Application of Nursing to Patient Teaching

The Nursing Process in Patient Teaching

The teaching- learning process is an integral part of the nursing process With a focus on learning and with regard for the principles variables, techniques and strategies of teaching and learning, the steps of the nursing process assessing, planning, implementing and evaluating- are used for the purpose of meeting the teaching and learning needs of the patient and his family

 Learning needs are defined as gaps in knowledge that exist between the desired level of performance and the actual level of performance (Healthcare Education Association, 1985) Learning needs is a gap between what someone knows and what someone needs or wants to know. Of the three determinants, learning needs must be identified first so that an instructional plan can be designed to address any deficit in the cognitive, affective, or psychomotor domains.

 Not every individual perceives a need for education Once this is determined, the information gathered can , in turn, be used to set objective and plan appropriate and effective teaching and learning approaches for education to begin at a point suitable to the learner rather than from an unknown or inappropriate place In one early study, there was only 20% nurse- patient agreement score with respect to congruency on needs/ problems identified ( Roberts,1982)

 Mordiffi, Tan and Wong (2003) cite more recent evidence from their research that the preoperative information provided by nurse and doctors was considered insufficient by the majority (66.7%) of patients who rated knowledge about anesthesia before scheduled surgery to be very or extremely important to them. According to the estimates of many cognitive experts in behavior and social sciences (Bloom 1968, Bruner 1966) most learners 9095% of them, can master a subject with a high degree of success if given sufficient time and appropriate support

 It is task to the educator to facilitate the determination of what exactly needs to be learned and identify approaches for presenting information in a way that will be best understood by the learner

Assessment of Learning Needs

Assess the patients learning needs and physical, emotional and experiential readiness for health education What are his health beliefs and behaviors? What psychosocial adaptations is he making? Is he ready to learn? Is he able to learn these behaviors? What are his expectations? What additional information is needed about him?

Important steps in the assessment of the learning needs:

Identify the learner Choose the right setting Collect data about the learner Collect data from the learner Involve member of the healthcare team Prioritize needs Determine availability of educational Assess demands of the organization Take time management issues into account

Important point with respect to time management issues:

Although close observation and active listening take time, it is much more efficient and effective to do a good initial assessment than to waste time going back to discover the obstacles to learning that prevented progress in the first place Learners must be given time to offer their own perceptions of their learning needs if the educator expert them to charge and become actively involved in the learning process

 Assessment can be made anytime and anywhere the educator has formal or informal contact with learners. Informing someone ahead of time that the educator wishes to spend time discussing problems or needs gives the person advanced notice to sort out his or her thoughts and feelings Minimizing interruptions and distractions during planned assessment interviews maximizes productivity such that the educator might accomplish in 15 minutes what otherwise might have taken an hour in less directed more frequently and interrupted circumstances

Methods to Assess Learning Needs

The nurse in the role of educator must obtain objective data about the learner as well as subjective data from the learner. The following are the various methods that can be used in conjunction with one another to yield the most reliable information (Haggard 1989) Informal Conversations Structured Interviews Focus Groups Self administered Questionnaires

Tests Observations Observing health behaviors in several different time periods can help to determine conclusions about established patterns of behavior that cannot and should not drawn from a single observation Patients Charts Physicians progress notes, nursing care plans, nurses notes and discharge planning form can provide information on the learning needs of the client

Assessing Learning Needs of Nursing Staff

Williams (1998) specifically addressed the importance of identifying the learning needs of staff nurses using the following methods: Written job description Formal and Informal Requests Quality Assurance Reports Chart Audits Rules and Regulation

Formulation of Teaching Plan

A teaching plan is a blueprint for action to achieve the goal and the objectives that have been agreed upon by the educator and the learner After mutually agreed upon goals and objectives have been written, it should be clear what the learner is to learn and what the teacher is to teach A predetermined goal and related objectives serve as basis for developing a teaching plan Organizing and presenting information in the format of an internally consistent teaching plan require skill by the nurse educator

 Teaching an informal group like a mothers class or a formally organized activity involving students or professionals like a seminar or symposium entails preparation and planning This ensures that the topic , chairman, speakers, logistics, physical set up and most especially the participants are all well organized and informed Health education plan may emphasizes a phase of the behaviorchange process that is related to the clients health needs/ problem The plan may also follow the sequence of that process from pre training to the continued performance of a behavior that helps resolve health need/ problem

