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Nurse as Educator

Principles of Teaching and Learning for Nursing Practice

FIFTH EDITION

Nurse as Educator: Principles of Teaching and Learning for Nursing Practice, Fifth Edition drives comprehension through various strategies that meet the learning needs of students, while also gen- erating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:

The Pedagogy

Chapter Highlights Chapter high- lights provide a quick-look over- view of the content presented in each chapter.

Key Terms Found in a list at the be- ginning of each chapter, these terms will create an expanded vocabulary.

Overview of Education in Health Care Susan B. Bastable Kattiria M. Gonzalez

CHAPTER 1

CHAPTER HIGHLIGHTS

■ Historical Foundations for Patient Education in Health Care ■ The Evolution of the Teaching Role of Nurses ■ Social, Economic, and Political Trends Affecting Health Care ■ Purposes, Goals, and Benefits of Patient and Nursing Staff/Student Education ■ The Education Process Defined ■ The Contemporary Role of the Nurse as Educator

• Nursing Education Transformation • Patient Engagement • Quality and Safety Education in Nursing • The Institute of Medicine Report: The Future of Nursing

■ Barriers to Teaching and Obstacles to Learning • Factors Affecting the Ability to Teach • Factors Affecting the Ability to Learn

■ Questions to Be Asked About Teaching and Learning ■ State of the Evidence

KEY TERMS

education process teaching/instruction learning

patient education staff education

barriers to teaching obstacles to learning

Objectives These learning objectives provide instructors and students with a snapshot of the key information they will encounter in each chapter. They serve as a checklist to help guide and focus study.

Evaluation is defined as a systematic pro-cess that judges the worth or value of some-thing—in this case, teaching and learning. Evaluation can provide evidence that what nurses do as educators makes a value-added difference in the care they provide.

Early consideration of evaluation has never been more critical than in today’s healthcare en- vironment, which demands that “best” practice be based on evidence. Crucial decisions regard- ing learners rest on the outcomes of learning. Can the patient go home? Is the nurse provid- ing competent care? If education is to be jus- tified as a value-added activity, the process of education must be measurably efficient and must be measurably linked to education out- comes. The outcomes of education, both for

the learner and for the organization, must be measurably effective.

For example, the importance of evaluating patient education is essential (London, 2009). Patients must be educated about their health needs and how to manage their own care so that patient outcomes are improved and healthcare costs are decreased (Institute for Healthcare Im- provement, 2012; Schaefer, Miller, Goldstein, & Simmons, 2009). Preparing patients for safe dis- charge from hospitals or from home care must be efficient so that the time patients are under the supervision of nurses is reduced, and it also must be effective in preventing unplanned read- missions (Stevens, 2015). Monitoring the hos- pital return rates of patients is not a new idea as a method to evaluate effectiveness of patient

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the term evaluation . 2. Discuss the relationships among evaluation, evidence-based practice, and practice-based evidence. 3. Describe the differences between the terms evaluation and assessment. 4. Identify the purposes of evaluation. 5. Distinguish between five basic types of evaluation: process, content, outcome, impact, and program. 6. Discuss characteristics of various models of evaluation. 7. Explain the similarities and differences between evaluation and research. 8. List the major barriers to evaluation. 9. Examine methods for conducting an evaluation.

10. Explain the variables that must be considered in selecting appropriate evaluation instruments for the collection of different types of data.

11. Identify guidelines for reporting the results of evaluation. 12. Describe the strength of the current evidence base for evaluation of patient and nursing staff

education.

KEY TERMS

evaluation evidence-based practice

(EBP) external evidence internal evidence practice-based evidence

assessment process evaluation

(formative evaluation) content evaluation outcome evaluation

(summative evaluation)

impact evaluation total program evaluation evaluation research reflective practice

596 Chapter 14 Evaluation in Healthcare Education

Review Questions Review key con- cepts from your reading with these exercises at the end of each chapter.

The importance of evaluation as internal evidence has gained even greater momentum with the movement toward EBP. Perhaps the most important point to remember is this: Each aspect of the evaluation process is important, but all these considerations are meaningless if the results of evaluation are not used to guide future action in planning and carrying out ed- ucational interventions.

Review Questions 1. How is the term evaluation defined? 2. How does the process of evaluation differ

from the process of assessment? 3. How is evidence-based practice (EBP)

related to evaluation? 4. How does internal evidence differ from

external evidence? 5. What is the first and most important step

in planning any evaluation? 6. What are the five basic components

included in determining the focus of an evaluation?

7. How does formative evaluation differ from summative evaluation, and what is another name for each of these two types of evaluation?

8. What are the five basic types (levels) of eval- uation, in order from simple to com plex, as identified in Abruzzese’s RSA evalua- tion model?

9. What is the purpose of each type (level) of evaluation as described by Abruzzese in her RSA evaluation model?

10. Which data collection methods can be used in conducting an evaluation of educational interventions?

11. What are the three major barriers to conducting an evaluation?

12. When and why should a pilot test be conducted prior to implementing a full evaluation?

13. What are three guidelines to follow in reporting the results of an evaluation?

results. Process, content, and outcome evalu- ations also are more frequently conducted as research projects, however, underscoring the importance of evidence as a basis for making practice decisions. Sinclair, Kable, Levett-Jones, and Booth (2016) conducted a systematic re- view of randomized clinical trials to determine the effectiveness of e-learning programs on health professionals’ behavior and patient out- comes. After screening articles initially iden- tified for review, the authors found 12 process and outcome RCTs worthy of further appraisal and 7 articles worthy of inclusion in the final systematic review. This is just one example of the increase in level of rigor in evaluations of healthcare education.

▸ Summary Conducting evaluations in healthcare educa- tion involves gathering, summarizing, inter- preting, and using data to determine the extent to which an educational activity is efficient, effective, and useful for those who participate in that activity as learners, teachers, or sponsors. Five types of evaluation were discussed in this chapter: (1) process, (2) content, (3) outcome, (4) impact, and (5) program evaluations. Each of these types focuses on a specific purpose, scope, and questions to be asked of an educational activity or program to meet the needs of those who ask for the evaluation or who can benefit from its results. Each type of evaluation also re- quires some level of available resources for the evaluation to be conducted.

The number and variety of evaluation models, designs, methods, and instruments are growing exponentially as the importance of evaluation becomes widely accepted in today’s healthcare environment. Many guidelines, rules of thumb, suggestions, and examples were in- cluded in this chapter’s discussion of how a nurse educator might go about selecting the most ap- propriate model, design, methods, and instru- ments for a certain type of evaluation.

627Review Questions

Case Studies Case studies encour- age active learning and promote critical thinking skills in learners. Students can read about real-life scenarios and then analyze the situation they are presented with.

Ammerman, A., Smith, T. W., & Calancie, L. (2014). Practice- based evidence in public health: Improving reach, relevance, and results. Annual Reviews in Public Health , 35 , 47–63. doi:10.1146/annurev-publhealth-032013-182458

Bahreini, M., Moattari, M., Shahamat, S., Dobaradaran, S., & Ravanipour, M. (2013). Improvement of Iranian nurses’ competence through professional portfolio: A quasi-experimental study, Nursing and Health Sciences , 15 , 51–57. doi:10.1111/j.1442-2018.2012.00733.x

Balas, M. C., Burke, W. J., Gannon, D., Cohen, M. Z., Colburn, L., Bevil, C., . . . Vasilevskis, E. E. (2013). Implementing the ABCDE bundle into everyday care: Opportuni- ties, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium (PAD) guidelines. Critical Care Medicine , 41 (9 Suppl. 1), S116–S127. doi: 10.1097/CCM.0b013e3182a17064

Bates, O. L., O’Connor, N., Dunn, D., & Hasenau, S. M. (2014). Applying STAAR interventions in incremental bundles: Improving post-CABG surgical patient care. Worldviews on Evidence-Based Nursing , 11 (2), 89–97.

References Abruzzese, R. S. (1992). Evaluation in nursing staff

development. In R. S. Abruzzese (Ed.), Nursing staff development: Strategies for success (pp. 235–248). St. Louis, MO: Mosby–Year Book.

Adams, R. J. (2010). Improving health outcomes with better patient understanding and education. Dovepress , 2010 (3), 61–72. Retrieved from http://www.ncbi.nlm.nih.gov /pubmed/22312219

Allen, J., Annells, M., Clark, E., Lang, L., Nunn, R., Petrie, E., & Robins, A. (2012). Mixed methods evaluation research for a mental health screening and referral clinical pathway. Worldviews on Evidence-Based Nursing, 9 (3), 172–185.

American Nurses Credentialing Center, Commission on Accreditation. (2014, September). The importance of evaluating the impact of continuing nursing education on outcomes: Professional nursing practice and patient care. Retrieved from http://www.nursecredentialing .org/Accreditation/ResourcesServices/Evaluating-the -Impact-CNE-Outcomes.pdf

CASE STUDY Having recently completed her master’s degree in nursing, Sharon has accepted a new role as clinical nurse educator for three adult medicine units in the medical center where she has been employed as a staff nurse for the past 6 years. Eager to put her education to practice in a manner that would benefit both patients and staff, Sharon meets with the nurse managers of the three units to learn what they view as priority issues on which she should focus. All three managers agree that their primary concern is teaching their staff how to better prepare patients with type 2 diabetes to care for themselves after they are discharged home. One manager comments, “Half of my nurses are new graduates. I’m not even certain that they know much about type 2 diabetes—how on earth can they teach the patients?” The other two managers nod, agreeing with the first, and chime in: “The patients aren’t being taught what they need to know, they don’t believe what they’re hearing, or they don’t understand what they’re hearing. As a result, I’m being told by ambulatory service nurses that our discharged patients aren’t taking their medications, aren’t making any changes in diet or lifestyle, and seem unconcerned about their hyperglycemia.”

You next meet with Eric, the certifi ed diabetes educator at your hospital, and he reminds you that all nurses are mandated to annually review the patient and family education program for patients with type 2 diabetes and complete the cognitive posttest.

1. Which type of evaluation is being conducted every year when the nurses review the program and complete the cognitive test?

2. Which type(s) of evaluation would be most relevant to the nurse manager’s concerns? 3. Putting yourself into Sharon’s place, describe in detail an evaluation that you would conduct

with the patients as a primary audience. 4. If evaluation is so crucial to healthcare education, what are some of the reasons why evaluation

seems often an afterthought or is even overlooked entirely by the educator?

628 Chapter 14 Evaluation in Healthcare Education

Susan B. Bastable, EdD, RN Nursing Education Consultant

Professor Emerita and Founding Chair Department of Nursing

Purcell School of Professional Studies Le Moyne College

Syracuse, New York

Nurse as Educator

Principles of Teaching and Learning for Nursing Practice

FIFTH EDITION

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Library of Congress Cataloging-in-Publication Data Names: Bastable, Susan Bacorn, editor. Title: Nurse as educator : principles of teaching and learning for nursing practice / edited by Susan B. Bastable. Description: Fifth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017030094 | ISBN 9781284127201 (pbk.) Subjects: | MESH: Patient Education as Topic--methods | Teaching | Learning | Nurses’ Instruction Classification: LCC RT42 | NLM WY 105 | DDC 610.73--dc23 LC record available at https://lccn.loc.gov/2017030094

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Printed in the United States of America 21 20 19 18 17 10 9 8 7 6 5 4 3 2 1

In memory of my dear colleague and friend of 43 years, Dr. M. Louise Fitzpatrick, Dean of the College of Nursing at Villanova University for 4 decades. She was

my advisor during my master’s program and chair of my doctoral dissertation committee at Columbia

University and a mentor throughout my professional career. Louise wrote the foreword for my first, second,

and third editions of this text. She was the ultimate educator and her advice, guidance, support, and

friendship will be dearly missed.

To nursing students and professional colleagues who over the years have shared their teaching experiences as well as their knowledge, skills, ideas, and reflections

on the principles of teaching and learning.

viii

Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process . . . . . . . . . . . . . . . . . . . . 35

M. Janice Nelson and Kattiria M. Gonzalez

A Differentiated View of Ethics, Morality, and the Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Evolution of Ethical and Legal Principles in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Application of Ethical Principles to Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

The Ethics of Education in Classroom and Practice Settings . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Legality of Patient Education and Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Legal and Financial Implications of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Economic Factors in Healthcare Education: Justice and Duty Revisited . . . . . . . . . . . . . . . . . . . . 57

Financial Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Program Planning and Implementation . . . . . . . . . . 60

Cost-Benefit Analysis and Cost-Effectiveness Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Chapter 3 Applying Learning Theories to Healthcare Practice . . . . . . . . . 69

Margaret M. Braungart, Richard G. Braungart, and Pamela R. Gramet

Psychological Learning Theories . . . . . . . . . . . . . . . . . 72

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi

About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

PART 1 Perspectives on Teaching and Learning 1

Chapter 1 Overview of Education in Health Care . . . . . . . . . . . . . . . 3

Susan B. Bastable and Kattiria M. Gonzalez

Historical Foundations for Patient Education in Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Evolution of the Teaching Role of Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Social, Economic, and Political Trends Affecting Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Purposes, Goals, and Benefits of Patient and Nursing Staff/Student Education . . . . . . . . . . 12

The Education Process Defined . . . . . . . . . . . . . . . . . . 13

The Contemporary Role of the Nurse as Educator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Barriers to Teaching and Obstacles to Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Questions to Be Asked About Teaching and Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Contents

Contents ix

Neuropsychology and Learning . . . . . . . . . . . . . . . . . 93

Comparison of Learning Theories . . . . . . . . . . . . . . . . 95

Motor Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Common Principles of Learning . . . . . . . . . . . . . . . . 106

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

PART 2 Characteristics of the Learner 117

Chapter 4 Determinants of Learning . . . 119

Sharon Kitchie

The Educator’s Role in Learning . . . . . . . . . . . . . . . . 121

Assessment of the Learner . . . . . . . . . . . . . . . . . . . . . 121

Assessing Learning Needs . . . . . . . . . . . . . . . . . . . . . 122

Methods to Assess Learning Needs . . . . . . . . . . . . 127

Readiness to Learn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Learning Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Learning Style Models and Instruments . . . . . . . . 140

Interpretation of the Use of Learning Style Models and Instruments . . . . . . . . . . . . . . . 159

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Chapter 5 Developmental Stages of the Learner . . . . . . . . . . . . . 169

Susan B. Bastable and Gina M. Myers

Developmental Characteristics . . . . . . . . . . . . . . . . . 171

The Developmental Stages of Childhood . . . . . . 172

The Developmental Stages of Adulthood . . . . . . 192

The Role of the Family in Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner . . . . . . . . . . . . . . . 219

Mary Ann Wafer

Compliance and Adherence . . . . . . . . . . . . . . . . . . . 221

Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Selected Models and Theories . . . . . . . . . . . . . . . . . 235

Models for Health Education . . . . . . . . . . . . . . . . . . . 244

The Role of Nurse as Educator in Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

Chapter 7 Literacy in the Adult Client Population . . . . . . . . . . . . . . . . 257

Susan B. Bastable, Gina M. Myers, and Leigh Bastable Poitevent

Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Scope and Incidence of the Problem . . . . . . . . . . . 266

Trends Associated with Literacy Problems . . . . . . 269

Those at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Myths, Stereotypes, and Assumptions . . . . . . . . . . 272

Assessment: Clues to Look For . . . . . . . . . . . . . . . . . 274

Impact of Illiteracy on Motivation and Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Ethical, Financial, and Legal Concerns . . . . . . . . . . 277

Readability of Printed Education Materials . . . . . 279

Measurement Tools to Test Literacy Levels . . . . . 281

Formulas to Measure Readability of Printed Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . 282

Tests to Measure Comprehension of Printed Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Tests to Measure General Reading Skills and Health Literacy Skills of Clients . . . . . . . . . . 286

Simplifying the Readability of Printed Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . 289

Teaching Strategies to Promote Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

x Contents

Assistive Technologies . . . . . . . . . . . . . . . . . . . . . . . . . 409

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

PART 3 Techniques and Strategies for Teaching and Learning 421

Chapter 10 Behavioral Objectives and Teaching Plans . . . . . . . . 423

Susan B. Bastable and Loretta G. Quigley

Types of Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426

Characteristics of Goals and Objectives . . . . . . . . 426

The Importance of Using Behavioral Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427

Writing Behavioral Objectives and Goals . . . . . . . 428

Common Mistakes When Writing Objectives . . . . . 431

Taxonomy of Objectives According to Learning Domains . . . . . . . . . . . . . . . . . . . . . . . . 432

Development of Teaching Plans . . . . . . . . . . . . . . . 444

Use of Learning Contracts . . . . . . . . . . . . . . . . . . . . . 448

The Concept of Learning Curve . . . . . . . . . . . . . . . . 449

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 453

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455

Chapter 11 Teaching Methods and Settings . . . . . . . . . . . . . . 459

Kathleen Fitzgerald and Kara Keyes

Teaching Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

Selection of Teaching Methods . . . . . . . . . . . . . . . . 486

Evaluation of Teaching Methods . . . . . . . . . . . . . . . 488

Increasing Effectiveness of Teaching . . . . . . . . . . . 489

Settings for Teaching . . . . . . . . . . . . . . . . . . . . . . . . . . 496

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 498

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 301

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner . . . . . . . . . . . . . 315

Susan B. Bastable and Deborah L. Sopczyk

Gender Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 317

Socioeconomic Characteristics . . . . . . . . . . . . . . . . . 327

Cultural Characteristics . . . . . . . . . . . . . . . . . . . . . . . . 330

Assessment Models for the Delivery of Culturally Sensitive Care . . . . . . . . . . . . . . . . . . . . . 330

The Four Major Subcultural Ethnic Groups . . . . . 337

Preparing Nurses for Diversity Care . . . . . . . . . . . . . 353

Stereotyping: Identifying the Meaning, the Risks, and the Solutions . . . . . . . . . . . . . . . . . 354

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359

Chapter 9 Educating Learners with Disabilities and Chronic Illnesses . . . . . . . . . . . . . . . . . . 369

Deborah L. Sopczyk

Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . 371

Models and Definitions . . . . . . . . . . . . . . . . . . . . . . . . 372

The Language of Disabilities . . . . . . . . . . . . . . . . . . . 374

The Roles and Responsibilities of Nurse Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Types of Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376

Sensory Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Learning Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Developmental Disabilities . . . . . . . . . . . . . . . . . . . . 393

Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

Physical Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

Communication Disorders . . . . . . . . . . . . . . . . . . . . . 403

Chronic Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407

The Family’s Role in Chronic Illness or Disability . . . 408

Contents xi

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy and Tools to Assess Instructional Materials . . . . 633

How to Use the Flesch–Kincaid Scale . . . . . . . . . . 633

How to Use the Fog Formula . . . . . . . . . . . . . . . . . . . 634

How to Use the Fry Readability Graph . . . . . . . . . . 634

How to Use the SMOG Formula . . . . . . . . . . . . . . . . 635

The Cloze Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637

Guidelines for Writing and Evaluating Printed Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . 642

Newest Vital Sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649

Appendix B Resources and Organizations for People with Disabilities . . . . . . . . . . . . . . 651

Assistive Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . 651

Augmentations and Alternative Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651

Blindness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651

Deafness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652

Developmental Disabilities . . . . . . . . . . . . . . . . . . . . 652

Disability Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652

Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Healthcare-Related Federal Agencies . . . . . . . . . . 653

Learning Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653

Neuromuscular Disorders . . . . . . . . . . . . . . . . . . . . . . 654

Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675

Chapter 12 Instructional Materials . . . . 505

Diane Hainsworth and Kara Keyes

General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507

Choosing Instructional Materials . . . . . . . . . . . . . . . 507

The Three Major Components of Instructional Materials . . . . . . . . . . . . . . . . . . . . . . . 508

Types of Instructional Materials . . . . . . . . . . . . . . . . 510

Evaluating Instructional Materials . . . . . . . . . . . . . . 537

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 539

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544

Chapter 13 Technology in Education . . . 549

Deborah L. Sopczyk

Health Education in a Technology-Based World . . . 551

The Impact of Technology on the Teacher and the Learner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554

Strategies for Using Technology in Healthcare Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557

The Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572

Issues Related to the Use of Technology . . . . . . . . 581

Technology for Professional Development in Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 587

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589

Chapter 14 Evaluation in Healthcare Education . . . . . . . . . . . . . . . . 595

Priscilla Sandford Worral

Evaluation, Evidence-Based Practice, and Practice-Based Evidence . . . . . . . . . . . . . . . . . . . . 597

Evaluation Versus Assessment . . . . . . . . . . . . . . . . . . 598

Evaluation Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600

Designing the Evaluation . . . . . . . . . . . . . . . . . . . . . . 611

Conducting the Evaluation . . . . . . . . . . . . . . . . . . . . 622

Analyzing and Interpreting Data Collected . . . . . 623

Reporting Evaluation Results . . . . . . . . . . . . . . . . . . . 625

State of the Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 626

xii

social and cultural requirements. Nurses also play a vital role in teaching other members of the healthcare team and in educating the next generation of nurses.

The author and her chapter contribu- tors have anticipated and explored all the di- mensions of teaching and learning in this very important text. Although it includes the funda- mentals of learning theories, teaching methods, and instructional materials, Nurse as Educator also focuses on critical issues such as readiness to learn, learning styles, motivation and com- pliance, and teaching people with disabilities, all based on the latest research and theoretical underpinnings.

Nurses will greatly benefit from the content and format of this comprehensive and well-or- ganized book that prepares them to fully em- brace the new challenges of an ever-changing healthcare environment. The knowledge, skills, and commitment of nurses in educating patients and families to manage their care independently and in teaching colleagues and students to prac- tice competently for the delivery of high- quality, compassionate, and efficient care will drive the necessary improvements in the health system and will demonstrate their leadership in trans- forming health care.

Nancy Schlichting Retired President and CEO Henry Ford Health System

Former Chair, Commission on Care Director, Walgreens Boots Alliance and

Hill-Rom Holdings, Inc.

Health care in the United States is being delivered during a time of great uncer-tainty, transformation, and consumer- ism. Patients and communities are demanding greater control and input into their healthcare decisions and how care should be provided. The positive impact of healthcare reform is improv- ing access to care, but the need continues for a more integrated and equitable health system, driven by highly competent and compassionate caregivers who fully understand and embrace the needs of their patients and who collaborate with all members of the healthcare team. In ad- dition, the future will require a relentless focus on quality, care coordination, innovation, and efficiency in an environment of ever scarcer re- sources and disruptive forces.

Nurse as Educator recognizes these sea changes and builds on the author’s four suc- cessful editions of the book, which have given nurses invaluable strategies for partnering with patients and serving the community. Nurses are the most trusted members of the health- care team and Nurse as Educator gives them all of the practical tools they need to provide ef- fective and efficient patient/family education as well as to educate nursing colleagues and nurs- ing students.

This book could not be more timely as nurses strive to enhance their patients’ abil- ity to manage their own care, educate fam- ily members to support the overwhelming complexity of clinical protocols, and under- stand the needs of learners who have highly variable levels of health literacy and diverse

Foreword

xiii

However, nurses are not born with the in- nate ability to teach or to understand the ways in which people learn. The art and science of teaching takes special expertise about how to best communicate information and about how that information is most successfully acquired by the learner. Teaching patients, staff, and stu- dents is critical to the provision of high-qual- ity nursing care, and nurses must capture this domain as an important and unique aspect of their holistic approach to professional practice.

This text is a timely resource that provides approaches essential to addressing many of to- day’s pressing issues in the healthcare environ- ment. The growing demand for nurses to deliver the highest quality of care possible, the criti- cal shortage of faculty in nursing schools na- tionwide, the significant problem of consumer health literacy, the ongoing movement to guar- antee access to care for all, the technological ad- vances increasing the complexity of health care, the changing demographics of the population, the increasing emphasis on health promotion and disease prevention, and the rise in chronic illnesses are just a few of the many important trends. Not only is it recognized that patient ed- ucation by nurses can significantly improve cli- ent health outcomes, but consumers today must be taught how to independently manage their own care. In turn, nurses must be adequately prepared as lifelong learners to participate in the constantly transformative and challenging system of health care.

The content of this text reflects a balance be- tween theories and models associated with teach- ing and learning and their application to the real world of patient, staff, and student education.

This text has been written for staff nurses as caregivers and as staff educators for whom the role of teacher is a significant practice component of their daily activities, for undergraduate and graduate nursing students learning the knowledge and skills to become the professional nurses of tomorrow, as well as for faculty teaching in academic nursing pro- grams to prepare future nurses at all levels of education. No matter their role or status, it is a legal, ethical, and moral responsibility of nurses practicing in any setting to teach others, whether their audience consists of patients and families, fellow colleagues, or prospective members of the profession. Mandates included in the nurse practice acts of all states and territories, expec- tations by the national and regional standards of nursing organizations and accrediting bodies, and the policies and procedures adopted by lo- cal healthcare institutions and agencies require that nurses function in the role of educators.

Teaching patients and their significant oth- ers has been the obligation of nurses since the profession began during the era of Florence Nightingale. Since then, the scope of nurs- ing practice has significantly evolved and has grown to include nurses teaching members of their own discipline to render safe, high-qual- ity care. Nevertheless, most nurses acknowledge that they have not had the formal preparation to successfully and securely carry out their ed- ucator role. Every nurse must have the knowl- edge and skills to competently and confidently teach learners with various needs in a variety of settings. Also, they must be able to do so with efficiency and effectiveness based on a solid mas- tery of the principles of teaching and learning.

Preface

xiv Preface

In essence, this text provides answers to ques- tions that pertain to the teaching process—who, what, where, when, how, and why.

Thus, the focus of this text is on the con- temporary role of the nurse as educator. Teach- ing patients, well or ill, to maintain optimal health and to prevent disease and disability as- sists them to become as independent as possi- ble in self-care activities. Properly educating consumers has the potential to accomplish the economic goal of reducing the high costs of healthcare services. Teaching staff and students to competently, confidently, effectively, and ef- ficiently practice in an interdisciplinary man- ner in any setting with individuals and groups from diverse backgrounds will ensure the de- livery of high-quality care.

I sincerely hope that this text serves as an invaluable resource to its readers who are striv- ing to become adept at delivering patient, staff, and/or student education based on the princi- ples of how the nurse can best teach and how consumers can best learn. As nurses, we must never forget our solemn duty to make a pos- itive difference in the lives of those we serve, and teaching is a major factor that influences the health, development, and well-being of our audience of learners.

Susan B. Bastable, EdD, RN Nursing Education Consultant

Professor Emerita and Founding Chair Department of Nursing

Purcell School of Professional Studies Le Moyne College

This latest edition fully acknowledges the im- portant role of the professional nurse as well as the changing role of the consumer of health care with respect to accountability and responsibil- ity for teaching and learning. No longer should the nurse be the giver of information only but must function as the guide on the side and as the facilitator in partnership with the consumer, who must assume a much greater role in learn- ing. The philosophy of the interdependence be- tween the teacher and learner in the education process is emphasized throughout the chapters.

All chapters have been revised to include new content, such as information on nursing education transformation, patient engagement, quality and safety education in nursing, interpro- fessional education, patient portals, new findings in neuroscience on gender differences in learn- ing, and third-party reimbursement for nurses doing patient teaching. Also, the most updated references have been added to every chapter, but classic works relevant to the field of educa- tion have been retained. Current statistics reflect changes in population trends, and new tables and figures have been added to visually sum- marize the information presented. In addition, the most recent websites are provided through- out the text as sources of further information on particular topics. And, by popular demand, case study scenarios have been retained at the end of each chapter for application of teach- ing and learning principles to nursing practice.

This text is comprehensive in scope, taking into consideration the basic foundations of the education process, the needs and characteristics of learners, the appropriate techniques and strat- egies for instruction, and the methods to eval- uate the achievement of educational outcomes.

publication. The incredible copyediting skills of Sandra Kerka must be acknowledged, too. All of them together are a very talented team of professionals!

In addition, Cathleen Scott, science librar- ian at Le Moyne College, worked diligently be- hind the scenes in locating relevant and current references used to update the content of many of the chapters. She made herself available at all times and responded promptly to my many re- quests for books and full-text journal articles. The in-depth investigation of resources for this book could not have been possible without her.

Thanks, too, to Nancy Schlichting who has written the foreword in this text. She has been a national leader in health care for decades and is recognized for her keen mind, person-centered leadership, incredible compassion toward oth- ers, and innovative spirit in transforming health- care delivery and advocating for the health of the public. She has been a close friend and col- league for many years.

And last, but certainly not least, my hus- band, Jeffrey, deserves the deepest gratitude from me for his steadfast support during the count- less hours and endless months that I devoted to research, writing, and editing, which was key to making this fifth edition a reality.

A special appreciation is extended to the original authors of the 14 chapters whose valuable work provided the founda- tion for adding new material to this most re- cent fifth edition. I am grateful for the loyalty of seven contributors who agreed to once again edit their own work and for a group of new col- leagues who joined the team to contribute their professional knowledge, practice expertise, and fresh perspectives in revising the content of the remaining chapters. Every one of them dedi- cated their efforts to significantly updating the information and references contained in ev- ery chapter for the benefit of the intended au- dience of readers.

Also, I extend my sincerest thanks to the entire publishing staff of the nursing division of Jones & Bartlett Learning for making this new- est edition possible. In particular, I would like to acknowledge Amanda Martin, director of prod- uct management; Rebecca Stephenson, product manager; Vanessa Richards, production editor; Wes DeShano, rights and media specialist; and Jennifer Scherzay, senior marketing manager. They have provided expert technical advice and guidance, organizational skills, and con- stant support, understanding, and encourage- ment throughout the process of launching this

Acknowledgments

xvi

Diane Hainsworth, MS, RN-C, ANP Clinical Case Manager—Oncology (retired) University Hospital State University of New York Upstate Medical University Syracuse, New York

Kara Keyes, MS, RN-BC, Doctoral Candidate Professor of Practice Department of Nursing Purcell School of Professional Studies Le Moyne College Syracuse, New York

Sharon Kitchie, PhD, RN Adjunct Instructor Keuka College Keuka Park, New York Director of Patient Education and Interpreter

Services (retired) University Hospital SUNY Upstate Medical University Syracuse, New York

Gina M . Myers, PhD, RN Adjunct Faculty Department of Nursing Purcell School of Professional Studies Le Moyne College Syracuse, New York Associate/Research Consultant St. Joseph’s Hospital Health Center Syracuse, New York

M . Janice Nelson, EdD, RN Professor and Dean Emerita College of Nursing State University of New York Upstate Medical University Syracuse, New York

Susan B . Bastable, EdD, RN Nursing Education Consultant Professor Emerita and Founding Chair Department of Nursing Purcell School of Professional Studies Le Moyne College Syracuse, New York

Margaret M . Braungart, PhD Professor Emerita of Psychology Center for Bioethics and Humanities State University of New York Upstate Medical University Syracuse, New York

Richard G . Braungart, PhD Professor Emeritus of Sociology and

International Relations Maxwell School of Citizenship and Public Affairs Syracuse University Syracuse, New York

Kathleen Fitzgerald, MS, RN, CDE Patient Educator (retired) St. Joseph’s Hospital Health Center Syracuse, New York

Kattiria M . Gonzalez, MS, RN, Doctoral Candidate Clinical Coordinator—Instructor Department of Nursing Purcell School of Professional Studies Le Moyne College Syracuse, New York

Pamela R . Gramet, PhD, PT Associate Professor and Chair (retired) Department of Physical Therapy State University of New York Upstate Medical University Syracuse, New York

Contributors

Contributors xvii

Mary Ann Wafer, PhD, RN, BC, CPHQ, CPHRM Former Associate, Quality Resources Associate for Alumni and Development for

the College of Nursing St. Joseph’s Hospital Health Center Syracuse, New York

Priscilla Sandford Worral, PhD, RN, FNAP Nurse Research Scientist University Hospital State University of New York Upstate Medical University Syracuse, New York

Leigh Bastable Poitevent, FNP, RN Former Critical Care Nurse, United States

Navy Nurse Corps Family Nurse Practitioner CVS Caremark Minute Clinic Cambridge, Massachusetts

Loretta G . Quigley, EdD, RN, CNE Academic Dean St. Joseph’s College of Nursing Syracuse, New York

Deborah L . Sopczyk, PhD, RN Provost and Chief Academic Officer Excelsior College Albany, New York

xviii

Susan Bacorn Bastable earned her MEd in com- munity health nursing and her EdD in curric- ulum and instruction in nursing at Teachers College, Columbia University, in 1976 and 1979, respectively. She received her diploma in nursing from Hahnemann Hospital School of Nursing (now known as Drexel Univer- sity of the Health Sciences) in Philadelphia in 1969 and her bachelor’s degree in nursing from Syracuse University in 1972.

Dr. Bastable was professor and found- ing chair of the Department of Nursing at Le Moyne College in Syracuse, New York for 11 years. She retired in May 2015 and was hon- ored with the title of professor emerita. She began her academic career in 1979 as assis- tant professor at Hunter College, Bellevue School of Nursing in New York City, where she remained on the faculty for 2 years. From 1987 to 1989, she was assistant professor in the College of Nursing at the University of Rhode Island. In 1990, she joined the faculty of the College of Nursing at the State Univer- sity of New York (SUNY) at Upstate Medical University in Syracuse, where she was associ- ate professor and chair of the undergraduate program for 14 years. In 2004, she assumed her leadership position at Le Moyne College and successfully established an RN-BS com- pletion program; an innovative 4-year under- graduate dual-degree partnership in nursing (DDPN) supported by a Robert Wood Johnson Foundation grant in conjunction with the as- sociate’s degree program at St. Joseph’s College of Nursing in Syracuse; a BS-MS bridge pro- gram; a postbaccalaureate RN-MS certificate

About the Author

program; a master of science program and three post-MS certificate programs with tracks in nursing education, nursing administration, and informatics; and most recently a family nurse practitioner (FNP) program as well as a post-MS FNP option.

Dr. Bastable has taught undergraduate courses in nursing research, community health, and the role of the nurse as educator, and courses at the master’s and postmaster’s level in the academic faculty role, curriculum and program development, and educational assess- ment and evaluation. For 31 years she served as consultant and external faculty member for Excelsior College (formerly known as Regents College of the University of the State of New York). Her clinical practice includes experiences

About the Author xix

In addition to authoring five editions of Nurse as Educator, she is the author of Essentials of Patient Education and is the main editor of the textbook Health Professional as Educator.

Currently, she actively serves in the role of a nursing education consultant for national and regional program accreditations and to assist colleges of nursing across New York and other states in replicating the unique 1+2+1 dual degree partnership model mentioned herein, the first of its kind in the country.

in community health, oncology, rehabilitation and neurology, occupational health, and med- ical/surgical nursing.

Dr. Bastable received the President’s Award for Excellence in Teaching at Upstate Medical University and the SUNY Chancellor’s Award for Excellence in Teaching. Also, she was rec- ognized for the Women in Leadership award from the Greater Syracuse Chamber of Com- merce and was honored with the Distinguished Achievement Award in Nursing Education from Teacher’s College, Columbia University.

PART ONE

Perspectives on Teaching and Learning CHAPTER 1 Overview of Education in Health Care

CHAPTER 2 Ethical, Legal, and Economic Foundations of the Educational Process

CHAPTER 3 Applying Learning Theories to Healthcare Practice

Overview of Education in Health Care Susan B. Bastable Kattiria M. Gonzalez

CHAPTER 1

CHAPTER HIGHLIGHTS

• Nursing Education Transformation • Patient Engagement • Quality and Safety Education in Nursing • The Institute of Medicine Report: The Future of Nursing

■ Barriers to Teaching and Obstacles to Learning • Factors Affecting the Ability to Teach • Factors Affecting the Ability to Learn

■ Questions to Be Asked About Teaching and Learning ■ State of the Evidence

KEY TERMS

education process teaching/instruction learning

patient education staff education

barriers to teaching obstacles to learning

Education in health care today—both pa-tient education and nursing staff/student education—is a topic of utmost interest to nurses in every setting in which they practice. Teaching is an important aspect of the nurse’s professional role (Andersson, Svanström, Ek, Rosén, & Berglund, 2015; Friberg, Granum, & Bergh, 2012), whether it be educating patients and their family members, colleagues, or nursing students. The current trends in health care are making it essential that patients be prepared to assume responsibility for self-care management and that nurses in the workplace be accountable for the delivery of safe, high-quality care (Hines & Barndt-Maglio, 2011; Lockhart, 2016; Shi & Singh, 2015; U. S. Department of Health and Human Services [USDHHS], 2015). The fo- cus of modern health care is on outcomes that demonstrate the extent to which patients and their significant others have learned essential knowl- edge and skills for independent care or to which staff nurses and nursing students have acquired the up-to-date knowledge and skills needed to competently and confidently render care to the consumer in a variety of settings (Adams, 2010; Committee on Quality of Health Care in Amer- ica & Institute of Medicine [IOM], 2001; Doyle, Lennox, & Bell, 2013).

According to Friberg and colleagues (2012), patient education is an issue in nursing practice and will continue to be a significant focus in

OBJECTIVES

After completing this chapter, the reader will be able to

1. Discuss the evolution of patient education in health care and the teaching role of nurses. 2. Recognize trends affecting the healthcare system in general and nursing practice in

particular. 3. Identify the purposes, goals, and benefits of patient and nursing staff/student education. 4. Compare the education process to the nursing process. 5. Define the terms education process, teaching, and learning. 6. Identify why patient and staff/student education is an important duty for nurses. 7. Discuss the barriers to teaching and the obstacles to learning. 8. Formulate questions that nurses in the role of educator should ask about the teaching–learning

process.

the healthcare environment. Because so many changes are occurring in the healthcare system, nurses are increasingly finding themselves in challenging, constantly changing, and highly complex positions (Gillespie & McFetridge, 2006). Nurses in the role of educators must un- derstand the forces, both historical and present day, that have influenced and continue to influ- ence their responsibilities in practice.

One purpose of this chapter is to shed light on the historical evolution of patient education in health care and the nurse’s role as teacher. An- other purpose is to offer a perspective on the cur- rent trends in health care that make the teaching of clients a highly visible and required function of nursing care delivery. Also, this chapter ad- dresses the continuing education efforts neces- sary to ensure ongoing practice competencies of nursing personnel.

In addition, this chapter clarifies the broad purposes, goals, and benefits of the teaching– learning process; focuses on the philosophy of the nurse–client partnership in teaching and learning; compares the education process to the nursing process; identifies barriers to teaching and obstacles to learning; and highlights the sta- tus of research in the field of patient education as well as in the education of nursing staff and students. The focus is on the overall role of the nurse in teaching and learning, no matter who the audience of learners might be. Nurses must

4 Chapter 1 Overview of Education in Health Care

have a basic prerequisite understanding of the principles and processes of teaching and learn- ing to carry out their professional practice re- sponsibilities with efficiency and effectiveness.

▸ Historical Foundations for Patient Education in Health Care

“Patient education has been a part of health care since the first healer gave the first patient advice about treating his (or her) ailments” (May, 1999, p. 3). Although the term patient education was not specifically used, considerable efforts by the earliest healers to inform, encourage, and cau- tion patients to follow appropriate hygienic and therapeutic measures occurred even in prehis- toric times (Bartlett, 1986). Because these early healers—physicians, herbalists, midwives, and shamans—did not have a lot of effective diag- nostic and treatment interventions, it is likely that education was, in fact, one of the most com- mon interventions (Bartlett, 1986).

From the mid-1800s through the turn of the 20th century, described as the formative period by Bartlett (1986) and as the first phase in the development of organized health care by Dreeben (2010), several key factors influenced the growth of patient education. The emergence of nursing and other health professions, tech- nological developments, the emphasis on the patient– caregiver relationship, the spread of tu- berculosis and other communicable diseases, and the growing interest in the welfare of mothers and children all had an impact on patient educa- tion (Bartlett, 1986; Dreeben, 2010). In nursing, Florence Nightingale emerged as a resolute advo- cate of the educational responsibilities of district public health nurses and authored Health Teach- ing in Towns and Villages, which advocated for school teaching of health rules as well as health teaching in the home (Monterio, 1985).

