Discussion Board

Educating Patients: understanding Barriers, Learning Styles, and Teaching Techniques

Linda Beagley, MS, BSN, RN, CPAN

Healtb care deliuery and education bas becorne a cballengefor prouicters. Nttrses ancl otber professionals are cballenged claily to assure that tbe patient bas tbe necessary infonnation to rnake informed decisions. Pcttients and tbeir fantilies are giuen a ntultitucle of information about tbeir bealth and commonly rnust make im.p<trtant decisictns from tbese facts. Obstacles tbat preuent easy deliuery of bealth care information include literacy, culture, language, and pl.tysiological barriers. It is up to tbe nurse ro 4s.re.,'\- and eualuate tbe patient's learning needs and read- iness to learn because euerlone learns clffirently. Tbis article utill examine bou each of tbese barriers inxpact care deliuery along ulith teaching and. learning strategies uill be exarnined. Keywords: patient education, barriers, culture, literacy, perianestbesia nursing.

@ 201 I by Arnerican Society of PeriAnestbesia Nurses

EDUCATING PATIENTS HAS bccomc a challenge for health care providers because the patient length ofstay has decreased and the need to deliver complex infbrntation has increased. A nerv version of the melting pot society requires special efTorts by hcalth care professionals to ensure that the pa- tient understands the information given to him or her. Barriers that inhibit patient education are liter- acy, language, cultnrc, and phl,siological obstacles. Assessing and evaluating the learning needs of the patient are essential before planning and inr- plementation of an educational plan. Presenting a well-formulated plan will increase the likelil-rood of a successful recovcry for the patient. In this article, barriers will be dissected and strategies examined to determine what will best suit the edu- cational needs of the patient.

Linda Beagley, MS, BSN RN, C?AN is a ?ACU Ctinical Eclu- cato4 Suedish Couenantt Hospital, Cbicago, IL.

Conllict of interest: Norre to report. Address conespon.lcrrce tct Linda Beaglel', Sutedish Coue-

flant Hospital, 5140 N. Cahrtraia Aue, Cbicago, IL 60625; e-mail address: lbeagley@scbosp.org.

@ 201 I by Americ..n Society of periAnestrresia Nurses I O89-9472,/$36.0o doi: I O. I O t 6/jjopan. 2 0 t t.06. 002

Adult Learning

To effectively educate patients, health care pro viders must havc an understanding of the princi- ples of adult learning. Malcolm Knowles, who began to study adult learners in the 1960s, is known as the father of adult learning principles be- cause of his exte nsive writing on adult education. The term andragogy, the art and science of teach- ing adults, is synonymous with that of Knowles. He deduced that adults learn differently than chil- dren. His stlldies determined five assumptions on learning: self-concept, experience, readiness to learn, orientation to learning, and motivation to learn.t According to Knowles, as a person ma- tures, his self-concept moves from one of being a dependent personality towards one of being a self-directed human being. Humans accumulate a growing reservoir of knowledge, followed by a readiness to learn, which increasingly is oriented towards developmental tasks related to social roles with immediate application of their new knowl- edge. Knowles'final assumption reflects the moti- vation of learning as moving from external to internal.l2 Tuble I compares and summarizes Knowles' assumption regarcting the adult (anclra- gogy) and the child (peclagogy) learner.

Jouml trf PeriAnestbcsia Nursing, Vol 2(r, No 5 (Octobcr), 2}lt: pp 331-337

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LINDA BEAGLEY

Table 1. Assumptions Differences of Pedagogy and Andragogyl'z

Assumptions Pedagogy Andragogy

Se lf-concept Experience Rcadiness Orientation to learning Motivation

Dependency Happens to learner Biologic antl acadcmic developmcnt Logical; directed by teacher External approval of teacher

Se lf-directecl Rich resource Evolving social and lifc rolcs Life centered; task/problem centered Internal drive; life goals

Literacy Barrier

Literacy is defined as "an individual's ability to read, write and speak in English and compute and solve problems at levels of proficiency neces- sary to function on the job and in society, to achieve one's goals, and to develop one's knowl- eclge ancl potential."s Itliteracy cloes not cliscrimi- nate; it can be found in all populations, and a person's grade level is not an accllrate gauge fbr reading ability. a Having any level of illiteracy can callse a number of problems with activities of daily living, strch as analyzing a transportation schedule, following directions, understanding rec- ipes, and completing job applications. Low liter- acy is describecl as those people who have'the ability to read, write, and understand information only at the seventh gracle reading level. According to the US Department of Health and Human Ser- vices (DHHS),3 demographics does play a role in literacy; certain groups demographically have a higher prevalence of low literacy. Table 2 out- lines this population.

