needs, motivation and ability to learn (see Table 13-4). A diagnostic statement specifies the information or skills that the client requires. The nurse sets specific learning objectives and implements the teaching plan using teaching and learning principles to ensure that the client acquires knowledge and skills. Finally, the teaching process requires an evaluation of learning based on the learning objectives.
TABLE 13-4 COMPARISON OF THE NURSING AND TEACHING PROCESSES
| BASIC STEPS | NURSING PROCESS | TEACHING PROCESS |
|---|---|---|
| Assessment | Collect data about client’s physical, psychological, social, cultural, developmental and spiritual needs from client, family, diagnostic tests, medical record, nursing history and literature | Gather data about client’s learning needs, motivation, ability to learn and teaching resources from client, family, learning environment, medical record, nursing history and literature |
| Nursing diagnosis | Identify appropriate nursing diagnoses based on assessment findings | Identify client’s learning needs on basis of three domains of learning |
| Planning | Develop individualised care plan. Set diagnosis priorities based on client’s immediate needs. Collaborate with client on care plan | Establish learning objectives, stated in behavioural terms. Identify priorities regarding learning needs. Collaborate with client on teaching plan. Identify type of teaching method to use |
| Implementation | Perform nursing care therapies. Include client as active participant in care. Involve family/significant other in care as appropriate | Implement teaching methods. Actively involve client in learning activities. Include family/significant other participation as appropriate |
| Evaluation | Identify success in meeting desired outcomes and goals of nursing care. Alter interventions as indicated when goals are not met | Determine outcomes of teaching–learning process. Measure client’s ability to achieve learning objectives. Reinforce information as needed |
Though similar, the nursing and teaching processes are not entirely the same. The nursing process requires assessment of all sources of data to determine a client’s total healthcare needs. The teaching process focuses on the client’s learning needs and willingness and capability to learn. Table 13-4 compares the teaching and nursing processes.
ASSESSMENT
Success in teaching a client requires the nurse to assess all factors influencing relevant content, the client’s ability to learn and the resources available for instruction. Learning needs, identified by both the client and the nurse, determine the choice of teaching content tailored to those needs.
Expectations of learning
Clients have the ability to identify learning needs in response to the implications of living with their illness. To meet these learning needs, the nurse assesses and identifies what information clients perceive as necessary in many ways, for example by listening to questions raised by the client or family about their health issues. The client is likely to be more receptive to any information presented to them when they have a need to know something.
Nurses also use assessment tools to determine the perceived learning needs of clients. Assessment tools are available within healthcare environments and are designed to assist the nurse to ask specific questions to measure needs. After having clients respond to the questions on the tool, the nurse identifies the perceived learning needs of the clients and the perceived importance of each need. Using an assessment tool provides an efficient way for nurses to determine appropriate information to share with their clients.
Learning needs
In addition to the perceived learning needs of the client, the nurse determines the information that is critical for the client to learn. Learning needs change, depending on the client’s current health status. Because a client’s health status is dynamic, assessment is an ongoing activity. The nurse assesses the following:
• the client’s level of understanding of current health status, implications of illness, types of therapy, and prognosis—including the source of information. This information helps determine a client’s perception of the threat of illness and its effect on lifestyle
• the information or skills needed by the client to perform self-care and to understand the implications of a health problem
• the client’s experiences that influence the need to learn—for example, a woman pregnant for the third time is more likely to be familiar with the implications of pregnancy than a woman pregnant for the first time
• information that family members or significant others require to support the client’s needs.
Motivation to learn
The nurse asks questions that define the client’s motivation. These questions help to determine whether the client is prepared and willing to learn. Although a client may have a variety of learning needs, a lack of motivation seriously threatens the success of the teaching plan. The nurse assesses the following motivational factors:
• client’s behaviour, for example attention span, tendency to ask questions, memory, ability to concentrate during the teaching session
• client’s health beliefs and perception of the severity of and susceptibility to a health problem, and the benefits and barriers to treatment
• client’s perceived ability to complete a required health behaviour
• client’s attitudes about healthcare providers, for example role of client and nurse in making decisions; mutually set goals are more likely to be achieved by the client
• client’s knowledge of information to be learned—the client must play an active role in seeking health-based information
• pain, fatigue, anxiety or other physical symptoms that can interfere with the ability to maintain attention and participate—in acute care settings, a client’s physical condition can easily detract from learning
• client’s sociocultural background—sociocultural norms or tradition (see Chapter 17) may influence a client’s beliefs and values about health and various therapies
• client’s learning style preference—when various options are available for learning (e.g. brochures, videotape, discussion), a client may perceive one approach as being more interesting.
Ability to learn
The nurse determines the client’s physical and cognitive levels. Healthcare providers may underestimate the client’s cognitive deficits. Many factors might impair the ability to learn, including body temperature, electrolyte levels, oxygenation status and blood glucose level. In any healthcare setting, several of these factors may influence a client at any one time. The nurse assesses the following factors related to the client’s ability to learn:
• physical strength, movement and coordination—the nurse determines the extent to which the client can perform skills
• sensory deficits that may affect the client’s ability to understand or follow instruction
• client’s reading level—this can be difficult to assess, because a functionally illiterate client is often able to conceal it by using excuses such as not having the time or not being able to see; to assess the client’s reading level and level of understanding, the nurse asks a client to read instructions from a teaching brochure and then explain their meaning
• client’s developmental level—this influences the approaches chosen by the nurse during teaching (see Table 13-3)
• client’s cognitive function, including memory, knowledge, association and judgment.
Teaching environment
The environment for a teaching session must be conducive to learning. The nurse assesses the following factors when seeking a place to teach clients:
Resources for learning
In some situations the client may require the support of family members or significant others. In these cases the nurse must also assess the readiness and ability of family and friends to learn the information necessary for the care of the client. The nurse also needs to gain an understanding of the client’s home environment as part of a comprehensive assessment. Assessment of resources will also include a review of any teaching tools available for the client. The nurse assesses the following resources for learning:
• family members’ perceptions and understanding of the client’s illness and its implications—family members’ perceptions should match those of the client, otherwise conflicts may arise in the teaching plan
• client’s willingness and consent to have family members and significant others involved in the teaching plan and to provide care—information about the client’s healthcare is confidential unless the client chooses to share it; sometimes it is difficult for the client to accept the help of family members, especially when bodily functions are involved
• family’s or significant other’s willingness to participate in providing care—if the client chooses to share information regarding their health status with family members, the family members must be assessed for their abilities and willingness to participate in care of the client; not all family members may be responsible, willing or able enough to assist in care
• resources within the home—these include people willing to assist the client with procedures, such as bathing or taking medications; financial or material resources; the ability to obtain healthcare equipment; and architectural resources, such as adapting rooms, doorways or stairways and installing ramps, etc.