Dreeben (2010) describes the first 4 decades of the 20th century as the second phase in the

development of organized health care. In sup- port of maternal and child health in the United States, the Division of Child Hygiene was estab- lished in New York City in 1908 (Bartlett, 1986). Under the auspices of this organization, public health nurses provided instruction to mothers of newborns in the Lower East Side on how to keep their infants healthy. Diagnostic tools, sci- entific discoveries, new vaccines and antibiotic medications, and effective surgery and treatment practices led to education programs in sanita- tion, immunization, prevention and treatment of infectious diseases, and a growth in the U.S. public health system. The National League of Nursing Education (NLNE) recognized that pub- lic health nurses were essential to the well-being of communities and the teaching they provided to individuals, families, and groups was consid- ered “a precursor to modern patient and health education” (Dreeben, 2010, p.11).

The third phase in the development of orga- nized health care began after World War II. It was a time of significant scientific accomplishments and a profound change in the delivery system of health care (Dreeben, 2010). From the late 1940s through the 1950s is described as a time when patient education continued to occur as part of clinical encounters, but often it was overshad- owed by the increasingly more technological ori- entation of health care (Bartlett, 1986). The first references in the literature to patient education began to appear in the early 1950s (Falvo, 2004). In 1953, Veterans Administration (VA) hospi- tals issued a technical bulletin titled Patient Ed- ucation and the Hospital Program. This bulletin identified the nature and scope of patient edu- cation and provided guidance to all hospital ser- vices involved in patient education (Veterans Administration, 1953).

In the 1960s and 1970s, patient education began to be seen as a specific task where empha- sis was placed on educating individual patients rather than providing general public health ed- ucation. Developments during this time, such as the civil rights movement, the women’s move- ment, and the consumer and self-help move- ment, all affected patient education (Bartlett,

Historical Foundations for Patient Education in Health Care 5

using the term health education (Falvo, 2004). Nixon later appointed the President’s Commit- tee on Health Education, which recommended that hospitals offer health education to families of patients (Bartlett, 1986; Weingarten, 1974). Although the terms health education and pa- tient education were used interchangeably, this recommendation had a great impact on the fu- ture of patient education because a health edu- cation focal point was established in what was then the U.S. Department of Health, Education, and Welfare (Falvo, 2004).

Resulting from this committee’s recom- mendations, the American Hospital Associa- tion (AHA) appointed a special committee on health education (Falvo, 2004). The AHA com- mittee suggested that it was a responsibility of hospitals as well as other healthcare institutions to provide educational programs for patients and that all health professionals were to be in- cluded in patient education (AHA, 1976). Also, the healthcare system began to pay more atten- tion to patient rights and protections involving informed consent (Roter, Stashefsky-Margalit, & Rudd, 2001).

Also in the early 1970s, patient education was a significant part of the AHA’s Statement on a Patient’s Bill of Rights, affirmed in 1972 and then formally published in 1973 (AHA, 1973). This document outlines patients’ rights to re- ceive current information about their diagno- sis, treatment, and prognosis in understandable terms as well as information that enables them to make informed decisions about their health care. The Patient’s Bill of Rights also guarantees a patient’s right to respectful and considerate care. The adoption of this bill of rights promoted additional growth in the concept of patient ed- ucation, which reinforced the concept as a “pa- tient right” as well as it being seen an obligation and legal responsibility of health professionals. In addition, patient education was recognized as a condition of high-quality care and as a fac- tor that could affect the efficiency of the health- care system (Falvo, 2004). Furthermore, during the 1970s, insurance companies began to deal

1986; Nyswander, 1980; Rosen, 1977). In the 1960s, voluntary agencies and the U.S. Pub- lic Health Service funded several patient and family education projects dealing with conges- tive heart failure, stroke, cancer, and renal dial- ysis, and hospitals in a variety of states became involved in various education programs and projects (Public Health Service, 1971). By the mid-1960s, patients were recognized as health- care consumers and society adopted the new perspective that health care was a right and not a privilege for all Americans. In 1965, the U.S. Congress passed Titles XVIII and XIX of the Social Security Act that created respectively the Medicare and Medicaid plans to provide health care to indigent persons, older adults, and peo- ple with medical disabilities (Dreeben, 2010).

Concerned that patient education was be- ing provided only occasionally and that patients were not routinely being given information that would allow them to participate in their own health care, the American Public Health Asso- ciation formed a multidisciplinary Committee on Educational Tasks in Chronic Illness in 1968 that recommended a more formal approach to patient education (Public Health Service, 1971). One of the committee’s seven basic premises was an educational prescription that would base teaching on individual patient needs and be in- cluded as part of the patient’s record. This rec- ommendation represented one of the earliest mentions of the documentation of patient edu- cation (Falvo, 2004). The committee ultimately developed a model that defined the educational processes necessary for patient and family ed- ucation that could be used with any illness by any member of the healthcare team (Health Ser- vices and Mental Health Administration, 1972).

In 1971, two significant events occurred: (1) A publication from the U.S. Department of Health, Education, and Welfare, titled The Need for Patient Education, emphasized a concept of patient education that provided information about disease and treatment as well as teaching patients how to stay healthy, and (2) President Richard Nixon issued a message to Congress

6 Chapter 1 Overview of Education in Health Care

agencies or organizations must provide to re- ceive accreditation. Required accreditation stan- dards have provided the impetus for nursing service managers to emphasize unit-based clin- ical staff education activities for the improve- ment of nursing care interventions to achieve expected client outcomes (JCAHO, 2001). These standards required nurses to achieve positive outcomes of patient care through teaching ac- tivities that must be patient centered and family oriented. More recently, TJC expanded its ex- pectations to include an interdisciplinary team approach in the provision of patient education as well as evidence that patients and their sig- nificant others participate in care and deci- sion making and understand what they have been taught. This requirement means that all healthcare providers must consider the liter- acy level, educational background, language skills, and culture of every client during the ed- ucation process (Cipriano, 2007; Davidhizar & Brownson, 1999; JCAHO, 2001).

In the mid-1990s, the Pew Health Profes- sions Commission (1995), influenced by the dra- matic changes surrounding health care, published a broad set of competencies it believed would mark the success of the health professions in the 21st century. Shortly thereafter, the commission released a fourth report as a follow-up on health professional practice in the new millennium (Pew Health Professions Commission, 1998). This report offered recommendations pertinent to the scope and training of all health professional groups, as well as a new set of competencies for the 21st century. Many of the competencies deal with the teaching role of health professionals, in- cluding nurses. These competencies for the prac- tice of health care include the need for all health professionals to do the following:

■ Embrace a personal ethic of social respon- sibility and service

■ Provide evidence-based, clinically competent care

■ Incorporate the multiple determinants of health in clinical care

with issues surrounding patient education, be- cause they saw how patient education could positively influence the costs of health care (Bartlett, 1986).

Further support for and validation of pa- tient education as a right and expectation of high-quality health care came in the 1976 edi- tion of the Accreditation Manual for Hospitals published by the Joint Commission on Accredi- tation of Healthcare Organizations, now known as The Joint Commission (Falvo, 2004). This man- ual broadened the scope of patient education to include both outpatient and inpatient services and specified that criteria for patient education should be established. Patients had to receive in- formation about their medical problem, prognosis, and treatment, and evidence had to be provided indicating that patients understood the informa- tion they were given (Joint Commission on Ac- creditation of Healthcare Organizations, 1976).

In the 1980s and 1990s, national health education programs once again became pop- ular as healthcare trends focused on disease prevention and health promotion. This evolu- tion represented a logical response to the cost- containment efforts occurring in health care at that time (Dreeben, 2010). The U.S. Department of Health and Human Services’ Healthy People 2000: National Health Promotion and Disease Prevention Objectives, issued in 1990 and build- ing on the U.S. Surgeon General’s Healthy Peo- ple report of 1979, established important goals for national health promotion and disease pre- vention in 22 areas (USDHHS, Office of Dis- ease Prevention and Health Promotion, 2000). Establishing educational and community-based programs was one of the priority areas identi- fied in this document.

Also, in recognition of the importance of patient education by nurses, The Joint Com- mission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), established nursing standards for patient education as early as 1993. These stan- dards, known as mandates, describe the type and level of care, treatment, and services that

Historical Foundations for Patient Education in Health Care 7

Healthy People initiative, Healthy People 2020 is the product of an extensive evaluation process by stakeholders. Its 40 topic areas support four overarching goals: attaining high-quality and longer lives; achieving health equity and elim- inating disparities; creating social and physi- cal environments that promote good health for all; and promoting quality of life, healthy de- velopment, and behaviors across the entire life span (USDHHS, 2010). Patient education is a fundamental component of these far-reaching national initiatives. Presently, the Secretary of Health and Human Services is in the process of establishing an advisory committee, informed by the latest scientific evidence, for the devel- opment and implementation of recommenda- tions on national health promotion and disease prevention objectives for Health People 2030 (USDHHS, 2017).

Thus, since the 1980s the role of the nurse as educator has undergone a paradigm shift, evolv- ing from what once was a disease-oriented ap- proach to a more prevention-oriented approach. In other words, the focus is on teaching for the promotion and maintenance of health (Roter et al., 2001). Education, which was once done as part of discharge planning at the end of hos- pitalization, has expanded to become part of a comprehensive plan of care that occurs across the continuum of the healthcare delivery pro- cess (Davidhizar & Brownson, 1999).

As described by Grueninger (1995), this transition toward wellness entails a progres- sion “from disease-oriented patient education (DOPE) to prevention-oriented patient edu- cation (POPE) to ultimately become health- oriented patient education (HOPE)” (p. 53). In- stead of the traditional aim of simply imparting information, the emphasis is now on empow- ering patients to use their potentials, abilities, and resources to the fullest (Glanville, 2000; Kelliher, 2013). Along with supporting patient empowerment, nurses must be mindful to con- tinue to ensure the protection of “patient voice” and the therapeutic relationship in patient edu- cation against the backdrop of ever-increasing

■ Rigorously practice preventive health care ■ Improve access to health care for those with

unmet health needs ■ Practice relationship-centered care with

individuals and families ■ Provide culturally sensitive care to a diverse

society ■ Use communication and information tech-

nology effectively and appropriately ■ Continue to learn and help others learn

For the 21st century, the Institute for Health- care Improvement announced the 5 Million Lives campaign in 2006. This campaign’s ob- jective was to reduce the 15 million incidents of medical harm that occur in U.S. hospitals each year. Such an ambitious campaign has ma- jor implications for teaching patients and their families as well as teaching staff and students the ways they can improve care to reduce in- juries, save lives, and decrease costs of health care (Berwick, 2006).

Another initiative was the formation of the Sullivan Alliance to recruit and educate health professionals, including nurses, to de- liver culturally competent care to the public they serve. Effective health care and health education of patients and their families de- pend on a sound scientific base and cultural awareness in an increasingly diverse society. This organization’s goal is to increase the ra- cial and cultural mix of health professional faculty, students, and staff, who are sensitive to the needs of clients of diverse backgrounds (Sullivan & Bristow, 2007).

Also, following on the heels of Healthy Peo- ple 2000, Healthy People 2010 built on the pre- vious two initiatives and provided an expanded framework for health prevention for the nation (USDHHS, 2000). Specific goals and objectives included the development of effective health ed- ucation programs to assist individuals to rec- ognize and change risk behaviors, to adopt or maintain healthy practices, and to make appro- priate use of available services for health care (USDHHS, 2010). As the latest iteration of the

8 Chapter 1 Overview of Education in Health Care

health teaching as a function within the scope of nursing practice. Two decades later, this or- ganization recognized nurses as agents for the promotion of health and the prevention of ill- ness in all settings in which they practiced (NLNE, 1937). By 1950, the NLNE had identi- fied course content in nursing school curricula to prepare nurses to assume the role. Most re- cently, the NLN (2006) developed the first Cer- tified Nurse Educator (CNE) exam to raise “the visibility and status of the academic nurse ed- ucator role as an advanced professional prac- tice discipline with a defined practice setting” (Klestzick, 2005, p. 1).

In similar fashion, the American Nurses Association (ANA, 2015) has for years issued statements on the functions, standards, and qual- ifications for nursing practice, of which patient teaching is a key element. In addition, the Inter- national Council of Nurses (ICN, 2012) has long endorsed the nurse’s role as patient educator to be an essential component of nursing care delivery.

Today, all state nurse practice acts (NPAs) in- clude teaching within the scope of nursing prac- tice responsibilities. Nurses, by legal mandate of their NPAs, are expected to provide instruction to consumers to assist them to maintain optimal levels of wellness and manage illness. Nursing career ladders often incorporate teaching effec- tiveness as a measure of excellence in practice (Rifas, Morris, & Grady, 1994). By teaching pa- tients and families, nurses can achieve the pro- fessional goal of providing cost-effective, safe, and high-quality care (Santo, Tanguay, & Purden, 2007; Shi & Singh, 2015).

A variety of other health professions also identify their commitment to patient education in their professional documents (Falvo, 2004). Standards of practice, practice frameworks, ac- creditation standards, guides to practice, and practice acts of many health professions de- lineate the educational responsibilities of their members. In addition, professional workshops and continuing education programs routinely address the skills needed for high-quality pa- tient and staff education. Although specific

productivity expectations and time constraints (Liu, Yu, & Yuan, 2016; Roter et al., 2001).

▸ The Evolution of the Teaching Role of Nurses

Nursing is unique among the health professions in that patient education has long been consid- ered a major component of standard care given by nurses. Since the mid-1800s, when nursing was first acknowledged as a unique discipline, the responsibility for teaching has been recog- nized as an important role of nurses as caregiv- ers. The focus of nurses’ teaching efforts is on the care of the sick and promoting the health of the well public.

Florence Nightingale, the founder of mod- ern nursing, was the ultimate educator. Not only did she develop the first school of nursing, but she also devoted a large portion of her career to teaching nurses, physicians, and health officials about the importance of proper conditions in hospitals and homes to improve the health of people. Nightingale also emphasized the impor- tance of teaching patients the need for adequate nutrition, fresh air, exercise, and personal hy- giene to improve their well-being. By the early 1900s, public health nurses in the United States clearly understood the significance of the role of the nurse as teacher in preventing disease and in maintaining the health of society (Chachkes & Christ, 1996; Dreeben, 2010).

For decades, then, patient teaching has been recognized as an independent nursing function. Nurses have always educated others—patients, families, colleagues, and nursing students. It is from these roots that nurses have expanded their practice to include the broader concepts of health and illness (Glanville, 2000).

As early as 1918, the NLNE in the United States, now known as the National League for Nursing (NLN), observed the importance of

The Evolution of the Teaching Role of Nurses 9

▸ Social, Economic, and Political Trends Affecting Health Care

In addition to the professional and legal stan- dards various organizations and agencies have put forth, many social, economic, and political trends nationwide that affect the public’s health have focused attention on the role of the nurse as teacher and the importance of client, staff, and student education. The following are some of the significant forces influencing nursing practice, in particular, and healthcare practice, in general (Ainsley & Brown, 2009; Berwick, 2006; Birch- enall, 2000; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Cipriano, 2007; Committee on Quality of Health Care in America & IOM, 2001; Gantz et al., 2012; Glanville, 2000; Hines & Barndt-Maglio, 2011; IOM, 2011; Lea, Skirton, Read, & Williams, 2011; Lockhart, 2016; Osborne, 2005; USDHHS, 2010; Shi & Singh, 2015; Zikmund-Fisher, Sarr, Fagerlin, & Ubel, 2006):

■ The federal government, as discussed earlier, published Healthy People 2020, a document that set forth national health goals and objectives for the next decade. Achieving these national priorities would dramatically cut the costs of health care, prevent the premature onset of disease and disability, and help all Americans lead healthier and more productive lives. Among the major causes of morbidity and mortality are those diseases now recognized as being lifestyle related and preventable through educational intervention. Nurses, as the largest group of health professionals, play an important role in making a real difference by teaching clients to attain and maintain healthy lifestyles.

■ The Institute of Medicine (2011) established recommendations designed to enhance the role of nurses in the delivery of health care. This includes nurses functioning to the full extent of their education and scope of

roles vary according to profession, directives re- lated to contemporary patient education clearly echo Bartlett’s (1986) assertion that it “must be viewed as a fundamentally multidisciplinary en- terprise” (p. 146).

In addition to providing patient education, professional nurses are responsible for educating their colleagues. Another role of today’s nurse educator is one of training the trainer—that is, preparing nursing staff through continuing ed- ucation, inservice programs, and staff develop- ment to maintain and improve their clinical skills and teaching abilities. Nurses must be prepared to effectively perform teaching services that meet the needs of many individuals and groups in dif- ferent circumstances across a variety of practice settings. The key to the success of our profession is for nurses to teach other nurses. We are the primary educators of our fellow colleagues and other healthcare staff personnel (Donner, Levo- nian, & Slutsky, 2005; Lockhart, 2016; McKinley, 2009). In addition, the demand for educators of nursing students is at an all-time high (Ameri- can Association of Colleges of Nursing, 2015).

Another very important role of the nurse as educator is serving as a clinical instructor for stu- dents in the practice setting. Many staff nurses function as clinical preceptors and mentors to ensure that nursing students meet their expected learning outcomes. However, evidence indicates that nurses in the clinical and academic settings feel inadequate as preceptors and mentors as a result of poor preparation for their role as teach- ers. This challenge of relating theory learned in the classroom setting to the practice environment requires nurses not only to keep up to date with clinical skills and innovations in practice but also to possess knowledge and skills related to the principles of teaching and learning. Knowing the practice field is not the same thing as know- ing how to teach the field. The role of the clini- cal educator is a dynamic one that requires the teacher to actively engage students to become competent and caring professionals (Billings, & Hallstead, 2016; Cangelosi, Crocker, & Sorrell, 2009; Gillespie & McFetridge, 2006; Salminen, Stolt, Koskinen, Katajisto, & Leino-Kilpi, 2013).

10 Chapter 1 Overview of Education in Health Care

and expertise, with client education as central to the practice of nursing.

■ Consumers are demanding increased knowledge and skills about how to care for themselves and how to prevent disease. As people are becoming more aware of their needs and desire a greater understanding of treatments and goals, the demand for health information is expected to inten- sify. The quest for consumer rights and responsibilities, which began in the 1960s, continues into the 21st century.

■ An increasing number of self-help groups exist to support clients in meeting their physical and psychosocial needs. The suc- cess of these support groups and behavioral change programs depends on the nurse’s role as teacher and advocate.

■ Demographic trends, particularly the aging of the population, require nurses to emphasize self-reliance and maintenance of a healthy status over an extended life span. As the percentage of the U.S. population older than age 65 years climbs dramatically in the next 20 to 30 years, the healthcare needs of the baby-boom generation of the post–World War II era will increase as this vast cohort deals with degenerative illnesses and other effects of the aging process.

■ In addition, millions of incidents of medical harm occur every year in U.S. hospitals. Clearly, it is imperative that clients, nursing staff, and nursing students be educated about preventive measures to reduce these incidents.

■ The increased prevalence of chronic and incurable conditions requires that indi- viduals and families become informed participants to manage their own illnesses. Patient teaching can facilitate an individual’s adaptive responses to illness and disability.

■ Advanced technology increases the com- plexity of care and treatment in home and community-based settings. More rapid hospital discharge and more procedures done on an outpatient basis force patients to be more self-reliant in managing their own health. Patient education assists them

practice. Patient and family education is a key component of the nurse’s role.

■ The U.S. Congress passed into law in 2010 the Affordable Care Act (ACA), a compre- hensive healthcare reform legislation. The ACA is designed to provide cost-effective, accessible, equitable, high-quality health care to all Americans with the intent of improving their health outcomes. Universal accessibility to health care has the potential to transform the healthcare system, and nurses will play a major role in meeting the demands and complexities of this increasing population of patients.

■ The growth of managed care has resulted in shifts in reimbursement for healthcare services. Greater emphasis is placed on outcome measures, many of which can be achieved primarily through the health education of clients.

■ Health providers are recognizing the eco- nomic and social values of reaching out to communities, schools, and workplaces, all settings where nurses practice, to provide public education for disease prevention and health promotion.

■ Politicians and healthcare administrators alike recognize the importance of health education to accomplish the economic goal of reducing the high costs of health services. Political emphasis is on productivity, competitiveness in the marketplace, and cost-containment measures to restrain health service expenses.

■ Health professionals are becoming increas- ingly concerned about malpractice claims and disciplinary action for incompetence. Continuing education, either by legislative mandate or as a requirement of the employing institution, has come to the forefront in response to the challenge of ensuring the competency of practitioners. It is a means to transmit new knowledge and skills as well as to reinforce or refresh previously acquired knowledge and abilities for the continuing growth of staff.

■ Nurses continue to define their professional role, body of knowledge, scope of practice,

Social, Economic, and Political Trends Affecting Health Care 11

skills, knowledge, and attitudes in the de- livery of safe comprehensive care.

Nurses recognize the need to develop their expertise in teaching to keep pace with the de- mands of patient, staff, and student education. As they continue to define their role, body of knowledge, scope of practice, and professional expertise, they are realizing, more than ever before, the significance of their role as educa- tors. Nurses have many opportunities to carry out health education. They are the healthcare providers who have the most continuous con- tact with clients, are usually the most accessi- ble source of information for the consumer, and are the most highly trusted of all health profes- sionals. In Gallup polls conducted since 2001, nurses have continued to be ranked number 1 for 15 consecutive years in honesty and ethical standards (McCafferty, 2002; Olshansky, 2011; Riffkin, 2014; Saad, 2008; Williamson, 2016).

▸ Purposes, Goals, and Benefits of Patient and Nursing Staff/Student Education

The purpose of patient education is to increase the competence and confidence of clients for self-management. The primary goal is to increase the responsibility and independence of clients for self-care. This can be achieved by support- ing patients through the transition from being dependent on others to being self-sustaining in managing their own care and from being pas- sive listeners to active learners. An interactive, partnership education approach provides clients with opportunities to explore and expand their self-care abilities (Cipriano, 2007).

The single most important action of nurses as educators is to prepare patients for self-care. If patients cannot independently maintain or improve their health status when on their own, nurses have failed to help them reach their

in following through with self-management activities independently.

■ Healthcare providers increasingly recognize client health literacy as an essential skill to improve health outcomes nationwide. Nurses must attend to the education needs of their patients and families to be sure that they adequately understand the information required for independence in self-care ac- tivities that promote, maintain, and restore their health.

■ Many healthcare providers believe—and this belief is supported by research—that client education improves compliance and, hence, health and well-being. Better understanding by patients and their families of the recommended treatment plans can lead to increased cooperation, decision making, satisfaction, and independence with therapeutic regimens. Health edu- cation enables patients to solve problems they encounter outside the protected care environments of hospitals, thereby increasing their independence.

■ The use of online technologies in nursing education programs is increasing. Nurses are expected to have the critical thinking skills needed to identify problems, conduct research on problems encountered, and apply new knowledge to address these problems. Also, nurses are expected to have familiarity with computerized charting and electronic health information records. Nursing informatics is becoming highly important in the paperless world of patient care, and nurse educators are beginning to address the gap in skills with respect to electronic data collection and analysis that nursing students and staff face in the practice settings.

■ The fields of genetics and genomics, as included in the holistic approach of nursing practice, are providing patients with more options to consider for screenings, procedures, and therapies to obtain optimal health. The United States and Europe have established core competencies in genetics and genomics for nurses to support the development of

12 Chapter 1 Overview of Education in Health Care

enhancing their practice. The purpose of staff and student education is to increase the compe- tence and confidence of nurses to function in- dependently in providing care to the consumer. The goal of education efforts is to improve the quality of care delivered by nurses. Nurses play a key role in improving the nation’s health, and lifelong learning is essential to keep their knowl- edge and skills current (DeSilets, 1995; Kelliher, 2013; Witt, 2011).

In turn, the benefits to nurses in their role as educators include increased job satisfaction when they recognize that their teaching actions have the potential to forge therapeutic relation- ships with clients, enhanced patient–nurse au- tonomy, increased accountability in practice, and the opportunity to create change that really makes a difference in the lives of others (Witt, 2011).

The primary aims of nurse educators, then, should be to nourish clients, mentor staff, and serve as teachers, clinical instructors, and pre- ceptors for nursing students. They must value their role in educating others and make it a pri- ority for their patients, fellow colleagues, and the future members of the profession. As the ancient Chinese (author unknown) proverb says “Provide a man a fish and he may eat for a day. Teach a man to fish and he may eat for a lifetime.” As Johaun Jackson (2015), a student in a nurse educator course, recently stated, this mantra speaks to the sacred and honorable act of teaching—imparting knowledge to others and empowering them to no end—and there can be no higher calling that that of an educator.

▸ The Education Process Defined

The education process is a systematic, sequen- tial, logical, scientifically based, planned course of action consisting of two major interdepen- dent operations: teaching and learning. This process forms a continuous cycle that also in- volves two interdependent players: the teacher and the learner. Together, they jointly perform

potential (Glanville, 2000). The benefits of cli- ent education are many (Abbott, 1998; Adams, 2010; Dreeben, 2010; LiberateHealth, 2014; Wingard, 2005). For example, effective teach- ing by the nurse can do the following:

■ Increase consumer satisfaction ■ Improve quality of life ■ Ensure continuity of care ■ Decrease patient anxiety ■ Effectively reduce the complications of

illness and the incidence of disease ■ Promote adherence to treatment plans ■ Maximize independence in the performance

of activities of daily living ■ Energize and empower consumers to become

actively involved in the planning of their care

Because patients must handle many health needs and problems at home, people must be educated on how to care for themselves—that is, both to get well and to stay well. Illness is a natural life process, but so is humankind’s ability to learn. Along with the ability to learn comes a natural curiosity that allows people to view new and difficult situations as challenges rather than as defeats. As Orr (1990) observes, “Illness can become an educational opportunity . . . a ‘teachable moment’ when ill health sud- denly encourages [patients] to take a more ac- tive role in their care” (p. 47). This observation remains relevant today.

Numerous studies have documented the fact that informed clients are more likely to comply with medical treatment plans, more likely to find innovative ways to cope with illness, and less likely to experience complications. Over- all, clients are more satisfied with care when they receive adequate information about how to manage for themselves. One of the most fre- quently cited complaints by patients in litigation cases is that they were not adequately informed (Reising, 2007).

Just as the need exists for teaching patients to become participants and informed consum- ers to achieve independence in self-care, so the need also exists for staff nurses to be exposed to up-to-date information with the ultimate goal of

The Education Process Defined 13

education process are achieved when changes in knowledge, attitudes, and skills occur. Both pro- cesses are ongoing, with assessment and evalu- ation perpetually redirecting the planning and implementation phases. If mutually agreed-on outcomes in either process are not achieved, as determined by evaluation, the process can and should begin again through reassessment, re-planning, and reimplementation.

Note that the actual act of teaching or in- struction is merely one component of the educa- tion process. Teaching and instruction—terms that are often used interchangeably—are delib- erate interventions that involve sharing informa- tion and experiences to meet intended learner outcomes in the cognitive, affective, and psy- chomotor domains according to an education plan. Teaching and instruction, both one and the same, are often thought of as formal, struc- tured, organized activities, but they also can be informal, spur-of-the-moment education ses- sions that occur during conversations and in- cidental encounters with the learner. Whether formal or informal, planned well in advance or spontaneous, teaching and instruction are nev- ertheless deliberate and conscious acts with the objective of producing learning (Carpenter & Bell, 2002; Gregor, 2001).

teaching and learning activities, the outcome of which leads to mutually desired behavior changes. These changes foster growth in the learner and, it should be acknowledged, growth in the teacher as well. Thus, the education pro- cess is a framework for a participatory, shared approach to teaching and learning (Carpenter & Bell, 2002; Kelo, Eriksson, & Eriksson, 2013).

The education process is similar across the practice of many of the health professions. In fact, it can be compared to the nursing process because the steps of each process run parallel to the steps of the other (FIGURE 1-1). The education process, like the nursing process, consists of the basic elements of assessment, planning, imple- mentation, and evaluation (Ward, 2012; Wingard, 2005). The two are different in that the nursing process focuses on the planning and implemen- tation of care based on the assessment and diag- nosis of the physical and psychosocial needs of the patient. The education process, in contrast, focuses on the planning and implementation of teaching based on an assessment and prioritiza- tion of the client’s learning needs, readiness to learn, and learning styles (Carpenter & Bell, 2002).

The outcomes of the nursing process are achieved when the physical and psychosocial needs of the client are met. The outcomes of the

FIGURE 1-1 Education process parallels nursing process.

Appraise physical and psychosocial needs

Ascertain learning needs, readiness to learn, and learning styles

Develop teaching plan based on mutually predetermined behavioral outcomes to meet individual needs

Perform the act of teaching using specific teaching methods and instructional materials

Determine behavior changes (outcomes) in knowledge, attitudes, and skills

Develop care plan based on mutual goal setting to meet individual needs

Carry out nursing care interventions using standard procedures

Determine physical and psychosocial outcomes

ASSESSMENT

PLANNING

IMPLEMENTATION

EVALUATION

Nursing Process Education Process

14 Chapter 1 Overview of Education in Health Care

(cognitive, affective, and psychomotor) can be met through the process of education.

The ASSURE model is a useful paradigm originally developed to assist nurses to orga- nize and carry out the education process (Rega, 1993). This model is appropriate for all health professional educators. The acronym stands for

Analyze the learner

State the objectives

Select the instructional methods and materials

Use the instructional methods and materials

Require learner performance

Evaluate the teaching plan and revise as necessary

▸ The Contemporary Role of the Nurse as Educator

Over the years, organizations governing and in- fluencing nurses in practice have identified teach- ing as an important responsibility (Lewenson, McAllister, & Smith, 2016). For nurses to fulfill the role of educator, no matter whether their audience consists of patients, family members, nursing students, nursing staff, or other agency personnel, they must have a solid foundation in the principles of teaching and learning.

With significantly more attention being paid to the teaching role of nurses, it is imper- ative that nurse educators recognize the theo- ries in nursing and educational psychology that provide the frameworks to guide them in un- derstanding how and why people change their health-related behaviors. Dorothy Orem’s Self- Care Theory professes that patients and family caregivers are capable of being self-reliant and responsible for their own care, a goal that can be achieved only through patient teaching (Orem, 1991). Other nursing theories—Betty Neuman’s Systems Model Theory (Neuman, 1995), Jean Watson’s Theory of Human Caring (Watson,

The fact that teaching and instruction are intentional does not necessarily mean that they must be lengthy and complex tasks, but it does mean that they comprise conscious actions on the part of the teacher in responding to an in- dividual’s need to learn. The cues that some- one has a need to learn can be communicated in the form of a verbal request, a question, a puzzled or confused look, a blank stare, or a gesture of defeat or frustration. In the broadest sense, then, teaching is a highly versatile strat- egy that can be applied in preventing, promot- ing, maintaining, or modifying a wide variety of behaviors in a learner who is receptive, mo- tivated, and adequately informed (Duffy, 1998; Gregor, 2001).

Learning is defined as a change in behav- ior (knowledge, attitudes, and/or skills) that can be observed or measured and that occurs at any time or in any place resulting from exposure to environmental stimuli. Learning is an action by which knowledge, skills, and attitudes are con- sciously or unconsciously acquired such that be- havior is altered in some way. The success of the nurse educator’s endeavors in teaching is mea- sured not by how much content the nurse im- parts but rather by how much the person learns (Musinski, 1999).

Patient education is a process of assist- ing people to learn health-related behaviors that they can incorporate into everyday life with the goal of achieving optimal health and indepen- dence in self-care. Friedman, Cosby, Boyko, Hatton-Bauer, and Turnbull (2011) specifically define it as “any set of planned educational ac- tivities, using a combination of methods (teach- ing, counseling, and behavior modification), that is designed to improve patients’ knowledge and health behaviors” (p. 12). Staff education, by contrast, is the process of influencing the be- havior of nurses by producing changes in their knowledge, attitudes, and skills to help them maintain and improve their competencies for the delivery of high-quality care to the consumer. Both patient and staff education involve forg- ing a relationship between the learner and the educator so that the learner’s information needs

The Contemporary Role of the Nurse as Educator 15

appropriate action to revise the approach to educating the patient if the patient does not comprehend the information provided through the initial approach?

■ Do nurses realize that they need to transition their role as educator from being a content transmitter to being a process manager, from controlling the learner to releasing the learner, and from being a teacher to becoming a facilitator?

A growing body of evidence suggests that effective education and learner participation go hand in hand (Kelliher, 2013). As a facilitator, the nurse should create an environment conducive to learning that motivates individuals to want to learn and makes it possible for them to learn (Musinski, 1999; Sykes, Durham, & Kingston, 2013). Both the educator and the learner should participate in the assessment of learning needs, the design of a teaching plan, the implementation of teaching methods and instructional materi- als, and the evaluation of teaching and learning. Thus, the emphasis should be on the facilitation of learning from a nondirective rather than a di- dactic teaching approach (Donner et al., 2005; Knowles, Holton, & Swanson, 1998; Mangena & Chabeli, 2005; Musinski, 1999).

No longer should teachers see themselves as simply transmitters of content. Indeed, the role of the educator has shifted from the tradi- tional position of giver of information to that of a process designer and coordinator. This role alteration from the traditional teacher-centered perspective to a learner-centered approach is a paradigm shift that requires educators to pos- sess skill in needs assessment as well as the abil- ity to involve learners in planning, link learners to learning resources, and encourage learner initiative (Kelliher, 2013; Knowles et al., 1998; Mangena & Chabeli, 2005).

Instead of the teacher teaching, the new ed- ucational paradigm focuses on the learner learn- ing. That is, the teacher becomes the guide on the side, assisting the learner in his or her effort to determine objectives and goals for learning, with both parties being active partners in deci- sion making throughout the learning process.

1999), and Patricia Benner’s Novice to Expert Theory (Benner, 1984)—are all foundational to how nurses can best teach and how learners can best learn. Also foundational are cognitive and social learning theories described in the Applying Learning Theories to Healthcare Practice chapter.

Legal and accreditation mandates as well as professional nursing standards of practice have made the educator role of the nurse an integral part of high-quality care to be delivered by all registered nurses (RNs) licensed in the United States, regardless of their level of nursing school preparation. Given this fact, it is imperative to examine the present teaching role expectations of nurses, irrespective of their preparatory back- ground. The role of educator is not primarily to teach but rather to promote learning and pro- vide for an environment conducive to learning. Also, the role of the nurse as teacher of patients and families, nursing staff, and students certainly should stem from a partnership philosophy (Gleasman-DeSimone, 2012). A learner cannot be made to learn, but an effective approach in educating others is to create the teachable mo- ment, rather than just waiting for it to happen, and to actively involve learners in the education process (Bodenheimer et al., 2002; Lawson & Flocke, 2009; Tobiano, Bucknell, Marshall, Gui- nane, & Chaboyer, 2015; Wagner & Ash, 1998).

Although all nurses are expected to teach as part of their licensing criteria, many lack formal preparation in the principles of teach- ing and learning (Donner et al., 2005). Obvi- ously, a nurse needs a great deal of knowledge and skill to carry out the role of educator with efficiency and effectiveness. Although all nurses have always functioned as givers of information, they must now assume a new role by acquiring the skills as a facilitator of the learning process (Kelliher, 2013; Musinski, 1999). Consider the following questions:

■ Is every nurse adequately prepared to assess for learning needs, readiness to learn, and learning styles?

■ Can every nurse determine whether the information given is actually received and understood? Are all nurses capable of taking

16 Chapter 1 Overview of Education in Health Care

and power differentials. However, interdisciplin- ary cooperation and teamwork are essential to improve the health outcomes of patients and to achieve a more highly functional healthcare sys- tem (Meleis, 2016). The Robert Wood Johnson Foundation (RWJF) has recently shifted its focus to build a Culture of Health by engaging people from diverse fields of expertise who can bring creative and innovative perspectives to solve the many challenges facing the nation’s healthcare system (Hassmiller, 2014).

Patient Engagement In 2001, the Health and Medicine Division (for- merly known as the Institute of Medicine) of the National Academies published a signal re- port, titled Crossing the Quality Chasm: A New Health System for the 2st Century (Committee on Quality of Health Care in America & IOM, 2001). This report called for urgent and funda- mental change to close the quality gap by re- designing the healthcare system in the United States. Among its many recommendations, per- formance expectations pertinent to nursing and patient education were put forth to guide patient– provider relationships for the improvement of quality and safety in care delivery. In the sec- tion of the report on preparing the workforce, one of the many recommendations was for lead- ers in the health professions to restructure their clinical education as well as their formal health education programs.

Berwick (2008) released a video describ- ing the six dimensions of quality outlined in the Crossing the Quality Chasm report. The follow- ing are the areas Berwick outlined that health care needed to improve on and the current lev- els of performance in all six areas still needing improvement:

1. Safety—not harming people with the care that is rendered.

2. Effectiveness—avoiding overuse of things that do not help and ensuring the use of things that do help.

3. Patient-centeredness—people should be in control of their own care by

To increase comprehension, recall, and application of information, clients must be actively involved in the learning experience (Adams, 2010; Kessels, 2003; London, 1995; Smith, Saunders, Stuckhardt, & McGinnis, 2013). Glanville (2000) describes this move toward assisting learners to use their own abilities and resources as “a pivotal trans- fer of power” (p. 58).

Nursing Education Transformation New evidence also supports a transformation of the process of how nurses are educated, which influences the role of the nurse as educator. Ben- ner, Sutphen, Leonard, and Day (2010) com- pleted a study of the national trends causing the nursing shortage and the increased com- plexity of demands on nursing practice. These trends have led to a significant gap between nursing education and practice. The results of Benner et al.’s study include 26 recommenda- tions in six key areas, including entrance into nursing education, pathways for nursing educa- tion, student population characteristics, student experiences, teaching in nursing, transition into practice, and professional oversight of nursing education and practice.

Another transformative movement is the rela- tively recent awareness of the importance of inter- professional education for the redesign of patient care delivery. To best serve consumers of health care, professionals need to work more closely to- gether in a collaborative, interdependent manner and in partnership with patients to deliver appro- priate, cost-effective, and efficient care within the complex environment of the healthcare system. Creating a linkage between interprofessional ed- ucation and collaborative practice will result in a climate whereby “all participants learn, all teach, all care, and all collaborate” (Josiah Macy Jr. Foun- dation, 2013, p. 1). In achieving the goal of safe, high-quality care, a collaborative process is re- quired whereby all team members have equal power. The silos that exist in the education and practice settings are difficult barriers to overcome because of the entrenched professional identities

The Contemporary Role of the Nurse as Educator 17

principles were released to encourage nurses and other healthcare providers to improve the quality and safety of the care they deliver. The focus is on developing policies that will lead to the integration of patients and their families in the decisions of their care. According to the NAQC (2012), the following principles should be at the core of professional nursing practice:

1. High-quality care is based on a dy- namic partnership between healthcare providers, patients, and their families. There must be a mutual respect of privacy, decision making, and ethical behaviors.

2. The relationship must be established on confidentiality, and the patient has the right to make his or her own decisions.

3. There are mutual responsibilities and accountabilities that must be observed by all parties to be effective.

4. Healthcare providers must understand to what extent the patient can engage in his or her own care and advocate for those patients who are not able to fully participate.

5. All interactions with the patient and family must respect the boundaries that protect the patient as well as healthcare providers.

6. Patient advocacy is a representation of a functioning dynamic partnership.

7. The patient–provider relationship is centered on respect for the patient’s rights, which includes mutuality.

8. Mutual decision making is based on the sharing of information.

9. Healthcare providers must be aware of the health literacy level and appreciate the diversity of cultural backgrounds of their patients and families to allow for full patient engagement.

With the national concern about lack of good information on the quality of care, the Consumer Assessment of Healthcare Providers and Systems

making decisions about what affects them.

4. Timeliness—avoiding delays by re- ducing needless wait times to be seen by a provider.

5. Efficiency—avoiding waste by reduc- ing duplication of tests and proce- dures, giving things that do not help, and losing ideas of the workforce by not listening to employee solutions.