Low literacy and low health literacy are related but not interchangeable. Health literacy is defined in Healthy People 201O as "the degree to which indi- viduals have the capacity to obtain, process, and understand basic health information and services neecled to make appropriate health decisionsl'5 Low health literacy is content speci-flc. An individ-

Table 2. Demographics of Low Literact'

Fewer years of education

Lower cognitive ability Elderly Some racial or ethnic Sroups from thc Sottth or

Northeast Female

Incarccration Low income status

ual may be able to read and write in certain con- texts but struggle to comprehend the unfamiliar vocabulary and concepts

-fourrd in hcalth-related

materials or instnlctions.) According to the US Department of Education, which conducts a na- tionwide survey of adult Americans to evaluate lit- eracy skills,5 an estimated neady one half of Americans (90 million) have dilliculty understand- ing and acting on health information. These stud- ies l.rave linked low health literacy with delayed diagnosis, poor disease management skills, and higher health care costs. These same individuals dernonstrate a limited understanding of their dis- ease processes resulting in worse health care out- comes.ti Unnecessary health care costs ranging from $ 106 to $238 billion are arrributed to limited health literacy.T

Factors associated with health literacy are depen- dent on the skills, preferences, and expectations of health information providers. At times, healtl-r care professionals may be oblivious to the effect of limited health literacy on patients and the healtl.r care system. In one studyT of 24O health care pro- viders and students, researchers found fewer than 12% of participants were aware of their degree of limitecl health literacy. Twenty-five percent were found to have a common misconccption that health literacy could be determined by race,.eth- nicity, culture, age, or socioeconomic status.T T<r heighten matters, responders inaccurately be- lieved that patients with a higher level of education were not at risk for having limited health literacy (7 .4%).In health care, nurses comprise the lirrgest group of providers and are rcsponsible f<-rr ensttr- ing patient education. The researchers recom- mend health literacy education for nurses during the education process.

Cutillis completed a systematic review of the liter- ature for the purpose of analyzing and evaluating the research on health literacy and the elderly.

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EDUCATING PATIENTS

Age becomes an important demographic marker with an inverse relationship to health literacy. Cutilli found that as the patient's age increases, the health literacy level decreases. This is an important element because of the aging popula- tion in the United States and the projected trend of aging. By 2O3O, it is estimated that 20% of the population will be 65 years and olcler.e The Federal Interagency Forum on Aginge reports older Americans are proportionately more likely to have below basic health literacy than other age groups. Thirry-nine percent of people trged 75 years or oldcr have below average health literacy skills conrpared to 23% of people aged 65 to 74 years :anrJ 13% of people aged 50 to 64 ,vears.

Language and Culture Barrier

The Unitecl States has been known as a melting pot of diversity over the last 100 plus years. Some changcs, however, have occurred from thosc early years. Ethnicities are found in large urban neigh- borhoods, as well as the suburbs and rural areas of the country. The diversity now existing across the country has presented many challenges for health care providers. In 2001, DHHS published national standards on culturally and linguisticallv appropriate services. These DHHS standardslt' re- quired health care institution.s to demonstrate cul- tural competency while caring for patients in a manner responsive to their beliefs, interpersonal sryles, attitudes, language, and behaviors ofthe in- dividual and required that care be provided in a manner that demonstrates respect for individual dignity, pcrsonal preference, and cultural differ- ences.