• teaching tools, including brochures, audiovisual materials and posters—printed material should present current information that is written clearly and logically and matches the client’s reading level. The nurse should also assess the client’s comprehension to ensure that they are able to understand information that they are provided with to read.
NURSING DIAGNOSIS
After assessing information related to the client’s ability and need to learn, the nurse interprets data and clusters defining characteristics to form diagnoses that reflect the client’s specific learning needs (see Box 13-2). This ensures that teaching will be goal-directed and individualised. If a client has several learning needs, nursing diagnoses allow for priority setting (see Box 13-3).
BOX 13-2SAMPLE NURSING DIAGNOSTIC PROCESS
| LEARNING NEEDS | ||
|---|---|---|
| ASSESSMENT ACTIVITIES | DEFINING CHARACTERISTICS | NURSING DIAGNOSIS |
| Have client describe what has been explained about planned surgery | Knowledge deficit (cognitive) regarding impending surgery related to lack of exposure and recall and misinterpretation of information | |
| Observe verbal and non-verbal response to discussion | ||
| Review medical record for past history of surgery | Has not had any surgery in the past | |
| Have client describe how to walk with crutches | Knowledge deficit (psychomotor) regarding use of crutches related to lack of exposure | |
| Have client demonstrate three-point crutch walking on level surfaces and up stairs |
Knowledge deficit (affective, cognitive, psychomotor)
Management of therapeutic regimen, community: ineffective
Management of therapeutic regimen, families: ineffective
Kay, a 50-year-old nurse, has recently had a myocardial infarction (heart attack). Her medical history reflects that she has a family history of heart disease and has had hypertension and high serum cholesterol levels for 15 years. She reports eating a diet high in fat and says that she does not exercise regularly. Kay experienced chest pain for 2 days that worsened with activity before she sought medical attention. She says, ‘The reason I can’t change my diet is that my husband won’t eat low-fat food, and I had a heart attack because I have been worried about my husband’s health.’ List your teaching priorities for this client.
Several nursing diagnoses apply to learning needs. Each diagnostic statement describes the specific type of learning need and its cause. Classifying diagnoses by the three learning domains helps the nurse to focus specifically on subject matter and teaching methods.
Some healthcare problems can be managed, minimised or eliminated through application of skills learned through an educative process. In these situations, the related factor of the diagnostic statement is knowledge deficit. For example, an older adult client may have difficulty managing a medication regimen because of the number of medications that must be taken at different times of the day. In this case, educating the client about the medications may improve the client’s ability to schedule and take the medications as directed.
Some nursing diagnoses also indicate that teaching may be inappropriate. The nurse may identify conditions that cause barriers to effective learning (e.g. nursing diagnosis of pain or activity intolerance). In these cases, the nurse delays teaching until the client is able to participate effectively in the learning program.
PLANNING
After determining the nursing diagnoses that identify a client’s learning needs, the nurse, in negotiation with the client, develops a teaching plan. Together they determine appropriate goals and expected outcomes. This process involves the client in selecting learning experiences (see Sample nursing care plan). Expected outcomes (or learning objectives) guide the choice of teaching strategies and approaches with a client. Engaging clients in the planning process helps in the development of a relevant and meaningful teaching plan.
Developing learning objectives
The first step in forming a teaching plan is developing learning objectives. A learning objective identifies the expected outcome of a planned learning experience and helps establish priorities for learning. Despite all planning, a particular instructional session often leads to unanticipated learning. It may be difficult to anticipate all the objectives for a teaching session. Objectives ensure that a teacher plans the teaching sessions so that time is maximised and the best resources are made available for learning.
Objectives can be either short-term or long-term in nature. Short-term objectives relate to the client’s immediate learning needs, such as understanding that during an MRI scan the knocking noise the client hears is a normal sound for the scanner to make. Long-term objectives relate to acquisition of the knowledge and skills that are needed to permanently adapt to a health problem (e.g. learning to plan a diet within restrictions caused by ulcerative colitis). Like a goal of care, a long-term objective is usually all-encompassing. Short-term objectives can be compared with outcomes of care.
The objectives established by the nurse and client guide the teaching plan. Poorly determined objectives can create confusion throughout the teaching–learning process. Thus, a learning objective includes the same criteria as outcomes in a nursing care plan (see Chapter 7), including the following:
CLIENT EDUCATION
ASSESSMENT*
As Nancy is preparing Mr Holland for his colon resection, which is scheduled in 1 week, she begins to assess his knowledge of the surgery, why he is having it, and what he can expect postoperatively. Mr Holland’s medical record reflects that he spoke with his doctor and scheduled the surgery 2 weeks ago. Mr Holland reports that he has had Crohn’s disease for 15 years. Although he has a good understanding of his illness and states why he must have the surgery, he cannot remember all that the doctor told him about his surgery. He is extremely anxious, gets teary eyed and asks many questions about what will happen to him after the surgery. He is unable to verbalise how to cough and deep-breathe or the importance of activity postoperatively.
NURSING DIAGNOSIS: Knowledge deficit (cognitive) regarding implications of surgery and postoperative care related to lack of recall and exposure to information.
| GOALS | EXPECTED OUTCOMES |
|---|---|
| Mr Holland will describe preoperative care by 12/10. | Mr Holland will verbalise preoperative care planned for the day before surgery by 12/10, including expected laboratory tests, visit by surgeon and anaesthetist, time of surgery and how his significant others will be notified of his progress through surgery. |
| Mr Holland will participate in preoperative and postoperative surgical care procedures during hospitalisation. |
| INTERVENTIONS† | RATIONALE |
|---|---|
| Learning readiness enhancement | |
|
• Determine readiness to learn and learning needs. Conduct the pre-op interview in an appropriate room. • Describe anticipated preoperative routine, including what laboratory tests will be drawn, who will speak to him before surgery, when the surgery is scheduled to occur, how his family will be notified during surgery, anticipated bowel preparation and the need to be NBM after midnight. |
Mr Holland must demonstrate readiness to learn, and information presented must be perceived as important, for the adult to learn effectively (McMillan and others, 2007). |
| Learning facilitation | |
| Early timing and reinforcement of preoperative teaching may improve knowledge of surgery routines, facilitate return to preoperative activity levels and enhance client satisfaction (Aldridge, 2004). | |
|
• Explain, demonstrate and have client perform return demonstration of coughing and deep-breathing, and range-of-motion exercises. • Describe anticipated postoperative care with rationale, including pain management, use of NG tube and progression of diet. Allow client to see and touch NG tube and patient-controlled analgesia pump. |
Improving self-efficacy by using role modelling and having the client perform behaviours enhances healthy behaviours (Bandura, 1997). Providing structured education about postoperative procedures and allowing clients to see and touch equipment before surgery enhances learning and decreases anxiety. Recognising the need for postoperative care and its positive outcomes has the potential to improve the client’s adherence to a treatment regimen postoperatively. |
| Task persistence and learning information over time will enhance the client’s understanding of information (McMillan and others, 2007). |
†Intervention classification labels from McCloskey JC, Bulechek GM 2000 Nursing interventions classification (NIC), ed 3. St Louis, Mosby.