6. Equity—closing the gap in justice as it relates to who receives health care in type and extent.

In response to the concern for safe, bet- ter quality care, the Nursing Alliance for Qual- ity Care (NAQC)—a partnership of the leading health and nursing organizations in the United States—proposed a strategic policy in 2010 to ad- vocate for the highest quality consumer-centered care. This policy aims to work with patients, nurses, and policymakers to encourage and pro- mote optimum health care to consumers. The NAQC (2010) established four goals address- ing key areas to support excellence in the de- livery of health care:

1. Consumer-centered health care: Estab- lish nursing health and safety goals to achieve safe, effective, timely, efficient, and equitable patient-centered care.

2. Performance measurement and public reporting: Advocate for the develop- ment, implementation, and public reporting of performance measures that reflect nursing’s contribution to patient care.

3. Advocacy: Establish policy reform focused on evidence-based nursing practice to improve patient care.

4. Leadership: Promote nursing’s ca- pability to serve in leadership roles that advance patient care standards.

In 2012, the NAQC issued another initia- tive as part of its drive to address care coor- dination and to promote patient engagement during care. In this announcement, nine core

18 Chapter 1 Overview of Education in Health Care

open communication, respect, and mutual decision making to achieve high-quality care.

3. Evidence-based practice: Current evidence must be integrated to sup- port clinical expertise in providing optimal health care.

4. Quality improvement: Measure data and monitor patient outcomes to develop changes in methods to con- tinuously improve the quality and safety in healthcare delivery.

5. Informatics: Use information tech- nology to effectively communicate, manage knowledge, eliminate er- ror, and support collaborative deci- sion making.

6. Safety: Minimize the risk of harm to patients and healthcare providers through self- and system evaluation.

In 2007, the RWJF funded phase II of the QSEN project, which included launching a website (http://QSEN.org) dedicated to teach- ing strategies and resources. A second goal of this phase was to collaborate with organizations that represent advanced practice nurses in de- veloping competencies for graduate education. Also, 15 schools served as pilot sites committed to a curriculum revision that included the QSEN competencies.

In 2009, the American Association of Col- leges of Nursing (AACN) also received funding to complete phase III of the QSEN project. The goal of this phase was to develop the faculty expertise needed to teach the competencies, incorporate the competencies in textbooks, implement inno- vative teaching strategies, and assist in the licen- sure and accreditation processes (QSEN, 2012). In February 2012, the RWJF supported the AACN in the development of a new project to establish national QSEN competencies for graduate ed- ucation. In September 2012, the AACN issued graduate-level QSEN competencies that focus on the knowledge, skills, and attitudes required for advanced practice nurses to effectively im- prove safety and quality in healthcare delivery.

(CAHPS) program was established as a multi- year initiative in 1995 by the Centers for Medi- care and Medicaid Services (CMS). The CAHPS national survey mandates that healthcare orga- nizations regularly collect data on consumer involvement in healthcare decision making. In 2005, the Hospital CAHPS (HCAHPS) was de- veloped that is specifically designed for use by hospitals (Agency for Healthcare Research and Quality, 2016). The purpose of the CAHPS and HCAHPS is to increase consumer engagement in healthcare decision making and to measure health outcomes. Also, many studies have fo- cused on how effectively outcomes have been achieved in healthcare organizations by exploring the links between patient experiences and health outcomes as well as the extent to which action- able information has facilitated organizational change (Doyle et al., 2013; Manary, Boulding, Staelin, & Glickman, 2013).

Quality and Safety Education in Nursing In 2005, the RWJF funded a national study, the Quality and Safety Education in Nursing (QSEN) project, to educate nursing students on patient safety and healthcare quality. The goal of this three-phase study was to address the chal- lenges in preparing nursing students with the knowledge, skills, and attitudes to improve the safety and quality of healthcare delivery (QSEN, 2012). During the first phase, 17 national leaders in nursing education were asked to outline the necessary competencies that should be mastered by prelicensure nursing students. Six competen- cies were developed in phase I (QSEN, 2012):

1. Patient-centered care: The patient has control of and is a full partner in the provision of holistic, compassionate, and comprehensive care based on the patient’s values, needs, and preferences.

2. Teamwork and collaboration: Nurses and other health professionals must collaborate effectively with

The Contemporary Role of the Nurse as Educator 19

Based on these four key messages, the re- port made eight recommendations to achieve a transformation in nursing education and prac- tice (IOM, 2011):

1. Remove scope of practice barriers (addressing key message #1).

2. Expand opportunities for nurses to lead in collaborative improvement efforts (addressing key message #3).

3. Implement nurse residency programs (addressing key message #1).

4. Increase the proportion of nurses with baccalaureate degrees to 80% by 2020 (addressing key message #2).

5. Double the number of nurses with a doctorate by 2020 (addressing key message #2).

6. Ensure that nurses engage in lifelong learning (addressing key message #2).

7. Prepare and enable nurses to lead change to advance health (addressing key message #3).

8. Build an infrastructure for the collec- tion and analysis of data (addressing key message #4).

Certainly, patient education requires a col- laborative effort among healthcare team mem- bers, all of whom play roles in teaching of greater or lesser importance. However, physi- cians are first and foremost prepared “to treat, not to teach” (Gilroth, 1990, p. 30). Nurses, by comparison, are prepared to provide a holistic approach to care delivery. The teaching role is a unique part of nursing’s professional domain. Because consumers have always respected and trusted nurses to be their advocates, nurses are in an ideal position to clarify confusing infor- mation and make sense out of nonsense. Amid a fragmented healthcare delivery system involving many providers, the nurse serves as coordina- tor of care. By ensuring consistency of informa- tion, nurses can support clients in their efforts to achieve the goal of optimal health (Donovan & Ward, 2001; Donovan et al., 2007). They also can assist their colleagues in gaining knowledge

Expert consultants and stakeholders achieved four primary goals (AACN, 2012):

1. Develop a consensus on the compe- tencies in quality and safety that must be mastered in a graduate nursing program.

2. Create learning resources and interac- tive materials to help prepare graduate students to deliver high-quality and safe care.

3. Host workshops to train faculty to facilitate implementation of compe- tencies into curriculum.

4. Develop an online collaborative of education materials for use by graduate-level faculty and clinical partners.

The Institute of Medicine Report: The Future of Nursing In 2011, the RWJF and the Institute of Medi- cine partnered to establish recommendations designed to enhance the role of nurses in the delivery of health care. In 2010, the U.S. Con- gress passed and President Barack Obama signed into law the Affordable Care Act, a compre- hensive healthcare reform legislation. In re- sponse to this transformation of U.S. health care, four key messages were developed by a multidisciplinary committee whose member- ship represented a variety of healthcare profes- sionals, educators, researchers, policymakers, consumers, advocacy groups, and healthcare institutions (IOM, 2011):

1. Nurses should practice to the full ex- tent of their education and training.

2. Nurses should achieve higher levels of education and training.

3. Nurses should be full partners with health professionals in redesigning health care.

4. Effective workforce planning and policymaking require better data collection.

20 Chapter 1 Overview of Education in Health Care

ability of the learner to pay attention to and process information.

Factors Affecting the Ability to Teach The following barriers (FIGURE 1-2) may inter- fere with the ability of nurses to carry out their roles as educators (Carpenter & Bell, 2002; Ca- sey, 1995; Chachkes & Christ, 1996; Donovan & Ward, 2001; Duffy, 1998; Farahani et al., 2013; Friberg et al., 2012; Glanville, 2000; Honan, Krsnak, Petersen, & Torkelson, 1988; Smith & Zsohar, 2013; Tobiano et al., 2015):

1. Lack of time to teach is cited by nurses as the greatest barrier to being able to carry out their educator role effec- tively. Early discharge from inpatient and outpatient settings often results in nurses and clients having fleeting contact with each other. In addition, the schedules and responsibilities of nurses are very demanding. Finding time to allocate to teaching is very challenging in light of other work demands and expectations. In one survey by TJC, 28% of nurses claimed that they were not able to provide patients and their families with the necessary instruction because of lack of time during their shifts at work (Stolberg, 2002). Nurses must know how to adopt an abbreviated, efficient, and effective approach to client and staff education first by adequately assessing the learner and then by using appropriate teaching methods and instructional tools at their disposal. Discharge planning is playing an ever more important role in ensuring continuity of care across settings.

2. Many nurses and other healthcare personnel admit that they do not feel competent or confident with their

and skills necessary for the delivery of profes- sional nursing care.

▸ Barriers to Teaching and Obstacles to Learning

It has been said by many educators that adult learning takes place not by the teacher initi- ating and motivating the learning process but rather by the teacher removing or reducing ob- stacles to learning and enhancing the process af- ter it has begun. The educator should not limit learning to the information that is intended but should clearly make possible the potential for informal, unintended learning that can occur each day with every teacher–learner encounter (Carpenter & Bell, 2002; Gregor, 2001). The ev- idence supports that these teachable moments are not necessarily unplanned or that a coordi- nated set of circumstances will always lead to positive health change. Instead, it is the inter- action between learner and teacher that is cen- tral to the development of a teachable moment, regardless of the obstacles or barriers that may be encountered (Konradsen, Nielson, Larsen, & Hansen, 2012; Lawson & Flocke, 2009).

Unfortunately, nurses must confront many barriers in carrying out their responsibilities for educating others. Also, learners face a variety of potential obstacles that can interfere with their learning. Conditional factors, such as the envi- ronment, the organization’s culture, the level of cooperation between the disciplines, beliefs and knowledge of the team members, types of patient education activities, and the patient population can either enable or hinder the teaching–learning process (Farahani, Mohammadi, Ahmadi, & Mo- hammadi, 2013; Friberg et al., 2012).

For the purposes of this text, barriers to teaching are defined as those factors that im- pede the nurse’s ability to deliver educational services. Obstacles to learning are defined as those factors that negatively affect the

Barriers to Teaching and Obstacles to Learning 21

1,230 nurses in staff, administrative, and education positions regarding their perceptions of the extent of nurses’ responsibility for and level of achievement of patient education. Although all three groups strongly believed that client and staff education is a primary responsibility of nurses, a large majority of respondents rated their ability to perform educator role activities as unsatisfactory. Many of the other health professions share similar views. Few new additional studies have been forthcoming on nurses’ perceptions of their pa- tient education and nursing staff/ student clinical teaching roles (Kelo, Martikainen, & Eriksson, 2013; Lahl, Modic, & Siedlecki, 2013; Nyoni &

teaching skills. As stated previously, although nurses are expected to teach, few have ever taken a specific course on the principles of teaching and learning. The concepts of patient education are often integrated throughout nursing curricula rather than being offered as a specific course of study. Pohl (1965) compiled some interesting statistics regarding nursing, long considered one of the first health professions to have a strong teaching role. As early as the mid-1960s, Pohl (1965) found that one third of 1,500 nurses, when questioned, reported that they had no preparation for the teaching they were doing, whereas only one fifth felt they had adequate preparation. Almost 30 years later, Kruger (1991) surveyed

FIGURE 1-2 Barriers to teaching.

Lack of time

Low priority status of client education

Lack of confidence and competence

Questionable effectiveness of client education

Documentation difficulties

Absence of third-party

reimbursement

Negative influence of environment

(lack of space and privacy, noise)

Lack of motivation and skill

Factors interfering with the health professional’s ability to teach

22 Chapter 1 Overview of Education in Health Care

separately reimbursed by insurance payers. In fact, patient education in some settings, such as home care, often cannot be incorporated as a legitimate aspect of routine nursing care delivery unless specifically ordered by a physician. Insurance coverage for healthcare services historically has been structured on a model of care with the physician as the pri- mary provider being reimbursed on a fee-for-service basis. However, as of January 1, 2013, a new Medicare rule allows for payment of advanced practice registered nurses (APRNs) for the delivery of primary care services in outpatient settings. “With up to 20% of Medicare patients readmitted to hospitals within 30 days of dis- charge, more value has been placed on effective transitional care and care coordination” by APRNs (Nurse. com, 2012, para. 3). Now a separate billing code for patient education and counseling by RNs is included in the American Medical Association’s Common Procedural Terminology (CPT) codes, but many restrictions exist in being able to use this code for reimbursement of staff nurse services. According to the sexually transmitted disease (STD)-related Reproductive Health Training and Technical Assistance Center (STD TAC), this code cannot be used for new patients being seen by the nurse, for nursing services provided to the patient on the same day prior to or after a visit with a physician, or for telephone counseling for follow-up teaching because the RN–patient encounter must be face to face (STD TAC, 2014). As for health education and wellness programs, Medicare generally does not cover these costs except in specific cases, such as diabetes and kidney disease

Barnard, 2016). Today, the role of the nurse as educator still needs to be strengthened in undergraduate nursing education. Fortunately, an upswing in interest and attention to the educator role has been gaining significant momentum in graduate nursing programs across the country.

3. Personal characteristics of the nurse educator play an important role in determining the outcome of a teaching–learning interaction. Mo- tivation to teach and skill in teaching are prime factors in determining the success of any educational endeavor.

4. Until recently, administrators and supervisory personnel assigned a low priority to patient and staff edu- cation. With the strong emphasis of TJC mandates, the level of attention paid to the educational needs of both consumers and healthcare personnel has changed significantly. However, budget allocations for educational programs remain tight and can inter- fere with the adoption of innovative and time-saving teaching strategies and techniques.

5. The environment in the various settings where nurses are expected to teach is not always conducive to carrying out the teaching–learning process. Lack of space, lack of privacy, noise, and frequent interruptions caused by patient treatment schedules and staff work demands are just some of the factors that may negatively affect the nurse’s ability to concentrate and effectively interact with learners.

6. An absence of third-party reimburse- ment to support patient education by RNs relegates teaching and learning to less than high-priority status. Nursing services within inpatient healthcare facilities are subsumed under hospital room costs and, therefore, are not specifically nor

Barriers to Teaching and Obstacles to Learning 23

8. The type of documentation system used by healthcare agencies has an impact on the quality and quantity of patient teaching. Both formal and informal teaching are often done but not written down because of insuffi- cient time, inattention to detail, and inadequate forms on which to record the extent of teaching activities. Many of the hard-copy forms or computer software used for documentation of teaching are designed to simply check off the areas addressed rather than allowing for elaboration of what has been accomplished. In addition, most nurses do not recognize the scope and depth of teaching that they perform daily. Communication among healthcare providers regarding what has been taught needs to be coordinated and appropriately del- egated so that teaching can proceed in a timely, smooth, organized, and thorough fashion.

Factors Affecting the Ability to Learn The following obstacles (FIGURE 1-3) may interfere with a learner’s ability to attend to and process information (Beagley, 2011; Billings & Kowal- ski, 2004; Glanville, 2000; Kessels, 2003; McDon- ald, Wiczorek, & Walker, 2004; Weiss, 2003):

1. Lack of time to learn as a result of rapid patient discharge from care and the amount of information a client is expected to learn can discourage and frustrate the learner, impeding his or her ability and willingness to learn.

2. The stress of acute and chronic ill- ness, anxiety, and sensory deficits in patients are just a few problems that can diminish learner motivation and interfere with the process of learn- ing. However, illness alone seldom

education, nutritional therapy for diabetes or kidney disease, obesity counseling, depression screenings, and counseling to stop smoking or for alcohol misuse (U.S. Centers for Medicare & Medicaid Services, n.d.). Thus, under most circumstances when nurses deliver patient education, this therapeutic intervention is not reimbursable by third-party payers. Recently, a new role has been created in primary care practices, known as health education specialists (HES). HESs are trained to teach individuals and populations to practice healthier behaviors and seek preventive care, which traditionally nurses have performed. But given the nursing shortage in primary care settings and the cost of nursing professionals, HESs are being hired as substitutes to deliver patient education and coach- ing (Chambliss, Lineberry, Evans, & Bibeau, 2014).

7. Some nurses and physicians question whether patient education is effective in improving health outcomes. They view patients as impediments to teach- ing when patients do not display an interest in changing behavior, when they demonstrate an unwillingness to learn, or when their ability to learn is in question. Concerns about coercion and violation of free choice, based on the belief that patients have a right to choose and that they cannot be forced to comply, explain why some professionals feel frustrated in their efforts to teach. Unless all healthcare members buy into the utility of patient education (that is, they believe it can lead to significant behavioral changes and increased compliance to thera- peutic regimens), some professionals may continue to feel absolved of their responsibility to provide adequate and appropriate patient education.

24 Chapter 1 Overview of Education in Health Care

social isolation, can interfere with a patient’s active role in health deci- sion making and involvement in the teaching–learning process.

5. Personal characteristics of the learner have major effects on the degree to which behavioral out- comes are achieved. Readiness to learn, motivation and compliance, developmental-stage characteristics, and learning styles are some of the prime factors influencing the success of educational endeavors.

6. The extent of behavioral changes needed, both in number and in com- plexity, can overwhelm learners and dissuade them from attending to and accomplishing learning objectives and goals.

acts as an impediment to learning. Rather, illness is often the impetus for patients to attend to learning, contact healthcare professionals, and take positive action to improve their health status.

3. Low literacy and functional health illiteracy have been found to be significant factors in the ability of clients to make use of the written and verbal instructions given to them by providers. Almost half of the American population reads and comprehends at or below the eighth-grade level, and an even higher percentage suffers from health illiteracy.

4. The negative influence of the hospital environment itself, which results in loss of control, lack of privacy, and

FIGURE 1-3 Obstacles to learning.

Lack of time (rapid discharge or episodic care)

Stress of illness

Readiness to learn issues (motivation

and adherence)

Complexity, fragmentation, and inconvenience of healthcare system

Denial of learning needs

Lack of support from health

professionals or significant others

Extent of needed behavior changes

Negative influence of environment

Literacy problems

Factors interfering with ability of

learner to process information

Barriers to Teaching and Obstacles to Learning 25

■ What can be done about the inequities (in quantity and quality) in the delivery of education services?

■ How can teaching be tailored to meet the needs of specific populations of learners, such as those with diverse cultural back- grounds, low literacy skills, physical and mental disabilities, and different socioeco- nomic and educational levels?

■ To what extent does teaching improve health status and reduce the costs of health care?

■ Which instructional methods and materials are available to support teaching efforts?

■ Which elements must the nurse as educator account for when developing and imple- menting teaching plans?

■ Under which conditions should nurses use certain teaching methods and materials?

■ Which common mistakes do nurses make when teaching others?

■ How can teaching and learning be best evaluated?

▸ State of the Evidence The literature on patient and staff education, from both a research- and non-research-based perspective, is particularly extensive in nurs- ing. The non-research-based literature on pa- tient education is prescriptive in nature and tends to offer anecdotal tips on how to take in- dividualized approaches to teaching and learn- ing. A computer literature search, for example, reveals literally thousands of nursing and allied health articles and books on teaching and learn- ing that are available, ranging from the general to the specific.

Although many research-based studies are being conducted on teaching specific popula- tion groups about a variety of topics, only re- cently has the field focused its attention on how to most effectively teach persons with long- term chronic illnesses. Nurses must conduct much more research on the benefits of patient education as they relate to the potential for in- creasing quality of life, enabling patients to lead

7. Lack of support and lack of ongoing positive reinforcement from the nurse and significant others serve to block the potential for learning.

8. Denial of learning needs, resentment of authority, and lack of willingness to take responsibility (locus of control) are some psychological obstacles to accomplishing behavioral change.

9. The inconvenience, complexity, inaccessibility, fragmentation, and dehumanization of the healthcare system often result in frustration and abandonment of efforts by the learner to participate in and comply with the goals and objectives for learning.

▸ Questions to Be Asked About Teaching and Learning

To maximize the effectiveness of patient, staff, and student education, the nurse must exam- ine the elements of the education process and the role of the nurse as educator. Many ques- tions arise related to the principles of teaching and learning, especially given the pressures to contain costs and to improve learner outcomes. The following are some of the important ques- tions that this text addresses:

■ How can members of the healthcare team work together more effectively to coordinate educational efforts?

■ What are the ethical, legal, and economic issues involved in patient and staff education?

■ Which theories and principles support the education process, and how can they be applied to change the behaviors of learners?

■ Which assessment methods and tools can nurse educators use to determine learning needs, readiness to learn, and learning styles?

■ Which learner attributes negatively and positively affect an individual’s ability and willingness to learn?

26 Chapter 1 Overview of Education in Health Care

how they interact. Research on the influence that socioeconomics has on learning reveals it plays a significant factor, but the underlying mech- anisms of its effects are still unclear. More re- search needs to be done on the extent to which teaching can improve health status of individ- uals and communities, decrease the incidence of disease, and enhance the quality and safety of healthcare delivery.

Despite the questions that remain unan- swered, nurses are expected to teach diverse populations with complex needs and a range of abilities in both traditional settings and nontra- ditional, unstructured settings. For more than 30 years, nurse researchers have been studying how best to teach patients, but much more re- search is required (Adams, 2010; Mason, 2001). Also, relatively few studies have examined nurses’ perceptions about their role as educators in the practice setting (Friberg et al., 2012). We need to establish a stronger theoretical basis for in- tervening with clients throughout “all phases of the learning continuum, from information acquisition to behavioral change” (Donovan & Ward, 2001, p. 211). Also, emphasis needs to be given to research in nursing education to ensure that the nursing workforce is prepared for a challenging, complex, and uncertain future in health care (Benner et al., 2010; Committee on Quality of Health Care in America & IOM, 2001; IOM, 2011; Meleis, 2016).

In addition, nurses as educators should further investigate the cost-effectiveness of ed- ucational efforts in reducing hospital stays, de- creasing readmissions, improving the personal quality of life, and minimizing complications of illness and therapies. Furthermore, given the number of variables that can potentially inter- fere with the teaching–learning process, addi- tional studies must be conducted to examine the effects of environmental stimuli, the factors in- volved in readiness to learn, and the influences of learning styles on learner motivation, com- pliance, comprehension, and the ability to ap- ply knowledge and skills once they are acquired. One notable void is the lack of information in the research database on how to assess motivation.

a disability-free life and manage themselves in- dependently at home, and decreasing the costs of health care through anticipatory teaching ap- proaches. Studies from acute-care settings tend to focus on preparing a patient for a procedure, with emphasis on the benefits of information in alleviating anxiety and promoting psychologi- cal coping. The evidence does suggest that pa- tients cope much more effectively when taught exactly what to expect (Adams, 2010; Donovan & Ward, 2001; Duffy, 1998; Mason, 2001; Wong, Chan, & Chair, 2010).

More research is needed on the benefits of teaching methods and instructional tools that use the technologies of computer-assisted in- struction, online and other distance-learning modalities, cable television, podcasts, and Inter- net access to health information for both patient and staff education. These new approaches to information dissemination require a role change for the educator, from being a giver of informa- tion to becoming a resource facilitator, as well as a shift in the role of the learner, from being a passive recipient to becoming an active part- ner. The rapid advances in technology for teach- ing and learning also require educators to have a better understanding of generational orienta- tions and experiences of the learner (Billings & Kowalski, 2004). Also, the effectiveness of vid- eotapes and audiotapes with different learners and in different situations must be further ex- plored (Kessels, 2003). Given the significant in- cidence of low literacy rates among patients and their family members, much more investiga- tion needs to be done on the impact of printed versus audiovisual materials as well as written versus verbal instruction on learner compre- hension (Weiss, 2003).

Gender issues, the influence of socioeconom- ics on learning, and the strategies of teaching cultural groups and populations with disabili- ties need further exploration as well. For exam- ple, the findings from interdisciplinary research on the influence of gender on learning remain inconclusive, although neuroscience is uncover- ing increasing evidence on the functions of the different parts of the male and female brain and

State of the Evidence 27

public, healthcare employers, healthcare pro- viders, and payers of healthcare benefits. To be effective and efficient, nurses must be willing and able to work collaboratively with one an- other to provide consistently high-quality edu- cation to the audiences they serve.

Nurses can demonstrate responsibility and accountability for the delivery of care to the consumer, in part, through education based on solid principles of teaching and learning. The key to effective education of the varied audiences of learners is the nurse’s under- standing of and ongoing commitment to the role of educator.

Review Questions 1. Which key factors influenced the growth

of patient education during its formative years?

2. How far back in history has teaching been a part of the nurse’s role?

3. Which nursing organization was the first to recognize health teaching as an important function within the scope of nursing practice?

4. Which legal mandate universally includes teaching as a responsibility of nurses?

5. How have the ANA, NLN, ICN, AHA, TJC, and Pew Commission influenced the role and responsibilities of the nurse as educator?

6. What is the current focus and orientation of patient education?

7. Which social, economic, and political trends today make it imperative that patients be adequately educated?

8. What are the similarities and differences between the education process and the nursing process?

9. What are three major barriers to teaching and three major obstacles to learning?

10. Which factor serves as both a barrier to teaching and an obstacle to learning?

11. What is the present status of research- and non-research-based evidence pertaining to education?

The Compliance, Motivation, and Health Behav- iors of the Learner chapter proposes parameters to assess motivation but notes the paucity of information specifically addressing this issue.

More than 20 years ago, Oberst (1989) de- lineated the major issues in patient education studies related to the evaluation of the existing research base and the design of future studies. The four broad problem categories that she iden- tified remain pertinent today:

1. Selection and measurement of appro- priate dependent variables (educational outcomes).

2. Design and control of independent variables (educational interventions).

3. Control of mediating and intervening variables.

4. Development and refinement of the theoretical basis for education.

▸ Summary Nurses can be considered information brokers— educators who can make a significant difference in how patients and families cope with their ill- nesses and disabilities, how the public benefits from education directed at prevention of dis- ease and promotion of health, and how staff and student nurses gain competency and con- fidence in practice through education activities that are directed at continuous, lifelong learn- ing. As the United States moves forward in the 21st century, many challenges and opportuni- ties lie ahead for nurse educators in the deliv- ery of health care.

The teaching role is becoming even more important and more visible as nurses respond to the social, economic, and political trends af- fecting health care today. The foremost chal- lenge for nurses is to be able to demonstrate, through research and action, that definite links exist between education and positive behavioral outcomes of the learner. In this era of cost con- tainment, government regulations, and health- care reform, the benefits of client, staff, and student education must be made clear to the

28 Chapter 1 Overview of Education in Health Care

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CASE STUDY As part of Lackney General Hospital’s continuous quality improvement plan, and in preparation for the next Joint Commission accreditation visit, all departments in the hospital are in the process of assessing the quality and effectiveness of their patient education efforts. When you solicit feedback from the professional nursing staff on your unit regarding their opinions on this topic, you are surprised at the frustration they express. Liz states, “Although I am incredibly frustrated by the lack of administrative support for patient education, I do believe that patient education makes a difference.” Jeremiah jumps in and says, “I am sick of continuously being interrupted when trying to educate my patients. I’m also tired of the boring, mandated continuing education programs we are required to attend.” Finally, Johaun comments, “I have no idea how I am supposed to fit education in with all the other tasks I need to complete, especially when patients are clearly not willing to learn.” Because the nursing staff obviously has some strong feelings about the department’s education efforts, you believe a SWOT (strengths, weaknesses, opportunities, threats) analysis is a good place to begin to gather information from your colleagues about the issues and problems they are facing.

1. As a prelude to the SWOT analysis, identify the goals of patient and staff education. 2. Use the section titled “Barriers to Teaching and Obstacles to Learning” as a beginning framework

for the weaknesses and threats section of the SWOT analysis and then describe five potential barriers to teaching and five potential obstacles to learning that your staff might identify.

3. Provide possible solutions to the barriers and obstacles identified that would serve to enhance patient education.

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33References

Ethical, Legal, and Economic Foundations of the Educational Process M. Janice Nelson Kattiria M. Gonzalez

CHAPTER HIGHLIGHTS

■ A Differentiated View of Ethics, Morality, and the Law ■ Evolution of Ethical and Legal Principles in Health Care ■ Application of Ethical Principles to Patient Education

• Autonomy • Veracity • Confidentiality • Nonmaleficence • Beneficence • Justice

■ The Ethics of Education in Classroom and Practice Settings • The Student–Teacher Relationship • The Patient–Provider Relationship

■ Legality of Patient Education and Information ■ Legal and Financial Implications of Documentation ■ Economic Factors in Healthcare Education: Justice and Duty Revisited

(continues)

CHAPTER 2

KEY TERMS

ethics ethical moral values ethical dilemmas legal rights and duties practice acts code of ethics autonomy decision aids veracity

confidentiality nonmaleficence negligence malpractice beneficence justice respondeat superior direct costs fixed costs variable costs

indirect costs hidden costs cost savings cost benefit cost recovery revenue generation cost-benefit analysis cost-benefit ratio cost-effectiveness analysis

OBJECTIVES

After completing this chapter, the reader will be able to

1. Identify major ethical principles as they apply to education in health care. 2. Distinguish between ethical and legal dimensions of the healthcare delivery system with

respect to patient, staff, and student education. 3. Describe the importance of nurse practice acts and the code of ethics for the nursing profession. 4. Recognize the potential ethical consequences of power imbalances between the teacher and

the student, or between the nurse and the patient, in educational and practice settings. 5. Describe the legal and financial implications of documentation. 6. Delineate the ethical, legal, and economic importance of federal, state, and accrediting body

regulations and standards in the delivery of healthcare services. 7. Differentiate among financial terms associated with the development, implementation, and

evaluation of patient and staff education programs.

■ Financial Terminology • Direct Costs • Indirect Costs • Cost Savings, Cost Benefit, and Cost Recovery

■ Program Planning and Implementation ■ Cost-Benefit Analysis and Cost-Effectiveness Analysis ■ State of the Evidence

CHAPTER HIGHLIGHTS (continued)

36 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

Approximately 45 years ago, the field of modern Western bioethics arose in re-sponse to the increasing complexity of medical care and decision making. Novel chal- lenges in health care continually stem from such influences as technological advances, changes in laws, and public awareness of scientific endeav- ors. The field of bioethics provides systematic theoretical and practical approaches for han- dling such complex issues and the dilemmas that ensue from them. As a result, programs of study for health professionals, including nurs- ing, now provide formal ethics education—some by mandate. Healthcare providers who commit ethical infractions while in training or practice may be referred for ethics remediation by their programs or specialty licensing boards or may risk professional sanctions.

In the popular media, bioethics translates into stem cell research, organ transplantation, genetic testing, and other sensational inno- vations. But every day, far from the spotlight, nursing students, nursing staff, and clinical instructors confront commonplace and vex- ing ethical dilemmas. Consider a patient who refuses a routine but lifesaving blood transfusion. Should he or she be allowed to refuse this treat- ment, or should the nursing staff persuade the patient otherwise? Suppose a nurse witnesses a confused patient signing a consent form for a procedure. Should he or she ask whether the patient is able to make the decision to agree to have the procedure done? Or suppose a sur- geon misleads a family by indicating that a sur- gical error was really a complication. Should the nurse practitioner who observed the error speak to a superior in the healthcare hierar- chy? What about a clinical nursing instructor who habitually introduces a nursing student to patients as a nurse, implying that the student has completed his or her program of study? Should the nursing student correct the fac- ulty member, and if so, when, where, and how?

These scenarios describe not only practice issues but also moral problems. They happen so frequently that convening an ethics committee

to address every one of them is impractical. In- creasingly, staff nurses, clinical educators, and nursing students are being called upon to reason through both medical and ethical issues. How- ever, knowledge of basic ethical principles and concepts does not always suffice. As the health- care field has developed, so has a critical con- sciousness of individual rights stemming from both natural and constitutional law. Healthcare organizations are laden with laws and regula- tions ensuring clients’ rights to a high-quality standard of care, to informed consent, and sub- sequently to self-determination. Further, in the interest of justice, it is worthwhile to acknowl- edge the relationship between costs to the health- care facility and the provision of health services. Consequently, it is crucial that the providers of care be equally proficient in educating the pub- lic and the nursing students and staff who are or will be the practitioner educators of tomorrow.

Although the physician is primarily held legally accountable for prescribing the medical regimen, it is a known fact that patient educa- tion generally falls to the nurse. Indeed, given the close relationship of the nurse to the client, the role of the nurse in this educational process is essential in providing safe, high-quality care as mandated in the standards and scope of nurs- ing practice through each state nurse practice act and each state’s board of nursing (Russell, 2012). Furthermore, the American public, ac- cording to the annual Gallup Poll, ranked reg- istered nurses for the 15th consecutive year as the professionals with the highest honesty and ethical standards. Nursing is the most trusted among all other professions (Norman, 2016).

Today’s enlightened consumers are aware of and demand recognition of their individ- ual constitutional rights regarding freedom of choice and self-determination. In fact, it may seem strange to some that federal and state gov- ernments, accrediting bodies, and professional organizations find it necessary to legislate, reg- ulate, or provide standards and guidelines to ensure the protection of human rights in mat- ters of health care. The answer, of course, is that

37Ethical, Legal, and Economic Foundations of the Educational Process

the federal government, which once had an his- torical hands-off policy toward the activities of physicians and other health professionals, has now become heavily involved in the oversight of provider practices. This is because of serious breaches of public confidence that resulted from shocking revelations of abuses of human rights in the name of biomedical research, which were first discovered in the mid-20th century. Un- fortunately, human rights violations continue to occur in health care to this day in the United States and worldwide.

These issues of human rights are funda- mental to the delivery of high-quality health- care services. They are equally fundamental to the education process, in that the intent of the educator should be to empower the client to identify and articulate his or her values and preferences; acknowledge his or her role in a family, community, or other relationship; and make well-informed choices, reasonably aware of the alternatives and consequences of those choices (Butts & Rich, 2016; Mason, Gardner, Outlaw, & O’Grady, 2016; Parker, 2007). Thus, an interpretation of the role of the nurse in the teaching–learning process must include the ethical and legal foundations of that process. Teaching and learning principles, with their in- herent legal and ethical dimensions, apply to any situation in which the education process occurs.

The purpose of this chapter is to provide the ethical, legal, and economic foundations that are essential to carrying out patient educa- tion initiatives, on the one hand, and the rights and responsibilities of the healthcare provider, on the other hand. This chapter describes the differences between and among ethical, moral, and legal concepts. It explores the foundations of human rights based on ethics and the law, and it reviews the ethical and legal dimensions of health care. This chapter also explores student–teacher and patient–provider relationships as they re- late to the ethics of education in the classroom and practice settings. Furthermore, this chap- ter examines the importance of documentation of patient teaching while highlighting the eco- nomic factors that must be considered in the

delivery of patient education in healthcare set- tings. An additional section provides a brief discussion of evidence-based practice and its relationship to quality and evaluation of patient education programs.

▸ A Differentiated View of Ethics, Morality, and the Law

Although ethics as a branch of classical philos- ophy has been studied throughout the centu- ries, by and large these studies were left to the domains of philosophical and religious think- ers. More recently, because of the complexities of contemporary life and the heightened aware- ness of an educated public, ethical issues related to health care have surfaced as a major concern of both consumers and healthcare providers. It is now a widely held belief that the patient has the right to know his or her medical diagnosis, the treatments available, and the expected out- comes. This information is necessary so that patients can make informed choices about their health and their care options with advice offered by health professionals.

Ethical principles that pertain to human rights are based on natural laws, which, in the absence of any other guidelines, are binding on human society. Inherent in these natural laws are, for ex- ample, the principles of respect for others, truth telling, honesty, and respect for life. Ethics as a discipline interprets these basic principles of be- havior in broad terms that direct moral decision making in all realms of human activity (Tong, 2007; World Health Organization [WHO], 2017).

Although multiple perspectives on the right- ness or wrongness of human acts exist, among the most commonly referenced are the writ- ings of the 18th-century German philosopher, Immanuel Kant, and those of the 19th-century English scholar and philosopher, John Stuart Mill (Edward, 1967). Kant proposed that in- dividual rights prevail and openly proclaimed

38 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

the deontological notion of the “Golden Rule.” Deontology (from the Greek word deon, which means “duty” and logos, which means “science” or “study”) is the ethical belief system that stresses the importance of doing one’s duty and following the rules (Stanford Encyclopedia of Philosophy, 2016a). Thus, according to Kant, respect for indi- vidual rights is key, and one person should never be treated merely for the benefit or well-being of another person or group (Tong, 2007). Mill, in contrast, proposed the teleological notion or util- itarian approach to ethical decision making that allows for the sacrifice of one or more individu- als so that a group of people can benefit in some important way. He believed that given the alter- natives, choices should be made that result in the greatest good for the greatest number of people (Stanford Encyclopedia of Philosophy, 2016b).

Likewise, the legal system and its laws are based on ethical and moral principles that, through experience and over time, society has accepted as behavioral norms (Hall, 1996; Lesnik & Anderson, 1962). In fact, the terms ethical, moral, and legal are often used in syn- chrony. It should be made clear, however, that although these terms are certainly interrelated, they are not necessarily synonymous.

Ethics refers to the guiding principles of behavior, and ethical refers to norms or stan- dards of behavior accepted by the society to which a person belongs. Although the terms moral and morality are generally used inter- changeably with the terms ethics and ethical, nurses can differentiate between the notion of moral rights and duties and the notion of ethi- cal rights and duties. Moral values refer to an internal belief system (what one believes to be right). This value system, defined as morality, is expressed externally through a person’s be- haviors. Ethical dilemmas are a “specific type of moral conflict in which two or more ethi- cal principles apply but support mutually in- consistent courses of action” (Dwarswaard & van de Bovenkamp, 2015, pp. 1131–1132). An example that these authors provide is that the nurse must respect patient autonomy and indi- vidual patient responsibility when encouraging

and supporting self- management behaviors, but the ethical principle of the patient’s right to self- determination may clash with profes- sional values that promote health and help achieve medical outcomes. Legal rights and duties, in contrast, refer to rules governing be- havior or conduct that are enforceable by law under threat of punishment or penalty, such as a fine, imprisonment, or both.

The intricate relationship between ethics and the law explains why ethics terminology, such as informed consent, confidentiality, non- maleficence, and justice, can be found within the language of the legal system. In keeping with this practice, nurses may cite professional commitment or moral obligation to justify the education of clients as one dimension of their role. By law, the teaching role of nurses is le- gally mandated in the rules and standards of the nurse practice act and the state board of nursing that exist in the specific state where the nurse resides, is licensed, and is employed.

Practice acts are documents that define a profession, describe that profession’s scope of practice, and provide guidelines for state pro- fessional boards of nursing regarding standards for practice, entry into a profession via licensure, and disciplinary actions that can be taken when necessary (Russell, 2012). Practice acts were de- veloped to protect the public from unqualified practitioners and to protect the professional ti- tle, e.g., such as registered nurse (RN), occupa- tional therapist (OT), respiratory therapist (RT), and physical therapist (PT).

A model practice act (American Nurses Association, 1978) serves as a template for in- dividual states to follow, with the goal being to minimize variability of professional practice from state to state within a profession. From the model, a state or other jurisdiction can de- velop its own practice act that addresses its spe- cific needs in addition to including the basic information regarding scope of practice, licen- sure requirements, and so forth (Flook, 2003; Russell, 2012). Essentially then, a professional practice act is not only legally binding but also protected by the police authority of the state in

A Differentiated View of Ethics, Morality, and the Law 39

with such mental, physical, or socioeconomic challenges (Neil, 2015).

Clearly, this situation has changed dramat- ically. For example, informed consent—a basic tenet of the ethical practice of health care—was established in the courts as early as 1914 by Jus- tice Benjamin Cardozo. Cardozo determined that every adult of sound mind has a right to protect his or her own body and to determine how it shall be treated (Hall, 1992; Schloendorff v. Society of New York Hospitals, 1914). Although the Cardozo decision has considerable magni- tude in its scope, governmental interest in the bioethical underpinnings of human rights in the delivery of healthcare services did not re- ally surface until after World War II.