Health care providers must be knowledgeable of cultural competencies. Nurses should have aware- ness of biases and prejudiccs by examining gener- alizations they might use routinely about cultures other than their own. Any biases must be con- fronted. A commitmcnt to learn morc about the cultures that have been generalized in the past must be made.rr Second, core cultural values need to be examined and understood about the varying populations that frequent rhe insritutioll. Cultures have several core values on wl.ricl.r all other values are based.r2 This foundation is a start_ ing point for health care providers in understand- ing different cultures.

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A challenging aspect is the ability to communicate effectively to the patient whose native language is not English. Thoroughly assessing the patient's comprehension and the need for a translator is vi- tal. Every attempt must be made to provide a qual- i-fied translator whether the translator is physically present or available via a telephone translation line. Family members as translarors may not be able to translatc important terms needcd in obtain- ing informed consent or education. Furthermore, caregivers must provide written education mate- rials for the patient to take home . Many concepts are not easily translated, and it is imperative to have a fluent translator translate the written word into the targeted language.l I

An estimated 40 different languages are spoken by the patients who use the services at one Midwest comnrunity hospital. Managing multiple languages and cultures has provcn to be a challengc. Thc hos- pital intranet offers resources for many of the cr-rl- tures including common practiccs, values, and beliefs. Another unique artribure for this hospital is the diverse nursing population. In the surgical arena, every eflbn is made to pair similar culttrre/ language of the patient to the health care provider. This luxury of a divcrsc nursing population is not common for man1, facilities, creating a need to relv on telephone language lines or hospital- employed interpreters.

Nladeleine Leininger's theory of cultural care diver- sity and universaliry defines cultrtre as a guide whereby the individual's thinking, as well as his de- cisions and actions, is patterned and usually passed on from one generation to another.l2 A person uses culture as a framework in viewing the world, including health and the need for health care. Be- cause patients can feel a sense of losing control, they have a tendency to hold onto family beliefs when they become ill. Successful teaching plans are congruent with patient and family values.{ Nursing care that incorporates cultural values and practices can be positively related to patient satisfaction, and paticr.rt compliance to treatment will be greater. Conflict will result if nursing care is in discord with the patient's belief systems.

Knowing one's patient is important for delivery of care. A recent Swahili refugee was admittect to have a cholecy,stectomy. She hacl been treated wirh tribal medicine, which rcsulted in several

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healed burn scars on her abdomen. Arousing from anesthesia, the patient relayed through her inter- preter that she wanted to see what was removed cluring surgery. The nurse triecl to explain that the patient's gallbladder had been removed ancl sent to pathology. The patient continued to insist that she needed to see the gallbladder. For this pa- tient, it was imperative to visualize the gallbladder to confirm that she was healed from her illncss. The nurse recognized the needs of the patient, contacted the snrgeon, and between the two of them, they were able to have the patient see her gallbladder through pictures taken during surgery.

Another example of the importance of cultural awarcness is demonstrated in the story below. The diabetic educator consults with patients who have gestational diabetes frequently in the clinic. A Muslim patient ancl her husband were scheduled for education. In this patient's culture, the educator was not pcrmitted tcl addrcss thc patient directly and was to speak only to the husband. To acknowledge the patient's cultural beliefs, the educator instructed the husband, who then instructed the patient in her presence. The educator used several different teaching tech- niques to quantiry that the patient could saf'ely ad- minister insulin to herself.

In the American culture, the patient is the key deci- sion maker in health care. 1l The patient may consult with other family members, but ultimately, the pa- tient makes the final decision.ra Traditionally, Amer- ican families have been defined as having a mother, fatheq and child/children. Familial hierarchy can be dilTerent for some cultures. How is the "family" de- fined for tlris patient? Is it the immediate lluclear family or the family that may include extended fam- ily members, close friends, or neighbors? Ide nti$ing who is the health care decision maker for the patient is important.{'t3 For some cultures, the decision maker is the head of the household or the entire extended family. All key players must be involved in any decisions because they will either reinforce or bl<lck health care behaviors.