Have Mr Holland describe what to expect before and after surgery.
Observe Mr Holland as he demonstrates coughing and deep-breathing, and range-of-motion exercises.
Assess Mr Holland’s level of pain and progression of activity level and diet postoperatively.
Observe Mr Holland’s verbal and non-verbal behaviour before and after surgery.
*Defining characteristics are shown in bold type.
Each objective is a statement of a singular behaviour that identifies the learner’s ability to do something after a learning experience. A behavioural objective contains an active verb, describing what the learner will do after the objective is met, such as ‘will empty colostomy bag’, ‘will administer an injection’ or ‘will verbalise drug dosages’. The verb should be clear and concise, and describe the outcome desired and how it will be demonstrated following the education process (e.g. verbalise, demonstrate, identify, describe, label, classify or select). Singular behaviours are also easier to evaluate at the end of instruction.
Behavioural objectives are measurable and observable and indicate how learning will be evidenced (e.g. ‘will perform three-point crutch gait’ or ‘will prepare foods without using salt’). The objective describes precise behaviours and content. An example of a vague or non-specific objective might be ‘will be familiar with chronic renal failure’. This example does not explain what the learner is to do, and it raises questions about how the behaviour can be measured. If content is missing, the objective cannot guide teaching and learning. The precise behaviours and content set the standard for feedback that reflects learning and form the basis for evaluation of the teaching plan.
An objective is more precise when it describes the conditions or timing under which the behaviour occurs. Conditions or timeframes should be realistic and designed for the learner’s needs (e.g. ‘will identify the side effects of warfarin by discharge’). It also helps to consider conditions under which the client or family will typically perform the learning behaviour (e.g. ‘will walk from bedroom to bathroom using crutches’). The criteria for acceptable performance set a standard by which achievement of objectives is measured. A teacher sets criteria on the basis of a desired level of accuracy, success or satisfaction. For example, a client undergoing therapy for a fractured leg will ‘walk on crutches to the end of the hall within 3 days’. Criteria are more acceptable when they are mutually established by the teacher and the learner. However, the nurse serves as a resource in setting the minimum criteria for success. Criteria on which the client and nurse agree help define the expected behaviours and the quality of performance. The client also uses these criteria for self-evaluation, which is a powerful motivator of behaviour.
After formulating objectives, the nurse and client work to establish a teaching plan. During planning, the nurse integrates basic teaching principles and develops a well-timed, organised teaching plan.
Integrating basic teaching principles
Teaching priorities should reflect the priorities of the nursing diagnoses. When developing a teaching plan, the nurse considers the principles that improve its effectiveness. The realm of teaching deals with teachers’ behaviour, the reason teachers behave the way they do and effects of their behaviour on learners. There is no single correct way to teach, since each learning situation determines the best way to teach. The principles of teaching are, in effect, techniques that incorporate the principles of learning.
Setting priorities
Priorities for teaching are based on the client’s immediate needs, nursing diagnoses and the learning objectives established for the client. Priorities also depend on what the client perceives to be most important, the client’s anxiety level and the amount of time available to teach. A client’s learning needs must be set in order of priority to conserve the time and energy of the client and the nurse. For example, a client recently diagnosed with coronary artery disease has a knowledge deficit related to the new illness and its implications. The client will benefit most by first learning about the correct way to manage their chest pain and how long to wait before calling for an ambulance if it occurs. Once these needs related to basic survival are met, then other topics, such as exercise and nutritional changes, can be discussed.
Timing
When is the right time to teach? Before a client enters a hospital? When a client first enters a clinic, or at discharge, or at home? Each may be appropriate, because clients continue to have learning needs and opportunities as long as they stay in the healthcare system. The nurse should plan teaching activities for a time when the client is most attentive, receptive and alert. The client’s activities should be organised to provide time for rest and teaching–learning interactions.
Timing can be difficult because emphasis is sometimes placed on a client’s early discharge from a hospital. For example, it may take several days after surgery for a client to become free of discomfort so that attention can be given to learning. By the time the client feels ready to learn, their discharge may have already been scheduled. Therefore, nurses need to anticipate educational needs of clients before they occur. For example, a client scheduled to have a hip replacement receives information about what to expect during and after the surgery the week before admission. Anticipating a client’s educational needs can improve the client’s outcomes.
The duration of teaching sessions also influences learning ability. Prolonged sessions cause concentration and attention to decrease. Frequent sessions lasting 20 minutes are more easily tolerated and retain the client’s interest in the material. However, factors such as shorter hospital stays and lack of health insurance reimbursement for outpatient education sessions may necessitate longer teaching sessions. The nurse assesses a client’s loss of concentration by observing for non-verbal cues, such as poor eye contact or slumped posture. After loss of concentration is noted, the session should be stopped. On the other hand, teaching sessions should not be too brief, as the client needs time to comprehend the information provided or to ask questions and to give feedback.
Teaching sessions should be held frequently enough to document the client’s learning. The frequency of sessions depends on the learner’s abilities and the complexity of the material. A child newly diagnosed with diabetes, for example, may require more visits to an outpatient centre than the elderly client who has had diabetes for 15 years and who lives in a nursing home. Intervals between teaching sessions should not be so long that the client might forget information previously provided to them. For a client discharged from a hospital, the home health or community nurses must reinforce learning and be aware of the education strategy set in motion.
Organising teaching material
A good teacher gives careful consideration to the order of information presented. An outline of content helps organise information into a logical sequence. Material should progress from simple to complex ideas because a person must learn the simple facts and concepts before learning how to make associations or complex interpretations of ideas. For example, to teach a woman how to feed her husband who has a percutaneous endoscopic gastric tube, the nurse first teaches her how to wash her hands and then assess the correct position of the tube. Once this is accomplished, the process of teaching the wife how to administer the feed can occur.