Over the years, legal authorities such as federal and state governments had maintained a hands-off posture when it came to issues of biomedical research or physician–patient re- lationships. However, the human atrocities committed by the Nazis in the name of bio- medical research during World War II shocked the world into critical awareness of gross vio- lations of human rights. Unfortunately, such abuses were not confined to wartime Europe. On U.S. soil, for example, the lack of treatment of African Americans with syphilis in Tuskegee, Alabama; the injection of live cancer cells into uninformed, nonconsenting older adults at the Brooklyn Chronic Disease Hospital; and the use of institutionalized mentally retarded children to study hepatitis at the Willow- brook State School on Staten Island, New York, startled the nation and raised public awareness of disturbing breaches in the physician–patient relationship (Brent, 2001; Centers for Disease Control and Prevention, 2005; Rivera, 1972; Thomas & Quinn, 1991; Weisbard & Arras, 1984).

Stirred to action by these disturbing phe- nomena, in 1974 Congress moved with all due deliberation to create the National Commission for the Protection of Human Subjects of Bio- medical and Behavioral Research (U.S. Depart- ment of Health and Human Services [USDHHS], 1983). As an outcome of this unprecedented act, an institutional review board for the protection

the interest of protecting the public (Brent, 2001; Mikos, 2004; Russell, 2012).

▸ Evolution of Ethical and Legal Principles in Health Care

In the past, ethics was relegated almost exclu- sively to the philosophical and religious do- mains. Likewise, from a historical vantage point, medical and nursing care was considered a hu- manitarian, if not charitable, endeavor. Often it was provided by members of religious commu- nities and others considered to be generous of spirit, caring in nature, courageous, dedicated, and self-sacrificing in their service to others. Public respect for doctors and nurses was so strong that for many years, healthcare organi- zations in which they worked were considered charitable institutions and, thus, were largely immune from legal action “because it would compel the charity to divert its funds for a pur- pose never intended” (Lesnik & Anderson, 1962, p. 211). In the same manner, healthcare prac- titioners of the past—who were primarily phy- sicians and nurses—were usually regarded as Good Samaritans who acted in good faith and for the most part were exempt from lawsuits.

Although court records of lawsuits involving hospitals, physicians, and nurses can be found dating back to the early 1900s, their numbers pale in comparison with the volumes being gen- erated daily in today’s world (Reising & Allen, 2007). Malpractice claims against nurses have risen significantly in the first decade of the 21st century and now constitute about 2 in every 100 malpractice payments (Reising, 2012). Further, despite the horror stories that have been handed down through the years regarding inhumane and often torturous treatment of prisoners, the mentally ill, the disabled, and the poor, in the past there was only limited focus on ethical as- pects of that care. In turn, little thought was given to legal protection of the rights of people

40 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

Ethics for Nurses with Interpretative Statements, that has since been revised and updated sev- eral times (ANA, 1976, 1985, 2001, 2015). This code of ethics represents an articulation of nine provisions for professional values and moral obligations with respect to the nurse– patient relationship and with respect of the profession and its mission. Lachman (2009a, 2009b) out- lines these provisions and further clarifies the nursing role in each provision:

1. Honor the human dignity of all pa- tients and coworkers.

2. Establish appropriate nurse–patient boundaries, and focus on interdisci- plinary collaboration.

3. The nurse–patient relationship is grounded in privacy and confiden- tiality.

4. The nurse is accountable for the personal actions and the behaviors of those persons to whom the nurse has delegated responsibilities.

5. The nurse is responsible for main- taining competence, preserving integrity and safety, and continuing personal growth.

6. The nurse has a responsibility to deliver high-quality care to patients.

7. The nurse contributes to the ad- vancement of the profession.

8. The nurse participates in global efforts for both health promotion and disease prevention.

9. Involvement in professional nursing organizations supports the develop- ment of social policy.

Although other health professions have adopted their own codes of ethics, the nursing profession’s code has been recognized as exem- plary and has been used as a template by other health discipline organizations in crafting their own ethics documents. Health professional or- ganizations have accepted the responsibility for establishing standards of ethical behavior for members of their disciplines in the context of healthcare practice. In the end, however, it is

of human subjects (IRBPHS) was rapidly es- tablished at the local level by any hospital, aca- demic medical center, agency, or organization where research on human subjects was being conducted. To this day, the primary function of these IRBs is to safeguard all human study sub- jects by insisting that research protocols include voluntary participation and withdrawal, confi- dentiality, truth telling, and informed consent and that they address additional specific con- cerns for vulnerable populations such as infants, children, prisoners, and persons with mental ill- nesses. Every proposal for biomedical research that involves human subjects must be submit- ted to a local IRBPHS for intensive review and approval before the proposed study proceeds (USDHHS, 1983). Further, in response to con- cerns about the range of ethical issues associated with medical practice and a perceived need to regulate biomedical research, in 1978 Congress established the President’s Commission for the Study of Ethical Problems in Medicine and Bio- medical and Behavioral Research (Brent, 2001; Thomas & Quinn, 1991; USDHHS, 1983).

But did the professions themselves speak up in the face of the outrageous violations of human rights in the name of research? Indeed, two professional groups acted well before the 1970s to establish uniform standards for profes- sional education and conduct. The first was the American Medical Association (AMA), which wrote and published its Code of Medical Eth- ics in 1847. Summarized as the Principles of Medical Ethics in 1903, the code is currently in its sixth revision (AMA, 2016). All five versions address the precedence of patients’ welfare and physicians’ moral rectitude over scientific accom- plishment and professional gain. Despite such regular attention to the values to which physi- cians commit themselves individually and col- lectively, the preceding historical examples attest to a disconnection between espoused values and actual practice, a failure of widespread individ- ual and collective professional accountability.

As early as 1950, the American Nurses Asso- ciation (ANA) developed and adopted an ethical code for professional practice, titled the Code of

Evolution of Ethical and Legal Principles in Health Care 41

rights and responsibilities into six expectations written in multiple languages and easy-to- understand terms (AHA, 2008). In 2010 with the enactment of the Affordable Care Act, a new patient’s bill of rights was passed to pro- vide dependents and people with preexisting conditions the right to be protected by health insurance (Bazemore, 2016).

▸ Application of Ethical Principles to Patient Education

Various theories and traditions frame a health professional’s understanding of the ethical di- mensions in the healthcare setting (Butts & Rich, 2016). In considering the ethical and legal re- sponsibilities inherent in the process of patient education, nurses and nursing students can turn to a framework of six major ethical principles— including the so-called big four principles ini- tially proposed by Beauchamp and Childress (1977)—that are specified in the ANA’s Code of Ethics (2015) and in similar ethics and pa- tient rights documents promulgated by other healthcare organizations as well as the federal government. These principles, which encom- pass the very issues that precipitated federal intervention into healthcare affairs, are auton- omy, veracity, confidentiality, nonmaleficence, beneficence, and justice.

Autonomy The term autonomy is derived from the Greek words auto (“self ”) and nomos (“law”) and re- fers to the right of self-determination (Butts & Rich, 2016; Tong, 2007). Laws have been enacted to protect the patient’s right to make choices independently. Federal mandates, such as those dealing with informed consent, must be evident in every application for federal fund- ing to support biomedical research. The local IRBPHS assumes the role of judge and jury to

up to the individual healthcare provider to take his or her professional ethics code to heart. The next section of this chapter addresses the appli- cation of ethical and legal principles and con- cepts by nurses to their clients.

In addition to these professional ethics codes, the American Hospital Association (AHA) cre- ated a document in 1973 titled A Patient’s Bill of Rights, which was revised in 1992 (Associ- ation of American Physicians and Surgeons, 1995). Since then, a copy of these patient rights has been framed and posted in a public place in every healthcare facility across the United States. This document listed 12 expectations that patients should have about their health care, such as communication with the health- care team, treatment, medical records, privacy, and confidentiality.

Further, federal standards developed by the Centers for Medicare and Medicaid Services (CMS)—an arm of the Health Care Financing Administration (HCFA)—require that each pa- tient be provided with a personal copy of these rights, either at the time of admission to the hos- pital or long-term care facility or prior to the initiation of care or treatment when admitted to a surgery center, health maintenance organi- zation (HMO), home care, or hospice. In fact, many states have adopted the statement of pa- tient rights for specific populations of health- care consumers as part of their state health code, which is why there is no one single ver- sion of this document but many versions to fit the needs of each facility (Academy of Medi- cal-Surgical Nurses, 2009).

Regardless of the version used, these pa- tient rights fall under the jurisdiction of the law, rendering them legally enforceable by threat of penalty. In 2005, new legislation to expand the patient’s bill of rights to cover man- aged care and other insurance plans was intro- duced by Senator Edward Kennedy (D-MA) in the U.S. Congress, but it was never passed into law (Govtrack.us, 2005). Nevertheless, in 2003 the AHA replaced its original patient’s bill of rights with what became known as The Pa- tient Care Partnership, which condensed these

42 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

to the community, such as childbirth education courses, smoking cessation classes, weight re- duction sessions, discussions of women’s health issues, and positive interventions for prevent- ing child abuse. Although health education per se is not an interpretive part of the principle of autonomy, it certainly lends credence to the ethical notion of assisting the public to attain greater autonomy when it comes to matters of health promotion and high-level wellness. In fact, consistent with the Model Nurse Practice Act (ANA, 1978), all contemporary nurse prac- tice acts contain some type of direct or implicit statements identifying health education as a legal duty and responsibility of the registered nurse.

An additional moral framework through which to view the practice of patient education is a framework of expansion of patient capabili- ties (Redman, 2008). The reason to view expan- sion of capabilities as a moral enterprise is that such goals as healthfulness, self-care, and en- gaging in life, relationships, and pursuits “have value in themselves and are of special impor- tance in making possible any choice of a way of life” (p. 815).

Another example of autonomy is the de- velopment and use of patient decision aid in- terventions that are designed to assist patients in making informed treatment choices (Bekker, 2010). These patient decision aids, which in- clude printed materials, videos, and interactive web-based tutorials, provide patients with infor- mation about specific health issues, diagnoses, treatment risks and benefits, and question- naires to determine whether they need more information. “The emphasis on collaboration between providers and patients on decision making has, in turn, stimulated the develop- ment of tools to help patients and their fami- lies participate in clinical discussions and reach decisions that incorporate personal values and goals” (Wittmann-Price & Fisher, 2009, p. 60).

Veracity Veracity, or truth telling, is closely linked to informed decision making and informed consent.

ascertain adherence to this enforceable regu- lation (Dickey, 2006).

The Patient Self-Determination Act (PSDA), which was passed by Congress in 1991 (Ulrich, 1999), is a clear example of the principle of au- tonomy enacted into law. Any healthcare fa- cility that receives Medicare and/or Medicaid funds, including acute- and long-term care in- stitutions, surgery centers, HMOs, hospices, or home care organizations, must comply with the PSDA. This law requires that, either at the time of hospital admission or prior to the ini- tiation of care or treatment in a community health setting,

every individual receiving health care be informed in writing of the right un- der state law to make decisions about his or her health care, including the right to refuse medical and surgical care and the right to initiate advance direc- tives. (Mezey, Evans, Golob, Murphy, & White, 1994, p. 30)

Although ultimate responsibility for dis- cussing treatment options and a plan of care as well as obtaining informed consent rests with the physician, Menendez (2013) points out that it is the nurse’s responsibility to ensure informed de- cision making by patients. This includes, but is certainly not limited to, advance directives (e.g., living wills, durable power of attorney for health care, and designation of a healthcare agent). Ev- idence of such instruction must appear in the patient’s record, which is the legal document val- idating that informed consent took place (Hall, Prochazka, & Fink, 2012).

One principle worth noting in the ANA’s Code of Ethics addresses collaboration “with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public” (New York State Nurses Association, 2001, p. 6). This principle certainly provides a justification for patient education both within and outside the healthcare organization. It provides an eth- ical rationale for health education classes open

Application of Ethical Principles to Patient Education 43

making up the notion of informed consent that are such vital aspects of patient education:

1. Competence, which refers to the capacity of the patient to make a reasonable decision.

2. Disclosure of information, which requires that sufficient informa- tion regarding risks and alternative treatments—including no treatment at all—be provided to the patient to enable him or her to make a ratio- nal decision.

3. Comprehension, which speaks to the individual’s ability to understand or to grasp intellectually the infor- mation being provided. A child, for example, may not yet be of an age to understand any ramifications of medical treatment and must, there- fore, depend on his or her parents to make a decision that will be in the child’s best interest. Similarly, for an adequate informed consent conversation, all options must be expressed in a language the patient can understand and in lay terms.

4. Voluntariness, which indicates that the patient can make a decision with- out coercion or force from others.

Although all four of these elements might be satisfied, the patient might still choose to reject the regimen of care suggested by health- care providers. This decision could be the re- sult of the exorbitant cost of a treatment or it might reflect certain personal or religious be- liefs. Whatever the underlying motivation, it must be recognized by all concerned that a competent, informed patient cannot be forced to accept treatment if he or she is aware of the alternatives as well as the consequences of any decision (Cisar & Bell, 1995; Menendez, 2013).

Finally, a dimension of the legality of truth telling relates to the role of the nurse as expert witness. Professional nurses who are recognized for their skill or expertise in a specific area of nursing practice may be called on to testify in

The landmark decision by Justice Benjamin Cardozo (Schloendorff v. Society of New York Hos- pitals, 1914) identified an individual’s fundamental right to make decisions about his or her own body. This ruling provides a basis in law for patient ed- ucation or instruction regarding invasive medi- cal procedures. Nurses are often confronted with issues of truth telling, as was exemplified in the Tuma vs. Board of Nursing case (Supreme Court of Idaho, 1979). In the interest of full disclosure of information, the nurse (Tuma) had advised a patient with cancer of alternative treatments without consulting the client’s physician. Tuma was sued by the physician for interfering with the medical regimen that he had prescribed for care of this patient (Rankin & Stallings, 1990). Although Tuma was eventually exonerated from professional misconduct charges, the case em- phasizes a significant point of law to be found in the New York State Nurse Practice Act (New York State Nurses Association, 1972), which states that nursing actions must be consistent with current medical therapies prescribed by physicians. However, others insist that failure to instruct the patient properly relative to invasive procedures is equivalent to battery (Creighton, 1986; Hall et al., 2012). Therefore, in some in- stances, the nurse may find himself or herself in a double bind. If in such a dilemma, the nurse has a variety of actions available. One possibility would be to inform the physician of the profes- sional double bind and engage with him or her in achieving a course of action that best meets the patient’s medical needs while respecting the patient’s autonomy. The second possibility is to seek out the institutional ethics committee or an ethics consultant for assistance in negotiating in- teractions with both the physician and the patient (Cisar & Bell, 1995; Menendez, 2013; Robichaux, 2012) as well as in resolving ethical conflicts that arise with differences between professional val- ues and the values of the organization in which nurses and physicians work (Gaudine, LeFort, Lamb, & Thorne, 2011).

Cisar and Bell (1995) address this concept of battery related to medical treatment and offer the following explanation of the four elements

44 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

the nurse. But is it fair to deprive a vulnerable spouse or other contact of this important health information? Is it morally acceptable to put one person’s rights above those of another? In some situations, yes, although these decisions are best considered after much deliberation with the pa- tient and other trusted health professionals. Of course, if a patient discloses the identity of his or her contacts, health professionals are mandated to inform them in accordance with applicable state laws. If a patient tests positive for HIV/AIDS, for example, and has no intention of telling his or her spouse about this diagnosis, the physician has an obligation to warn the spouse directly or indirectly (i.e., through anonymous lab report- ing) of the risk of potential harm (Tong, 2007).

Adequate deliberation with the patient and others can reveal circumstances in which the re- ality is even more complex. For example, if the physician or other primary healthcare provider explores the patient’s rationale for not wanting to inform his or her spouse of the infectious disease status, it may be out of fear of inciting domestic violence. According to Brent (2001), “this area of legislation concerned with health care privacy and disclosure reveals the tension between what is good for the individual vis-à- vis what is good for society” (p. 141).

The 2003 updated Health Insurance Porta- bility and Accountability Act (HIPAA) ensures nearly absolute confidentiality related to dis- semination of patient information, unless the patient himself or herself authorizes release of such information (Kohlenberg, 2006). One goal of the HIPAA policy, first enacted by Congress in 1996, is to limit disclosure of patient health- care information to third parties, such as insur- ance companies or employers. This law, which requires patients’ prior written consent for release of their health information, was never meant to interfere with consultation between professionals but is intended to prevent, for example, “elevator conversations” about private matters of individ- uals entrusted to the care of health profession- als. In a technologically advanced society such as exists in the United States today, this law is a must to ensure confidentiality (Tong, 2007).

court on behalf of either the plaintiff (the one who initiates the litigation) or the defendant (the one being sued). In any case, the concept of expert testimony speaks for itself. Regardless of the situation, the nurse must always tell the truth and the patient (or his or her healthcare agent) is always entitled to the truth (Hall, 1996).

Confidentiality Confidentiality refers to personal information that is entrusted and protected as privileged information via a social contract, healthcare standard or code, or legal covenant. When this information is acquired in a professional capacity from a patient, healthcare providers may not disclose it without consent of that pa- tient. If sensitive information were not to be protected, patients would lose trust in their providers and would be reluctant to openly share problems with them or even seek medi- cal care at all (Butts & Rich, 2016; University of California, Irvine, 2015).

A distinction must be made between the terms anonymous and confidential. Information is anonymous, for example, when researchers are unable to link any subject’s identity in the med- ical record of that person. Information is con- fidential when identifying materials appear on subjects’ records but can be accessed only by the researchers (Tong, 2007).

Only under special circumstances may se- crecy be ethically broken, such as when a pa- tient has been the victim or subject of a crime to which the nurse or doctor is a witness (Lesnik & Anderson, 1962). Other exceptions to confiden- tiality occur when nurses or other health pro- fessionals suspect or are aware of child or elder abuse, narcotic use, legally reportable communi- cable diseases, gunshot or knife wounds, or the threat of violence toward someone. To protect others from bodily harm, health professionals are legally permitted to breach confidentiality.

In the case of communicable diseases, pa- tients should not be forced or coerced to name their contacts, again because respecting confiden- tiality maintains trust between the patient and

Application of Ethical Principles to Patient Education 45

duty by a professional person that results in in- jury or damage to a patient” (Reising & Allen, 2007, p. 39). Thus, malpractice is limited in scope to those whose life work requires special educa- tion and training as dictated by specific educa- tional standards. In contrast, negligence refers to all improper and wrongful conduct by any- one arising out of any activity.

Reising and Allen (2007) describe the most common causes for malpractice claims specif- ically against nurses, but these causes are also relevant to the conduct of other health pro- fessionals within the scope of their practice responsibilities:

1. Failure to follow standards of care 2. Failure to use equipment in a respon-

sible manner 3. Failure to communicate 4. Failure to document 5. Failure to assess and monitor 6. Failure to act as patient advocate 7. Failure to delegate tasks properly

The concept of duty is closely tied to the concepts of negligence and malpractice. Nurses’ duties are spelled out in job descriptions at their places of employment. Policy and procedure manuals of healthcare facilities are certainly in- tended to protect the patient and ensure good- quality care, but they also exist to protect both the employee—in this instance, the nurse—and the employer against litigation. Policies are more than guidelines. Policies and procedures determine standards of behavior (duties) ex- pected of employees of an institution and can be used in a court of law in the determination of negligence (Morales, 2012; Reising, 2012; Weld & Bibb, 2009; Yoder-Wise, 2015).

The role of the registered nurse has evolved over the past few decades. Nurses’ responsibil- ities now include monitoring complex equip- ment and data, operating lifesaving equipment, coordinating patient care and services, and ad- ministering million-dollar healthcare programs (Weld & Bibb, 2009). As a result, nurses now have a higher duty of care to their patients, which in return can result in more risk of claims

Currently, in some states and under certain conditions, such as death or impending death, a spouse or members of the immediate family can be apprised of the patient’s condition if this information was previously unknown to them. Despite federal and state legislation protecting the confidentiality rights of individuals, the is- sue of the ethical/moral obligation of the patient with HIV/AIDS or genetic disease, for example, to voluntarily divulge his or her condition to others who may be at risk remains largely un- resolved (Legal Action Center, 2001).

Nonmaleficence Nonmaleficence is defined as “do no harm” and refers to the ethics of legal determina- tions involving negligence and/or malpractice (Beauchamp & Childress, 2012). According to Brent (2001), negligence is defined as “con- duct which falls below the standard established by law for the protection of others against un- reasonable risk of harm” (p. 54). She further asserts that the concept of professional neg- ligence “involves the conduct of professionals (e.g., nurses, physicians, dentists, and lawyers) that falls below a professional standard of due care” (p. 55). As clarified by Tong (2007), due care is “the kind of care healthcare profession- als give patients when they treat them atten- tively and vigilantly so as to avoid mistakes” (p. 25). For negligence to exist, there must be a duty between the injured party and the person whose actions (or nonactions) caused the in- jury. A breach of that duty must have occurred, it must have been the immediate cause of the injury, and the injured party must have experi- enced damages from the injury (Brent, 2001).

The term malpractice, by comparison, still holds as defined by Lesnik and Anderson in 1962. Malpractice, these authors assert, “refers to a limited class of negligent activities committed within the scope of performance by those pur- suing a particular profession involving highly skilled and technical services” (p. 234). More recently, malpractice has been specifically de- fined as “negligence, misconduct, or breach of

46 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

interest of the patient. Such behavior empha- sizes patient welfare but not necessarily to the harm of the healthcare provider.

The effort to save lives and relieve human suffering is a duty to do what is right only within reasonable limits. For example, when AIDS first appeared, the cause of and means to control this fatal disease were unknown. Some health professionals protested that the duty of beneficence did not include caring for patients who put them at risk for this deadly, infectious, and untreatable disease. Others maintained that part of the decision to become a health professional involves the acceptance of certain personal risks: It is part of the job. Neverthe- less, once it became clear that HIV transmis- sion through occupational exposure was quite small, most healthcare practitioners concurred with the opinion of the AMA that it would be unethical to refuse to care for patients just because they were HIV positive (Tong, 2007).

Justice Justice speaks to fairness and the equitable dis- tribution of goods and services. The law is the justice system. The focus of the law is the pro- tection of society; the focus of health law is the protection of the consumer. It is unjust to treat one person better or worse than another person in a similar condition or circumstance, unless a difference in treatment can be justified with good reason (Beauchamp & Childress, 2012). Feinsod and Wagner (2008) point out that jus- tice is a complex ethical principle concerned with distributing benefits and burdens fairly to individuals in social institutions, but they ques- tion what it means to be fair. In today’s health- care climate, professionals must be as objective as possible in allocating scarce medical resources in a just manner. Decision making for the fair distribution of resources includes the following criteria as defined by Tong (2007):

1. To each, an equal share 2. To each, according to need 3. To each, according to effort

against them for negligence or malpractice. Ex- pectations of professional nursing performance also are measured against the nurse’s level of education and concomitant skills, standing or- ders issued by the physician, institution-specific protocols, standards of care upheld by the pro- fession (ANA), and standards of care adhered to by any subspecialty organizations of which the nurse may be a member. If, for example, a nurse is certified in a clinical specialty or is identified as a “specialist” although not certified as such, he or she will be held to the standards of that specialty (Yoder-Wise, 2015).

In the instance of litigation, the key opera- tional principle is that the nurse is not measured against the optimal or maximum professional standards of performance; rather, the yardstick consists of the prevailing practice of what a pru- dent and reasonable nurse would do under the same circumstances in a similar community (Morales, 2012). Thus, the nurse’s duty to per- form patient education (or lack thereof ) is mea- sured against not only the prevailing policy of the employing institution but also the prevailing practice in the community. In the case of clini- cal nurse specialists (CNSs), nurse practitioners (NPs), and clinical education specialists (CESs), for example, the practice is measured against institutional policies for this level of worker as well as against the prevailing practice of nurses performing at the same level in the community or in the same geographic region.

Beneficence Beneficence is defined as “doing good” for the benefit of others. It is a concept that is legalized through properly carrying out critical tasks and duties contained in job descriptions; in poli- cies, procedures, and protocols set forth by the healthcare facility; and in standards and codes of ethical behaviors established by professional nursing organizations (Beauchamp & Childress, 2012). Adherence to these various professional performance criteria and principles, including adequate and current patient education, speaks to the nurse’s commitment to act in the best

Application of Ethical Principles to Patient Education 47

Budget Reconciliation Act [COBRA] of 1985). In other words, all patients who present with an emergency medical condition (or in active la- bor) must be treated in the same way, regard- less of insurance status.

Nevertheless, uninsured and Medicare and Medicaid patients remain subject to other, more subtle discrimination. Because many outpatient facilities do not accept these patients, this restric- tion on their right of access to health care ex- tends to their right to access health education. Emanuel (2000) raises a critical point in asserting that “the diffuseness of decision making in the American health care system precludes a coher- ent process for allocating health care resources” (p. 8). Emanuel further contends that managed care organizations have systematically pursued drastic cost reductions by restructuring delivery systems and investing in expensive and elabo- rate information systems. For example, HMOs have bought out physician practices and have become involved in numbers of related activities with no substantial evidence that a high quality of health care will be achieved at lower prices.

These issues influence whether health ed- ucators can surmount the obstacles potentially blocking the patient education process. In the interest of cutting costs, HMOs also have suc- ceeded in shortening lengths of hospital stays. This development, in turn, has had a tremen- dous effect on the delivery of education to the hospitalized patient and presents serious obsta- cles to the implementation of this mandate. Lack of time serves as a major barrier to the nurse’s or other health professional’s ability to give dis- charge instructions that contain sufficient in- formation for self-care. Also, illness acuity level interferes with the patient’s ability to process the information necessary to meet his or her physi- cal and emotional needs.

Clearly, professional nurses are mandated by organizational policy as well as by federal and state regulations to provide patient educa- tion. Great care must be taken to ensure that the education justly due to the patient will be ad- dressed post discharge, either in the ambulatory care setting, at home, or in the physician’s office.

4. To each, according to contribution 5. To each, according to merit 6. To each, according to the ability to

pay (p. 30)

According to Tong (2007), professional nurses may have second thoughts about the ap- plication of these criteria in certain circumstances because one or more of the criteria could be at odds with the concept of justice. “To allocate scarce resources to patients on the basis of their social worth, moral goodness, or economic con- dition rather than on the basis of their medical condition is more often than not wrong” (p. 30).

As noted earlier, adherence to the rights of patients is legally enforced in most states. In turn, the nurse, or any other health professional, can be subjected to penalty or to litigation for dis- crimination in provision of care. Regardless of his or her age, gender, physical disability, sexual orientation, or race, for example, the patient has a right to proper instruction regarding risks and benefits of invasive medical procedures. She or he also has a right to proper instruction regard- ing self-care activities, such as home dialysis, for example, that are beyond normal activities of daily living for most people.

Furthermore, when a nurse is employed by a healthcare facility, she or he agrees to a bind- ing contract, written or tacit, to provide nurs- ing services in accordance with the policies of the facility. Failure to provide nursing care (in- cluding educational services) based on patient diagnosis or persistence in providing substan- dard care based on patient age, diagnosis, cul- ture, national origin, sexual preference, and the like can result in liability for breach of contract with the employing institution (Emanuel, 2000).

In 1986, it became illegal for virtually ev- ery U.S. hospital to deny emergency evaluation and treatment to patients solely based on their ability to pay. Called the Emergency Medical Treatment and Active Labor Act (EMTALA), this federal legislation prohibits hospitals from rejecting or “dumping” uninsured patients or those covered by Medicare or Medicaid on “char- ity” or county hospitals (Consolidated Omnibus

48 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

advisors for students, typically the advice given in the context of that relationship pertains to professional education matters. At other times, a teacher may be approached because he or she is known to the student and is trustworthy in a classroom context, but the issue at hand re- quires counseling of a noneducational nature. In such a case, the teacher is expected to ad- dress openly and honestly with the student the potential consequences to their student– teacher relationship of discussing personal issues (Ewashen & Lane, 2007).

Educators can use the following specific criteria to distinguish between interactions that are appropriate in the context of the educational process and those that are less appropriate or even frankly inappropriate (Martinez, 2000):

■ Risk of harm to the student or to the student– teacher relationship

■ Presence of coercion or exploitation ■ Potential benefit to the student or to the

student–teacher relationship ■ Balance of student’s interests and teacher’s

interests ■ Presence of professional ideals

These five criteria can assist the teacher in being fully honest with himself or herself re- garding the appropriateness of counseling the student and can serve as an extremely useful guide in uncertain situations.

Students are autonomous agents. If they choose to follow the prescribed course of study and are successful, they will develop professional autonomy, attain their professional goals, achieve professional competence, and be equipped to de- velop relationships with colleagues and patients. Students in disciplines such as cytotechnology or laboratory technology, who do not have direct patient care responsibilities but who will spend their careers in a laboratory, also have a fiduciary relationship to the patients whose diagnoses, treatments, and future lives depend on the accu- rate examination of tissues and other specimens.

Students are responsible for speaking up when they experience problems with or obstacles to their learning. Otherwise, their teachers may

▸ The Ethics of Education in Classroom and Practice Settings

The Student–Teacher Relationship Many of the foundational principles and con- cepts of ethics that apply to patient care also ap- ply to questions of what ought to be done or how health professionals ought to behave in the ed- ucation of students for the health professions. Students and teachers have their own perspec- tives, visions, values, and preferences that are unknown to each other. These two worldviews come together in the classroom. They must be negotiated and understood by each party for the process of education to proceed with trust and respect (Freedman, 2003).

A balance of power exists between the teacher (expert) and the student (novice). The teacher possesses discipline-specific expertise, which is key to the student’s academic success, career achievement, and competent care of patients. Students must be able to trust their teachers— even instantaneously—and believe that the instruction provided by them will be accurate, appropriate, and up to date. Students have a right to assume their instructors are competent and will employ that competence in the best inter- ests of the students and the nursing profession.

Another area of ethical import inherent in student–teacher relationships is the potential blurring of professional–personal boundaries. Students may experience personal difficulties that can interfere with their studies or with their goals in pursuing a degree in the health professions. If the nature of the student’s con- cerns is outside pedagogic goals, how should the teacher respond? In such a case, the eth- ics of the situation applies not to the process of education itself but to two individuals who happen to know each other because of an ed- ucational context. This distinction is import- ant. When teachers are called upon to serve as

The Ethics of Education in Classroom and Practice Settings 49

In addition, consider the ethical import of the transience of many student–teacher relation- ships (Christakis & Feudtner, 1997). For exam- ple, the system of nursing education can create communities of relative strangers. A nursing student may conflate trust with authority when a visiting professor teaches a core course in the curriculum. Although the visiting professor may be a renowned authority on complementary and alternative therapies, she may be authoritarian in the classroom, a poor exemplar of putting the student’s educational needs first. The stu- dent may deferentially endure the class, knowing that sooner or later it will end and the professor will return to her home institution. Such a poor learning climate discourages any reciprocity of concern or trust, impedes the student’s profes- sional development, and deprives the professor of valuable opportunities to demonstrate humil- ity before the students.

Students rely on their teachers to be role models and mentors. They observe how teach- ers hold themselves and other instructors ac- countable to honest and conscientious practice standards. They witness how teachers treat stu- dents and colleagues. Such teacher behaviors exemplify instruction in a relational context: Technical information is interwoven with role modeling. From these observations, students re- ceive lessons that assist them in developing and establishing habits of interaction with coworkers, patients, and, if they become educators them- selves, their own future students (Reiser, 1993).

The Patient–Provider Relationship Nurses (and nursing students) and the patients they care for also have their own worldviews that come together in the practice setting. These per- spectives must be negotiated and understood by each party for the process of patient education to occur with a sense of trust.

As with the student–teacher relationship, it is important to recognize the balance of power that exists between a nurse—even a nursing student—and a patient. The nurse possesses

make overly ambitious demands on and have unrealistic expectations for students in the learn- ing process. Just as students have the right to ex- pect honesty from their teachers, so do they have a reciprocal duty to be truthful—such as when they have not done an assignment or prepared for a class activity or have made a mistake. In addition, truthfulness affects a vulnerable third party: the patient whose care is at the hands of the student. Taking responsibility for one’s mis- steps as a student reveals the student’s commit- ment to honesty, the primacy of patient welfare, and trustworthiness (Reiser, 1994).

Sometimes students in the health profes- sions also decide to shield their instructors from the complexities of their patients’ situations. Per- haps students want to help their patients appear as “good” as possible. Alternatively, perhaps mo- tivated by a desire to get a good evaluation them- selves and avoid descriptors such as “difficult,” “took up too much time with details,” or “not a team player,” students may select what they be- lieve their instructors will want to deal with. One student who was following a postsurgical pa- tient remarked, “[I]n bringing up my patient’s [sore] throat, I was also wasting precious time . . ., and so I learned to keep quiet about his com- plaints” (Zucker, 2009). By acting in this way, stu- dents place their perceptions of their instructors’ needs before the needs of their patients, at a time when the students are trying to learn exactly which bona fide medical needs should legiti- mately assume priority over others. Who else but instructors can most effectively assist students to learn how to prioritize among competing patient concerns? Yet how can instructors perform this important component of their jobs if they are hearing a censored rendition of those concerns?

By trying to appear “good” and restrict the range and depth of concerns patients bring to their health professionals, students may under- mine the reciprocity of the healthcare provider– patient relationship. Without the framework of an explicitly bidirectional education model, pa- tients may be reluctant to voice all their concerns, reservations, and questions about a proposed recommendation or treatment.

50 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

Nurses are obligated to remain mindful of the power imbalance between themselves and their patients, to put the patient’s welfare be- fore their own concerns, and to reflect honestly on the consequences of blurred boundaries to the patient and to their relationship with the patient in the practice setting.

Out of a respect for patient autonomy, a model of medical decision making shared between health professionals and patients has assumed primacy in various health communication cur- ricula and practices (deBocanegra & Gany, 2004; Donetto, 2010; Freedman, 2003; Visser, 1998). This model supports imparting health-related in- formation selected by the health professional to the patient for the purposes of the patient mak- ing his or her choices and preferences known. Although health professionals engaging in this process may mean well, the unidirectional nature of this model of patient education succeeds in re- inforcing the power that health professionals have over patients because of their technical knowl- edge. Therefore, ethical decision making is nec- essary in ensuring patients’ safety and well-being.

New evidence indicates that concerns may arise regarding healthcare professionals’ ethi- cal competency. Park (2012) developed an in- tegrated model consisting of six steps designed to better guide ethical decision making:

1. The identification of an ethical problem

2. The collection of information to identify the problem and develop solutions

3. The development of alternatives for analysis and comparison

4. The selection of the best alternatives and justification

5. The development of diverse, practi- cal ways to implement ethical deci- sions and actions

6. The evaluation of effects and de- velopment of strategies to prevent a similar occurrence

Park (2012) acknowledges that the use of this model does not guarantee ethically right or

medical expertise: keys to the patient’s health, well-being, and ability to work, play, go to school, or engage in social relationships. For those rea- sons, the ethics of being a patient typically in- cludes respecting nurses and trusting them to have the patient’s best interests at heart. Lach- man (2012) speaks to the care nurses render to patients as being an ethical task. Caring is not only essential for the physical and psychological well-being of patients but caring also requires getting involved in a network of relationships to meet patient’s needs. Patients have a moral claim on the nurse’s competence and on the use of that competence for the patient’s welfare (Pellegrino, 1993).

The blurring of professional–personal bound- aries is also an area of ethical impor tance com- mon to nurses’ (or nursing students’) relationships with their patients. The potential for blurred boundaries between professionals and patients is particularly evident because of the intimacies of the practice setting. Patient education can take place when patients are wearing little clothing, are lying down in a bed, are sharing personal information with the nurse, or are in the con- text of medically related physical contact. Again, the five criteria noted earlier in the students and teachers section (Martinez, 2000) are relevant. Simply substitute the word patient or client for student to distinguish between interactions that are appropriate in the context of the practice set- ting and those that are less appropriate or even frankly inappropriate (Martinez, 2000):

■ Risk of harm to the patient or to the patient– teacher relationship

■ Presence of coercion or exploitation ■ Potential benefit to the patient or to the

patient–teacher relationship ■ Balance of the patient’s interests and the

teacher’s interests ■ Presence of professional ideals

These five criteria can assist the teacher in being fully honest with himself or herself re- garding the appropriateness of counseling the patient and can serve as an extremely useful guide in uncertain situations.

The Ethics of Education in Classroom and Practice Settings 51

the better the patient education, the longer the patient will likely remain out of the hospital. However, if the nurse is extremely busy with other competing priorities or is tired from hav- ing worked two shifts in a row, he or she may not reflect on how fatigue or work demands lead to a failure to focus primarily on this pa- tient’s welfare. It may be easier for the nurse to assume a let-someone-else-deal-with-it at- titude. Transient relationships facilitate a lack of focus on the welfare, time, and interests of each patient.

All professional nurses will face a conflict of values, ethically and professionally, at some point in their career (Robichaux, 2012). Ethical dilemmas happen when ethics principles can be interpreted from different perspectives. That is, what is right or wrong can be debated and dif- ferent courses of action are recommended by one or more parties. So, too, some actions can have two outcomes, one of which is beneficial and the other harmful. In ethics, this is known as the doctrine of double effect. For example, withdrawing life support relieves suffering but may result in someone’s demise or administer- ing high doses of opioids to a terminally ill pa- tient may relieve pain and dyspnea but likely hastens death (Di Leonardi, 2012a). With re- spect to ethical leadership, nursing leaders need to be able to anticipate ethical challenges and focus on appropriate professional values. Key to ethical nurse leadership is a willingness to col- laborate with colleagues, apply evidence-based practice to remain competent, and invite feed- back from others for ethical decision making (Gallagher & Tschudin, 2010).

▸ Legality of Patient Education and Information

The patient’s right to adequate information re- garding his or her physical condition, medica- tions, risks, and access to information regarding

good decisions, but it does support an improved process of making ethical decisions.

Nursing students may be inclined to rely on a largely information- dissemination method of educating patients. This is understandable during the formative years of their education when they are beginning to appreciate and employ their own technical knowledge. In- evitably, such a reductionistic conception of patient education will bump up against real practice situations in which the complex- ity of individual patients’ circumstances de- mands a more reciprocal model of education (Donetto, 2010).

Like students, patients are autonomous agents. They may choose to follow the rec- ommended course of treatment because they trust their health professional and believe that what has been recommended will improve their condition. They may also follow rec- ommendations because they understand the rationale for the treatment, they consider the treatment to be acceptable or at least tolera- ble, the treatment fits into their lifestyle and worldview, they can afford it financially, and for many other reasons.

Furthermore, some patients believe that they should behave like good patients by tak- ing all medications or doing all exercises as pre- scribed, adhering to a recommended diet, not complaining, and so forth, so that their health professional will like them, consider them wor- thy of their time, and want to continue to take care of them (Buckwalter, 2007; Freedman, 2003). This desire to be a good patient under- scores how dependent and vulnerable patients can feel. Even when presenting for a screen- ing mammogram or follow-up urine culture, patients are not at their best. At every medical encounter, there exists the potential for discov- ering something that merits concern.

In the practice setting, it is plausible that a nurse providing discharge instructions to a patient might not necessarily give the patient a fair share of his or her time or be open to all the patient’s questions if the nurse knows he or she will never see that patient again. Admittedly,

52 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

to the laws and professional standards appli- cable to each principle.

Physicians are responsible and accountable for proper patient education. Realistically, how- ever, the nurse or some other physician-appointed designee often carries out patient education. Physicians’ responsibility notwithstanding, “pa- tient education is central to the culture of nurs- ing as well as to its legal practice” (Redman, 2008, p. 817) by virtue of respective state nurse practice acts. The issue regarding patient edu- cation is not necessarily one of omission on any- one’s part. Rather, the heart of the matter may be proper documentation that teaching has, in fact, been done.

▸ Legal and Financial Implications of Documentation

The 89th Congress enacted the Comprehensive Health Planning Act in 1965, Public Law 89-97, 1965 (Boyd, Gleit, Graham, & Whitman, 1998). The entitlements of Medicare and Medicaid— which revolutionized the provision of health care for older adults and people who are socioeco- nomically deprived—were established through this act. The act stressed the importance of dis- ease prevention and rehabilitation in health care. Thus, to qualify for Medicare and Medicaid re- imbursement, “a hospital has to show evidence that patient education has been a part of patient care” (Boyd et al., 1998, p. 26). Proper documen- tation provides written testimony that patient education has indeed occurred.