The nurse must be aware of both verbal and non-

verbal communication behaviors. There are vast

differences in culturally defined communication behaviors. Before discussion of personal informa-

tion, it is important to understand culturtl prac- tices related to nonverbal communication during

LINDA BEAGLEY

collvefsation, communication practices related to the opposite gender, and cultural practices of so- cial conversation.4 Gender-specific topics coulcl be taboo fbr some cnltures. For some, direct eye contact is a sign of disrespect. Be aware of cultures in which disagreement is perceivecl as impolite- ness. The patient may be agreeing with what the health provider is saying purely out of civility rather than out of agreement.l3'15

Physical and Environmental Barriers

Physiological factors play a role in how the patient is able to process health information. As a person ages, visual clarity and auditory acuiry will decrease, mak- ing it difficult for the person to receivc information. Many times, a patient may reftlse to wear corrective devices. Altered mental capaciry because of patho- logic clisease processes, such as Alzheimer disease, or pharmacologic interventions, such as medica- tions, can create a barrier for effective teaching. Increased aging may cause decline in cognitive capa- bilities in processing information, memory and comprehending abstractions.'6 As the adult ages, the abiliry to reason and process information occurs at a slower rate rnd reaction or response time in- creases significantly after the age 65. Managing multiple messages simultaneously is harder to do. Short-term memory loss and the quantiry of new information may limit the length of thc teaching session and amount of information given. The capacity to draw conch.rsions from inference decreases in the older adult. Vrgue terms of "adequate," "several times a dayl' and "often" can have multiple meanings. Directions shoulcl be spe- cific to time and order with quantities delined.

Physical conclitions can limit rnobility and the pa- tient's ability to sit and be receptive to learning. Many times, patients seek out health care be- cause of pain or not feeling well. Uncontrollecl pain will block the patient's ability to receivc in- formation. Anticipation, anxiety, and f'ear are all contributing factors in diminishing reception of knowledge. In the perianesthesia area, pain and anxiety are obstacles that mtlst be identified and controlled for the patient to comprehend information.

Because of busy schedules, environmental barriers

are challenging at times. Poor lighting' noise levels'

ancl room temperatures can inhibit the learning

EDUCATING PATIENTS

proccss. These barriers are difficult to control be- cause of capped thermostats and controlled light- ing. Noise levels are under careful consideration because of the complaints of patients who have not been able to resr because of noise while hospi- talized. Hospitals have responded by instituring quiet times during the day. Physical space tbr the health care professional to share information with the patient that is private, quiet, and with minimal distractions can be at a premium, although necessary for effective learning. Lastly, time to devote to adequate teaching is a large bar- rier in today's health care environment. Profes- sionals are asked to do more with less, including time. Patients' length of stay has shortened be- cause of many fact<lrs, giving the nurse less time with the patient to accomplish important teaching elements.

Learning Styles

Besides understanding barriers that impact rhe re- ception of education, the nurse must be aware of how an individual learns. Learning patterns are de- veloped as a child and the "learner" discovers what works best for his or her individual leaming style. Assessment of the patient is essential for effective teaching, which may require more than one learn- ing style fbr comprehension. Learning patterns in- clude visual, auditory and kinesthetic.17 A visual learner prefers to see what he or she is learning. Pictures and images help the learner understand ideas and information better than an explanation. The auditory learncr needs to hcar the message or instructions being given. This rype of learner wants to be talked through a process rather than reading about it first. Thc kinesthetic learner does not like lecture or discussion, preferring the movement of the skill or task. Demonstration and return demonstration works best with kines- the tic learners. l7'1lt

Once thc learning style i.s cstablishe<I, thc nurse adapts the teaching materials to the preferred sr),Ie. For the visual learneq the nurse will have ma_ terials fbr rhe patient to read or watch. The infor- nlatiol.l should be well organized, interesting, appealing, and easl.to read. !flith toclay's advance- rnent of technology, there are many choices to of_ fer the visual learner, including computers, live vidco feeds, close circuit television, photography, and the Internet.

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For the auditory learne! the nurse should repltrase important points and questions in several different ways to communicate the intended message. Vary- ing the speed, volume, and pitch helps creare an interesting aural texture. An environment where the patient and family can hear the message is im- portant while encouraging the patient to write key elements. A quiet space , preferably with rhe abiliry to close tlle door along with minimal distractions, assists the teacher to maximum the learning for an auditory learner. To assist the auditory learner, in- corporate multimedia of sounds, music, or speech.