The nurse begins any instruction with essential content. Clients are more likely to remember information that is taught at the beginning of a teaching session. For example, after surgical removal and postsurgical treatment of a malignant breast tumour, the chance for cancer recurrence makes learning the signs of metastasised breast cancer crucial. The nurse starts with essential information and then completes a teaching session with informative but less-critical content. Key points should be summarised. Repetition also reinforces learning.
Maintaining learning attention and participation
Active participation is the key to learning. Individuals learn better when more than one of the body’s senses is stimulated. Audiovisual aids and role-playing are good teaching strategies. By actively experiencing a learning event, the person will be more likely to retain the knowledge gained.
A teacher’s actions can also increase learner attention and interest. When conducting a discussion with a learner, the teacher should stay active by changing the tone and intensity of their voice, making eye contact and using gestures that accentuate key points of discussion. An effective teacher often uses as much energy as the learner, talking and moving among a group rather than remaining stationary behind a lectern or table. A learner remains interested in a teacher who is actively enthusiastic about the subject under discussion.
Building on existing knowledge
A client learns best on the basis of pre-existing cognitive abilities and knowledge, which can be obtained from a wide variety of sources including the internet. A teacher is more effective presenting information that builds on a learner’s existing knowledge, as a client quickly loses interest if a nurse begins with familiar information. For example, a client who has lived with multiple sclerosis is beginning a new medication that is given subcutaneously; on assessment, the nurse learns that the client’s father had diabetes and that the client often administered his insulin injections for him. The nurse then individualises the teaching plan for this client by building on the client’s previous knowledge and experience with injections.
Selection of teaching methods
During planning, the nurse chooses appropriate teaching methods and encourages the client to offer suggestions on how they best learn. A teaching method is the way that the teacher delivers information and is based on the client’s learning needs (see Box 13-4). For example, a client with a psychomotor deficit learns best through demonstrations and supervised practice. Discussions, question-and-answer sessions and formal lectures are effective methods for promoting cognitive learning. Clients with intellectual deficits are given the opportunity to explore new ideas, recognise new relationships and apply knowledge to their unique needs. A highly effective method for stimulating affective learning is group discussion. A mixed approach to applying teaching strategies may also be useful, depending on the client and their learning needs.
BOX 13-4 APPROPRIATE TEACHING METHODS BASED ON CLIENTS’ LEARNING NEEDS
COGNITIVE
Discussion (one-on-one or group):
• May involve nurse and one client or nurse with several clients
• Promotes active participation and focuses on topics of interest to client
• Is more formal method of instruction because it is controlled by teacher
• Helps learner acquire new knowledge and gain comprehension
Independent project (computer-assisted instruction often on the internet), field experience:
AFFECTIVE
PSYCHOMOTOR
Demonstration (actual or videos, DVDs, etc.):
• Provides presentation of procedures or skills by nurse
• Permits client to incorporate modelling of nurse’s behaviour
Availability of teaching resources
In managing highly complex cases, the nurse identifies appropriate health education resources within the healthcare system or the community during the planning stage. Resources for client education include diabetes education clinics, cardiac rehabilitation programs, prenatal classes and support groups. When clients receive education and support from these types of resources, the nurse is responsible for providing a referral if necessary, encouraging clients to attend and reinforcing information taught. It is important for the nurse to source resources that are specific to the needs of the client. In some cases teaching resources have been developed that have specialised functions, for example the use of a practice model designed to teach the skill of using a metered dose inhaler for the client with asthma.
Writing teaching plans
In all healthcare settings, nurses should develop written teaching plans for use by colleagues. The teaching plan includes topics for instruction, resources (e.g. equipment, teaching booklets, referrals to special educational programs), recommendations for involving family and objectives of the teaching plan.
A plan should provide continuity of instruction, particularly when several nurses are involved in caring for the client. The more specific the plan, the easier it is for nurses to follow through. To enhance communication among nurses and to avoid duplication, the nurse should know the point at which the last teaching session ended.
IMPLEMENTATION
The successful implementation of a teaching plan depends on the nurse’s ability to critically analyse assessment data when identifying learning needs and developing the teaching plan. The nurse carefully evaluates the learning objectives and determines which teaching and learning principles will most effectively and efficiently help the client meet expected goals and outcomes. Implementation involves believing that each interaction with a client is an opportunity to teach. The nurse maximises opportunities for effective learning and uses a diversified approach to create an active learning environment.
Teaching approaches
A variety of different approaches may be used by nurses, depending on the context in which the education is taking place. Some situations require a teacher to be directive; others may require a non-directive approach. An effective teacher concentrates on the task and uses teaching approaches according to the learner’s needs. A learner’s needs and motives can change over time; the teacher must therefore always be aware of the need to reassess and perhaps modify their teaching approaches.
TELLING
The telling approach is useful when limited information must be taught (e.g. preparing a client for a diagnostic procedure). If a client is highly anxious but it is vital for information to be given, telling can be effective. When using telling, the nurse outlines the task to be done by the client and gives explicit instructions. There is no opportunity for feedback with this method.
SELLING
The selling approach uses two-way communication. The nurse paces instruction based on the client’s response. Specific feedback is given to the client who shows success in learning. For example, the client learns a step-by-step procedure for changing a dressing. The nurse uses information from the client to adapt the teaching approach.
PARTICIPATING
The participating approach involves the nurse and client setting objectives and participating in the learning process together. The client helps decide content, and the nurse guides and counsels the client with pertinent information. In this method, there is opportunity for discussion, feedback, mutual goal-setting, and revision of the teaching plan. For example, a parent caring for a child with leukaemia who is receiving chemotherapy must learn how to care for the child at home and how to recognise problems that need to be reported immediately. The parent and the nurse collaborate on developing an appropriate teaching plan that will facilitate the parent’s learning and the child’s discharge from the hospital. After each teaching session is completed, parent and nurse review the objectives together, determine if the objectives were met and plan what will be covered in the next session.
ENTRUSTING
The entrusting approach gives the client the opportunity to manage self-care. Responsibilities are accepted, and tasks are performed correctly and consistently by the client. The nurse observes the client’s progress and remains available to assist without introducing more new information. For example, a client has been managing their indwelling catheter for 5 years and now has been offered the opportunity to replace their drainage system with a catheter valve. The nurse only needs to instruct the client about the new attachment and its care.