For at least the past 25 years, TJC has rein- forced the federal mandate by requiring docu- mentation of patient and/or family education in the patient record. Pertinent to this point is the doctrine of respondeat superior, or the master–servant rule. Respondeat superior pro- vides that the employer may be held liable for negligence, assault and battery, false imprison- ment, slander, libel, or any other tort committed

alternative treatments is specifically spelled out in the revised edition of A Patient’s Bill of Rights (AHA, 1992; President’s Advisory Commission, 1998). As noted earlier, many states have adopted these rights as part of their health code, thus ren- dering them legal and enforceable by law. Pa- tients’ rights to education and information also are regulated through standards put forth by ac- crediting bodies such as The Joint Commission [TJC] (2015), formerly known as the Joint Com- mission on Accreditation of Healthcare Orga- nizations (JCAHO). Although these standards are not enforceable in the same manner as law, lack of organizational conformity can lead to loss of accreditation, which in turn jeopardizes the facility’s eligibility for third-party reimburse- ment, as well as loss of Medicare and Medicaid reimbursement. Lack of organizational confor- mity can also lead to loss of public confidence in the institution.

In addition, state regulations pertaining to patient education are published and enforced under threat of penalty (fine, citation, or both) by the department of health in many states. Federal regulations, enforceable as laws, also mandate patient education in those health- care facilities receiving Medicare and Med- icaid funding. Moreover, as discussed earlier, the federal government mandates full patient disclosure in cases of participation in biomed- ical research in any setting or for any feder- ally funded project or experimental research involving human subjects.

It should be noted that the AHA’s 1975 orig- inal draft rendition of A Patient’s Bill of Rights, along with all the later revision of these rights, is linked to or associated with every ethical principle. The revised A Patient’s Bill of Rights (AHA, 1992) is rooted in the conditions of participation in Medicare set forth under fed- eral standards established by the CMS. Corre- sponding accreditation standards promulgated by TJC further emphasize these standards. All these laws and professional standards serve to ensure the fundamental rights of every person as a consumer of healthcare services. TABLE 2-1 outlines the relationship of ethical principles

Legal and Financial Implications of Documentation 53

TABLE 2-1 Linkages Between Ethical Principles, the Law, and Practice Standards

Ethical Principles Legal Actions/Decisions and Standards of Practice

Autonomy (self-determination) Cardozo decision regarding informed consent Institutional review boards Patient Self-Determination Act A Patient’s Bill of Rights Joint Commission/CMS standards

Veracity (truth telling) Cardozo decision regarding informed consent A Patient’s Bill of Rights Tuma decision Joint Commission/CMS standards

Confidentiality (privileged information)

Privileged information A Patient’s Bill of Rights Joint Commission/CMS standards HIPAA

Nonmaleficence (do no harm) Malpractice/negligence rights and duties Nurse practice acts A Patient’s Bill of Rights Darling v. Charleston Memorial Hospital State health codes Joint Commission/CMS standards

Beneficence (doing good) A Patient’s Bill of Rights State health codes Job descriptions Standards of practice Policy and procedure manuals Joint Commission/CMS standards

Justice (equal distribution of benefits and burdens)

A Patient’s Bill of Rights Antidiscrimination/affirmative action laws Americans with Disabilities Act Joint Commission/CMS standards

by an employee (Lesnik & Anderson, 1962). The landmark case supporting the doctrine of respondeat superior in the healthcare field was the 1965 case of Darling v. Charleston Memorial Hospital. Although the Darling case dealt with negligence in the performance of professional

duties of the physician, it brought out—possibly for the first time—the professional obligations or duties of nurses to ensure the well-being of the patient (Brown, 1976).

In any litigation where the doctrine of re- spondeat superior is applied, outcomes can hold

54 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

Although the EMR/EHR system promises many benefits, it also has potentially “serious unintended consequences” (Bowman, 2013, p. 1). Its advantages, for example, are that typed notes are much easier to read, prompts remind providers to deliver medications and care on time, information can be rapidly retrieved for team-based care coordination, confidentiality of patient information is more protected, infor- mation is provided for third-party billing, and in the long run healthcare costs are expected to decrease. However, digital recording also has its disadvantages, such as drop-down menus do not allow for as much detail as handwritten notes, if no new information has surfaced it is easy to be tempted not to record anything, all it takes is the click of a mouse on a wrong choice in the elec- tronic system that can lead to the wrong medi- cation being prescribed, and digital entries are not as robust as personal handwritten entries to trigger clear memory of events.

Poor documentation, regardless of whether it be paper or digital recordings, carries the same weight in the court of law (Gamble, 2012; Hoyt, 2014; Zamboni, 2016). With the relatively re- cent adoption and use of EHRs, legal and ethical dilemmas as well as financial questions remain with respect to the extent to which digital re- cords can reform health care (Gamble, 2012; Sittig & Singh, 2011; Zamboni, 2016). Infor- mation integrity—that is, data being lost or incorrectly entered, displayed, and transmit- ted (known as e-iatrogenesis), and reduced provider–patient focus—that is, the consumer perceiving the nurse is not listening or mak- ing sufficient eye contact because of attention being given instead to navigating the screens and making entries, are still serious issues that need to be resolved (Bowman, 2013; Hoyt, 2014; Zamboni, 2016).

Even in today’s current practice environ- ment, an invaluable interdisciplinary method proposed by Snyder (1996) to document pa- tient education is still pertinent. This method relies on a flow sheet that used to be included in the patient’s paper chart but now can be

the organization liable for damages (monetary retribution). Thus, it behooves the nurse as both employee and professional providing patient edu- cation to document that education appropriately and to be critically conscious of the legal and fi- nancial ramifications to the healthcare facility in which he or she is employed (ANA, 2010).

Casey (1995) pointed out many years ago that of all lapses in documentation, patient teach- ing was identified as “probably the most undoc- umented skilled service because nurses do not recognize the scope and depth of the teaching they do” (p. 257). Lack of documentation con- tinues to reflect negligence in adhering to the mandates of the nurse practice acts. This lax- ity is unfortunate because patient records can be subpoenaed for court evidence in malprac- tice cases. Appropriate documentation can be the determining factor in the outcome of litiga- tion (Di Leonardi, 2012b). Pure and simple, if the instruction isn’t documented, it didn’t occur!

Furthermore, documentation is a vehicle of communication that provides critical infor- mation to other health professionals involved with the patient’s care. Failure to document not only renders other staff potentially liable but also renders the facility liable and in jeop- ardy of losing its accreditation. Concomitantly, the institution is also in danger of losing its ap- propriations for Medicare and Medicaid reim- bursement (Leventhal, 2014).

In this digital age, implementation of elec- tronic medical records (EMR) system, also known as electronic health records (EHR) sys- tem, is widespread in all healthcare settings with the passage of the Health Information Tech- nology for Economic and Clinical Health Act (HITECH), which was part of the American Re- covery and Reinvestment Act of 2009 (Blumenthal & Tavenner, 2010). Thorough and accurate doc- umentation has always been of utmost impor- tance in the delivery of safe, high-quality care and it applies equally to paper and digital records. It has been estimated that 35–40% of malprac- tice cases are lost because of poor documenta- tion (Zamboni, 2016).

Legal and Financial Implications of Documentation 55

consent. The process should involve the phy- sician providing the patient with information on the diagnosis, procedure, treatment options (including no treatment), and the risks and ben- efits of the procedure. The nurse’s role is to en- sure this information was provided and that the patient understands what has been communi- cated by the physician. Most often, consent is completed by using a specific consent form, but the process should be well documented in other areas of the patient’s medical record to ensure that legal and ethical components are reflected (Menendez, 2013).

Hall et al. (2012) and Menendez (2013) also list several factors that affect obtaining in- formed consent:

1. Patient comprehension: Readiness to learn, locus of control, patient age, prior education, reading level, cognitive function, and anxiety can determine the level of understanding.

2. Patient use of disclosed information: The amount of detail the patient wants to know about a procedure can vary, and decision making can be influenced by a belief that there is “no other choice” or by a feeling of being forced to sign permission.

3. Patient autonomy: Decision mak- ing can be made independently, in collaboration with others, or turned over to a legally appointed person.

4. Demands on providers: Time can influence the ability to adequately complete the process.

5. Physicians meeting minimum demands: Criteria must be met for completely informed decision making.

Brenner, Brenner, and Horowitz (2009) further examined informed consent and pro- posed returning to an educational model to increase patients’ sense of control and thereby improve healthcare outcomes, such as com- pliance, disease prevention, and health pro- motion. These authors state that the current

incorporated into electronic medical records. The flow sheet includes identification of patient and family educational needs based on the fol- lowing important variables:

■ Readiness to learn (based on admission assessment of the patient)

■ Obstacles to learning, which might include language, sensory deficits such as lack of vision or hearing, low literacy, cognitive deficits, or other challenges

■ Referrals, which might include a patient advocate or an ethics committee

The form provides documentation space for who was taught (e.g., patient or family), what was taught (e.g., medication administration), when it was taught, which strategies of teach- ing were used (teaching methods and instruc- tional materials), and how the patient responded to instruction (which outcomes were achieved).

Informed consent has become the pri- mary standard of protecting patients’ rights and assists in guiding ethical healthcare prac- tice. Although nurses are not responsible for completing the process of informed consent, they do have the duty to verify that consent has been given. Consent must be granted by the patient or legal guardian before a patient undergoes a procedure. The nurse also acts as a resource to patients who may ask for clarifi- cation or information to be repeated in terms they can understand. Simplistically, informed consent is a patient’s right to establish what should or should not be done to his or her body (Menendez, 2013).

According to Hall and collegues (2012), in- formed consent has three purposes—legal, eth- ical, and administrative—which may overlap depending on the context and situation. Legally, consent protects patients’ rights to autonomy and self-determination and guards against assault and battery from unwanted medical interven- tions. Ethically, consent also protects patients’ right to autonomy as well as supports their goals in care. Administratively, compliance involves the physical process of completing informed

56 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

▸ Economic Factors in Healthcare Education: Justice and Duty Revisited

Some might consider the parameters of health- care economics and finances as objective in- formation that can be used for any number of purposes. Fiscal solvency and forecasting of economic growth of an organization are good examples of such purposes. Others would agree that in addition to the legal mandates for pa- tient education and the importance of docu- mentation, another ethical principle speaks to both quality of care and justice, which refers to the equitable distribution of goods and ser- vices. In the interest of patient care, the patient as a human being has a right to good-quality care regardless of his or her economic status, national origin, race, and the like. Furthermore, health professionals have a duty to ensure that such services are provided, and the healthcare organization has the right to expect that it will receive its fair share of reimbursable revenues for services rendered.

Thus, as an employee of a healthcare insti- tution or agency, the nurse has a duty to carry out organizational policies and mandates by acting in an accountable and responsible man- ner. In an environment characterized by shrink- ing healthcare dollars, continuous shortages of staff, and dramatically shortened lengths of stay yielding rapid patient turnover, organizations are challenged to ensure that their professional staff are competent to provide educational ser- vices, while at the same time doing so in the most efficient and cost-effective manner possi- ble. This is an interesting dilemma considering that patient education is identified as a legal re- sponsibility of nurses in their state practice acts. Prelicensure education programs are challenged to prepare nursing students adequately for this critical function.

process of informed consent has discouraged patients from taking an active part in mak- ing their own healthcare decisions, by turn- ing this process into essentially one of signing a liability waiver. However, to return to an ed- ucational model, the consent forms must be re- viewed and revised for comprehensibility and educational value.

First and foremost, health literacy plays a significant role in a patient’s ability to actively and effectively take part in his or her care. See Chapter 7 for more information on tools to as- sess the literacy level of patients and the read- ability of materials, such as consent forms.

Second, the informed consent process must change the way physicians deliver information. Brenner et al. (2009) explain that patients may have the fantasy misconception that the physi- cian is a “great healer,” which creates a false per- ception of the outcome. A positive perception is developed when the physician shows empa- thy toward patients, acknowledging their fears and concerns, and reassuring them that their fears and concerns are expected and respected. The physician must recognize that negative out- comes can develop, as with any procedure, but continued support of the patient, regardless of the outcomes, is a necessity.

Because patient education and patient en- gagement are critical elements to meaning- ful consent, healthcare providers must be sure that patients understand their consent options and the impact of their decisions in choos- ing to consent. In the electronic age, informed consent involves educating patients about the sharing of their health information via the elec- tronic health information exchange (eHIE)—the way healthcare providers access and share pa- tient health information with one another by way of their computers. Patient education must include full transparency about such factors as privacy and security regarding who has ac- cess to information, why information might be shared, and how information is protected so that patients can make informed consent deci- sions (HealthIT.gov, 2014).

Economic Factors in Healthcare Education: Justice and Duty Revisited 57

(Arline, 2015; Gift, 1994; Hughes, 2011). The sources of revenue (profit) that an institution or agency can accumulate from patient education efforts are known as cost savings, cost benefit, and cost recovery (Abruzzese, 1992; Ghebrehi- wet, 2005; Mitton & Donaldson, 2004; Wasson & Anderson, 1993).

Direct Costs Direct costs are tangible, predictable expenses, a substantial portion of which include person- nel salaries, employment benefits, and equip- ment (Arline, 2015; Gift, 1994; Hughes, 2011). This share of an organization’s budget is almost always the largest percentage of the total costs to operate any healthcare facility. Because of the labor-intensive function of nursing care de- livery, the costs of nurses’ salaries and benefits usually account for at least 50%—if not more— of the total facility budget. Of course, the higher the educational level of nursing staff, the higher the salaries and benefits, and, therefore, the higher the institution’s total direct costs.

Time also is considered a direct cost, but it is often difficult to predict how long it will take nurses to plan, implement, and evaluate the individual patient teaching encounters and the educational programs being offered. Although the purpose of salary is to buy an employee’s time and special expertise, planning and carrying out patient or staff education may exceed the time allocated for care, and the nurse educator draws overtime pay. That extra cost may not have been anticipated in the budget planning process.

Time as a direct cost is a major factor in- cluded in a cost-benefit analysis. If the time it takes to prepare and offer patient or staff educa- tion programs is greater than the financial gain to the institution, the facility may seek other ways of providing this service, such as com- puterized programmed instruction or a patient television channel.

Also, equipment is classified as a direct cost. No organization can function without proper materials and tools, which also means there is the need to replace them when necessary.

The principle of justice is a critical consid- eration in patient education. The rapid changes and trends in contemporary health care are, for the most part, economically driven. Described as chaotic by some, the U.S. healthcare sys- tem in many ways is challenged to maintain its humanistic and charitable origins that have characterized healthcare services in this coun- try across the decades. Indeed, organizations that provide health care are caught between the need to allocate scarce resources and the necessity to provide just, yet economically feasible, services.

On the one hand, the managed care ap- proach results in shrinking revenues. This trend, in turn, dictates shorter patient stays in hospi- tals and doing more with less. Despite contin- ued shortages of healthcare personnel in most geographic areas of the United States, health fa- cilities are continuing to expand their clinical offerings into satellite types of ambulatory and home care services in a bid to increase their rev- enues. On the other hand, these same organi- zations are held to the exact standards of care written in A Patient’s Bill of Rights (AHA, 1992), which is regulated as a contingency of Medicare and Medicaid participation by the CMS and for agency accreditation. In turn, accreditation of hospitals and other healthcare organizations dictates eligibility for third-party reimbursement in both the public and private sectors. Thus, the regulated right of clients to health education carries a corresponding duty of healthcare in- stitutions and agencies to provide that service.

▸ Financial Terminology Given the fact that the role of the nurse as edu- cator is an essential aspect of care delivery, this section provides an overview of financial terms that directly affects both staff and patient edu- cation. Such educational services are not pro- vided without an accompanying cost of human and material resources. Thus, it is important to know that expenses are essentially classified into two categories: direct costs and indirect costs

58 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

program. They include, but are not limited to, institutional overhead such as heating and air conditioning, lighting, space, and support ser- vices of maintenance, housekeeping, and secu- rity. Such services are necessary and ongoing whether a teaching session is in progress or not.

Hidden costs—a type of indirect cost— cannot be anticipated or accounted for until after the fact. Low employee productivity can produce hidden costs, for example. Organiza- tional budgets are prepared based on what is known and predictable, with projections for variability in patient census included. Person- nel budgets are based on levels of staff needed (e.g., number of registered nurses, licensed prac- tical nurses, and nursing assistants) to accom- modate the expected patient volume. This is determined by an annual projection of patient days and the number of patients for whom an employee can effectively care for daily. Low pro- ductivity of one or two personnel on a nursing unit, for example, can have a significant impact on the workload of others, which in turn leads to low morale and employee turnover. Turn- over increases recruitment and new employee orientation costs. In this respect, the costs are appropriately identified as hidden.

In a classic description of understanding costs, Gift (1994) makes a point of distinguish- ing between costs—direct or indirect—and charges. As just described, direct and indirect costs are those expenses incurred by the facil- ity. Charges are set by the provider, but they are billed to the recipient of the services. There may or may not be equivalence between costs and charges. In the retail business, for example, if costs of raw materials are low, and charges for the items, goods, or services are high, the re- tailer realizes a profit. In the healthcare arena, not-for-profit organizations are limited by federal law as to the amount they can charge in relation to the actual cost of a service. In many instances, particularly as it relates to pharmaceutical goods, the actual cost to the facility is what is charged. As such, the facil- ity provides a service but realizes no finan- cial profit (Kaiser Family Foundation, 2005).

Teaching requires written materials, audiovi- sual tools, and other equipment for the delivery of instruction, such as handouts and brochures, models, closed-circuit televisions, computers, and copy machines. Although renting or leas- ing equipment may sometimes be less expen- sive than purchasing it, rental and leasing costs are still categorized as direct costs.

Direct costs are divided into two types: fixed and variable. Fixed costs are those expenses that are predictable, remain the same over time, and can be controlled. Salaries, for example, are fixed costs because they remain relatively stable and also can be manipulated. The facility usually makes annual decisions to give employee raises, to freeze salaries, or to cut positions, thereby in- fluencing the budgeted amount for direct cost expenditures. In addition, mortgages, loan repay- ments, and the like are included as fixed costs.

Variable costs are those costs that, in the case of healthcare organizations, depend on volume. The number of meals prepared, for example, depends on the patient census. From an educational perspective, the demand for patient teaching depends on the number and diagnostic types of patients. For example, if the volume of total hip replacement patients is low, educational costs may be high resulting from the fact that intensive one-to-one instruc- tion must be offered to each patient admitted. Conversely, if the volume of total hip replace- ment surgeries is high, it is relatively less ex- pensive to provide standardized programs of instruction via group teaching sessions. As an- other example, if demand or turnover of nurs- ing staff increases, the number of orientation sessions for new employees would increase in volume. Supply-related expenses—another di- rect, variable cost—can change depending on the amount and type needed. Variable costs can become fixed costs when volume remains con- sistently high or low over time.

Indirect Costs Indirect costs are those costs not directly re- lated to the actual delivery of an educational

Financial Terminology 59

Cost recovery results when either the pa- tient or the insurer pays a fee for educational services that are provided. Cost recovery may be captured by offering health education pro- grams for a fee. Also, under Medicare and Med- icaid guidelines, reimbursement may be made for programs and services if they are deemed reasonable, appropriate, and necessary to treat a person’s illness or injury (Kaiser Family Foun- dation, 2005). The key to success in obtain- ing third-party reimbursement is the ability to demonstrate that due to education, patients can manage self-care at home and consequently ex- perience fewer hospitalizations.

To take advantage of cost recovery, hospi- tals and other healthcare agencies develop and market a number of health education programs that are open to all members of a community. If well attended, these fee-for-service programs can result in revenues for the institution. The critical element, of course, is not just the recov- ery of costs but also the generation of revenue. Revenue generation (i.e., profit) refers to in- come earned that is over and above the costs of the programs offered.

To offset the dilemma of striving for cost containment and solvency in an environment of shrinking fiscal resources, healthcare orga- nizations have developed alternative strategies for patient education to realize cost savings, cost benefit, cost recovery, or revenue generation. For example, Wasson and Anderson (1993) explained that a preoperative teaching program for surgi- cal patients given prior to admission to the hos- pital was found to lower patient anxiety, increase patient satisfaction, decrease nursing hours de- voted to patient education during hospitaliza- tion, and lessen the length of the hospital stay.

▸ Program Planning and Implementation

The key elements to consider when planning a patient education offering intended for generation

Cost Savings, Cost Benefit, and Cost Recovery Patient teaching is mandated by state laws, professional and institutional standards, ac- crediting body protocols, and regulations for participation in Medicare and Medicaid reim- bursement programs. However, unless educa- tion is ordered by a physician, patient education costs are generally not recoverable as a sepa- rate entity under third-party reimbursement. Even though the costs of educational programs, for both patients and nursing staff, are a legit- imate expense to the facility, these costs usu- ally are subsumed under hospital room rates and, therefore, are technically absorbed by the healthcare organization.

Hospitals incur cost savings when patient lengths of stay are shortened or fall within the al- lotted diagnosis-related group (DRG) time frames (CMS, 2016). Patients who have fewer compli- cations and use less expensive services will yield a cost savings for the institution. In an ambula- tory care setting, cost savings may occur when patient education keeps people healthy and in- dependent for a longer time, thereby preventing high use of expensive diagnostic testing or inpa- tient services. Perhaps most important, patient education becomes even more essential when a pattern of early discharge is detected, resulting in frequent readmissions to a facility. In such a scenario, the facility comes under scrutiny by HCFA/CMS and may be penalized through ei- ther citation or loss of payment—in which case any cost savings may be offset by the amount of revenue lost.

Cost benefit occurs when there is increased patient satisfaction with the services an institu- tion provides, including educational programs such as childbirth classes, weight and stress re- duction sessions, and cardiac fitness and rehabil- itation programs. Patient satisfaction is critical to the individual’s return for future healthcare services. Such programs may represent an op- portunity for an institution to capture a patient population for lifetime coverage.

60 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

▸ Cost-Benefit Analysis and Cost-Effectiveness Analysis

In most healthcare organizations, the educa- tion department bears the major responsibility for staff development, for inservice employee training, and for patient education programs that exceed the boundaries of bedside instruc- tion. Total budget preparation for these depart- ments is best explained by the experts in the field. Demeere et al. (2009), for example, ad- dress the need for patient care units to engage in responsibility-centered budgeting, which also is referred to as activity-based costing. Given the shift away from providing at-will services and toward greater demand for cost accountability for services performed, these authors propose a model for costing out programs that allows patient care units to identify and recoup their true costs while responding to increased mar- ket competition.

There is no single best method for measur- ing the effectiveness of patient education pro- grams. Most experts in the field tend to rely on determining actual costs or actual impact of pro- grams in relationship to outcomes by employ- ing one of two concepts: cost-benefit analysis or cost-effectiveness analysis (Abruzzese, 1992).

Cost-benefit analysis measures the rela- tionship between costs and outcomes (Russell, 2015). Outcomes can be the actual amount of revenue generated resulting from an educational offering, or they can be expressed in terms of shorter patient stays or reduced hospitaliza- tions for specific diagnostic groups of patients. If, under DRGs or capitation methods of re- imbursement, the facility makes a profit, this outcome can be expressed in monetary terms. If an analysis reveals that an educational pro- gram costs less than the revenue it generates, that expense can be recovered by third-party reimbursement. If savings exceed costs, then the program is considered a cost benefit for

of revenue include an accurate assessment of direct costs such as paper supplies, printing of program brochures, publicity, rental space, and professional time (based on an hourly rate) re- quired of nurses to prepare and offer the ser- vice. If an hourly rate is unknown, a simple rule of thumb is to divide the annual base salary by 2080, which is the standard number of hours for which people working full time are paid during one year.

If the program is to be offered at the facil- ity, there may be no need to plan for a rental fee for space. However, indirect costs such as house- keeping and security should be factored in as an expense. Such a practice not only is good fiscal management but also provides an accounting of the contributions of other departments to the educational efforts of the facility.

Fees for a program should be set at a level high enough to cover the aggregate costs of program preparation and delivery. If an educa- tion program is intended to result in cost sav- ings for the facility, such as education classes for patients with diabetes to reduce the num- ber of costly hospital admissions, then the aim may be to break even on costs. In such a case, the price is set by dividing the calculated cost of the program by the number of antici- pated attendees. If the goal is for the institu- tion to improve cost benefits, then success can be measured by increased patient satisfaction (as determined by questionnaires or evaluation forms) or by increased use of the facility’s ser- vices (as determined by recordkeeping). If the intent is to offer a series of classes for smoking cessation or childbirth preparation to improve the wellness of the community and to gener- ate income for the facility, then the fee is set higher than cost to make a profit (cost recov- ery). An annual report to administration of the time and money spent on education efforts in outpatient and inpatient care units may be required to determine if the institution made a profit in terms of cost savings, cost benefit, or cost recovery (Demeere, Stouthuysen, & Roodhooft, 2009).

Cost-Benefit Analysis and Cost-Effectiveness Analysis 61

evaluation, in policy setting, and in interac- tive networking on cost-effectiveness research, cost-saving strategies, and best practice stan- dards (Ghebrehiwet, 2005).

▸ State of the Evidence Practice driven by evidence is defined as prac- tice “based on research, clinical expertise, and patient preferences that guide decisions about the healthcare of individual patients” (Hospice and Palliative Nursing Association, 2004, p. 66). Much evidence suggests that ethical principles and theories play a highly significant role in shaping contemporary healthcare delivery prac- tices and decision making. Whereas complex and technological advances in health care have given rise to numerous questions about what is right or wrong—or morally or ethically defensible— few situations yield clear-cut or perfectly right answers to solving a problem or need. Numerous case studies, books, and articles have addressed

the facility. The measurement of costs against monetary gains is commonly referred to as the cost-benefit ratio, which is the cost of educa- tion per patient divided by the total savings per patient (EuroMed Info, 2017).

Cost-effectiveness analysis measures the impact of an educational offering on patient behavior. If program objectives are achieved, as evidenced by positive and sustained changes in the behavior of the participants over time, the program is said to be cost effective (Russell, 2015). Although behavioral changes are highly desirable, in many instances they are less ob- servable, less tangible, and not easily measur- able. For example, reduction in patient anxiety cannot be converted into a gain in real dollars. Consequently, it is wise to analyze the outcome of teaching interventions by comparing behav- ioral outcomes between two or more programs to identify the one that is most effective and ef- ficient when actual costs cannot be determined.

A nurse as educator may be called upon to interpret the costs of behavioral changes (out- comes) to the institution by conducting a cost- effectiveness analysis between programs. This can be accomplished by first identifying and itemiz- ing for each program all direct and indirect costs, including any identifiable hidden costs. Second, it is necessary to identify and itemize any bene- fits derived from the program offering, such as revenue gained or decreased readmission rates that can be expressed in monetary values. Re- sults of these findings can then be recorded on a grid so that each program’s cost-effectiveness is visually apparent (EXHIBIT 2-1).

Mitton and Donaldson (2004) suggest a nonvested team approach to an analysis of program effectiveness for determining the al- location or reallocation of valuable resources between and among services or programs. This approach ensures the integrity of the to- tal process of program evaluation. In addition to this recommendation, the International Council of Nurses (2001) published a position statement that, among other things, obligates nurses to demonstrate their value in promot- ing cost- effective, high-quality care by play- ing a leadership role in program planning and

EXHIBIT 2-1 Cost-Effectiveness Grid

Program I II

Costs

Direct $ $

Indirect $ $

Hidden $ $

Benefits

Decreased readmissions

$ $

Revenue generated $ $

Total $ $

62 Chapter 2 Ethical, Legal, and Economic Foundations of the Educational Process

performance standards promulgated by accred- iting bodies and professional organizations for implementation at the local level. The nurse’s role as educator is legitimized through the defi- nition of nursing practice as set forth by the pre- vailing nurse practice act in the state where the nurse is licensed and employed and by codes of ethics governing professional conduct in vari- ous employment settings. In this respect, patient education is a nursing duty that is grounded in justice; that is, the nurse has a legal responsibil- ity to provide education to all patients, regard- less of their age, gender, culture, race, ethnicity, literacy level, religious affiliation, or other de- fining attributes. All patients have a right to re- ceive health education relevant to their physical and psychosocial needs. Justice also dictates that education programs be designed not only to be consistent with organizational goals but most important to meet the needs of patients to be informed, self-directed, and in control of their own health, and ultimately of their own destiny.

Review Questions 1. What are the definitions of the terms

ethical, moral, and legal, and how do they differ from one another?

2. Which national, state, professional, and private-sector organizations legislate, regulate, and provide standards to ensure the protection of human rights in matters of health care?

3. Which ethical viewpoint, deontological or teleological, refers to the decision-making approach that choices should be made for the common good of people?

4. How are the six ethical principles applied to the delivery of patient education?

5. What are four examples of direct costs and five examples of indirect costs in the provision of patient/staff education?

6. What are the definitions of the following terms: fixed direct costs, variable direct costs, indirect costs, cost savings, cost benefit, cost recovery, revenue generation, cost-benefit analysis, cost benefit ratio, and cost-effectiveness analysis?

the challenge of dealing with ethical dilemmas in health care. They attempt to provide evidence for how to deliver health care, including patient education, in the most equitable and beneficial manner possible. Our increasingly multicultural and pluralistic society is being asked to address the vast array of biomedical ethical issues con- fronting healthcare practitioners daily in a way that preserves an individual’s rights but also pro- tects the well-being of other persons, groups, and communities.

Laws and standards governing the role of the nurse as educator are firmly established and provide both the legal foundations and the professional expectations for the delivery of high-quality patient care. Also, the impor- tance of documenting patient education in- terventions is well established. More research must be conducted to provide evidence of the frequency and amount of informal patient education that nurses provide but that never gets recorded in the chart. In addition, al- though strategies exist for analyzing the cost- effectiveness and cost benefit of educational programming offered by health professionals, more research evidence is needed to substan- tiate the value of the educator’s role in influ- encing overall costs of care.

Further comparative analysis research needs to be conducted to determine which types of patient education programs are the most equitable, beneficial, and cost effective for patients, nursing staff, the institution, and the communities served. Evidence is scarce on the economics associated with various ap- proaches to education and the value of the nurse educator’s role as it affects behavioral outcomes related to cost savings, cost benefit, and cost recovery.

▸ Summary Ethical and legal dimensions of human rights pro- vide the justification for patient education, partic- ularly as it relates to issues of self-determination and informed consent. These rights are enforced through federal and state regulations and through

63Review Questions

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CASE STUDY Laura is a nursing staff member on a medical–surgical unit. She notices that there has been focused attention on one specific patient who is now receiving comfort care measures. The patient does not appear in any distress or pain. The family members, however, have been difficult to manage and have made constant demands for the patient to receive increased doses of medication to be sure their loved one does not suffer. Laura witnesses a staff nurse, who is assigned to the comfort care of the patient, tell another nurse that she is going to give a “nurse’s dose” of morphine because she is “tired of the family’s criticism” of the care she is giving.

1. What plausible actions should Laura take at this point? 2. Which legal and ethical reasons could Laura rely on to justify the actions she takes? 3. Which of Laura’s actions seem the most justified from a moral and ethical standpoint?

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Applying Learning Theories to Healthcare Practice Margaret M. Braungart Richard G. Braungart Pamela R. Gramet

CHAPTER HIGHLIGHTS

■ Psychological Learning Theories • Behaviorist Learning Theory • Cognitive Learning Theory • Social Learning Theory • Psychodynamic Learning Theory • Humanistic Learning Theory

■ Neuropsychology and Learning ■ Comparison of Learning Theories ■ Motor Learning

• Stages of Motor Learning • Motor Learning Variables

■ Common Principles of Learning • How Does Learning Occur? • Which Kinds of Experiences Facilitate or Hinder the Learning Process? • What Helps Ensure That Learning Becomes Relatively Permanent?

■ State of the Evidence

CHAPTER 3

KEY TERMS

learning learning theory respondent conditioning association learning classical conditioning Pavlovian conditioning systematic desensitization stimulus generalization discrimination learning spontaneous recovery operant conditioning escape conditioning avoidance conditioning metacognition gestalt perspective information processing

cognitive load mnemonic devices cognitive development social constructivism social cognition attribution theory cognitive-emotional

perspective emotional intelligence (EI) self-regulation role modeling vicarious reinforcement defense mechanisms resistance transference hierarchy of needs

neuropsychology plasticity motor learning motor performance cognitive map

(cognitive plan) massed practice distributed practice contextual interference effects discovery learning mental practice intrinsic feedback (inherent

feedback) extrinsic feedback (augmented

feedback/enhanced feedback)

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the principal constructs of each learning theory. 2. Differentiate among the basic approaches to learning for each of the five psychological learning

theories. 3. Give an example of applying each psychological theory to changing the attitudes and behaviors

of learners in a specific situation. 4. Outline alternative strategies for learning in a given situation using at least two different

psychological learning theories. 5. Identify the differences and similarities in the psychological learning theories specific to (a) the basic

procedures of learning, (b) the assumptions made about the learning, (c) the task of the educator, (d) the sources of motivation, and (e) the way in which the transfer of learning is facilitated.

6. Discuss how neuroscience research has contributed to a better understanding of learning and learning theories.

7. Identify specific teaching strategies for each stage of Fitts and Posner’s three stages of motor learning. 8. Explain how different types of practice and feedback variables in motor learning can be applied

to patient teaching.

Learning is defined in this chapter as a rel-atively permanent change in mental pro-cessing, emotional functioning, skill, and/ or behavior as a result of exposure to different experiences. It is the lifelong, dynamic process by which individuals acquire new knowledge or skills and alter their thoughts, feelings, atti- tudes, and actions.

Learning enables individuals to adapt to de- mands and changing circumstances and is cru- cial in health care—whether for patients and families grappling with ways to improve their health and adjust to their medical conditions, for students acquiring the information and skills necessary to become a nurse, or for staff nurses devising more effective approaches to educating

70 Chapter 3 Applying Learning Theories to Healthcare Practice

thought, emotions, and social interaction. Mo- tor learning is of particular interest to nurses as they try to help their patients and students ac- quire or relearn skills.

The construction and testing of learn- ing theories over the past century contributed much to the understanding of how individuals acquire knowledge and change their ways of thinking, feeling, and behaving. Reflecting an evidence-based approach to learning, these the- oretical explanations may sound reasonable but need to be tested through solid research, then applied and evaluated. The accumulated body of research information can be used to guide the educational process and has challenged many popular notions and myths about learning (e.g., “Spare the rod and spoil the child,” “You can’t teach an old dog new tricks,” “The more prac- tice and feedback, the better”). In addition, the major learning theories have wide applicability and form the foundation of not only the field of education but also psychological counseling, workplace organization and human resources management, and marketing and advertising.

Whether used singly or in combination, learn- ing theories have much to offer the practice of health care. Increasingly, health professionals— including nurses—must demonstrate that they regularly employ sound methods and a clear rationale in their education efforts, patient and family interactions, staff management and training, and continuing education and health promotion programs (Ferguson & Day, 2005).

Given the current structure of health care in the United States, nurses, in particular, are often responsible for designing and implement- ing plans and procedures for improving health education and encouraging wellness. Beyond one’s profession, however, knowledge of the learning process relates to nearly every aspect of daily life. Nurses can apply learning theo- ries at the individual, group, and community levels, not only to comprehend and teach new material and tasks but also to solve problems, change unhealthy habits, build constructive re- lationships, manage emotions, and develop ef- fective behavior.

and treating patients and one another in part- nership. There are times when what was learned needs to be unlearned. In health care, unlearning is often of special interest, as nurses and others attempt to replace faulty learning and behavior with more accurate information and healthier behavior. Despite the significance of learning to an individual’s development, functioning, health, and well-being, debate continues about how learn- ing occurs, which kinds of experiences facilitate or hinder the learning process, and what ensures that learning becomes relatively permanent.

Until the late 19th century, most of the discus- sions and debates about learning were grounded in philosophy, school administration, and con- ventional wisdom (Hilgard, 1996). Around the dawn of the 20th century, the new field of edu- cational psychology emerged and became a de- fining force for the scientific study of learning, teaching, and assessment (Woolfolk, 2012). As a science, educational psychology rests on the systematic gathering of evidence or data to test theories and hypotheses about learning. The more that is discovered about learning through research, the more it is recognized how complex and diverse learning really is.

A learning theory is a coherent frame- work of integrated constructs and principles that describe, explain, or predict how people learn. Psychological learning theories and mo- tor learning are discussed in this chapter, each of which has direct applicability to nursing practice. Rather than offering a single theory of learning, psychology provides alternative theories and perspectives on how learning oc- curs and what motivates people to learn and change (Hilgard & Bower, 1966; Ormrod, 2014; Snowman & McCown, 2015). Motor learning evolved as a branch of experimental psychology and can be differentiated from “verbal” learning (Newell, 1991). By the middle of the 20th cen- tury, motor learning was established as a spe- cialized area of study, and it has been influenced by behavioral theory, cybernetics, and informa- tion processing (VanSant, 2003). Psychological learning theories are useful in acquiring in- formation and in situations involving human

71Applying Learning Theories to Healthcare Practice

Next, motor learning theories and variables are reviewed and discussed, including their ap- plication for teaching skills to patients and stu- dents. Finally, the theories are compared and then synthesized by identifying their common features and addressing three questions: (a) How does learning occur? (b) Which kinds of experi- ences facilitate or hinder the learning process? and (c) What helps ensure that learning becomes relatively permanent? While surveying this chapter, readers are encouraged to think of ways to apply the learning theories to both their pro- fessional and personal lives.

The goals of this chapter are to provide a conceptual framework for subsequent chapters in this text and to offer a toolbox of approaches that nurses can use to enhance learning and change in patients, students, staff, and them- selves. Although there is a trend toward integrat- ing learning theories in education, knowledge of each theory’s basic principles, advantages, and shortcomings will enable nurses to select, combine, and apply the most useful compo- nents of learning theories to specific patients and situations in health care. After completing the chapter, readers should be able to identify the essential principles of learning, describe var- ious ways in which the learning process can be approached, and develop alternative strategies to change the attitudes, behaviors, and skills of learners in different settings.

▸ Psychological Learning Theories

This section summarizes the basic concepts and principles of the behaviorist, cognitive, so- cial learning, psychodynamic, and humanistic learning theories. While reviewing each the- ory, readers are asked to consider the follow- ing questions:

■ How do the environment and the internal dynamics of the individual influence learning?

■ Is the learner viewed as relatively passive or more active?

In this chapter the principal psychological and motor learning theories reviewed and discussed are those that are especially useful to health edu- cation and clinical practice. Behaviorist, cogni- tive, and social learning theories are most often applied to patient education as an aspect of pro- fessional nursing practice. It can be argued that emotions and feelings also need explicit focus in relation to learning in general (Goleman, 1995) and to health care in particular (Halpern, 2001). Why? Emotional reactions are often learned as a result of experience, they play a significant role in the learning process, and they are a vital consid- eration when dealing with health, disease, pre- vention, wellness, medical treatment, recovery, healing, and relapse prevention. To address this concern, psychodynamic and humanistic per- spectives are treated as learning theories because they encourage a patient-centered approach to care and add much to our understanding of hu- man motivation and emotions in the learning pro- cess. The review provided here includes motor learning because it offers a framework for nurses teaching motor tasks to patients and students.

The chapter is organized as follows. First, the basic psychological principles of learning for the behaviorist, cognitive, social learning, psychodynamic, and humanistic theories are summarized and illustrated with examples from psychology and healthcare research. With the upsurge of interest in neuroscience research, brief mention is made of some of the contribu- tions of neuropsychology to understanding the dynamics of learning and sorting out the claims of learning theories.