Kinesthetic learners prefer frequent breaks so that they can move around. The nurse should encorlr- age the patient to take notes while providing tacti- cal and hands-on activities. Providing samples will allow the kinesthetic learner to practice what he or she is learning, verifying comprehen- sion through return demonstration. Table 3 sum- maries learning sryles e,ith teaching strategies.

In the perianesthesia arena, more than one type of teaching strategy may be necessary ro successfully deliver the mcssage and establish comprchension. Forexample, the follow-up telepl'rone call was indi- cating negative outcomes for several patients who were to remove their urinary catheterat home. The patient teaching before going home for this parient population had become labor intensive, yet urinary catheters were still being removed without deflat- ing the catheter balloon, causing harm to the patient and unhappy surgeons. Brainstorming,

Table 3. Learning Styles With Teaching Strategies

Learn Styles Teaching Strategies

Visual Visual material Handouts-casy to read Varieq, of technology-computers,

overhead, video, ly Intcrnet Rcphrasc key points Vary speed, volume, and pitch Write down key points Positioned to hear the message clearly Usc multimcdia-tapcs, music Frequent breaks to nrove around Learner writes own notes Provide tactile activities Product samples

Auditory

Kinesthe tic

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a group of nllrses looked tcl see how those in the unit could improve the education process and otlt- comes. The result was to continue to demonstrate to the patient ancl significant other how to deflate the balloon and remove the catl'reter. A return dem- onstration was verified by both the patient and the tirmily member, each practicing using the syringe and inserting it into the catheter port (without re- moving the catheter). The department also devel- oped a step-by-step handout with pictures for the patient to take home. All three learning styles were institutecl to ensure a positive change of no longer having patients remove the urinary device with the balloon intact.

Teaching Methodologies

Teaching methodologies are multiple, and not all will work in the perianesthesia settinS. The most common method is lecture, in which the presenter gives information to the learner and learning is pas- sive. Discussion allows for participation and for the ability of the learner to ask and answer clttcs- tions and share feelings. Demonstration is a useful technique using both psychomotor and social skills of the learner. In health care, demonstration with return demonstration is commonly used when a new technique or skill is to be learned by the patient. fur example of demonstratiou was the urinary catheter instructious and patient demon- stration previously mentioned.

Another common method of teaching is the use of printed instructions. Printed healtl-r care informa- tion should avoid technical language: ttse sltort simple sentellces and write at a level that most pa- tients will understand.a The recommendation for written instructions is that they be at the fifth gracle level. Avoidance of glossy paper and small tbnts also assists the learner.

The Internet can be a friend or foe when obtaining

health care information. Hospitals are sctting up

LINDA BEAGLEY

\fleb sites for paticnts to obtain information. In one pre-surgical testing department, the nurse gives the scheduled surgical patient a Web site where he or she can learn more about anesthesia before coming to the hospital. Health care prof'es- sionals also need to establish that the Patient is ob-

taining reliable information on the Internet and steer the patient to government and academic sites

that are proven to be more trustworthy.le Inpa- tients can watch health-related stations on their televisions.rr On the obstetric unit, patients can access the television to learn abottt a variety of is- sues related to the mother and care of the ncw baby. The disadvantage of watching a television stxtion or already-taped segment is the inability to ask and have questions answered immediately. The nurse must be diligent in following up with the patient to answer questions ancl reinforce the teachings from the video.

Conclusion

For ef}'ective delivery of health information and ed- ucation, the nurse must be awltre of the barriers that can impede the patient's ability and readiness to learn. Awareness of the potential barriers of lit- er'.rcy, culture, language , and physiological factors will help the nurse determinc what tools he or she may need to assist in the delivery of informa- tion. Awareness of one's biases and prejudices and overcoming them will assist in the eclucation process. The nurse assesses the patient's under- standing by looking at both verbal and nonverbal clres that the patient is displaying. I-lsing more than one way of delivering the mcssage will pro- mote the patient's learning. A family member pres-

ent dllring key moments will assist and help the patient to remember the information. The asttlte nurse will be more successfttl in overcoming bar- riers if she or he is aware of patient's needs and areas where aclditional assistance is needed.

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