REINFORCING
The principle of reinforcement applies to the process of learning; however, the teacher must often be the source of reinforcement. Reinforcement is using a stimulus that increases the probability of a response. A learner who receives reinforcement before or after a desired learning behaviour is likely to repeat the behaviour. Feedback is a common form of reinforcement.
Reinforcers can be either positive or negative. Positive reinforcement, such as a smile or spoken approval, produces desired responses. By contrast, the effects of negative reinforcement are less predictable and often undesirable.
Three types of reinforcers are social, material and activity. When a nurse works with a client, most reinforcers are social ones (e.g. smiles, compliments, words of encouragement, physical contact), which are used to acknowledge a learned behaviour. Examples of material reinforcers are food, toys and music. These work best with young children. Activity reinforcers rely on the principle that a person is motivated to engage in an activity if they are promised that after its completion the opportunity to engage in more desirable activity will be available.
Choosing an appropriate reinforcer involves giving careful thought and attention to individual preferences. Observing behaviour often helps reveal the best reinforcer to use. Reinforcers should never be used as threats and are not always effective with every client. A young child responds more to social reinforcers than do older children or adults.
Incorporating teaching with nursing care
Many nurses find that they can teach more effectively while delivering nursing care; for example, the nurse who explains the application of a leg bag drainage system to a client with an indwelling catheter while demonstrating it. An informal, unstructured style relies on the positive therapeutic relationship between nurse and client, which fosters spontaneity in the teaching–learning process. This does not suggest that teaching should occur without a formal plan. When the nurse follows a teaching plan informally, the client feels less pressure to perform and learning becomes more of a shared activity. Teaching during routine care is efficient and cost-effective (see Figure 13-3).
Instructional methods
Instructional methods used depend on the client’s learning needs, the time available for teaching, the setting, the resources available and the nurse’s own comfort level with teaching. Skilled teachers are flexible, altering teaching methods according to learner responses. An experienced teacher uses a variety of techniques and teaching aids. A nurse cannot expect to be an expert educator when first entering nursing practice. Learning to become an effective educator takes time, practice and experience. Therefore, this does not mean that the nurse must have all of the answers; it simply means that clients expect that the nurse will keep them appropriately informed. The nurse can provide an effective teaching plan, keeping it simple and focused on the clients’ needs, using a variety of teaching methods and teaching aids.
ONE-ON-ONE DISCUSSION
Perhaps the most common method of instruction used by a nurse is one-on-one discussion. When teaching a client at the bedside, at the family doctor practice, in the home or in the community setting, the nurse talks directly to the client face to face. Various teaching aids can be used during the discussion, depending on the client’s learning needs. Information is usually given in an informal manner, allowing the client to ask questions or share concerns. The nurse uses unstructured and informal discussion when helping the client understand the implications of illness and ways to cope with health stressors.
GROUP INSTRUCTION
Groups are often an effective way of disseminating health information. Nurses often use groups because they are efficient in terms of resources and frequently offer clients a supportive learning environment.
Group instruction can be offered in a highly formal manner with a structured lecture followed by group discussion. For example, a nurse might teach groups of clients about the warning signs of breast cancer, the health risks of smoking, or the normal development of a fetus. Groups can also be more informal, with the nurse leading the group in a relatively unstructured way. For example, a group of young mothers might be asked to brainstorm what information they need and then the nurses can decide with them on the order of the topics for the sessions. In this situation, the nurse leads the group discussion, reinforcing important information as it arises from the group and tactfully correcting misinformation.
Group discussions allow clients and families to learn from each other as they review common experiences. A productive group discussion helps participants solve problems and arrive at solutions to their health issues. To be an effective group leader, the nurse must be able to guide participation. Acknowledging a look of interest, asking questions and summarising key issues foster group involvement. However, not all clients benefit from group discussions, and sometimes the physical or emotional level of wellness may prohibit participation.
PREPARATORY INSTRUCTION
Clients often face unfamiliar tests or procedures that create significant anxiety. Providing information about procedures helps clients form realistic images of what to anticipate. This is a common expectation of clients in acute care settings because information helps to give them a sense of control. When the experience matches expectations, the client is more likely to attend to the nurse’s future explanations. A nurse gains respect when preparatory explanations prove useful. The nurse uses the following guidelines for giving preparatory explanations.
• Physical sensations during the procedure are described but not evaluated. For example, when inserting an indwelling catheter the nurse will explain to the client that they may feel the need to void.
• The cause of the sensation is described, preventing misinterpretation of the experience. For example, the nurse explains that the catheter makes the client feel this way as it is inserted because it stimulates the nerve endings used to void normally.
• Clients are prepared only for aspects of the experience that have commonly been noticed by other clients. For example, the nurse explains that it is normal for the catheter to irritate the urethra when it is in place.
The client finds comfort in knowing what to expect. The known is less threatening than the unknown.
DEMONSTRATIONS
Demonstrations are useful methods for teaching psychomotor skills such as preparation of a syringe, bathing an infant, walking with crutches or measuring a pulse. The client is able to observe a skill before practising it. Demonstrations are most effective when learners first observe the teacher and then practise the skill in mock or real situations (return demonstrations). Nurses commonly use demonstrations for teaching motor skills to clients; for example, self-injecting enoxaparin to prevent thrombosis.
A demonstration should always be combined with discussion to clarify concepts, techniques and feelings the client may experience. An effective demonstration also requires advanced planning.
• Be sure the learner can easily see the demonstration. Position the learner to provide a clear view of the skill being performed.
• Review the rationale and steps of the procedure.
• Assemble and organise equipment. Be sure that all equipment works.
• Perform each step in sequence while analysing the knowledge and skills involved.
• Determine when explanations are to be given, considering the client’s learning needs.
• Judge proper speed and timing of the demonstration, based on the client’s cognitive abilities and anxiety level.
The nurse demonstrates steps of a skill in the same order in which the client will perform them. The demonstration involves the following:
• performing each step slowly and accurately
• encouraging the client to ask questions so that each step is understood
• explaining the rationale for each step
• allowing the client to observe each step
• allowing the client to handle equipment and practise the skill under supervision.
The client demonstrates the procedure to ensure that learning has occurred. The independent demonstration should occur under the same conditions that will be experienced at home or in the place where the skill is to be performed. For example, if a client is learning to walk with crutches, the nurse simulates the home environment. If short, narrow steps lead to the client’s bedroom, the client should learn to climb similar stairs in the hospital.