Then, the psychological learning theories are compared with one another on the follow- ing aspects:

■ The fundamental procedures for changing behavior

■ The assumptions made about the learner ■ The role of the educator in encouraging

learning ■ The sources of motivation for learning ■ The ways in which learning is transferred

to new situations and problems

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Respondent conditioning (also termed association learning, classical conditioning, or Pavlovian conditioning) emphasizes the im- portance of stimulus conditions and the associ- ations formed in the learning process (Ormrod, 2014). In this basic model of learning, a neu- tral stimulus (NS)—a stimulus that has no spe- cial value or meaning to the learner—is paired with a naturally occurring unconditioned or unlearned stimulus (UCS) and unconditioned response (UCR) (FIGURE 3-1). After a few such pairings, the neutral stimulus alone (i.e., with- out the unconditioned stimulus) elicits the same unconditioned response. Thus, learning takes place when the newly conditioned stim- ulus (CS) becomes associated with the condi- tioned response (CR)—a process that may well occur without conscious thought or awareness.

Consider an example from health care. Someone without much experience with hos- pitals (NS) may visit a relative who is ill. While in the relative’s room, the visitor may smell of- fensive odors (UCS) and feel queasy and light- headed (UCR). After this initial visit and later repeated visits, hospitals (now the CS) may be- come associated with feeling anxious and nause- ated (CR), especially if the visitor smells similar odors to those encountered during the first ex- perience (see Figure 3-1).

In health care, respondent conditioning highlights the importance of a healthcare facil- ity’s environment and culture as it may affect patients, staff, and visitors. For example, often without thinking or reflection, patients and vis- itors formulate associations about health care based on their hospital experiences, providing the basis for long-lasting attitudes toward medicine, healthcare facilities, and health professionals.

In addition to influencing the acquisition of new responses to environmental stimuli, princi- ples of respondent conditioning may be used to extinguish, or unlearn, a previously learned re- sponse. Responses decrease if the presentation of the conditioned stimulus is not accompanied by the unconditioned stimulus over time. Thus, if the visitor who became dizzy in one hospi- tal subsequently goes to other hospitals to see

■ What is the educator’s task in the learning process?

■ What motivates individuals to learn? ■ What encourages the transfer of learning

to new situations? ■ What are the contributions and criticisms

of each learning theory?

Behaviorist Learning Theory Focusing mainly on what is directly observable, behaviorists view learning as the product of the stimulus conditions (S) and the responses (R) that follow. Whether dealing with animals or people, the learning process is relatively sim- ple. Generally ignoring what goes on inside the individual—which, of course, is always difficult to ascertain—behaviorists closely observe responses to a situation and then manipulate the environ- ment in some way to bring about the intended change (Kazdin, 2013). Not as popular as it once was, the behaviorist approach is more likely to be used in combination with other learning the- ories, especially cognitive theory (Dai & Stern- berg, 2004; Shanks, 2010). However, behaviorist theory can be particularly useful in nursing prac- tice for the delivery of health care, because pa- tients may not be in a physiological state to want to engage in much thought and reflection. The theory also directly addresses how to break or unlearn bad habits and correct faulty learning.

To modify people’s attitudes and responses, behaviorists either alter the stimulus conditions in the environment or change what happens af- ter a response occurs. Motivation is explained as the desire to reduce some drive (drive re- duction); hence, satisfied, complacent, or sati- ated individuals have little motivation to learn and change. Getting behavior to transfer from the initial learning situation to other settings is largely a matter of practice (strengthening hab- its). Transfer is aided by a similarity in the stim- uli and responses in the learning situation and those encountered in future situations where the response is to be performed. Much of be- haviorist learning is based on respondent con- ditioning and operant conditioning procedures.

Psychological Learning Theories 73

stimulus. Finally, the client is able to confront the stimulus without being anxious and afraid.

In healthcare research, respondent condi- tioning has been used to extinguish chemother- apy patients’ anticipatory nausea and vomiting (Lotfi-Jam et al., 2008; Stockhurst, Steingrueber, Enck, & Klosterhalfen, 2006). Systematic de- sensitization has been used to treat drug ad- diction (Piane, 2000), phobias (McCullough & Andrews, 2001), and tension headaches (Deyl & Kaliappan, 1997) and to teach children with attention-deficit/hyperactivity disorder (ADHD) or autism to swallow pills (Beck, Cataldo, Slifer, Pulbrook, & Guhman, 2005). As another illus- tration, prescription drug advertisers regularly employ conditioning principles to encourage consumers to associate a brand-name medica- tion with happy and improved lifestyles. Once conditioned, consumers will likely favor the

relatives or friends without smelling offensive odors, then her discomfort and anxiety about hos- pitals may lessen after several such experiences.

Systematic desensitization is a technique based on respondent conditioning that is used by psychologists to reduce fear and anxiety in their clients (Wolpe, 1982). The assumption is that fear of a certain stimulus or situation is learned; therefore, it also can be unlearned or extinguished. Because a person cannot be both anxious and relaxed at the same time, fearful in- dividuals are first taught relaxation techniques. While they are in a state of relaxation, the fear- producing stimulus is gradually introduced at a nonthreatening level so that anxiety and emo- tions are not aroused. After repeated pairings of the stimulus under relaxed, nonfrightening conditions, the individual learns that no harm will come to him from the once fear-inducing

BASIC MODEL OF LEARNING

EXAMPLE

UCS

NS = Neutral stimulus UCS = Unconditioned stimulus UCR = Unconditioned response CS = Conditioned stimulus CR = Conditioned response

NS + UCS UCR

UCR

where:

UCR

(Several pairings)

Offensive odors (UCS)

Queasy feeling (UCR)

Hospital + Offensive odors (UCS)(NS)

(Several pairings of Hospitals + Offensive odors Queasy feeling)

Queasy feeling (CR)

Hospital (CS)

FIGURE 3-1 Respondent conditioning model of learning.

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Another widely recognized approach to learning is operant conditioning, which was developed largely by B. F. Skinner (1974, 1989). Operant conditioning focuses on the behavior of the organism and the reinforcement that occurs after the response. A reinforcer is a stimulus or event applied after a response that strengthens the probability that the response will be per- formed again. When specific responses are rein- forced on the proper schedule, behaviors can be either increased or decreased (Prichard, 2014).

BOX 3-1 summarizes the principal ways to increase and decrease responses by applying the contingencies of operant conditioning. Under- standing the dynamics of learning presented in

advertised drug over competitors’ medications and the much less expensive generic form. As a third example, taking the time to help pa- tients relax and reduce their stress when apply- ing some medical intervention—even a painful procedure—lessens the likelihood that patients will build up negative and anxious associations about medicine and health care.

Certain respondent conditioning concepts are especially useful in the healthcare setting. Stimulus generalization is the tendency of initial learning experiences to be easily applied to other similar stimuli. For example, when lis- tening to friends and relatives describe a hos- pital experience, it becomes apparent that a highly positive or negative personal encounter may color patients’ evaluations of their hospital stays as well as their subsequent feelings about having to be hospitalized again. With more and varied experiences, individuals learn to differ- entiate among similar stimuli, at which point discrimination learning is said to have oc- curred. As an illustration, patients who have been hospitalized a number of times often have learned a lot about hospitalization. As a result of their experiences, they make sophisti- cated distinctions and can discriminate among stimuli (e.g., what the various noises mean and what the various health professionals do), which novice patients cannot. Much of professional education and clinical practice involves mov- ing from being able to make generalizations to discrimination learning.

Spontaneous recovery is a useful respon- dent conditioning concept that needs to be given careful consideration in relapse prevention pro- grams. The underlying principle operates as fol- lows: Although a response may appear to be extinguished, it may recover and reappear at any time (even years later), especially when stimu- lus conditions are similar to those in the initial learning experience. Spontaneous recovery helps us understand why it is so difficult to eliminate completely unhealthy habits and addictive be- haviors such as smoking, alcoholism, and drug abuse. As this principle demonstrates, it is much easier to learn a behavior than to unlearn it.

BOX 3-1 Operant Conditioning Model: Contingencies to Increase and Decrease the Probability of an Organism’s Response

To increase the probability of a response:

A. Positive reinforcement: application of a pleasant stimulus

Reward conditioning: a pleasant stimulus is applied following an organism’s response

B. Negative reinforcement: removal of an aversive or unpleasant stimulus

Escape conditioning: as an aversive stimulus is applied, the organism makes a response that causes the unpleasant stimulus to cease

Avoidance conditioning: an aversive stimulus is anticipated by the organism, which makes a response to avoid the unpleasant event

To decrease or extinguish the probability of a response:

A. Nonreinforcement: an organism’s conditioned response is not followed by any kind of reinforcement (positive, negative, or punishment)

B. Punishment: following a response, an aversive stimulus is applied that the organism cannot escape or avoid

Psychological Learning Theories 75

If allowed to stay home from school, the child increasingly may complain of sickness to avoid unpleasant situations. Thus, when fearful events are anticipated, sickness, in this case, is the be- havior that has been increased through nega- tive reinforcement.

According to operant conditioning princi- ples, behaviors also may be decreased through either nonreinforcement or punishment. Skin- ner (1974) maintained that the simplest way to extinguish a response is not to provide any kind of reinforcement for some action. For example, offensive jokes in the workplace may be handled by showing no reaction; after several such ex- periences, the joke teller, who more than likely wants attention—and negative attention is pref- erable to no attention—may curtail his or her use of offensive humor. Keep in mind, too, that desirable behavior that is ignored may lessen as well if its reinforcement is withheld.

If nonreinforcement proves ineffective, then punishment may be employed as a way to de- crease responses, although this approach carries many risks. Under punishment conditions, the individual cannot escape or avoid an unpleas- ant stimulus. Suppose, for example, a nursing student is continually late for class and noisily disrupts the class when she finally arrives, an- noying both other students and the instructor. The instructor discovers there is no valid rea- son for the student’s lateness—the student says she overslept and did not allow sufficient time to find a parking place and cites other factors she should have more control over. The instruc- tor tries praising the student the few times she comes to class on time (positive reinforcement) and tries not paying attention to her when she arrives late (nonreinforcement), but the student continues to be late to class more often than she is on time. The student appears to enjoy the at- tention she receives. As a last resort, the in- structor may try punishment, which involves applying a negative reinforcer and removing a positive reinforcer. The positive reinforcers to be removed are the attention the student re- ceives and the fact that she does not really need to change her behavior to conform to classroom

this box can prove useful to nurses in assessing and identifying ways to change individuals’ be- haviors in the healthcare setting. The key is to carefully observe individuals’ responses to spe- cific stimuli and then select the best reinforce- ment procedures to change a behavior.

Two methods to increase the probability of a response are to apply positive or negative re- inforcement after a response occurs. According to Skinner (1974), giving positive reinforcement (i.e., reward) greatly enhances the likelihood that a response will be repeated in similar cir- cumstances. As an illustration, although a pa- tient moans and groans as he attempts to get up and walk for the first time after an opera- tion, praise and encouragement (reward) for his efforts at walking (response) will improve the chances that he will continue struggling toward independence.

A second way to increase a behavior is by applying negative reinforcement after a response is made. This form of reinforcement involves the removal of an unpleasant stimulus through either escape conditioning or avoidance condi- tioning. The difference between the two types of negative reinforcement relates to timing.

In escape conditioning, as an unpleas- ant stimulus is being applied, the individual responds in some way that causes the uncom- fortable stimulation to cease. Suppose, for ex- ample, that when a member of the healthcare team is being chastised in front of the group for being late and missing meetings, she says some- thing humorous. The head of the team stops criticizing her and laughs. Because the use of humor has allowed the team member to escape an unpleasant situation, chances are that she will employ humor again to alleviate a stressful en- counter and thereby deflect attention from her problem behavior.

In avoidance conditioning, the unpleasant stimulus is anticipated rather than being applied directly. Avoidance conditioning has been used to explain some people’s tendency to become ill to avoid doing something they do not want to do. For example, a child fearing a teacher or test may tell his mother that he has a stomachache.

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The use of reinforcement is central to the success of operant conditioning procedures. For operant conditioning to be effective, it is nec- essary to assess which kinds of reinforcement are likely to increase or decrease behaviors in an individual. Not every patient, for example, finds health practitioners’ terms of endearment rewarding. Comments such as “Very nice job, dear,” may be presumptuous or offensive to some clients. A second issue involves the timing of reinforcement. Through experimentation with animals and humans, researchers have demon- strated that the success of operant conditioning procedures partially depends on the schedule of reinforcement. Initial learning requires a contin- uous schedule, reinforcing the behavior quickly every time it occurs. If the desired behavior does not occur, then responses that approximate or resemble it can be reinforced, gradually shaping behavior in the direction of the goal for learning. As an illustration, for geriatric patients who ap- pear lethargic and unresponsive, nurses might begin by rewarding small gestures such as eye contact or a hand that reaches out and then build on these friendly behaviors toward greater hu- man contact and connection with reality. Once a response is well established, however, it be- comes ineffective and inefficient to continu- ally reinforce the behavior. Reinforcement then can be administered on a fixed (predictable) or variable (unpredictable) schedule after a given number of responses have been emitted or af- ter the passage of time.

Operant conditioning techniques provide relatively quick and effective ways to change be- havior. Carefully planned programs using be- havior modification procedures can readily be applied to health care. For example, computerized instruction and tutorials for patients and staff rely heavily on operant conditioning principles in structuring learning programs. In the clini- cal setting, the families of patients with chronic back pain have been taught to minimize their at- tention to the patients whenever they complain and behave in dependent, helpless ways, but to pay a lot of attention when the patients attempt to function independently, express a positive

expectations. The instructor might tell the stu- dent that if she is late, she must come in the back door and sit at the back of the class, mak- ing sure not to disturb anyone (removal of the positive reinforcer of attention). Each time the student is late, the instructor will make note in her grade book (negative reinforcer of not do- ing well in the course).

The problem with using punishment as a technique for teaching is that the learner may become highly emotional and may well divert attention away from the behavior that needs to be changed. Some people who are being pun- ished become so emotional (sad or angry) that they do not remember the behavior for which they are being punished. One of the cardinal rules of operant conditioning is to “punish the behavior, not the person.” In the preceding ex- ample, the instructor must make it clear that she is punishing the student for being late and dis- rupting class rather than convey that she does not like the student.

If punishment is employed, it should be ad- ministered immediately after the response with no distractions or means of escape. Punishment also must be consistent and at the highest reason- able level (e.g., nurses who apologize and smile as they admonish the behavior of a staff mem- ber or patient are sending mixed messages and are not likely to be taken seriously or to decrease the behavior they intend). Moreover, punishment should not be prolonged (bringing up old griev- ances or complaining about a misbehavior at ev- ery opportunity), but there should be a time-out following punishment to eliminate the oppor- tunity for positive reinforcement. The purpose of punishment is not to do harm or to serve as a release for anger; rather, the goal is to decrease a specific behavior and to instill self-discipline.

Operant conditioning and discussions of punishment were more popular during the mid-20th century than they are currently. How- ever, it is important for nurses to be aware of the many cautions about punishment because punishment continues to be used more than it should in the healthcare setting and all too of- ten in damaging ways.

Psychological Learning Theories 77

Cognitive Learning Theory Whereas behaviorists generally ignore the in- ternal dynamics of learning, cognitive learning theorists stress the importance of what goes on inside the learner. Cognitive theory is composed of subtheories and is widely used in education and counseling. According to this perspective, the key to learning and changing is the individ- ual’s cognition (perception, thought, memory, and ways of processing and structuring infor- mation). Cognitive learning is viewed as a highly active process largely directed by the individ- ual. It involves perceiving the information, in- terpreting it based on what is already known, and then reorganizing the information into new insights or understanding (Matlin, 2013; Stern- berg & Sternberg, 2017).

Unlike behaviorists, cognitive theorists main- tain that reward is not necessary for learning to take place. More important are learners’ goals and expectations, which create disequilibrium, imbalance, and tension that motivate learners to act. Educators trying to influence the learn- ing process must recognize the variety of past experiences, perceptions, ways of incorporat- ing and thinking about information. They also need to consider the diverse aspirations, ex- pectations, and social influences that affect any learning situation. Also influencing the process of learning is the learner’s metacognition, or her understanding of her way of learning. To promote transfer of learning, the learner must mediate or act on the information in some way. Similar patterns in the initial learning situation and subsequent situations facilitate this transfer.

Cognitive learning theory includes sev- eral well-known perspectives, such as gestalt, information processing, human development, social constructivism, and social cognition the- ory. More recently, attempts have been made to incorporate considerations related to emo- tions within cognitive theory. Each of these perspectives emphasizes a particular feature of cognition. When pieced together, they in- dicate much about what goes on inside the learner. As the various cognitive perspectives

attitude, and try to live as normal a life as pos- sible. Some patients respond so well to operant conditioning that they report experiencing less pain as they become more active and involved. A systematic review of physiotherapist-provided operant conditioning (POC) found moderate evidence showing that POC is more effective than a placebo intervention in reducing short- term pain in patients with subacute low back pain (Bunzli, Gillham, & Esterman, 2011). Operant conditioning and behavior modifica- tion techniques also have been found to work well with some nursing home and long-term care residents, especially those who are losing their cognitive skills (Proctor, Burns, Powell, & Tarrier, 1999; Spira & Edelstein, 2007).

The behaviorist theory is simple and easy to use, and it encourages clear, objective analysis of observable environmental stimulus conditions, learner responses, and the effects of reinforce- ments on people’s actions. There are, however, some criticisms and cautions to consider when relying on this theory. First, behaviorist theory is a teacher-centered model in which learners are assumed to be relatively passive and eas- ily manipulated, which raises a crucial ethical question: Who is to decide what the desirable behavior should be? Too often the desired re- sponse is conformity and cooperation to make someone’s job easier or more profitable. Sec- ond, the theory’s emphasis on extrinsic rewards and external incentives reinforces and promotes materialism rather than self-initiative, a love of learning, and intrinsic satisfaction. Third, re- search evidence supporting behaviorist theory is often based on animal studies, the results of which may not be applicable to human behav- ior. A fourth shortcoming of behavior mod- ification programs is that learners’ changed behavior may deteriorate over time, especially once they return to their former environment— an environment with a system of rewards and punishments that may have fostered their prob- lems in the first place.

The next section moves from focusing on responses and behavior to considering the role of mental processes in learning.

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situation with an individual or group. Moreover, because individuals vary widely regarding these and other characteristics, they will perceive, in- terpret, and respond to the same event in differ- ent ways, perhaps distorting reality to fit their goals and expectations. This tendency helps ex- plain why an approach that is effective with one client may not work with another client. People with chronic illnesses—even different people with the same illness—are not alike, and helping any patient with disease or disability includes rec- ognizing each person’s unique perceptions and subjective experiences (Imes, Clance, Gailis, & Atkeson, 2002). Also, some interesting applica- tions of gestalt theory can lead to changing ad- dictive behaviors (Brownell, 2012).

Information processing is a cognitive perspective that emphasizes thinking processes: thought, reasoning, the way information is en- countered and stored, and memory function- ing (Gagné, 1985; Sternberg & Sternberg, 2017). How information is incorporated and retrieved is useful for nurses to know, especially in rela- tion to learning by older adults (Park, Morrell, & Shifren, 2014).

FIGURE 3-2 illustrates an information- processing model of memory functioning. Tracking learning through the various stages of this model is helpful in assessing what hap- pens to information as each learner perceives, interprets, and remembers it. Undertaking this analysis may suggest ways to improve the structure of the learning situation as well as ways to correct misconceptions, distortions, and errors in learning.

The first stage in the memory process in- volves paying attention to environmental stimuli; attention, then, is the key to learning. Thus, if a patient is not attending to what a nurse educator is saying, perhaps because the patient is weary or distracted, it would be prudent for the educa- tor to try the explanation at another time when the individual is more receptive and attentive.

In the second stage, the information is pro- cessed by the senses. Here it becomes import- ant to consider the client’s preferred mode of sensory processing (visual, auditory, or motor

are briefly summarized here, readers are encour- aged to imagine their potential applications in the healthcare setting. In keeping with cogni- tive principles of learning, being mentally ac- tive when processing information encourages its retention in long-term memory.

One of the oldest psychological theories is the gestalt perspective, which emphasizes the importance of perception in learning and lays the groundwork for various other cognitive perspectives that followed (Hilgard & Bower, 1966; Murray, 1995). Rather than focusing on discrete stimuli, gestalt refers to the configura- tion or patterned organization of cognitive ele- ments, reflecting the maxim that “the whole is greater than the sum of its parts.” A principal assumption is that each person perceives, inter- prets, and responds to any situation in his or her own way. Although many gestalt principles are worth knowing, the discussion here focuses on those that are particularly useful to health care.

A basic gestalt principle is that psychological organization is directed toward simplicity, equi- librium, and regularity. For example, study the bewildered faces of some patients listening to a complex, detailed explanation about their disease; instead what they desire most is a simple, clear ex- planation that settles their uncertainty and relates directly to them and their familiar experiences.

Another central gestalt principle with sev- eral ramifications is that perception is selective. First, because no one can attend to all possi- ble surrounding stimuli at any given time, in- dividuals attend (orient) to certain features of an experience while screening out or ignoring (habituating to) other features. Patients who are in severe pain or who are worried about their hospital bills, for example, may not attend to well-intentioned patient education informa- tion. Second, what individuals pay attention to and what they ignore are influenced by a host of factors: past experiences, needs, personal motives and attitudes, reference groups, and the actual structure of the stimulus or situation (Sherif & Sherif, 1969). Assessing these internal and external dynamics has a direct bearing on how a health educator approaches any learning

Psychological Learning Theories 79

information and making it meaningful. A use- ful, descriptive model has been provided by Rob- ert Gagné (1985). Subsequently, Gagné and his colleagues outlined nine events and their corre- sponding cognitive processes that activate effec- tive learning (Gagné, Briggs, & Wagner, 1992):

■ Gain the learner’s attention (reception) ■ Inform the learner of the objectives and

expectations (expectancy) ■ Stimulate the learner’s recall of prior learn-

ing (retrieval) ■ Present information (selective perception) ■ Provide guidance to facilitate the learner’s

understanding (semantic encoding) ■ Have the learner demonstrate the informa-

tion or skill (responding) ■ Give feedback to the learner (reinforcement) ■ Assess the learner’s performance (retrieval) ■ Work to enhance retention and transfer

through application and varied practice (generalization)

In employing this model, teachers must carefully analyze the requirements of the activ- ity, design and sequence the instructional events, and select appropriate media to achieve the out- comes. Other similar cognitive models for learn- ing exist (Prichard, 2014). Nurses familiar with cognitive theory may want to design their own

manipulation) and to ascertain whether he or she has any sensory deficits. For a variety of rea- sons, presenting material using multiple sen- sory modes aids learning as well (Collins, 2016).

In the third stage of the memory process, the information is transformed and incorpo- rated (encoded) briefly into short-term mem- ory, after which it suffers one of two fates: The information is disregarded and forgotten, or it is stored in long-term memory. Long-term mem- ory involves the organization of information by using a preferred strategy for storage (e.g., im- agery, association, rehearsal, or breaking the information into units). Although long-term memories are enduring, a central problem is retrieving the stored information in the future.

The last stage in the memory-processing model involves the action or response that the individual undertakes based on how information was processed and stored. Education requires as- sessing how a learner attends to, processes, and stores the information that is presented as well as finding ways to encourage the retention and retrieval processes. Errors are corrected by help- ing learners reprocess what needs to be learned (Kessels, 2003).

In general, cognitive psychologists note that memory processing and the retrieval of information are enhanced by organizing that

Stage 1 Attention

Stage 2 Processing

Stage 4 Action

Stage 3 Memory Storage

EXTERNAL PROCESSES

INTERNAL PROCESSES

Sensory Memory

Short- Term Memory

Long- Term Memory

Response encoding storage

strategy

(Brief: less than 30 seconds)

(Fleeting: less than 1 second)

(Enduring: but retrieval problems)

Orienting stimuli

Physical and emotional properties arouse interest

FIGURE 3-2 Information-processing model of memory.

80 Chapter 3 Applying Learning Theories to Healthcare Practice

of information (Sweller, Ayers, & Kalyuga, 2011). To aid learning at the input stage, some sugges- tions are to break the material into small parts or chunks, use memory tricks and techniques (mnemonic devices), relate the new material to something familiar, and put it into context for learners (Collins, 2016). At the output end, it may be a retrieval problem. For example, the information has faded from lack of use, other information interferes with its retrieval (what comes before or after a learning session may well confound storage and retrieval), or indi- viduals are motivated to forget for a variety of conscious and unconscious reasons.

This material on memory processing and functioning is highly pertinent to healthcare practice—whether in developing health educa- tion brochures, engaging in one-to-one patient education, delivering a staff development work- shop, preparing community health lectures, or helping students to study for courses and ex- aminations. Focusing on attention, storage, and memory is essential in the education of older adult patients, including the identification of fa- tigue, medications, and anxieties that may inter- fere with learning and remembering (Park et al., 2014). A common issue with older adults is they may recognize they should know the information, but they have trouble recalling names, dates, and other specifics. And, for everyone, the issue of competence versus performance is always a fac- tor: although learners may truly know informa- tion or a skill (competence), they fail to produce it at a specific moment (performance).

Heavily influenced by gestalt psychology, cognitive development is a third perspective on learning that focuses on qualitative changes in perceiving, thinking, and reasoning as indi- viduals grow and mature (Crandell, Crandell, & Vander Zanden, 2012; Newman & Newman, 2015). Cognitions are based on how external events are conceptualized, organized, and rep- resented within each person’s mental framework or schema, which is partially dependent on the individual’s stage of development in percep- tion, reasoning, and readiness to learn. In other words, age and stage of life can affect learning.

cognitive models and assess how well they work with patients, staff, and students.

Within the information-processing per- spective, Sternberg (1996) reminds educators to consider styles of thinking, which he defines as “a preference for using abilities in certain ways” (p. 347). In education, the instructor’s task is to get in touch with the learner’s way of processing information and thinking. Differences in learn- ing styles is one reason an educational theory or model may not work for everyone. (See the re- view of learning styles in Chapter 4.) Some im- plications for health care include the need to carefully match jobs with styles of thinking, to recognize that people may shift from prefer- ring one style of thinking to another, and, most important, to appreciate and respect the differ- ent styles of thinking reflected among the many players in the healthcare setting. Yet striving for a match in styles is not always necessary or de- sirable. Tennant (2006) notes that adult learners may actually benefit from grappling with views and styles of learning unlike their own, which may promote maturity, creativity, and a greater toler- ance for differences. Because nurses are expected to instruct a variety of people with diverse styles of learning, Tennant’s suggestion has interesting implications for nursing education programs.

The information-processing perspective is particularly helpful for assessing problems in acquiring, remembering, and recalling infor- mation. Some strategies include the following:

1. Have learners indicate how they believe they learn (metacognition)

2. Ask them to describe what they are thinking as they are learning

3. Evaluate learners’ mistakes 4. Give close attention to learners’ in-

ability to remember or demonstrate information

For example, forgetting or having difficulty in retrieving information from long-term mem- ory is a major stumbling block in learning. This problem may occur at the input end, such as a failure to pace the amount of information (cogni- tive load) and/or the timing of the presentation

Psychological Learning Theories 81

solitary manner, Russian psychologist Lev Vy- gotsky (1986) emphasizes the significance of lan- guage, social interaction, and adult guidance in the learning process. When teaching children, the job of adults is to interpret, respond, and give meaning to children’s actions. Rather than the discovery method favored by Piaget, Vygotsky advocates clear, well-designed instruction that is carefully structured to advance each person’s thinking and learning.

In practice, some children may learn more effectively by discovering and putting pieces to- gether on their own, whereas other children ben- efit from a more social and directive approach. It is the health educator’s responsibility to iden- tify the child’s or teenager’s stage of thinking, to provide experiences at an appropriate level for the child to actively discover and participate in the learning process, and to determine whether a child learns best through language and so- cial interaction or through perceiving and ex- perimenting in his or her own way. Research suggests that young children’s learning is of- ten more solitary, whereas older children may learn more readily through social interaction (Palincsar, 1998).

What do cognitive developmental theorists say about adult learning? First, although the cog- nitive stages develop sequentially, some adults never reach the formal operations stage. These adults may learn better from explicitly concrete approaches to health education. Second, devel- opmental psychologists and gerontologists have proposed advanced stages of reasoning in adult- hood that go beyond formal operations. For ex- ample, it is not until the adult years that people become better able to deal with contradictions, synthesize information, and more effectively in- tegrate what they have learned—characteristics that differentiate adult thought from adolescent thinking (Kramer, 1983). Third, older adults may demonstrate an advanced level of reasoning de- rived from their wisdom and life experiences, or they may reflect lower stages of thinking result- ing from lack of education, disease, depression, extraordinary stress, or medications (Hooyman, Kawamoto, & Kiyak, 2015).

Much of the theory and research in this area has been concerned with identifying the characteristics and advances in the thought pro- cesses of children and adolescents. A principal assumption is that learning is a developmental, sequential, and active process that transpires as the child interacts with the environment, makes discoveries about how the world operates, and interprets these discoveries in keeping with what she knows (schema).

Jean Piaget is the best known of the cogni- tive developmental theorists. His observations of children’s perceptions and thought processes at different ages have contributed much to our recognition of the unique, changing abilities of youngsters to reason, conceptualize, commu- nicate, and perform (Piaget & Inhelder, 1969). By watching, asking questions, and listening to children, Piaget identified and described four se- quential stages of cognitive development: sen- sorimotor, preoperational, concrete operations, and formal operations. These stages become evi- dent over the course of infancy, early childhood, middle childhood, and adolescence, respec- tively. According to Piaget’s theory of cognitive learning, children take in or incorporate infor- mation as they interact with people and the en- vironment. They either make their experiences fit with what they already know (assimilation) or change their perceptions and interpretations in keeping with the new information (accom- modation). Nurses and family members need to determine what children are perceiving and thinking in a particular situation. As an illustra- tion, young children usually do not comprehend fully that death is final. They respond to the death of a loved one in their own way, perhaps asking God to give back the dead person or believing that if they act like a good person, the deceased loved one will return to them (Gardner, 1978).

Proponents of the cognitive development perspective manifest some differences in their views that are worth considering by nurse ed- ucators. For example, although Piaget stresses the importance of perception in learning and views children as little scientists exploring, in- teracting, and discovering the world in a relative

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cannot be ignored, and learning is facilitated by sharing beliefs, by acknowledging and challeng- ing differing conceptions, and by negotiating new levels of conceptual understanding (Mar- shall, 1998). Cooperative learning and self-help groups are examples of social constructivism in action. Given the rapidly changing age and ethnic composition in the United States, the social con- structivist perspective has much to contribute to health education and health promotion efforts.

Rooted in social psychology, the social cognition perspective reflects a constructivist orientation and highlights the influence of so- cial factors on perception, thought, and mo- tivation. A host of scattered explanations can be found under the rubric of social cognition (Carlston, 2013; Fiske & Taylor, 2013), which, when applied to learning, emphasize the need for instructors to consider the dynamics of the social environment and groups on both inter- personal and intrapersonal behavior. As an il- lustration, attribution theory focuses on the cause-and-effect relationships and explana- tions that individuals formulate to account for their own and others’ behavior and the way in which the world operates. Many of these expla- nations are unique to the individual and tend to be strongly colored by cultural values and beliefs. For example, patients with certain re- ligious views or a type of parental upbringing may believe that their disease is a punishment for their sins (internalizing blame); other pa- tients may attribute their disease to the actions of others (externalizing blame). From this per- spective, patients’ attributions may or may not promote wellness and well-being. The route to changing health behaviors is to change dis- torted attributions. Nurses’ prejudices, biases (positive and negative), and attributions need to be considered as well in the healing process.

Cognitive theory has been criticized for ne- glecting emotions, and efforts have been made to incorporate considerations related to emo- tions within a cognitive framework, an approach known as the cognitive-emotional perspec- tive. As Eccles and Wigfield (2002) comment, “‘Cold’ cognitive models cannot adequately

Research indicates that adults generally do better when offered opportunities for self- directed learning (emphasizing learner con- trol, autonomy, and initiative), and they have an explicit rationale for learning. They also may do better with a problem-oriented rather than subject-oriented approach and when they have opportunities to use their experiences and skills to help others (Tennant, 2006). Educators must keep in mind too that anxiety, the demands of adult life, and past childhood experiences may interfere with learning in adulthood.

Cognitive theory has been criticized for ne- glecting the social context. To counteract this omission, the effects of social factors on per- ception, thought, and motivation require at- tention. Social constructivism and social cognition are two increasingly popular per- spectives within cognitive theory that take the social milieu into account.

Drawing heavily from gestalt psychology and developmental psychology, social construc- tivists take issue with some of the highly ratio- nal assumptions of the information-processing view and build on the work of John Dewey, Jean Piaget, and Lev Vygotsky (Palincsar, 1998). These theorists posit that individuals formulate or con- struct their own versions of reality and that learn- ing and human development are richly colored by the social and cultural context in which peo- ple find themselves. A central tenet of the social constructivist approach is that ethnicity, social class, gender, family life, life history, self-concept, and the learning situation itself all influence an individual’s perceptions, thoughts, emotions, in- terpretations, and responses to information and experiences. A second principle is that effec- tive learning occurs through social interaction, collaboration, and negotiation (Shapiro, 2002).

According to this view, the players in any healthcare setting may have differing perspectives on external reality, including distorted percep- tions and interpretations. Every person operates on his or her own unique representations and interpretations of a situation, all of which have been heavily influenced by that individual’s social and cultural experiences. The impact of culture

Psychological Learning Theories 83

well-being, optimism, and meaningful social interactions (Brackett, Lopes, Ivcevic, Mayer, & Salovey, 2004). EI has been applied to reduc- ing stress and violence in the healthcare work- place (Littlejohn, 2012) and used as a predictor of professional satisfaction and well-being (Zeidner & Hadar, 2014).

A significant benefit of the cognitive theory to health care is the recognition of individual- ity and diversity in how people learn and pro- cess experiences. When applied to health care, cognitive theory has proved useful in formulat- ing exercise programs for breast cancer patients (Rogers et al., 2004), understanding individual differences in bereavement (Stroebe, Folkman, Hansson, & Schut, 2006), and dealing with ad- olescent depression in girls (Papadakis, Prince, Jones, & Strauman, 2006). This theory high- lights the wide variation in how learners actively structure their perceptions; confront a learning situation; encode, process, store, and retrieve information; and manage their emotions—all of which are influenced by social and cultural forces. The challenge for educators is to iden- tify each learner’s level of cognitive development and the social factors that affect learning. This information then is used to find ways to foster insight, creativity, and problem solving.

Difficulties may arise in ascertaining exactly what is transpiring inside the mind of each indi- vidual and in designing learning activities that encourage people to restructure their percep- tions, reorganize their thinking, regulate their emotions, change their attributions and behavior, and create workable solutions. This is no small challenge. Research indicates people often have a “faulty mental model of how they learn and re- member.” Another factor to consider is how so- ciety contributes assumptions and attitudes that “can be counterproductive in individuals becom- ing maximally effective learners” (Bjork et al., 2013, p. 417). Teaching people to learn how to learn and to monitor and regulate their own learn- ing is now considered part of the educator’s job.

The next learning theory combines principles from both the behaviorist and cognitive theories.

capture conceptual change; there is a need to consider affect as well” (p. 127).

Several slightly different cognitive orienta- tions to emotions have been proposed and are briefly summarized here:

■ Empathy and the moral emotions (e.g., guilt, shame, distress, moral outrage) play a significant role in influencing children’s moral development and in motivating people’s prosocial behavior, activism, and ethical responses (Braungart & Braungart, 2006; Hoffman, 2000).

■ Memory storage and retrieval, as well as moral decision making, involve both cogni- tive and emotional brain processing, espe- cially in response to situations that directly involve the self and are stressful (Collins, 2016; Greene, Sommerville, Nystrom, Darley, & Cohen, 2001).

■ Emotional intelligence (EI) entails an individual managing his emotions, mo- tivating himself, reading the emotions of others, and working effectively in interper- sonal relationships. Some argue EI is more important to leadership, social judgment, and moral behavior than cognitive intelli- gence is (Goleman, 1995; Mayer, Roberts, & Barsade, 2008).

■ Self-regulation includes learners moni- toring their own cognitive processes, emo- tions, and surroundings to achieve goals. The ability to self-regulate has been found to be a key factor in learning and studying (Bjork, Dunlosky, & Kornell, 2013) and for successful living and effective social behav- ior (Baumeister & Vohs, 2007).

The implications are that nursing and other health professional education programs would do well to exhibit and encourage empathy and EI in working with patients, family, and staff and to attend to the dynamics of self-regulation as an approach to promoting positive personal growth and effective leadership. Research indi- cates that the development of these attributes in self and patients is associated with a greater likelihood of healthy behavior, psychological

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willingness to provide guidance to others— influence the outcomes of the clinical supervi- sion process (Berggren & Severinsson, 2006). How nurse mentors perceive their role is an im- portant consideration in the leadership selection process (Coombs-Ephraim, 2016; Neary, 2000).

Vicarious reinforcement, another con- cept from social learning theory, involves de- termining whether role models are perceived as rewarded or punished for their behavior. Reward is not always necessary, however, and a learner may imitate the behavior of a role model even when no reward is available to ei- ther the role model or the learner. Neverthe- less, in many cases, whether the model is viewed by the observer as rewarded or punished may have a direct influence on learning. This rela- tionship may be one reason why it is difficult to attract health professionals to geriatric care. Although some highly impressive role models work in this field, geriatric health care is often accorded lower status with less pay in compar- ison to other specialty areas.

Subsequently, Bandura (1977) included cognitive principles in his social learning the- ory, stressing the self-regulation and control that the individual exerts in the process of acquir- ing knowledge and changing behavior. He out- lined a four-step, largely internal process that directs social learning (FIGURE 3-3). Although some of this model’s components are similar to the information-processing model described previously, a principal difference is the inclu- sion of a motivational component in the social learning theory model.

The first step in Bandura’s model is the at- tentional phase, a necessary condition for any learning to occur. Research indicates that role models with high status and competence are more likely to be observed, although the learner’s own characteristics (e.g., needs, self-esteem, compe- tence) may be the more significant determiner of attention. The second step is the retention phase, which involves the storage and retrieval of what was observed. Third is the reproduction phase, where the learner copies the observed behavior. Mental rehearsal, immediate enactment, and

Social Learning Theory Social learning theory is largely based on the work of Albert Bandura (1977, 2001), who mapped out a perspective on learning that includes con- sideration of the personal characteristics of the learner, behavior patterns, and the environment. Since its inception, this theory has gone through several “paradigm shifts” (Bandura, 2001, p. 2). In early formulations, Bandura emphasized behaviorist features and the imitation of role models; later, his focus shifted to cognitive con- siderations, such as the attributes of the self and the internal processing of the learner. Ban- dura’s attention then turned to the impact of social factors and the social context within which learning and behavior occur. As Bandura’s model of social learning has evolved, the learner is now viewed as central (what Bandura calls a “human agency”), which suggests the need to identify what learners are perceiving and how they are interpreting and responding to social situations. As such, careful consideration needs to be given to the healthcare environment as a social situation.

One of Bandura’s early observations was that individuals do not need to have direct experi- ences to learn. Considerable learning occurs by taking note of other people’s behavior and what happens to them. Thus, learning is often a so- cial process, and other individuals, especially significant others, provide compelling examples or role models for how to think, feel, and act.

Role modeling, therefore, is a central con- cept of social learning theory. As an example, a more experienced nurse who demonstrates desir- able professional attitudes and behaviors some- times serves as a mentor for a less experienced colleague. Armstrong (2008) emphasizes that to facilitate learning, role models need to be enthu- siastic, professionally organized, caring, and self- confident, as well as knowledgeable, skilled, and good communicators. Research indicates that nurse managers’ attitudes and actions—ensuring safety, integrating knowledge with practice, sharing feelings, challenging staff nurses and students, and demonstrating competence and

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of the self-system to produce behavioral effects” (p. 4). In his model, Bandura stresses the internal dynamics of personal selection, intentionality, self-regulation, self- efficacy, and self-evaluation in the learning process. Culture and self- efficacy play a key role, with Bandura noting that indi- vidualistic cultures interpret self- efficacy dif- ferently from the way group-oriented cultures interpret it. However self-efficacy is defined, a low sense of self- efficacy in either kind of cul- ture produces stress. This perspective applies particularly well to the acquisition of health be- haviors and partially explains why some peo- ple select positive role models and effectively regulate their attitudes, emotions, and actions, whereas other people choose negative role mod- els and engage in unhealthy and destructive be- haviors. Nurses need to find ways to encourage patients’ feelings of competency, to promote their wellness, and to make certain not to fos- ter dependency, helplessness, and feelings of low self-worth in them.