Process of generating a teaching plan helps the Health Educator

Recognize and use methods of learning that involve the client as an active participants

Include a list of specific actions or abilities that the client may perform at intervals during the educational interventions and at the end

Three major reasons for constructing teaching plans are

To force the teacher to examine the relationship among the steps of the teaching process to ensure the logical approach to teaching, which can serve as a map for organizing and keeping instruction on target To communicate in writing and in an outline format exactly what is being taught, how it is being taught, and evaluated and the time allotted for accomplishment of the behavioral objectives To legally document that an individual plan for each learner is in place and is being properly implemented.

A teaching plan should consist of the following eight basics elements (Ryan and Marinelli, 1990):
The purpose A statement of overall goal A list of objectives ( a sub objectives if necessary) An outline of related content The instructional methods used for teaching a related content The time allotted for the teaching of each objectives The instructional resources( materials/tools and equipment) needed The methods used to evaluate learning

Planning
An ongoing phase of the teaching process, involves consideration of the ff.: Why Teach? What should be taught? How should Teaching be done? Who should teach and who should be taught? When Should Teaching Occur? Where should teaching occur?

Implementation of Teaching Education

Put the teaching plan into action Knows the materials to be presented Provide the atmosphere conducive to learning Use language the patient can understand Use appropriate teaching techniques and methods Use some equipments that the patient will use after discharge

 Encourage the patient and his family to participate actively in learning Coordinate the activities of the patient his family and significant others and other health team members Emphasize the importance of learning to the care for self after discharge Records the patients responses to the teaching actions

Kotz (1997) suggest several strategies to achieve clients lead as outlined following sections:
Get and Keep the Clients Attention Stick to the Basic Use time wisely Reinforce Information

Learning Throughout the Life Cycle

One basic assumption underlies teaching effectiveness, all people are capable of learning, and however the ability to learn does vary from person to person and from situation to situation. Further, learning needs and learning abilities change throughout life and the clients chronological age and developmental stage greatly influence the ability to learn Teaching approaches must be modified according to clients developmental stage and level of understanding

Examples of patient education program specific to each developmental stage:

Patient Education for Children Readiness for learning (evidence of willingness to learn) varies during childhood depending on maturation level Responding to knowledge deficits of young children requires that the nurse work closely with childs caretaker. Including the family on significant others in teaching is especially important when caring for young children Young children learn primarily through play, including play into teaching activities for children can therefore enhance learning.

Tips in Teaching Children

Ensure that the client is comfortable Encourage caregiver participation Asses the childs learning readiness, motivation and developmental level. Do not equate age with developmental level Assess the childs psychological status Determine self care abilities of child and caregiver Use play, imitation and role play to make learning fun and meaningful

 Use different visual stimuli, such as books, chalkboards and videos to convey information and arises understanding Use terms that are easily understood by the client and the caregiver Provide frequent repetition and reinforcement

 Develop realistic goals that are consistent and developmental abilities In planning teaching approaches , remember that the goal of educating children are to present excessive anxiety improve cooperation and fasten the recovery process (Biddinger, 1993)

Patient Education for Families with Adolescents

As individual approach adolescent, they are better able to conceptualize relationship between things Usually reading and comprehension ability have advanced and adolescents can understand more complex information Because one of the strongest influences the adolescents is peer support , group meetings are often useful in teaching The nurse can often be a powerful teaching by acting as a role model The accompanying display provides guidelines

Tips in Teaching Adolescents

Show respect for adolescents by recognizing their struggles to gain knowledge and experience of adulthood while breaking away from the grasp of childhood Boost adolescents confidence by asking their input and opinions on health care matters Encourage adolescents to explore their own feelings above self- concepts and independence Be sensitive to the peer pressure may adolescents face

 Help adolescents identify and build their positive qualities Gear teaching to the adolescents developmental level and use language that is clear yet appropriate to the health care setting To encourage and informed decision making, engage adolescents in problem solving activities

Patient Education for Women

Consider patient education on: Pregnancy Childbirth Postpartum Behavior Physical changes during and after pregnancy Child rearing Family Planning