ANALOGIES
Learning occurs when a teacher translates complex language or ideas into words or concepts that the client understands. In addition, the client benefits by integrating new information into daily routines. Analogies are used to help clarify and explain difficult concepts by making them contextual to the client’s life experience. For example, when explaining arterial blood pressure, an analogy would be the flow of water through a hose. To use analogies, the nurse uses the following general principles.
ROLE-PLAYING
A nurse uses role-play for teaching ideas and attitudes. During role-play, people are asked to play themselves or someone else. The technique involves rehearsing a desired behaviour. For example, a nurse teaches a parent to respond to a child’s behaviour by pretending to be a child who is having a temper tantrum. This scenario allows the parent to practise responding in this situation. Afterwards, the nurse evaluates the parent’s response and determines whether an alternative approach would have been more appropriate. As a result of role-play, clients are taught the skills required and feel more confident in being able to perform them independently.
DISCOVERY
Discovery is a useful technique for teaching clients problem solving, application and independent thinking. During individual or group discussion, a nurse poses a pertinent problem or situation for clients to solve. For example, clients with heart disease are asked to plan a meal that is low in cholesterol and fat. The clients in the group decide which foods would be appropriate. The nurse asks the group members to present their meal, providing an opportunity to identify mistakes and reinforce correct information.
Speaking the client’s language
It is important to use words a client can understand. Medical jargon can be confusing. Clients understand fewer medical words than healthcare professionals sometimes realise. The problem of functional illiteracy is also real. In the 2006 literacy survey carried out in Australia (Australian Bureau of Statistics, 2008), it was found that almost half of all Australians aged 15–74 had ‘poor’ or ‘very poor’ literacy skills. In the survey, people’s skills were ranked from ‘very poor’ (level 1) to ‘good/very good’ (level 4/5) for each of prose literacy, document literacy and quantitative literacy. It was found that approximately 17% of Australians are at level 1 (very poor); these people could be expected to face difficulties using the common printed material of everyday life. Even the 29% of people at level 2 (poor) would experience some difficulties and would require help in reading or filling out official forms. The situation is even worse for Australians from non-English-speaking backgrounds; almost half of this group is at level 1 (very poor). These unsatisfactory figures on literacy are comparable with those in other developed countries.
Ensuring the readability of literature is, therefore, an imperative for the nurse. Literature should be reasonably short, avoid heavy technical jargon, be sensitive to cultural aspects of specific subpopulations and use logical text organisation (Gal and Prigat, 2005).
Implications of illiteracy include an impaired ability to analyse instructions or synthesise information and incorporate it into a behaviour task. Also, many illiterate adults have not acquired the problem-solving skills of drawing conclusions and inferences from experience, and they will not ask questions to obtain or clarify information that has been presented. Appropriate nursing interventions to use with illiterate clients are summarised in Box 13-5.
BOX 13-5 CLIENT TEACHING FOR THE ILLITERATE CLIENT
TEACHING STRATEGIES
• Use simple terminology to enhance the client’s understanding
• Avoid medical jargon if possible or, if necessary, explain medical terms using basic one- or two-syllable words
• Keep teaching sessions short and to the point
• Include the most important information at the beginning of the session
• Relate information to personal experiences or real-life situations
• Use simple analogies when appropriate
• Frequently ask the client for feedback to determine whether the client comprehends information
• Ask for return demonstrations (provides opportunity to clarify instructions and time to review procedures)
• Provide teaching materials that reflect the reading level of the client, with attention given to short words and sentences, large type and simple format (generally, information written at a primary-school reading level is recommended for adult learners)
• Reinforce the most important information at the end of the session
Data from Murphy PW, Davis TC 1997 When low literacy blocks compliance. Regist Nurse 60(10):58.
Anne, who is 20 years old, has just delivered a healthy baby boy. According to her care map, now that she is in the mother–baby unit you are to review her teaching plan with her and individualise it to meet her needs. You ask Anne to review the teaching plan with you. You ask her to read the medical centre’s baby care pamphlet and discuss its content with you. You discover that although the pamphlet is written at a Year 5 level, Anne is unable to comprehend the information in the brochure. When you ask her how well she can read and write English, she responds, ‘I can read and write well.’
Describe how you would individualise Anne’s teaching plan to effectively teach her how to care for her baby.
The nurse must also have knowledge of the client’s cultural background and beliefs, as well as the client’s ability to understand instructions developed outside their native language. Cultural diversity is increasing and poses a great challenge to the nurse who is providing culturally sensitive care. Nurses today are required to develop new skill sets when educating clients of different ethnic groups. These include an awareness of cultural diversity and strategies to minimise any misunderstanding by the client during contact with healthcare providers, and integrating cultural and diversity awareness into healthcare programs. Employing healthcare workers according to equal-opportunity principles also adds to the cultural skill mix of organisations.
Cross-generational conflict may occur in relation to changing value sets and the nurse must acknowledge and assess this family dynamic. This may occur particularly when immigrant parents uphold their traditional values while their children, who are exposed to Australian values in social encounters, develop beliefs similar to those of their Australian peers. This conflict in values must be considered when providing information to families or groups that are composed of members from different generations.
In order to enhance client education in culturally diverse populations, nurses must know when and how to provide education so that cultural values are respected. Teaching regarding interventions or desired behaviours may need to be modified to mediate cultural differences (see Working with diversity). Effective educational strategies may require the nurse to use different patterns of communication.
Using teaching tools
Many teaching tools are available for nurses to use when instructing a client. Selection of the right tool depends on the instructional method chosen, the client’s learning needs and the client’s ability to learn (see Table 13-5). For example, a printed pamphlet may not be the best tool to use for a client with poor reading comprehension, and an audiotape may be the best choice for a client with visual impairment.