Social learning theory extends the learning process beyond the educator–learner relation- ship to the larger social world. This theory helps explain the socialization process as well as the

corrective feedback strengthen the reproduction of behavior. The fourth step is the motivational phase, which focuses on whether the learner is motivated to perform a certain type of behavior. Reinforcement or punishment for a role model’s behavior, the learning situation, and the appro- priateness of subsequent situations where the be- havior is to be displayed all combine to affect a learner’s performance (Bandura, 1977; Gage & Berliner, 1998). Well suited to conducting health education and staff development training, this organized approach to learning requires paying attention to the social environment, the behav- ior to be performed, and the individual learner (Aliakbari, Parvin, Heidari, & Haghani, 2015; Bahn, 2001).

Reflecting a social cognition orientation, Bandura (2001) then shifted his focus to socio- cultural influences, viewing the learner as the agent through which learning experiences are filtered. He argues that the human mind is not just reactive; it is generative, creative, and re- flective. Essentially, the individual engages in a transactional relationship between the social en- vironment and the self, where sociocultural fac- tors are mediated by “psychological mechanisms

Motivational Phase

Reproduction Phase

Retention Phase

Attentional Phase

Performance

INTERNAL PROCESSES EXTERNAL PROCESSES

EXTERNAL PROCESSES

Observation of role model

Processing and repre- sentation in memory

Memory guides performance of model's actions

Influenced by vicarious rein- forcement and punishment

Covert cogni- tive activity, consequences of behavior, and self- reinforcement and punishment

Self-Regulation and Control

Role model demonstrates behavior, which is perceived by the learner to be reinforced (vicarious reinforcement); model may facilitate or inhibit learning a behavior.

FIGURE 3-3 Social learning theory.

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and his followers) have significant implications for learning and changing behavior (Hilgard & Bower, 1966; O’Loughlin, 2013). It is largely a theory of motivation that stresses emotions rather than cognition or responses. The psy- chodynamic perspective emphasizes the im- portance of conscious and unconscious forces in guiding behavior, personality conflicts, and the enduring effects of childhood experiences on adult behavior. This theory may be especially useful to healthcare professionals (Bower, 2005; O’Loughlin, 2013). As Pullen (2002) points out, negative emotions are important to recognize and assess in nurse–patient–physician–family interactions, and psychodynamic theory can be helpful in this regard.

A central principle of the theory is the idea that behavior may be conscious or unconscious— that is, individuals may or may not be aware of their motivations and why they feel, think, and act as they do. According to the psychodynamic view, the most primitive source of motivation comes from the id and is based on libidinal en- ergy (the basic instincts, impulses, and desires humans are born with). The id includes two components: eros (the desire for pleasure and sex, sometimes called the life force) and than- atos (aggressive and destructive impulses, or the death wish). Patients who survive or die de- spite all predictions to the contrary provide il- lustrations of such primitive motivations. The id, according to Freud, operates on the pleasure principle—to seek pleasure and avoid pain. For example, dry, dull lectures given by nurse edu- cators who go through the motions of the pre- sentation without much enthusiasm or emotion inspire few people (patients, staff, or students) to listen to the information or heed the advice being given. This does not mean, however, that only pleasurable presentations are acceptable.

Countering the id (primitive drives) is the superego, which involves the internalized so- cietal values and standards, or the conscience. Mediating these two opposing forces in the per- sonality is the ego, which operates based on the reality principle. Rather than insisting on im- mediate gratification, people learn to take the

breakdown of behavior in society. Responsibil- ity is placed on the educator or leader to act as an exemplary role model and to choose socially healthy experiences for individuals to observe and repeat. This obligation requires the care- ful evaluation of learning materials for stereo- types, mixed or hidden messages, and negative effects. Yet simple exposure to role models cor- rectly performing a behavior that is rewarded (or performing some undesirable behavior that is punished) does not ensure learning. Attention to the learner’s self-system and the dynamics of self-regulation may help sort out the varying ef- fects of the social learning experience.

In health care, social learning theory has been applied to nursing education, to commu- nity mental health settings, to addressing psy- chosocial problems, and to maximizing the use of support groups. For example, research in- dicates that those managers who are aware of their roles and responsibilities in promoting a positive work environment enhance learning, competence, and satisfaction. Dissatisfaction, in contrast, has a detrimental effect and is a sig- nificant cause of staff turnover (Kane- Urrabazo, 2006). Nurses have applied social learning prin- ciples successfully when working with teen- age mothers (Stiles, 2005) and in addressing alcoholism among older adults (Akers, 1989). Mental health providers used a social learning theory paradigm to organize training and pro- duce changes within their system to make em- ployment a higher priority among community mental health services (Waynor, Pratt, Dolce, Bates, & Roberts, 2005). A major difficulty with applying social learning theory in practice is that this theory is complex and not easily op- erationalized, measured, and assessed.

The final two theories reviewed in this chapter focus on the importance of emotions and feelings in the learning process.

Psychodynamic Learning Theory Although not typically treated as a learning the- ory, some of the constructs from psychodynamic theory (based on the work of Sigmund Freud

Psychological Learning Theories 87

BOX 3-2 Ego Defense Mechanisms: Ways of Protecting the Self from a Perceived Threat

Denial: Ignoring or refusing to acknowledge the reality of a threat

Rationalization: Excusing or explaining away a threat

Displacement: Taking out hostility and aggression on other individuals rather than directing anger at the source of the threat

Repression: Keeping unacceptable thoughts, feelings, or actions from conscious awareness

Regression: Returning to an earlier (less mature, more primitive) stage of behavior as a way of coping with a threat

Intellectualization: Minimizing anxiety by responding to a threat in a detached, abstract manner without feeling or emotion

Projection: Seeing one’s own unacceptable characteristics or desires in other people

Reaction formation: Expressing or behaving the opposite of what is really felt

Sublimation: Converting repressed feelings into socially acceptable action

Compensation: Making up for weaknesses by excelling in other areas

long road to pleasure and to weigh the choices or dilemmas in the conflict between the id and the superego. Healthy ego (self ) development, as emphasized by Freud’s followers, is an im- portant consideration in healthcare fields. For example, patients with ego strength can cope with painful medical treatments because they recognize the long-term value of enduring dis- comfort and pain to achieve a positive outcome. Patients with weak ego development, in contrast, may miss their appointments and treatments or engage in short-term pleasurable activities that work against their healing and recovery. A signif- icant aspect of the learning and healing process involves helping patients develop ego strength and adjust realistically to a changed body im- age or lifestyle brought about by disease and medical interventions.

Nurses and other health professionals also require personal ego strength to cope with the numerous predicaments in the everyday practice of delivering care as they face conflicting values, ethics, and demands. Professional burnout, for example, is rooted in an overly idealized con- cept of the healthcare role and unrealistic ex- pectations for the self in performing the role. Malach-Pines (2000) notes that burnout may stem from nurses’ childhood experiences with lack of control.

When the ego is threatened, as can easily occur in the healthcare setting, defense mech- anisms may be employed to protect the self. The short-term use of defense mechanisms is a way of coming to grips with reality. The danger arises from the overuse or long-term reliance on defense mechanisms, which allows individ- uals to avoid reality and may act as a barrier to learning and transfer. BOX 3-2 describes some of the more commonly used defense mechanisms. Because of the stresses involved in health care, knowledge of defense mechanisms is useful, whether for nursing students who are grappling with the challenges of nursing education, staff nurses who are dealing with the strains of work- ing in hospitals and long-term care facilities, or patients and their families who are learning to cope with illnesses and injuries.

As an example of defense mechanisms in health care, Kübler-Ross (1969) points out that many terminally ill patients’ initial reaction to being told they have a serious threat to their health and well-being is to employ the defense mechanism of denial. Patients typically find it too overwhelming to process the information that they are very ill or likely to die. Although most patients gradually accept the reality of their illness, the dangers are that if they remain in a state of denial, they may not seek treatment and care, and if their illness is contagious, they may not protect others against infection.

On the healthcare side, a common defense mechanism employed by medical staff is to intellectualize the significance of disease and

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and social isolation. One danger is that young people may treat their illness or impairment as a significant dimension of their identity and self-concept—a perspective well described in poet Lucy Grealy’s (1994) personal account in Anatomy of a Face.

According to the psychodynamic view, dif- ficulties arise and learning is limited when in- dividuals become fixated or stuck at an earlier stage of personality development. They then must work through their previously unresolved cri- ses to develop and mature emotionally. For ex- ample, some staff members and patients feel an inordinate need to control the self, other people, and certain social situations. This behavior may be rooted in their inability to resolve the crisis of trust versus mistrust at the earliest stage of life. In working with these individuals, it is important to build a trusting relationship and to encour- age them to gradually relinquish some control.

In some cases, past conflicts, especially during childhood, may interfere with the abil- ity to learn or to transfer learning. What peo- ple resist talking about or learning—a process termed resistance—is an indicator of under- lying emotional difficulties, which must be dealt with for them to move ahead emotion- ally and behaviorally. For instance, if a young, pregnant teenager refuses to engage in a seri- ous conversation about sexuality (e.g., changes the subject, giggles, looks out into space, ex- presses anger), this behavior indicates that she has underlying emotional conflicts that need to be addressed. One study explored psychody- namic sources of resistance among nursing stu- dents and examined how they engaged with or resisted the learning process. A number of fac- tors requiring consideration surfaced in this re- search, including childhood struggles, a history of overadaptation, self-image, and learning cli- mate (Gilmartin, 2000).

Serious problems in miscommunication can occur in health care as a result of childhood learn- ing experiences. For example, some physicians and nurses may have had the childhood expe- rience of standing helplessly by watching some- one they loved and once depended on endure

death rather than to deal with these issues realis- tically at an emotional level. This defense mech- anism may contribute to the reported tendency of oncologists to ignore, rather than address, the emotions that patients express during commu- nication (Friedrichsen & Strang, 2003; Pollak et al., 2007). One study found that in respond- ing to patients expressing fear, oncologists more often addressed the topic causing the fear rather than addressing the emotion itself (Kennifer et al., 2009). Telford, Kralik, and Koch (2006) report that nurses may strive to categorize ter- minally ill patients within a denial–acceptance framework too quickly and, as a result, may not listen to patients as they attempt to tell their stories and interpret their illness experiences. Protecting the self (ego) by dehumanizing pa- tients and treating them as diseases and body parts rather than as whole individuals (with spiritual, emotional, and physical needs) is an occupational hazard for nurses and other health professionals.

Another central assumption of psychody- namic theory is that personality development occurs in stages, with much of adult behavior derived from earlier childhood experiences and conflicts. One of the most widely used models of personality development is Erikson’s (1968) eight stages of life, with the model organized around a psychosocial crisis to be resolved at each stage. Including considerations of the patient’s stage of personality development is essential in health care when designing and carrying out treatment regimens, communication, and health education. For example, in working with 4- and 5-year-old patients, where the psychosocial crisis defined by Erikson is “initiative versus guilt,” nurses should encourage the children to offer their ideas and to make and do things themselves. Staff also must be careful not to make these children feel guilty about their illness or misfortune. As a second example, an adolescent’s developmental need to have friends and to find an identity requires special attention in health care. Adolescent pa- tients may benefit from help and support in adjusting to a changed body image and in ad- dressing their fears of weakness, lack of activity,

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motivations, and the psychological growth and development of all those involved in health care and learning. The success of health care rests on both interpersonal and intrapersonal pro- cesses integral to the therapeutic use of the self in carrying out patient care (Gallop & O’Brien, 2003). Psychodynamic theory is well suited to understanding patient and family noncompli- ance (Menahern & Halasz, 2000), trauma and loss (Duberstein & Masling, 2000), palliative care and the deeply emotional issues of termi- nal illness (Chochinov & Breitbart, 2000), and the anxieties of working with long-term psychi- atric residents (Goodwin & Gore, 2000).

The psychodynamic approach has been crit- icized because much of the analysis is speculative and subjective, and the theory is difficult to op- erationalize and measure. Psychodynamic theory also can be used inappropriately; it is not the job of nurses with little clinical psychology or psy- chiatric training to probe into the private lives and feelings of patients to uncover deep, uncon- scious conflicts. Another danger is that nurses and other health professionals may use the many psychodynamic constructs as a way of intellec- tualizing or explaining away, rather than dealing with, people as individuals who need emotional care. Nonetheless, the psychodynamic perspec- tive is helpful in more fully understanding learn- ing and teaching because it highlights a number of underlying considerations and subtleties in the process, such as motivations, emotional develop- ment, and internal conflicts related to learning. It also gives focus to problems with learning or with the teacher–learner relationship.

Humanistic Learning Theory Underlying the humanistic perspective on learn- ing is the assumption that every individual is unique and that all individuals have a desire to grow in a positive way. Unfortunately, positive psychological growth may be damaged by some of society’s values and expectations (e.g., males are less emotional than females, some ethnic groups are inferior to others, making money is more important than caring for people) and by

disease, suffering, and death. Although they could do little as children to improve the situa- tion, they may be compensating for their child- hood feelings of helplessness and dependency as adults by devoting their careers to fending off and fighting disease and death. These motiva- tions, however, may not serve them well as they attempt to care for, communicate with, and ed- ucate terminally ill patients and their families.

Emotional conflicts are not always caused by internal forces, however; society exerts pres- sures on individuals that promote emotional difficulties as well. The reluctance of health professionals to be open and honest with ter- minally ill patients may be derived to some ex- tent from American culture, which encourages medical personnel to “fix” their patients and extend life. Staff members may or may not be conscious of these pressures, but either way they may feel guilty and perceive themselves as fail- ures when dealing with a patient who is dying.

The concept of transfer has special mean- ing to psychodynamic theorists. Transference occurs when individuals project their feelings, conflicts, and reactions—especially those de- veloped during childhood with significant oth- ers such as parents—onto authority figures and other individuals in their lives. The danger is that the relationship between the health pro- fessional and the patient may become distorted and unrealistic because of the biases inherent in the transference reaction. For example, because patients are sick, they may feel helpless and de- pendent and then regress to an earlier stage in life when they relied on their parents for help and support. Their childhood feelings and re- lationship with a parent—for better or worse— may be transferred to a nurse or physician taking care of them. Although sometimes flattering, the love and dependency that patients feel may op- erate against the autonomy and independence they need to get back on their feet. A particu- lar patient may also remind a staff member of someone from his past, creating a situation of countertransference.

The psychodynamic approach reminds nurses to pay attention to emotions, unconscious

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ideology than on critical examination. This au- thor encourages further scrutiny of the concept of humanism in the profession.

Like the psychodynamic theory, the hu- manistic perspective is largely a motivational theory. From a humanistic perspective, moti- vation is derived from each person’s needs, sub- jective feelings about the self, and the desire to grow. The transfer of learning is facilitated by curiosity, a positive self-concept, and open sit- uations in which people respect individuality and promote freedom of choice. Under such conditions, transfer is likely to be widespread, enhancing flexibility and creativity.

Abraham Maslow (1954, 1987), a major contributor to humanistic theory, is perhaps best known for identifying the hierarchy of needs (FIGURE 3-4), which he says plays an im- portant role in human motivation. At the bottom

adults’ mistreatment of their children and one another (e.g., inconsistent or harsh discipline, humiliation and belittling, abuse and neglect). Spontaneity, the importance of emotions and feel- ings, the right of individuals to make their own choices, and human creativity are the cornerstones of a humanistic approach to learning (Rogers, 1994; Snowman & McCown, 2015). Humanis- tic theory is especially compatible with nursing’s focus on caring and patient centeredness— an orientation that is increasingly being chal- lenged by an emphasis in medicine and health care on “impersonal” science, technology, cost efficiency, for-profit medicine, bureaucratic orga- nization, and time pressures. Taking a skeptical approach, Traynor (2009) suggests the pro- motion of humanism in nursing in the United Kingdom, particularly by nurse scholars, may be based more on unexamined professional

FIGURE 3-4 Maslow’s hierarchy of needs. Modified from Maslow, A. (1987). Motivation and personality (3rd ed.). New York, NY: Harper & Row.

Self-Actualization Need to fulfill one’s potential

Esteem Need to be perceived as competent, have confidence and independence,

and have status, recognition, and appreciation

Safety Need for security, stability, structure, and protection

as well as freedom from fear

Belonging and Love Need to give and receive affection

Physiological To have basic survival needs met

(food, water, warmth, sleep)

Psychological Learning Theories 91

between the educator and the learner, with in- struction being tailored to the needs, self-esteem, and positive growth of each learner. Learners— not educators—choose what is to be learned. Within this framework, educators serve as re- source persons whose job is to encourage learners to make wise choices. Because the central focus is on learners’ perceptions, desires, and decision making, the humanistic orientation is referred to as a learner-directed approach.

Mastering information and facts is not the central purpose of the humanistic model of learning. Instead, fostering curiosity, enthusi- asm, initiative, and responsibility is considered more important and enduring and should be the primary goal of any educator. For example, rather than playing health education videos for hospitalized patients to view or routinely dis- tributing lots of pamphlets and pages of small- print instructions, the humanistic perspective would suggest establishing rapport and becom- ing emotionally attuned to patients and their family members. In professional education, the goal is to provide psychologically safe class- rooms and clinical environments, where human- istic principles can be taught through caring, role modeling, small-group interactions, and case discussions. Attention to self-awareness and feelings are crucial. Helpful techniques include role playing, listening exercises, and filming students in the clinical setting (Bider- man, 2003). Providing time for student reflec- tion is essential, and instructor feedback must be given sensitively and thoughtfully (Fryer- Edwards et al., 2006).

Feelings and emotions are the keys to learn- ing, communication, and understanding in hu- manistic psychology. Humanists worry that in today’s stressful society, people can easily lose touch with their feelings, which sets the stage for emotional problems and difficulties in learn- ing (Rogers, 1961). To humanists, “Tell me how you feel” is a much more important instruction than “Tell me what you think” because thoughts and admonitions (the latter of which Rogers calls “the shoulds”) may be at odds with true feel- ings. Consider the implications of the following

of Maslow’s hierarchy are physiological needs (food, warmth, sleep); then come safety needs, then the need for belonging and love, followed by self-esteem. At the top of the hierarchy are self-actualization needs (maximizing one’s po- tential). Additional considerations include cog- nitive needs (the desire to know and understand) and, for some individuals, aesthetic needs (the desire for beauty). Within this model, it is as- sumed that basic-level needs must be met before individuals can be concerned with learning and self-actualizing. Thus, clients who are hungry, tired, and in pain are motivated to get these bi- ological needs met before they will be open to learning about their illness, rules for self-care, and health education. Although this model is intuitively appealing, research findings in sup- port of Maslow’s hierarchy of needs have been in- consistent. For example, although some people’s basic needs may not be met, they may nonethe- less engage in creative activities, extend them- selves to other people, feel a subjective sense of well-being, and enjoy learning (Pfeffer, 1985; Tay & Diener, 2011).

Besides personal needs, humanists con- tend that self-concept and self-esteem are nec- essary considerations in any learning situation. The therapist Carl Rogers (1961, 1994) argues that what people want is unconditional positive self-regard (the feeling of being loved without strings attached). Experiences that are threat- ening, coercive, and judgmental undermine the ability and enthusiasm of individuals to learn. Therefore, those in positions of authority need to convey a fundamental respect for the people with whom they work. If a nurse is prejudiced against patients with AIDS, for example, then little will be healing or therapeutic in that nurse’s relationship with them until she is genuinely able to feel respect for each patient as an individual.

Rather than acting as an authority, say hu- manists, the role of any educator or leader is to serve as a facilitator (Rogers, 1994). Listening— rather than talking—is the skill needed. Because the uniqueness of the individual is fundamen- tal to the humanistic perspective, much of the learning experience requires a direct relationship

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knowledge building, and skill development (Gage & Berliner, 1992).

Following in the tradition of humanistic theory is positive psychology, which is more oriented to health and well-being than to learn- ing per se (Lopez, Pedrotti, & Snyder, 2014). The emphasis is on positive emotions and op- timism, which appears to make it well suited to health care. However, positive psychology has its share of critics (Ehrenrich, 2009). In relation to health care, some family members and med- ical professionals may earnestly encourage pa- tients to be positive and think themselves well. Yet, this pressure can overburden patients, and some may blame themselves (or be blamed by others) if they do not improve and their illness or injury worsens.

▸ Neuropsychology and Learning

A rapidly growing area of psychology research involves investigations into the physiologi- cal and neurological foundations of thinking, learning, and behavior. Neuropsychology is the scientific study of psychological behav- ior based on neurological assessments of the brain and central nervous system. Neuropsy- chology is not a theory but a body of research that may be applied to psychological aspects of behavior, including learning (Benjamin, de Belle, Etnyre, & Polk, 2008; Kolb & Whishaw, 2015; Sousa, 2012).

Neuropsychology is a branch of psychol- ogy that contributes to the neurosciences, which draws researchers from medicine, chemistry, physiology, engineering, physics, and other dis- ciplines. Neuroscientists are concerned with studying the brain and central nervous system’s structures, anatomy, chemistry, electrical activ- ity, hormones, and neurotransmitters as these affect functioning and behavior. From this per- spective, learning is viewed as involving changes in the brain and central nervous system that af- fect responses and behavior. To these researchers,

statements: (a) a young person who says, “I know I should go to medical school and become a doctor because I am smart and that is what my parents want, but I don’t feel comfortable with people who are sick—I don’t even like them!” and (b) the patient who is dying and says, “I realize that I am going to die and should be brave, but I feel so sad that I am losing my family, my friends, and myself; frankly, I am afraid of dying—all the pain and suffering, being a burden—I’m scared!” In both cases, humanists would argue, the over- riding factor that will affect the behavior of the young person and the patient who is dying is their feelings, not their cognitions.

The humanistic learning theory has mod- ified the approach to education and changing behavior by giving primary focus to the sub- jective needs and feelings of the learner and by redefining the role of the educator. Human- istic principles have become a cornerstone of self-help groups, wellness programs, and pal- liative care. Humanistic theory also has been found to be well suited to working with chil- dren and young patients undergoing separation anxiety caused by illness, surgery, and recovery (Holyoake, 1998) and to working in the areas of mental health and palliative care (Barnard, Hollingum, & Hartfiel, 2006). As in psychody- namic theory, a principal emphasis is on the healing nature of the therapeutic relationship (Pearson, 2006) and the need for nursing stu- dents and staff to grow emotionally from their healthcare experiences (Block & Billings, 1998).

The theory has its weaknesses as well. Re- search has not been able to substantiate some of its strongest claims, and the theory has been criticized for promoting self-centered learners who cannot take criticism or compromise their deeply felt positions. Charged with being more of a philosophy—or a cult—than a science, human- ism has a touchy-feely aspect that makes some learners and educators feel truly uncomfortable. Moreover, information, facts, memorization, drill, practice, and the tedious work sometimes required to master knowledge—which human- ists minimize and sometimes disdain—have been found to contribute to significant learning,

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■ Learning is a function of physiological and neurological developmental changes that are ongoing and dynamic—the brain is now viewed as less fixed than once thought, and it changes with learning and experience (a phenomenon called plasticity).

■ Brain processing is different for each learner; thus, methods of gaining the learner’s at- tention, controlling the amount and pace of learning, and identifying the specific mechanisms for enhancing learning are unique for each person.

■ Meaningful practice strengthens learning connections, which may fade from lack of use; therefore, one-shot patient education efforts are not likely to be effective in per- manently changing behavior.

■ Stress can interfere with or stimulate learn- ing, although the responses to stress may change with age and differ for males and females and for those who have experienced traumatic events.

■ Neuropsychology research has confirmed that learning is an active, multifaceted, complex process that involves preferred and interacting sensory modes. It is colored by the past and present social context, and is regulated largely by the learner based on his or her development, physiological state, experiences, and sense of self. Think for a moment about the ramifications of these findings for healthcare education, learning, and teaching.

Neurophysiological aspects of learning become even more germane for children and adults with physiological disorders; for indi- viduals with mental, emotional, and behavioral problems; and for persons facing the stresses of trauma, disease, disability, and socioeconomic hardship. The following are some implications for teaching, learning, and memory (Collins, 2016; Prichard, 2014):

■ Consider the physiological, mental, and emotional condition of the learner, such as nutrition, hydration, the need for stimulation

learning occurs at the cellular level and produces structural changes in brain structure, wiring pat- terns, and chemistry (Collins, 2016).

Much of the information in neuropsychol- ogy has been gained through advances in neuro- imaging techniques such as functional magnetic resonance imaging (fMRI) and positron emis- sion tomography (PET). Other methodologies employed include animal studies based on sur- gery, electrical recordings such as electroenceph- alograms (EEG) and event-related potentials (ERP), and case studies of children and adults with head trauma, brain lesions, and neurolog- ical abnormalities (Byrnes, 2001). The result- ing findings highlight the underlying biological mechanisms of learning and provide evidence to support some of the principal constructs and dynamics of existing learning theories.

In synthesizing neuropsychology research, many generalizations about learning can be made (Collins, 2016; Gazzaniga, 2000; Page, 2006; Phelps, 2006; Prichard, 2014; Shors, 2006; Sil- verstein & Uhlhaas, 2004). Each of the follow- ing generalizations has implications for health education in the clinical setting, and readers are encouraged to formulate applications to nurs- ing and health care:

■ Emotions have been found to play a key role in Pavlovian conditioning, information pro- cessing, memory, and motivation. Emotions are considered to interact with cognitive factors in any learning situation, suggesting that they cannot be ignored when teaching, learning, reasoning, or making decisions.

■ Neuropsychology research has confirmed the validity of learning theories and constructs, including gestalt principles, constructivism, Piaget’s notions of assimilation and accom- modation, and Freud’s conceptualization of conscious and unconscious processes.

■ In studying the dynamics of brain and central nervous system processing of information, this research has documented the role of physiological arousal and has tracked at- tention, perception, and the organization of experience while learning.

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learner as a person and the effects of the social environment on learning easily can be forgotten. Criticisms aside, concepts derived from neuro- psychology are especially useful to nurses who are educating patients dealing with medical and health problems.

▸ Comparison of Learning Theories

TABLE 3-1 provides a comparative summary of the five psychological learning theories outlined in this chapter. Nurse educators can make gen- eralizations about both the differences and the similarities in what the theories say about ac- quiring knowledge and changing feelings, at- titudes, and behavior. With respect to some of the differences among the theories, each theory has its own assumptions, vocabulary, and way of conceptualizing the learning process. The theories differ in their emphasis on the relative influence of external or internal factors in learn- ing, the view of the learner as more passive or active, the task of the educator, the explanation for motivation, and the way in which the trans- fer of learning is accomplished.

A logical question is which of these five theories best describes or explains learning— which theory, in other words, would be the most helpful to nurses interested in increasing knowl- edge or changing the behavior of patients, staff, or themselves? The answer to this question is that each theory contributes to understanding various aspects of the learning process and can be used singly or in combination to help prac- titioners acquire new information and alter ex- isting thoughts, feelings, and behavior.

Each theory highlights important consid- erations in any learning situation, involving the relative influence of external social factors and internal psychological processing. For ex- ample, behaviorists urge nurses in the role of teaching others to pay attention to and change stimulus conditions and to provide reinforce- ment to alter behavior. Although criticized for

or rest, novelty, and adequate time to process, store, and relate information.

■ Organize and pace learning; be playful and explore.

■ Anchor new learning to something already known or familiar; put the learning into context.

■ Take breaks, including the opportunity to exercise or shift focus, to allow the learning to “sink in” or incubate.

■ And yes, we can teach old dogs new tricks— thanks to brain plasticity—but there are physiological and developmental limits regarding what is reasonable and possible for every individual.

A few cautions. Despite numerous neuro- scientific studies related to learning, this line of research is in its early stages and remains frag- mented, scattered, and lacking in integration. In addition, neuropsychological studies may be based on animal research or involve highly specialized and restricted human samples. As a result, few broad generalizations can be made based on such limited samples. And as Murphy (2016) points out, there are issues with the vari- ous equipment and techniques used to measure and assess neuropsychological activity along with the challenge of inferring what it all means for human behavior and learning.

Although addressing the various biologi- cal connections to learning and behavior is cur- rently a popular and relatively well-funded area of research, there is a risk of reducing human be- havior to mere biology. Critics charge that this narrow focus ignores the individual as a per- son and neglects the significance and complex- ity of psychological and social processes in any learning situation. As Prichard (2014) argues, “brain-based learning” oversimplifies learning (p. 116). Another of his criticisms is that this physiological explanation for learning has pro- duced a “commercial bandwagon” for compa- nies to exploit to make money, such as computer games and costly workshops to “train the brain.” With so much emphasis on the brain and phys- iology in learning, considerations related to the

Comparison of Learning Theories 95

TABLE 3-1 Summary of Learning Theories

Learning Procedures

Assumptions About the Learner Educator ’s Task

Sources of Motivation

Transfer of Learning

Behaviorist

Environmental stimulus conditions and reinforcement promote changes in responses. To change behavior, change the environment.

Passive, reactive learner responds to environmental conditions (stimuli and reinforcement).

Active educator manipulates stimuli and reinforcement to direct learning and change.

Drive reduction

Practice Similarity in stimulus conditions and responses between learning and new situations

Cognitive

Internal perception and thought processing within a context of human development promote learning and change. To change behavior, change cognitions.

Active learner determines patterning of experiences, is strongly influenced by attributions.

Active educator structures experiences (through organization and meaningfulness) to encourage the reorganization of cognitions.

Goals Expectations Disequilibrium

Mental and physical activity Common patterns Understanding Learning to learn

Social Learning

External role models and their perceived reinforcement along with learner’s internal influences. To change behavior, change role models, perceived reinforcement, and the learner’s self-regulating mechanisms.

Active learner observes others and regulates decision to reproduce behavior.

Active educator models behavior, encourages perception of reinforcement, carefully evaluates learning materials for social messages, and attempts to influence learner’s self-regulation.

Socialization experiences, role models, and self- reactive influences (observe self, set goals, and reinforce performance)

Similarity of setting and role models’ behavior

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Learning Procedures

Assumptions About the Learner Educator ’s Task

Sources of Motivation

Transfer of Learning

Psychodynamic

Internal forces such as developmental stage, childhood experiences, emotional conflicts, and ego strength influence learning and change. To change behavior, change interpretations and make unconscious motivations conscious.

Active learner’s lifestyle, past experiences, and current emotional conflicts influence what is learned and how it is remembered and performed.

Educator as a reflective interpreter makes sense of learner’s personality and motivation by listening and posing questions to stimulate conscious awareness, insight, and ego strength.

Pleasure principle and reality principle Tension and imbalance Conscious and unconscious influence of conflict, development, and defense mechanisms

Personality conflict, resistance, and transference associated with learning situations may act as barriers to transfer.

Humanistic

Internal feelings about self, ability to make wise choices, and needs affect learning and change. To change behavior, change feelings, self-concept, and needs.

Active learner attempts to actualize potential for positive self- growth and confirm self- concept; learner is spontaneous, creative, and playful.

Facilitative educator encourages positive self- growth, listens empathetically, allows freedom of choice, and respects learner.

Needs, desire for positive self- growth, and confirmation of self- concept

Positive or negative feelings about self and freedom to learn promote or inhibit transfer.

being reductionistic, behaviorism is admittedly simpler and easier to use than trying to under- take a massive overhaul of an individual’s inter- nal dynamics (perceptions, cognition, memory, feelings, and personality history and conflicts). Moreover, asking someone first to behave in a more appropriate way (abstaining from bad hab- its and engaging in healthy behavior) may not be as threatening or daunting to the learner as it is to suggest the need for internal personality changes. Desired responses are modified and strengthened through practice, and the new

learned responses, in turn, may lead to more fundamental changes in attitudes and emotions. The behaviorist aspects of social learning the- ory are relatively straightforward as well, such as using effective role models, who, by their ex- ample, demonstrate exactly what behaviors are expected and are perceived as rewarded.

Cognitive, social learning, psychodynamic, and humanistic theories remind nurses to con- sider internal factors—perceptions, thoughts, ways of processing information, feelings, and emotions. When teaching others, nurses cannot

Comparison of Learning Theories 97

whereas other learners do not seem to need— and may even resent—attempts to manipulate and reinforce them. Individuals who are well educated, verbal, and reflective may be better candidates for cognitive and psychodynamic ap- proaches, whereas behaviorist approaches may be more suitable for persons whose cognitive pro- cesses are impaired or who are uncomfortable dealing with abstractions or scrutinizing and communicating their thoughts and emotions.

In addition, an individual’s preferred modes of learning and processing (learning style) may help determine the selection of suitable theoreti- cal approaches. That is, although some individu- als learn by acting and responding (behaviorist), the route to learning for others may be through perceptions and thoughts (cognitive) or through feelings and emotions (humanistic and psycho- dynamic). When teaching a group, multiple ap- proaches and ways of processing information are needed. Most people appear to benefit from demonstration and example (social learning).

▸ Motor Learning Because nurses teach motor skills to patients, family members, staff, and students at one time or another, it is important for them to explore theories and applications of motor learning in addition to theories of psychological learning (Cano-de-la-Cuerda, et al., 2015). For exam- ple, Wulf, Shea, and Lewthwaite (2010) stress the importance of and need for motor skill training in medical education. Theories and variables of motor learning are useful when teaching skilled movement-related activities in a variety of settings, ranging from acute care to rehabilitation to home care. The patient learn- ing to walk with crutches, the student learning to take a blood pressure, the nurse learning to irrigate an indwelling catheter, and the family member learning to assist with ostomy care can all benefit from the application of motor learn- ing principles. The objective of this section is to summarize selected aspects of this topic that are relevant and applicable to a wide variety of

afford to ignore these factors because, ultimately, the learner controls and regulates learning—or how information is perceived, interpreted, and remembered and whether the new knowledge is expressed or performed.

In practice, psychological learning theo- ries should not be considered mutually exclu- sive but rather they operate together to change attitudes and behavior. As an illustration: pa- tients undergoing painful procedures are first taught systematic desensitization (behaviorist) and while experiencing pain or discomfort are encouraged to employ imagery, such as think- ing about a favorite, beautiful place or imagin- ing the healthy cells gobbling up the unhealthy cells (cognitive). Staff members are highly re- spectful, upbeat, and emotionally supportive of each patient (humanistic) and create the time and opportunity to listen as patients discuss some of their deepest fears and concerns (psy- chodynamic). Waiting rooms and lounge areas for patients and their families are designed to be comfortable, friendly, and pleasant (gestalt) to facilitate conversation and interaction (hu- manist). Support groups may help patients and family members learn from one another about how to cope with illness or disability and how to regulate their emotions so that their health is not further compromised (social learning). And it always needs to be kept in mind that learning requires attention and active brain processing, which are affected by the physiological state of the learner, often involve emotions, and depend on the organization, pace, and amount of mate- rial to be learned and practiced (neuropsychol- ogy, cognitive).

Another generalization from this discussion is that some psychological learning theories are better suited to certain kinds of individuals than to others. Theoretical assumptions about the learner range from passive to highly active. Pas- sive individuals may learn more effectively from behaviorist techniques, whereas curious, highly active, and self-directed persons may do better with cognitive and humanistic approaches. Also, educators must keep in mind that some learners require external reinforcement and incentives,

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Woollacott, 2017). Applying different aspects of these theories to patient care and education is challenging because so many variables affect the desired outcome and because research in this area has often yielded contradictory results. Dif- ferent individual characteristics, different types of tasks and skills, and different environments all affect a patient’s, student’s, or staff member’s ability to learn a motor skill. For example, Smits, Verschuren, Ketelaar, and van Heugten (2010) suggest that attending to patients’ learning styles can enhance the efficiency of learning and the effectiveness of outcomes during motor skill learning in rehabilitation. Wulf, Chiviacowsky, and Cardozo (2014) discovered that by support- ing a person’s autonomy (giving them a choice) and providing positive feedback during task per- formance increased self-efficacy and positively influenced motor learning. Lewthwaite, Chivia- cowsky, Drews, and Wulf (2015) also found that allowing a person to have task-relevant control during motor performance satisfies a psycho- logical need and enhances learning outcomes.

Stages of Motor Learning Similar to Cronbach’s concept of the learn- ing curve (see Chapter 10), Fitts and Posner’s (1967) three-stage sequential model of motor learning is a classic model that provides a frame- work for nurses to use as they organize learn- ing strategies for patients, students, and staff nurses. Within this model, the three phases of skill learning are identified as follows:

1. The cognitive stage 2. The associative stage 3. The autonomous stage

In the first (cognitive) stage, the learner works to develop an overall understanding of the skill, called the cognitive map (cog- nitive plan)—basically solving the problem of “what is to be done.” Learners must con- sciously focus and pay attention in this stage. During this stage of learning, the use of spe- cific teaching techniques and strategies is prob- ably the most beneficial (Nicholson, 2002).

teaching and learning situations involving nurses, patients, colleagues, and students. The discus- sion here is not intended to provide an exhaus- tive review of the vast topic of motor learning.

Nurses teach patients and family members an assortment of skills that can range from walk- ing to putting on a colostomy bag, and they teach students and colleagues skills that range from simple procedures to operating sophisti- cated medical equipment. Using theory and ev- idence to support and guide them as they teach motor skills can help make nurses’ instruction more effective and efficient. Motor learning is defined as “a set of processes associated with practice or experience leading to relatively per- manent changes in the capability for movement” (Schmidt & Lee, 2005, p. 302). It differs from motor performance, which involves initial acquisition of a skill but not necessarily longer term retention of that skill (Schmidt & Wrisberg, 2004). All too often, nurses tend (erroneously) to equate performance of a skill with learning. For example, a nurse may demonstrate a skill to the patient, such as changing a sterile dressing, and then ask the patient to “teach back” the skill. If the patient does it relatively accurately, it is as- sumed that the skill has been “learned.” Yet when the patient is asked to carry out the skill 2 days later during a home visit, the patient may not be able to perform the skill. He may struggle with the order of the steps of changing the dressing, or forget how to keep the field sterile, or not be able to manipulate the bandages. As this exam- ple suggests, performance in the moment is not always an accurate reflection of learning because the performance can be influenced by many vari- ables, and the changes observed in the skill may be only temporary. Retention, which involves demonstrating a skill over time and after a pe- riod of no practice, indicates that true learn- ing has occurred (O’Sullivan & Portney, 2014).

Multiple theories of motor learning have been proposed (Adams, 1971; Newell, 1991; Schmidt, 1975), as is true for theories related to stages of learning motor skills (Fitts & Posner, 1967; Gentile, 1972). Each theory has its own clinical implications and limitations (Shumway-Cook &

Motor Learning 99

■ Emphasizing problem solving ■ Decreasing guidance and feedback ■ Avoiding manual guidance (Kisner & Colby,

2012)

Nurses should promote learner self-assessment by encouraging identification of both mistakes and success before providing feedback. They should intervene only when errors appear to be consistent (O’Sullivan & Portney, 2014).

The third and final (autonomous) stage of motor learning is the automatic stage, during which speed and efficiency of performance gradually improve and which requires little at- tention and conscious information processing (Nicholson, 2002). An advanced level of skill is achieved and the learner can perform different tasks simultaneously and in changeable envi- ronments. In this stage, learners no longer must “think about” the skill. Nurses can set up pro- gressively more difficult activities in this stage and provide more challenging environments (Kisner & Colby, 2012). Unfortunately, some patients with disabilities never reach this stage, and most patients are discharged from health- care facilities prior to reaching this stage.