Patient Education for Older Adults/Senior Citizens

Aging is accompanied by many physiological changes. As a result of these changes, some older adult experience perceptual impairments The nurse must thus assess for perceptual changes and adjust teaching material accordingly eg, providing large print written material and verifying that the client hears all instructions as directions are strategies helpful in teaching older adults

Tips in Teaching Older Adults

Ensure that the clients is comfortable, pain, fatigue, a full bladder or hunger can impair learning Assess the clients learning readiness, motivation and developmental level. Do not equate age with developmental level Assess the clients psychological status. Depression, severe anxiety, denial can interfere with learning Ascertain the time of a day when the client is best able

 Use terms that are easily understood by the client Avoid talking down to the client; a condescending paternalistic manner impede learning Present materials slowly and use examples Encourage client involvement and participation Ask for feedbacks and employ active listening Provide frequent feedback Assess for perceptual impairment and individualize teaching strategies accordingly

For Memory Impaired Clients Use repetition Use a variety of cues ( spoken words, written materials pictures and symbols) For Visually Impaired Clients Provide large prints materials Provide magnifying glasses Be sure client is wearing prescription eyeglasses Provide adequate lightning and reduce glare

 For bearing- impaired Clients Face the client directly when speaking Use short sentences and words that are easily understood Use signal to reinforce verbal life Eliminate distractions (noises) as much as possible

Evaluation
Collect objective data Observe the patient Ask questions to determine if the patient understands Use rating scales, checklists, anecdotal notes and written tests when appropriate Compare the patients behavioral outcomes with the outcome criteria, determined extends to which the goals were achieved Include the patient, his family and or significant others, nursing team member and other health team member in the evaluation

 Identify attractions that need to be made in a teaching plan Male referrals to appropriate resource persons or agencies for reinforcement of leaving after discharge Continue all steps of teaching and learning process: assessing, planning, implementing and evaluating

The following strategies can be used to evaluate client learning: Oral Questioning Observation Return Demonstration

Evaluation is facilitated by the use of the goal that are measurable and specific several activities can be used in evaluating teaching effectiveness: Feedback from the learner Feedback from the colleague Situational feedback Self -evaluation

Teaching Demonstration
Unlike lecture, which essentially is telling students which the teacher wishes them to learn, a demonstration primarily involves showing Have the advantage of enabling students to observe the demonstration engaged in the learning task rather than simply talking about it A good demonstration can be like a picture worth a thousand words

 In a demonstration, students are afford the opportunity of looking at something instead of merely talking or hearing about it Demonstration is done by the teacher to show the learner how to perform a particular skill Return Demonstration is carried out by the learner in an attempt to perform a task with cues from the teacher as needed

Demonstration
Prior to giving demonstration, the teacher should inform learners of the purpose of the procedure , the sequential steps involved, the equipment needed and the actions expected of them Equipment should be tested before use to ensure that it is complete and in working order For the demonstration method to be employed effectively, the learners must be able to clearly see and hear the step of being taught.

 Therefore, the demonstration method is best suited to teaching individuals or small groups The demonstration can be enhanced if the teacher slows down the pace of performing the demonstration, exaggerates some of the steps( de Tornyay and Thompson) or breaks lengthy procedures into a series of shorter steps

 In the process of demonstrating a skill to either nurses or patients, it is important to explain why each step needs to be carried out in a certain manner Demonstration allows for mental rehearsal of procedure (Haggard, 1989).

Return Demonstration
Should be planned to occur as close as possible to when the demonstration was given Learners may need reassurance to reduce their anxiety prior to beginning of the performance because the opportunity for return demonstration may be viewed by them as a test

 This may lead them to believe they are expected to carry out the expectation of perfect performance the very first time around Allowing the learner to manipulate the equipment before being expected to use it may help to reduce anxiety levels

Advantages of Demonstration and Return Demonstration

Limitations of Demonstration and Return Demonstration:

Especially effective for learning in the psychomotor domain Actively engages the learner through stimulation of visual, auditory and tactile senses

Requires plenty of time to be set aside for teaching as well as learning Size of audience must be kept small to ensure opportunity for practice and close supervision

 Repetition of movement and constant reinforcement increases confidence, competence and skill retention Provides opportunity for over learning to achieve the goal

Requires plenty of time to be set aside for teaching as well as learning Size of audience must be kept small to ensure opportunity for practice and close supervision