TABLE 13-5 TEACHING TOOLS FOR INSTRUCTION
| DESCRIPTION | LEARNING IMPLICATIONS |
|---|---|
| PRINTED MATERIAL | |
| Written teaching tools available as pamphlets, booklets, brochures | |
| PROGRAMMED INSTRUCTION | |
| Written sequential presentation of learning steps requiring that learners answer questions and that the teacher informs them whether they are right or wrong. This can also be in printed form. | |
| COMPUTER INSTRUCTION | |
| Use of programmed instruction format in which computers store response patterns for learners and select further lessons on basis of these patterns (programs can be individualised) | Method requires reading comprehension, psychomotor skills and familiarity with computer |
| NON-PRINT MATERIALS | |
| Diagrams | |
| Illustrations that show interrelationships by means of lines and symbols | Method demonstrates key ideas, summarises and clarifies key concepts |
| Graphs (bar, circle, or line) | |
| Visual presentations of numerical data | Graphs help learner to grasp information quickly about single concept |
| Charts | |
| Highly condensed visual summary of ideas and facts that may highlight series of ideas, steps or events | Charts demonstrate relationship of several ideas or concepts. Method helps learners know what to do |
| Pictures | |
| Photographs or drawings used to teach concepts in which the third dimension of shape and space is not important | |
| Physical objects | |
| Use of actual equipment, objects or models to teach concepts or skills | |
| Other audiovisual materials | |
| Slides, audiotapes, television, videotapes, CDs and DVDs used with printed material or discussion | Materials are useful for clients with reading comprehension problems and visual deficits |
Working with diversity
A nurse’s choice of instructional methods and application of teaching–learning principles are based on a client’s age and developmental level. Children, adults and older adults learn differently. The nurse adapts teaching strategies to each learner.
Children pass through several developmental stages (see Part 4). In each developmental stage, children acquire new cognitive and psychomotor abilities that respond to different types of learning (see Figure 13-4). For example, a nurse teaches school-age children about health as they acquire the ability to see things through the point of view of others. Dental hygiene, nutrition, safety measures and sex education are examples of topics that may be presented to school children of varying ages. Parental input is incorporated in planning health education for children.
FIGURE 13-4 The preschool child learns not to be afraid of medical equipment by being allowed to handle the stethoscope and imitating its use.
From Potter PA, Perry AG 2004 Fundamentals of Nursing, ed 6. St Louis, Mosby.
WORKING WITH DIVERSITY FOCUS ON CULTURAL CARE
New Zealand and Australia are multicultural communities. The Nursing and Midwifery Board of Australia and the Nursing Council of New Zealand hold that one of the primary responsibilities of the nurse in providing care to the client is the ability to recognise that cultural differences exist, and are to be acknowledged as essential to an individual’s care. Addressing a client’s educational needs in a culturally sensitive and responsive way is an essential aspect of nursing care.
Assessing the cultural needs of the client in their care requires the nurse to develop an understanding of the specific needs of each and every individual client. High standards of communication skills between the nurse and the client are required to ensure that the specific cultural needs of the client are met during the course of their interaction.
Assessing the client’s learning needs may require the use of resources not usually relied upon during the course of everyday care provision, for example employing the skills of an interpreter to bridge language barriers. Other reading and research also might be required to understand fully the implications of aspects of care discussed between the nurse and the client.
Avoiding stereotypes and acknowledging the individual and their learning needs are essential in the delivery of culturally appropriate nursing care.
Older adults experience numerous physical and psychological changes as they age (see Chapter 22). These changes not only increase the educational needs of older adults, but they can also create barriers to learning unless adjustments are made in nursing interventions. Sensory changes such as visual and hearing deficits require teaching methods that enhance the functioning of older adult clients. For example, the nurse sits to face clients with hearing problems and speaks in a low tone of voice during discussions. Clients with visual problems can benefit from the use of printed materials containing large print. Although older adults have slower cognitive function and reduced short-term memory, nurses can facilitate learning in several ways to support behaviours that maximise the individual’s capacity for self-care (see Working with diversity). When teaching older clients, information must be based on the client’s previous level of understanding, and reachable, short-term goals should be established. Family members who may be assuming partial care for the client must also be included. However, the nurse must be sensitive to the client’s desire for assistance, since offering unwanted support may result in negative outcomes and may be perceived as nagging and interference. Furthermore, not all relationships between older adults and other family members are therapeutic. The nurse must therefore undertake a comprehensive assessment of the social and support system circumstances that the client lives within. The nurse must also negotiate with the client to discover whom they want involved in their care.
George, who is 70 years old, has had a cerebrovascular accident (CVA). Before his CVA, he was very active socially, went to work 2 days a week and played golf 3–4 days a week. He is about to start the rehabilitation process. Although he appears to have limited cognitive deficits, he will need to use a walker at home. He states, ‘Walkers are for old people.’
Describe how you will approach George and what factors you will consider as you teach him how to use his walker.
WORKING WITH DIVERSITY FOCUS ON OLDER ADULTS
Nurses can facilitate learning by using the following interventions when providing client education to older adults:
• Speak in a low tone of voice (lower tones are easier to hear than higher tones)
• Allow ample time for understanding of the material
• Emphasise concrete material that applies to current situations
• Reduce environmental distractions
• Provide information in frequent, small amounts
• Reinforce important information
• Relate new material to previous life experiences
• Establish mutually set goals
• Allow clients to progress at their own pace (older adults are more cautious, so it may take longer to adopt a behaviour change)
• Use group experiences if appropriate to enhance problem solving
• If written material is used, assess the client’s ability to read and use information that is printed in a large font size and in a colour that contrasts highly with the background (e.g. black 14-point font printed on buff coloured paper)
Data from: Edelman CL, Mandle, CL 1998 Health promotion throughout the lifespan, ed 4. St Louis, Mosby; Lusis S 1996 The challenges of nursing elderly surgical patients. AORN J 64(6):954; Rankin SH, Stallings KD 1996 Patient education: issues, principles, practices, ed 3. Philadelphia, JB Lippincott; Tiivel J 1997 Increasing the effectiveness of your teaching program for the elderly: assessing the client’s readiness to learn. Perspectives 21(3):7.
EVALUATION
Client education is not complete until the nurse evaluates outcomes of the teaching–learning process (see Sample nursing care plan, above). The nurse determines whether clients have learned the material. Evaluation provides the opportunity for the nurse to assess the outcomes and effectiveness of any program of client education in relation to the objectives set. This might include assisting the client to correct any aspects of the program that they are having difficulties with or are misunderstanding. Evaluation also provides the opportunity for feedback to the nurse on the program and its delivery. The nurse may also use the evaluation process to provide the client with positive feedback and encouragement.
The nurse evaluates success by observing the client’s performance in relation to expected behaviours (see Sample nursing care plan, above). Success depends on the client’s ability to meet the established performance criteria.
Direct observation of client behaviours is useful when determining how a person will act in the future. In direct observation the nurse has the client demonstrate the behaviours described in the learning objectives. If the evaluation process indicates a knowledge or skill deficit, the nurse repeats or modifies the teaching plan. Watching a client demonstrate a skill helps the nurse to know whether the correct technique is being used. However, a client may choose to behave differently later. Therefore observation works best in real-life situations (Miller and Stoeckel, 2011).
Oral and written questioning are other useful evaluation methods. Questions measure behaviours that are not easily observed. The client verbally answers carefully phrased questions about the topic that was taught, which measures a client’s success in cognitive learning in relation to the set objectives.
Another form of evaluation includes self-reports (oral and written) and self-monitoring (written). This involves the client or family member providing information independently. An example might include a client’s written log of foods eaten during a specific week, matched against a newly prescribed diet. The nurse relies on the client’s honesty and memory in self-reporting.
Nurses should evaluate whether clients have the information they want. Have their expectations been met? A client may want specific information that they know will be necessary to continue a normal lifestyle at home. Nurses must include client expectations as a part of their evaluation. For example, during teaching sessions the nurse periodically asks clients if they understand what is being taught. At the end of the teaching session, the nurse asks clients to identify information that was not provided that should have been covered. Clients may also be given the opportunity to evaluate a teaching session (or the nurse doing the teaching) in writing. Questionnaires used in these situations ask clients to express their satisfaction with the education they received. At times, written evaluations may be more truthful than evaluations obtained in a face-to-face situation.
Evaluation may reveal new learning needs or the existence of new factors that may interfere with the client’s ability to learn. Alternative teaching methods often help clarify information or skills that the client was unable to comprehend or perform originally. When a client has difficulty in an acute care setting, the nurse may make a referral to resources, such as home healthcare or an outpatient clinic, for further education and evaluation. Like the nursing process, the teaching–learning process is continuous and ever-changing.
Documentation of client teaching
Because client teaching often occurs informally between nurse and client (e.g. during medication administration or physical examination), it is difficult to document it consistently. Nurses often fail to take the time to write down material that is taught. Because a nurse is legally responsible for providing accurate, timely client information that promotes continuity of care, it is essential to document the outcomes of teaching. Many institutions have special forms that allow for easy documentation of client care and education. For instance, teaching flow-sheets are excellent records that document the plan, implementation and evaluation of learning.
Nurses are also legally required to be accountable for their care, so documenting all interventions including teaching sessions is a professional expectation highlighted within the Australian Nursing and Midwifery Council’s National competencies for the registered nurse (2006). The potential for litigious claims against the nurse for providing negligent advice also make the documentation of the process an imperative. To this end, the whole process from assessment to planning to implementation and evaluation should be documented concisely within the client’s notes.
KEY CONCEPTS
• In the healthcare system today, there is great emphasis on providing quality healthcare education.
• The nurse must ensure that clients, families and communities receive information needed to maintain optimal health.
• The nurse’s own experiences of teaching and learning, subsequent reflective practice in client care and own health beliefs inform their clinical practice.
• Health education is aimed at the promotion, restoration and maintenance of health.
• Teaching is most effective when it is responsive to the learner’s needs.
• Teaching is a form of interpersonal communication, with the teacher and student actively involved in a process that increases the student’s knowledge and skills.
• Factors influencing ability to attend to the learning process include physical comfort, anxiety levels, the presence of environmental distraction and a person’s physical and cognitive attributes.
• A person’s health beliefs influence their willingness to gain the knowledge and skills necessary to maintain health.
• Teaching must be timed to coincide with the client’s readiness to learn.
• Clients of different age groups require different teaching strategies as a result of differing developmental capabilities.
• The client should be an active participant in a teaching plan, agreeing to the plan, helping choose instructional methods and recommending times for instruction.
• Learning objectives describe what a person is to learn in behavioural terms.
• A combination of teaching methods improves the learner’s attentiveness and involvement, and the teacher is more effective when presenting information that builds on a learner’s existing knowledge.
• A teacher who uses reinforcing, such as praise or encouragement, for a behaviour is increasing the probability of the behaviour recurring.
• The older adult learns most effectively when information is slowly paced and presented in small amounts.
• Effective documentation describes the entire process of client education, promotes continuity of care and demonstrates that educational standards have been met.
ONLINE RESOURCES
www.hsc.org.nza web-based resource providing access to information on health promotion activities through the Health Sponsorship Council, which is an agency of the New Zealand government
www.health.gov.aua web-based resource providing access to the Australian Government Department of Health and Ageing health promotion activities and resources
www.health.vic.gov.au/healthpromotionan online site providing a gateway to health promotion activities within the Department of Human Services and other key health promotion resources throughout Australia
Aldridge MD. Writing and designing readable patient education materials. Nephrol Nurs J. 2004;31(4):373–377.
Australian Bureau of Statistics (ABS). 4102.0—Australian Social Trends 2008. Canberra: ABS, 2008.
Australian Nursing and Midwifery Council (ANMC). National competencies for the enrolled nurse. Canberra: ANMC, 2002.
Australian Nursing and Midwifery Council (ANMC). National competency standards for the registered nurse. Canberra: ANMC, 2006.
Bandura A. Self-efficacy: the exercise of control. New York: WH Freeman, 1997.
Bennett JK, et al. The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Educ Couns. 2011;85(1):53–59.
Berry DB, et al. Benefits for Latino, African American, and White children and parents taught together in the same community-based weight management intervention. Hispanic Health Care Int. 2009;7(4):203–212.
Bloom BS, ed. Taxonomy of educational objectives. Handbook I: cognitive domain. New York: Longman, 1956.
Dettmer P. New blooms in established fields: four domains of learning and doing. Roeper Rev. 2006;28(2):70–78.
Esposito E, Fitzpatrick J. Registered nurses’ beliefs of the benefits of exercise, their exercise behavior and their patient teaching regarding exercise. Int J Nurs Pract. 2011;17(4):351–356.
Forrest S. Learning and teaching: the reciprocal link. J Contin Educ Nurs. 2004;35(2):74–79.
Gal I, Prigat A. Why organizations continue to create patient information leaflets with readability and usability problems: an exploratory study. Health Educ Res. 2005;20(4):485–493.
Krathwohl DR, et al. Taxonomy of educational objectives: the classification of educational goals. Handbook II: affective domain. New York: David McKay, 1964.
McMillan DE, et al. From anxiety to enthusiasm: facilitating graduate nursing students’ knowledge development in science and theory. J Nurs Educ. 2007;46(2):88–91.
Miller MA, Stoeckel PR. Client education: theory and practice. Massachusetts: Jones, 2011.
Redman BK. The practice of patient education; a case study approach, ed 10. St Louis: Mosby, 2007.
Stein-Parbury J. Patient and person: interpersonal skills in nursing, ed 4. Sydney: Churchill Livingstone, 2009.