Motor Learning Variables It is clear from a review of motor learning re- search that the variables of practice and feed- back have widespread clinical applications for nurses. Gaining an understanding of these variables can assist nurses in optimizing their motor-skill teaching with patients, family mem- bers, students, and staff.

Prepractice Certain variables can influence motor learning even before the learner begins to practice the skill. Nurse educators, for example, must be concerned with prepractice variables that include motiva- tion, attention, goal setting, and understanding of the task goals (Kisner & Colby, 2012; Nicholson, 2002). These variables are particularly import- ant when nurses work with patients who have ill- nesses or disabilities that may impair their ability

Instructional strategies for the educator during this stage include:

■ Emphasizing the purpose of the skill in a context that is functionally relevant to the learner

■ Pointing out similarities to other learned motor skills

■ Minimizing distractions ■ Using clear and concise instructions ■ Demonstrating ideal performance of the skill ■ Breaking down complex movements into

parts, where appropriate ■ Encouraging the learner to verbalize the

instructions and watch the movement ■ Providing some manual guidance but also

allowing for errors in performance (Kisner & Colby, 2012; O’Sullivan & Portney, 2014)

Initially, nurses can expect irregular per- formance with many errors. Eventually, how- ever, learners become able to process sensory cues and organize their perceptual-motor sys- tem to carry out reasonable approximations of the skill (O’Sullivan & Portney, 2014). Rapid improvement but variable performance char- acterizes this stage.

The second (associative) stage of motor learning entails more consistent performance, slower gains, and fewer errors (Schmidt & Lee, 2005). The patient, student, or staff nurse fo- cuses on “how to do” the skill. The goal in this stage is to fine-tune the skill through contin- ued practice. During this stage, better organi- zation is evident, and the movement becomes coordinated and more accurate (O’Sullivan & Portney, 2014). Dependence on visual cues de- creases and movement feedback becomes more important. In this stage, nurses can continue to provide opportunities for practice, emphasizing how the movement feels and assisting learners in finding the safest and most efficient ways to carry out the skills. Helpful instructional strat- egies for this stage include the following:

■ Increasing the complexity of the task ■ Increasing the level of distraction in the

environment ■ Encouraging learners to practice independently

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blocked practice, guidance versus discovery learning, and mental practice. Each type of prac- tice has advantages and disadvantages and spe- cific populations for which it is better suited.

Massed practice is a sequence of practice and rest times in which practice time greatly ex- ceeds the time off task (Schmidt & Lee, 2005). For example, nurses may use massed practice when teaching students to take blood pressure readings. The nurse educator might ask the stu- dent to practice taking 15 blood pressure read- ings in sets of 3 with only a short period of rest between sets. Massed practice can lead to fatigue and possible injury, so it must be used with cau- tion when treating at-risk populations. This type of practice has been shown to markedly decrease motor performance in continuous tasks (such as walking, which involves repetitive, uninterrupted movements); however, massed practice seems to affect learning only slightly when learning is measured on a transfer task in distributed con- ditions (Shumway-Cook & Woollacott, 2017). Thus, the decrease in performance that occurs with massed practice does not seem to affect re- tention negatively. This finding likely reflects the effect of fatigue in masking the original learn- ing outcomes during massed practice. Massed practice is useful when working with individu- als with high levels of motivation and skill who exhibit good endurance, attention, and concen- tration (O’Sullivan, 2014).

Distributed practice consists of spaced practice intervals in which the amount of rest (or time off task) between practice times is equal to or greater than the amount of time within each practice trial (Schmidt & Lee, 2005). This for- mat is more typical of the type of practice nurses might use in a hospital setting where, because of the severity of their conditions, patients need frequent rest periods as they learn to manipulate necessary medical equipment, walk, or perform self-care activities. Distributed practice results in the most learning in relation to training time, but the total training time is typically increased as compared to massed practice (Schmidt & Lee, 2005). It is the preferred mode of practice for in- dividuals with limited endurance and for those

to focus on a task. Goals should be measurable and achievable and should focus on a functional task. Family members and patients should have input into the goals, and the task should be mean- ingful to the learner. In addition, the nurse must determine whether the learner understands the goals and the strategies for achieving a task and is able to pay attention to the task.

Modeling and/or demonstration almost al- ways should be a part of teaching any task. For example, a nurse working in the home care set- ting with a patient who is recovering from a stroke may believe the most important goal for the per- son is to be independent in the self- monitoring of his blood pressure. The patient, in contrast, might believe that being able to use the toilet in- dependently is all he wants to work on, claim- ing that he does not feel comfortable having his wife help him in the bathroom. In order for the nurse to take advantage of the patient’s drive and enthusiasm, it makes sense to set this task as an initial goal and work at a later time on the self- monitoring of his blood pressure. Before teach- ing the patient how to safely use the toilet, the nurse makes sure the patient pays close attention as she explains the steps that are involved with safely getting on and off the toilet, and she con- firms that he has a verbal understanding of those activities. The stage is now set for the nurse to demonstrate and then practice this task with him.

Practice Practice is the most important factor in develop- ing and retaining motor skills. The amount, type, and variability of practice all affect how well a target skill is acquired and retained (Schmidt & Lee, 2005). Because skill in performance gener- ally increases as a direct function of time spent practicing, staff and family members need to continuously reinforce the skills taught by nurses and other health professionals. This emphasis on reinforcement reflects behaviorist theory, as discussed previously in this chapter.

Types of practice variables include massed versus distributed practice, variability of prac- tice, whole versus part practice, random versus

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of this type of teaching depends on the type of task they are trying to teach the patient or other learner. Breaking tasks into smaller units is an effective way to teach tasks that can be naturally divided into segments that reflect the inherent goals of the task or that require information processing ver- sus coordination (Nicholson, 2002; Winstein, 1991a). For example, the tasks of giving an in- jection or setting up a sterile field both have many components that need to be performed in an orderly fashion. Some components of these tasks, such as measuring out the dosage, drawing up the medication, or opening pack- ages of bandages, are more difficult than others. Breaking these types of tasks into their com- ponent parts is an effective way to teach the tasks completely. Conversely, when the task to be learned involves timing between segments and coordinated movements, such as in a con- tinuous task like walking, practice should focus on the whole task rather than on component parts (Nicholson, 2002).

An interesting and counterintuitive find- ing of motor learning research is that some fac- tors that make the initial performance of a task more difficult may make learning more effec- tive (Shumway-Cook & Woollacott, 2017). These factors, first identified by Battig (1966) in ver- bal learning studies, are called contextual in- terference effects (Brady, 2008). It is natural to assume that practicing several different tasks in blocked order (practicing one specific task repeatedly and uninterruptedly in a block, and then the next task in a block, and then the third task in a block) would make for more effective learning than practicing the tasks in random order (defined as high contextual interference). However, this is not necessarily the case. Al- though blocked practice makes initial acqui- sition of the skill easier, some research shows that it is not as effective as random practice for applying the motor skill in other environments and for longer term retention (Shumway-Cook & Woollacott, 2017; Wulf & Schmidt, 1997). In ran- dom practice, it is hypothesized that a greater depth of cognitive processing develops while

who are at risk of injury—a description that ap- plies to many of the patients seen in the health- care environment (O’Sullivan, 2014).

An important goal for learning new motor skills is that patients, staff, and students are able to transfer their learning to new situations or new tasks. For example, nurses often teach patients how to get in and out of the chair next to their hospital bed. The goal is that patients can trans- fer the learning to the new situations they face at home when they try to get in and out of their own kitchen and living room chairs. Research- ers have noted that the more closely the sensory, cognitive, and motor processing demands in the practice environment resemble those in the actual environment, the better the transfer of learning will be (Schmidt & Lee, 2005; Winstein, 1991a). For this reason, it is important to use a variety of chairs in the hospital that resemble chairs at home when teaching this task and not to only limit practice to the chair next to the bed.

Variable practice conditions also appear to increase an individual’s ability to generalize learning to new situations and seem to be par- ticularly effective for children and adult females (Schmidt & Lee, 2005). Research in which subjects practiced a timing task showed that those who practiced at variable speeds were more success- ful than those who practiced at constant speeds in transferring the learning to a novel speed sit- uation (Catalano & Kleiner, 1984). According to Shumway-Cook and Woollacott (2017), us- ing variable practice conditions may be most important when teaching tasks that the patient will perform in diverse conditions. For exam- ple, patients need to practice walking under as many different conditions as possible (e.g., in a busy corridor, in a narrow hallway, on differ- ent surfaces) to help them generalize the skill to the novel conditions and environments they will face when they return home. With regard to self-care tasks such as self- catheterization, patients need to practice these types of tasks in multiple settings, such as in bed, on a com- mode, and in a public restroom.

Nurses often break down tasks into compo- nent parts for easier learning. The effectiveness

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however, can interfere with learning because it does not allow the learner to solve problems on his or her own. Therefore, it is important for nurses to resist the common urge to give con- tinual direction and assistance to patients and students, especially once the learners are famil- iar with the task and demonstrate some degree of physical performance.

The opposite of guidance is trial and er- ror or discovery learning—a cornerstone of cognitive and humanistic theories. This type of teaching presents learners with challenging, yet achievable problems and encourages them to dis- cover their own solutions. Discovery learning seems to be less effective in terms of increasing the speed of initial skill acquisition but more effective for later transfer and retention of the skill (Schmidt & Wulf, 1997; Singer, 1980). For example, a nurse might introduce students to an unfamiliar piece of equipment, tell them to figure out how the equipment works, and then leave the classroom for about 15 minutes. The instructor in this case contends that many stu- dents learn how to operate equipment more ef- fectively by having time initially to discover for themselves before being formally taught how to use medical equipment. Discovery learning is important, the instructor maintains, because throughout their careers nurses face the pros- pect of having to learn for themselves how to use new and updated equipment in a variety of practice settings.

Whereas physical practice is best for learn- ing a motor skill, mental practice (imagining or visualizing the skill without body movement) can also have positive effects on the performance and learning of the skill (Dickstein & Deutsch, 2007). In fact, Allami, Paulignan, and Brovelli (2008) found that high rates of imagery even led to performance and learning levels similar to those of physical practice in an object-slot task. Research indicates that when mental practice is used together with physical practice, motor skill acquisition is enhanced (Gentili, Papaxanthis, & Pozzo, 2006; Hamel & Lajoie, 2005) and occurs at a faster rate than with physical practice alone (Malouin, Richards, Doyon, Desrosiers, &

the individual is retrieving information from memory stores (O’Sullivan, 2014).

As an illustration, the concept of contextual interference effect can be applied to the earlier example of the patient in the hospital learning how to get into the chair from the hospital bed. Once the patient has a basic understanding and some ability to perform the task, it may be bet- ter for the nurse to vary the practice routine and have the patient work on all the different skills the nurse would like her to achieve in random order. Rather than just practicing getting in the chair for a set number of trials, and then per- forming breathing exercises, and then walking, the nurse can vary the order of the activities in the training session: The patient can practice getting in and out of the chair and then perform breathing exercises, go back to the task of get- ting up from the chair again for several trials, walk for a while, do breathing exercises again, repeat getting in the chair, and continue the ac- tivities in random order.

When deciding whether to use blocked or random practice, the nurse must consider char- acteristics of both the task and the learner. Indi- vidual characteristics such as intellectual ability and experience levels may influence the out- come of random practice (Rose, 1997). In fact, random practice has not been found to be su- perior to blocked practice in adolescents with Down syndrome (Edwards, Elliott, & Lee, 1986) or in a pilot study of adults with Parkinson dis- ease (Lin, Sullivan, Wu, Kantak, & Winstein, 2007). Patients who need a high degree of con- sistency and structure for learning may bene- fit the most from blocked practice (O’Sullivan, 2014). In a comprehensive review of the sub- ject, Brady (2008) suggests that the contextual interference effect may be weaker in application than it is in basic research.

Nurses routinely give verbal and physical (manual) guidance to assist a patient or stu- dent in performing tasks. Such guidance seems to be most effective during the initial stages of teaching a task when the task is unfamiliar to the learner and for tasks that are slow in time (Schmidt & Lee, 2005). Too much guidance,

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feedback include knowledge of results (KR) and knowledge of performance (KP). KR is terminal feedback about the outcome of the movement relative to the movement’s goal, whereas KP is feedback about the movement pattern used to achieve the goal (Schmidt & Lee, 2005). For ex- ample, a nurse working with a patient who is learning to care for an ostomy gives the patient KP feedback when she says, “You coordinated your hands really well when you were removing your old pouch from your skin.” A little later in the session, the nurse gives KR feedback when she says, “You put your new pouch on with a nice, tight seal.” Extrinsic feedback can be given at the same time as the task (concurrently) or immediately after the task, or it can be delayed for a specified amount of time. Also, it can be given continuously or intermittently.

Some types of skills, such as tracking tasks, depend more on KP, whereas KR is more im- portant in other types of tasks, such as transfers, where information is needed to shape the gen- eral movements for the next attempt at the task (O’Sullivan, 2014). Research by Wulf, Hob, and Prinz (1998) demonstrates that focusing a per- son’s attention on the outcomes of movements (KR) enhances learning more than when the person focuses on the details of the movements.

Nurses also need to adjust the timing of feedback during the learning process. Initially, concurrent, continuous feedback may be nec- essary in the early stages of teaching a skill to ensure safety and understanding; however, con- tinuous feedback can interfere with learning over time. For example, suppose the nurse seeks to teach a patient how to give herself an injection. Initially, the nurse must show the patient how to hold the needle, often physically guiding the placement of the patient’s hands on the needle. He also tells the patient step by step how to pro- ceed with the injection, giving praise along the way when the patient is successful. If the nurse continues to give this level of extensive concur- rent feedback each time the patient practices, it may retard the patient from learning the skill. For retention and longer term learning, learners

Belleville, 2004; Page, Levine, Sisto, & Johnston, 2001). Several researchers assert that at least some degree of familiarity with the task is nec- essary for mental imagery practice to be success- ful (Mulder, Zijlstra, Zijlstra, & Hochstenbach, 2004; Mutsaarts, Steenbergen, & Bekkering, 2006). Nevertheless, patients who cannot carry out physical practice of motor skills as a result of fatigue, pain, or impairments are often good candidates for the technique of mental practice alone. Patients who are too ill to exercise or get out of bed can gain a head start on learning by mentally “practicing” these activities. They can do so by reviewing with the nurse the steps for getting out of bed and then imagining themselves carrying out those steps, one after the other. Men- tal practice also can help to increase self-efficacy (Callow, Hardy, & Hall, 2001; Martin, Moritz, & Hall, 1999) and can decrease anxiety in patients who are apprehensive about making the initial movement, perhaps because of fear of falling or pain (O’Sullivan, 2014). When possible, mental practice should be combined with physical practice to increase the rate and quality of skill learning.

Feedback Feedback plays a critical role in promoting mo- tor learning and is considered the second most important element involved with learning a skill after practice (Bilodeau, 1966; Newell, 1976). Feedback can be either intrinsic or extrinsic. In- trinsic feedback (inherent feedback) is the sensory and perceptual information that arises when a movement is produced and can include both visual and somatosensory information. Extrinsic feedback (augmented feedback/ enhanced feedback) is information provided to the learner from an outside source (Schmidt & Wrisberg, 2004). The outside source can be the nurse, or it can be some type of instrumen- tation, such as biofeedback.

Extrinsic feedback supplements intrin- sic feedback. Variables to consider when giv- ing extrinsic feedback include the type, timing, and frequency of feedback. Types of extrinsic

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that balances safety and support with allowing patients and students to solve problems, self- monitor, and self-correct when learning new motor skills. BOX 3-3 reviews the practice vari- ables and feedback variables in motor learning.

Including motor learning principles in their repertoire adds depth and breadth to the teach- ing skills of nurses. Although different areas of the brain are involved in motor learning as com- pared to psychological learning, considerable over- lap occurs and the integration and application of both sets of principles are necessary for optimal teaching and learning of motor skills. Selective aspects of some psychological theories—such as reinforcement from behaviorist theory, the ge- stalt and information-processing perspective from cognitive theory, modeling from social learning theory, and focusing on subjective needs and feel- ings of the learner from humanistic theory—are seminal to the teaching of motor skills.

Although a large body of complex research has been published about motor learning, follow- ing several simple guidelines can help nurses be more effective when they teach motor skills to patients or to students. Nurses should remem- ber to do the following:

1. Practice motor skills with patients and students as much as possible, and encourage other staff and family members also to practice skills with patients.

2. Encourage mental practice prior to or along with motor practice.

3. Make sure patients and students un- derstand the purpose of the skill, and give clear guidance and assistance in the initial stages of learning.

4. Vary the conditions of learning as much as possible.

5. Within the limits of safety, decrease the amount of guidance and feedback to allow learners to solve problems, make mistakes, and self-correct errors.

Nurses who consistently apply knowledge of the three stages of motor learning and the

need to self-detect and self-correct errors, so educators should use the least amount of con- current feedback for the shortest time possible (Gentile, 2000). Nurses often can find withhold- ing feedback challenging because many view giving large amounts of concurrent feedback is a way of positively supporting the patient or student. Nevertheless, intermittent feedback during practice promotes learning more effec- tively than does continuous feedback. Immedi- ate, postresponse feedback, in which the nurse provides knowledge of the outcome of the task right after each trial, is often used in the early stages of learning. Although this type of feed- back may enhance early skill performance, it also delays learning (Kisner & Colby, 2012).

Effective learning includes retention. Pro- viding continuous feedback interferes with learn- ers’ development of the ability to solve problems and self-detect errors (Kisner & Colby, 2012). Conversely, feedback that is not given after ev- ery trial (summary feedback) slows initial skill acquisition but improves performance on reten- tion tests (Winstein & Schmidt, 1990). Winstein (1987, 1991b) has demonstrated that progressively decreasing the rate at which feedback is given, called fading of feedback, appears to be most ef- fective in promoting learning. Fading feedback and using summary feedback (allowing several repetitions of a task before providing feedback) are good ways of reducing the amount of feed- back the nurse provides. For example, the nurse teaching a patient to use an incentive spirom- eter first explains and demonstrates its use. He or she then allows the patient to practice using the spirometer two or three times (if no harm- ful errors occur) before giving feedback about how good a seal the patient made around the device, how deeply he or she inhaled, and how well the patient held his or her breath. Eventually, the nurse “fades” the feedback and gives it after four or five trials rather than after two or three, hoping the patient will self-correct any errors.

The extensive use of any type of augmented feedback can create dependence on the feed- back, so nurses need to develop a comfort level

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BOX 3-3 Practice and Feedback Variables in Motor Learning

Practice Variables in Motor Learning ■ Massed practice: Practice time is more than rest time (off task). ■ Distributed practice: Rest time (off task) is the same as or greater than practice time. ■ Variability of practice: The task is practiced under a variety of conditions. ■ Whole-task practice: The entire task is practiced at once. ■ Part–task practice: The task is divided into its component parts and each part is practiced separately. ■ Random practice: A variety of tasks are practiced in random order over different trials. ■ Blocked practice: One task is practiced continuously without interruption before proceeding to the

next task to be learned. ■ Guidance practice/learning: Physical and verbal guidance are provided while practicing the task. ■ Discovery practice/learning: While practicing a task the learner is encouraged to find a solution to a

challenging yet attainable problem. ■ Mental practice: The learner cognitively rehearses a motor task without any body movement.

Feedback Variables in Motor Learning ■ Intrinsic (inherent) feedback: Sensory and perceptual information originates from the learner when

movement is produced. ■ Extrinsic (augmented or enhanced) feedback: Supplemental information is provided from an outside

source such as the teacher or instrumentation when movement is produced. ■ Knowledge of results (KR) feedback: Terminal feedback is provided about the outcome of the

movement relative to the movement goal. ■ Knowledge of performance (KP) feedback: Feedback about the movement pattern used to achieve

the goal is given. ■ Continuous feedback: Feedback is ongoing during performance of the movement. ■ Intermittent feedback: Feedback occurs randomly and irregularly during performance of the

movement. ■ Concurrent feedback: Feedback occurs during performance of the movement. ■ Postresponse (terminal) feedback: Feedback occurs after completion of the movement:

• Immediate: Occurs directly after the movement is completed • Delayed: Occurs after an amount of time to allow reflection by the learner • Summary: Occurs after several repetitions of the movement and describes average performance

Data from Dickstein, R., & Deutsch, J. E. (2007). Motor imagery in physical therapist practice. Physical Therapy, 87(7), 942–953; Kisner, C., & Colby, L. A. (2012). Therapeutic exercise: Foundations and techniques (6th ed.). Philadelphia, PA: F. A. Davis; O’Sullivan, S. B. (2014). Strategies to improve motor function. In S. B. O’Sullivan, T. J. Schmitz, & G. D. Fulk (Eds.), Physical rehabilitation (6th ed., pp. 393–443). Philadelphia, PA: F. A. Davis; Schmidt, R. A., & Lee, T. D. (2005). Motor control and learning: A behavioral emphasis (4th ed.). Champaign, IL: Human Kinetics; Schmidt, R. A., & Wrisberg, C. A. (2004). Motor learning and performance: A problem-based learning approach (3rd ed.). Champaign, IL: Human Kinetics; Shumway-Cook, A. S., & Woollacott, M. H. (2017). Motor control: Translating research into clinical practice (5th ed.). Philadelphia, PA: Wolters Kluwer.

variables of practice and feedback when teach- ing motor skills to patients, students, and col- leagues give themselves the best chances for successful teaching outcomes.

The next section discusses common princi- ples of learning integrating information from all the learning theories presented in this chapter.

▸ Common Principles of Learning

Taken together, the theories discussed in this chapter indicate that learning is a more compli- cated and diverse process than any one theory

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A critical influence on whether learning occurs is motivation. The learning theories re- viewed here suggest that to learn, the individ- ual must want to gain something (i.e., receive rewards and pleasure, meet goals and needs, master a new skill, confirm expectations, grow in positive ways, or resolve conflicts), which in turn arouses the learner by creating tension (i.e., drives to be reduced, disequilibrium, and imbalance) and the propensity to act or change behavior.

The relative success or failure of the learn- er’s performance may affect subsequent learn- ing experiences. In some cases, an inappropriate, maladaptive, or harmful previously learned be- havior may need to be extinguished and then re- placed with a more positive response. As noted earlier, it is easier to instill new learning than to correct faulty learning. That is why it is smart to invest time and care in the early stages of learning and make sure what is learned is ac- curate or correct.

Which Kinds of Experiences Facilitate or Hinder the Learning Process? The educator exerts a critical influence on learning through role modeling, the selection of learning theories, and the way a learning experience is structured for each learner. To be effective, edu- cators must have knowledge (of the material or skill to be learned, the learner, the social context, and educational psychology), and they must be competent (be imaginative, flexible, and able to employ teaching methods; display solid com- munication skills; and able to motivate others).

All the learning theories discussed in this chapter acknowledge the need to recognize and relate the new information to the learner’s past experiences (old habits, previous skills, culture, familiar patterns, childhood memories, feelings about the self, and what is valued, normative, and perceived as successful or rewarded in so- ciety). The ultimate control over learning rests with the learner, but effective educators influence

implies. Besides the distinct considerations for learning suggested by each theory, the simi- larities among the perspectives point to some core features of learning. The following ques- tions raised at the beginning of the chapter can be addressed by synthesizing the learning the- ories and identifying their common principles.

How Does Learning Occur? Learning is an active process that takes place as individuals interact with their environment and incorporate new information or experiences with what they already know or have learned. Factors in the environment that affect learning include the society and culture, the structure or pattern of stimuli, the effectiveness of role models and reinforcements, feedback for cor- rect and incorrect responses, and opportunities to process and apply learning to new situations.

Furthermore, the individual exerts signif- icant control over learning, with that control often reflecting his or her physiological state, developmental stage, history (habits, cultural conditioning, socialization, childhood experi- ences, and conflicts), cognitive style, dynamics of self-regulation, conscious and unconscious motivations, personality (stage, conflicts, and self-concept), and emotions. Although learn- ers often have a preferred mode for taking in information (visual, motor, auditory, or sym- bolic), using multiple sensory modes often fa- cilitates learning. Although some individuals may learn best on their own, others benefit from expert guidance, social interaction, and cooperative learning.

Learning is an individual matter. Neuro- psychology research is beginning to document the uniqueness of each person’s way of actively perceiving and processing information, as well as his or her flexibility and reactions to stress. Thanks to research, much more is known these days about the impact of culture and emotions on how and what is learned and remembered— compared to when people supported the saying “Spare the rod and spoil the child,” believing that humiliation and punishment aided learning.

Common Principles of Learning 107

procedures, and the willingness and resources to engage in assessment are now considered essen- tial responsibilities of the educator in carrying out the teaching–learning process. Evaluation feedback can then be used by the nurse educator to revamp and revitalize learning experiences.

▸ State of the Evidence The study of learning in educational psychol- ogy is based on evidence from research, similar to research-based evidence that is advocated in nursing, medicine, and health care. Rather than assuming the instructor knows best, researchers gather evidence and test learning theories, teach- ing methods, and beliefs about learners, teach- ers, and the environment. The research results are then evaluated to determine if the theories, methods, applications, and assumptions about learning need to be modified.

Ideally in health education, existing research in psychology, nursing, and medicine is used to design learning experiences for patients, fami- lies, and communities. The same is true for de- veloping, implementing, and evaluating teaching and learning experiences for nursing students and staff. Based on research findings, what does not work is eliminated, modifications grounded in additional research are made, and new pro- grams are attempted and assessed. Educational accountability is stressed, and decisions about how to educate must be justified based on data and research. Times change, settings change, and people change, so research must be an on- going process of monitoring and updating what we know about learning and education.

The applications of the learning theories and principles discussed in this chapter are il- lustrated by many research studies in nursing, psychology, education, and health care. Because of this research, nurses can feel more confident about their ability to choose the most appropri- ate theories and principles for each educational experience and hone their approach to teaching and learning in the healthcare setting. Educa- tional research has confirmed many of the con- structs and principles from the various learning

and guide the process so that learners advance in their knowledge, skills, perceptions, thoughts, emotional maturity, or behavior.

Ignoring these considerations, of course, may hinder learning. Other impediments to learn- ing may involve a lack of clarity and meaning- fulness in what is to be learned; fear, neglect, or harsh punishment; and negative or ineffective role models. Providing inappropriate materials for an individual’s ability, readiness to learn, or stage of life-cycle development creates another obstacle to learning. Moreover, individuals are unlikely to want to learn if they have had detri- mental socialization experiences, are deprived of stimulating environments, or lack goals and realistic expectations for themselves.

What Helps Ensure That Learning Becomes Relatively Permanent? Four considerations assist learning in becom- ing permanent. First, the likelihood of learn- ing is enhanced by organizing the learning experience, making it meaningful and plea- surable, recognizing the role of emotions in learning, and pacing the teaching session in keeping with the learner’s ability to pro- cess information. Second, practicing (men- tally and physically) new knowledge or skills under varied conditions strengthens learn- ing. The third issue concerns reinforcement: Although reinforcement may or may not be necessary, some theorists have argued that it may be helpful because it serves as a signal to the individual that learning has occurred and thereby acts as feedback for learners. This also means that rewarding individuals when they have not learned or giving rewards prior to a learning session works against the usefulness of giving rewards for learning.

A fourth consideration involves whether learning transfers beyond the initial educa- tional setting. Learning cannot be assumed to be relatively lasting or permanent; it must be as- sessed and evaluated by the educator soon after the learning experience has occurred as well as through follow-up measurements made at later times. Research skills, knowledge of evaluation

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▸ Summary This chapter demonstrates that learning is com- plex and diverse. Readers may feel overwhelmed by the different theories, sets of constructs and learning principles, and the specific cautions as- sociated with employing the various approaches. Yet, like the blind men exploring the elephant, each theory highlights an important dimension that affects the overall learning process, and to- gether the theories provide a wealth of comple- mentary strategies and alternative options. There is, of course, no single best way to approach learning, although all the theories indicate the need to be sensitive to the unique characteristics and motivations of each learner. For additional sources of information about psychological the- ories of learning and health care, see BOX 3-4.

Educators in the health professions cannot be expected to know everything about the teach- ing and learning process. More important, per- haps, is that they can determine what needs to be known, where to find the necessary informa- tion, and how to help individuals, groups, and themselves benefit directly from a learning sit- uation. Psychology and nursing work well to- gether. Psychology has much to contribute to

perspectives. It also provides evidence to dispute some of the conventional wisdom and myths about learning—for example, helping nurses as educators realize that punishment is not gener- ally effective and may inhibit learning, and con- tinual guidance, practice, and feedback are not always better. Also, when teaching people, keep in mind that strongly held beliefs—that may or may not be rational—will strongly influence each learner’s processing of the educational experience. The research on learning in general and health care in particular demonstrates clearly that no one-size-fits-all approach works in educating patients, nursing students, or nursing staff. To be effective, educational experiences need to be refined and tailored to each individual learner.

Although many advancements have been made in understanding the learning process over the past century, much remains unknown and requires careful research, such as why some pa- tients and nursing students are much more eager to learn than are others and what can be done to encourage reluctant learners to change their at- titudes or behavior. We also need a lot more re- search on how the various learning theories and principles can work together to benefit every learner and how the healthcare setting changes the teaching–learning situation. In the future, more interdisciplinary efforts between psychologists and nurses are needed to move toward a more sophisticated level of research and understand- ing that can be applied to the healthcare setting.

Research is not a panacea, however. Critics charge that the widely promoted, research-based evidence approach to education and health care is peculiar to these professions and places the emphasis on outcomes rather than on the pro- cess of learning. The challenges of measurement are immense and require a highly sophisti- cated knowledge of research methods and their weaknesses—always keeping in mind that attempts to measure and evaluate learning can oversim- plify the complexity and nuances of learning. No small challenge these days is the lack of resources, support, and well-trained personnel needed to truly implement and sustain a research-based approach to teaching and learning (Ferguson & Day, 2005).

BOX 3-4 Psychological Theories of Learning and Health Care Weblinks

Graduate Student Instructor Teaching and Resource Center, University of California, Berkeley: http://gsi.berkeley.edu/gsi-guide -contents/learning-theory-research/learning -overview/

American Psychological Association (search for principles of learning): http://www.apa.org

Instructional Design, Learning Theories: http://www.instructionaldesign.org/theories/

SlideShare: Teaching and Learning Aids: http://www.slideshare.net/jellyways/aids-and -applications-for-easier-learning-and-teaching -finals

National Institutes of Health (search for patient education topics): http://www.nih.gov

Summary 109

6. How does motivation serve as a critical influence on whether learning occurs?

7. Which types of experiences can hinder the learning process?

8. Which factors help ensure that learning becomes relatively permanent?

9. What are some ways that emotions might be given more explicit consideration in nursing and patient education?

10. Describe some of the implications of neuropsychology research for nurses conducting patient education?

11. In motor learning, how do the instructional strategies used during the associative stage of learning differ from those used during the cognitive stage?

12. What is the difference between perfor- mance and learning?

13. Which variables make initial skill ac- quisition more difficult but strengthen retention and learning?

14. How do the different types of practice and feedback variables affect motor learning?

15. Which of the learning theories and principles of learning do you think will be the most useful in conducting patient education? Briefly explain why for each of your choices.

healthcare practice, and nursing is in a strate- gic position to apply and test psychological and motor learning principles, constructs, and the- ories in both educational and clinical settings.

Review Questions 1. What are the five psychological learning

theories discussed in this chapter? 2. What are the principal constructs and

contributions of each of the five psycho- logical learning theories?

3. According to the concept of operant conditioning, what are three techniques to increase the probability of a response, and what are two techniques to decrease or extinguish the probability of a response?

4. What are some ways the behaviorist theory (which focuses on the environment and responses to it) and the cognitive perspec- tive (which emphasizes the individual’s internal processing) could be combined to facilitate knowledge acquisition or change a health behavior?

5. How do the major psychological learning theories compare to one another with re- spect to their similarities and differences?

CASE STUDY You are designing an education session for your colleagues on transitioning from a paper-based documentation system to an electronic medical record (EMR) system. Time is of the essence, and you have three 1-hour sessions planned to cover the information they need to incorporate the new EMR system into their daily practice. Several of your colleagues are concerned about their ability to master the new system. Jack, the nursing unit supervisor, confides, “I am terrified. Learning a whole new system of documentation is overwhelming to my staff, given so many of their other responsibilities. I worry that this new EMR system will have a negative impact on morale, just at the time when we are feeling pressure to increase the amount of work that we do.”

1. Describe how you will structure the educational sessions using two of the psychological learning theories discussed in this chapter. Explain why you chose each theory.

2. Judge which learning theory can best assist you in addressing the issues your colleagues raise about their ability to master the new system and feelings of being overwhelmed. Why did you choose this theory?

3. What can you do to ensure that learning will become relatively permanent?

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117

PART TWO

Characteristics of the Learner CHAPTER 4 Determinants of Learning

CHAPTER 5 Developmental Stages of the Learner

CHAPTER 6 Compliance, Motivation, and Health Behaviors of the Learner

CHAPTER 7 Literacy in the Adult Client Population

CHAPTER 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

CHAPTER 9 Educating Learners with Disabilities and Chronic Illnesses

Determinants of Learning Sharon Kitchie

CHAPTER HIGHLIGHTS

■ The Educator’s Role in Learning ■ Assessment of the Learner ■ Assessing Learning Needs ■ Methods to Assess Learning Needs

• Informal Conversations • Structured Interviews • Focus Groups • Questionnaires • Tests • Observations • Documentation • Assessing the Learning Needs of Nursing Staff

■ Readiness to Learn • Physical Readiness • Emotional Readiness • Experiential Readiness • Knowledge Readiness

■ Learning Styles • Determining Learning Styles

■ Learning Style Models and Instruments • Right-Brain/Left-Brain and Whole-Brain Thinking • Field-Independent/Field-Dependent Perception • Dunn and Dunn Learning Styles • Jung and Myers–Briggs Typology • Kolb’s Experiential Learning Model • 4MAT System • Gardner’s Eight Types of Intelligence • VARK Learning Styles

■ Interpretation of the Use of Learning Style Models and Instruments ■ State of the Evidence

119

CHAPTER 4

In a variety of settings, nurses are responsi-ble for the education of patients, families, staff, and students. Numerous factors make the nurse educator’s role particularly challeng- ing in meeting the information needs of these various groups of learners. For example, short lengths of stay compress the amount of contact time the nurse has with patients and families, making it difficult to capitalize on teachable moments. In the case of staff, educational and experiential levels differ widely and time con- straints are ever present in the practice setting. Various staffing patterns, part-time employ- ment, and varied job functions can put the edu- cator’s ability to complete an accurate education assessment of staff to the test.

Also, the nurse educator must consider many other factors in meeting information needs of learners. For example, the U.S. population is be- coming more culturally and linguistically diverse because of the increased number of foreign-born individuals entering the country in recent years.

Notably, the percentage of baccalaureate nursing students from minority backgrounds rose from 25.2% in 2006 to 31.6% in 2015 (American As- sociation of Colleges of Nursing, 2016). In ad- dition, the nation’s population 65 and older is growing rapidly. As for age, students are enter- ing schools of nursing at an older age, bringing with them diverse life experiences and the de- mands of working and raising families while fur- thering their education. These factors all affect the nurse educator’s assessment of information needs of nursing students, patients, and fam- ilies (U.S. Census Bureau, 2012, 2015). Other changing healthcare trends and population de- mographics mean that nurse educators must constantly assess the determinants of learning for the varied audiences of learners they teach.

To meet these challenges, the nurse educa- tor must be aware of the various factors that in- fluence how well an individual learns. The three determinants of learning that require assess- ment are (a) the needs of the learner, (b) the state

OBJECTIVES

After completing this chapter, the reader will be able to

1. Explain the nurse educator’s role in the learning process. 2. Identify the three components of the determinants of learning. 3. Describe the steps involved in the assessment of learning needs. 4. Explain methods that can be used to assess learner needs. 5. Discuss the factors that need to be assessed in each of the four types of readiness to learn. 6. Describe what is meant by learning styles. 7. Discriminate between the major learning style models and instruments identified. 8. Discuss ways to assess learning styles. 9. Identify the evidence that supports assessment of learning needs, readiness to learn, and

learning styles.

KEY TERMS

determinants of learning learning needs

readiness to learn reachable moment

teachable moment learning styles

120 Chapter 4 Determinants of Learning

of readiness to learn, and (c) the preferred learn- ing styles for processing information. This chapter addresses these three determinants of learning as they influence the effective and efficient delivery of patient/family, student, and staff education.

▸ The Educator’s Role in Learning

The role of educating others is one of the most es- sential interventions that a nurse performs. To do it well, the nurse must both identify the informa- tion learners need and consider their readiness to learn and their styles of learning. The learner— not the teacher—is the single most important person in the education process.

Educators can greatly enhance learning when they serve as facilitators helping the learner be- come aware of what needs to be known, why know- ing is valuable, and how to be actively involved in acquiring information (Musinski, 1999; Sykes, Durham, & Kingston, 2013). Just providing infor- mation to the learner, however, does not ensure that learning will occur. There is no guarantee that the learner will acquire the information given, al- though there is a greater opportunity to learn if the educator assesses the determinants of learning.

Assessment permits the nurse educator to facilitate the process of learning by arranging experiences within the environment that assist the learner to find the purpose, the will, and the most suitable approaches for learning. An assess- ment of the three determinants of learning en- ables the educator to identify information and present it in a variety of ways, which a learner cannot do alone. Manipulating the environment allows learners to experience meaningful parts and wholes to reach their individual potentials.

The educator plays a crucial role in the learn- ing process by doing the following:

■ Assessing problems or deficits and learners’ abilities

■ Providing important best evidence infor- mation and presenting it in unique and appropriate ways

■ Identifying progress being made ■ Giving feedback and follow-up ■ Reinforcing learning in the acquisition of

new knowledge, skills, and attitudes ■ Determining the effectiveness of education

provided

The educator is vital in giving support, en- couragement, and direction during the process of learning. Learners may make choices on their own without the assistance of an educator, but these choices may be limited or inappropriate. For example, the nurse facilitates necessary changes in the home environment, such as minimizing distractions by having family members turn off the television to provide a quiet environment conducive for concentrating on a learning ac- tivity. The educator assists in identifying opti- mal learning approaches and activities that can both support and challenge the learner based on his or her individual learning needs, readiness to learn, and learning style.

▸ Assessment of the Learner

Assessment of learners’ needs, readiness, and styles of learning is the first and most import- ant step in instructional design—but it is also the step most likely to be neglected. The im- portance of assessment of the learner may seem self-evident, yet often only lip service is given to this initial phase of the educational process. Frequently, the nurse dives into teaching be- fore addressing all the determinants of learn- ing. The result is that information given to the patient is neither individualized nor based on an adequate educational assessment. Evidence suggests, however, that individualizing teaching based on prior assessment improves patient out- comes (Corbett, 2003; Frank-Bader, Beltran, & Dojlidko, 2011; Kim et al., 2004; Miaskowski et al., 2004) and satisfaction (Bakas et al., 2009; Wagner, Bear, & Davidson, 2011). For example, Corbett’s (2003) research demonstrates that pro- viding individualized education to home care

Assessment of the Learner 121

patients with diabetes significantly improves their foot care practices.

Nurses are taught that any nursing interven- tion should be preceded by an assessment. Few would deny that this is the correct approach, no matter whether planning for giving direct phys- ical care, meeting the psychosocial needs of a patient, or teaching someone to be independent in self-care or in the delivery of care. The effec- tiveness of nursing care clearly depends on the scope, accuracy, and comprehensiveness of as- sessment prior to interventions.

What makes assessment so significant and fundamental to the educational process? This initial step in the process validates the need for learning and the approaches to be used in design- ing learning experiences. Patients who desire or require information to maintain optimal health as well as nursing colleagues who must have a greater scope or depth of knowledge to deliver high-quality care to patients deserve to have an assessment done by the educator so that their needs as learners are appropriately addressed.

Assessments do more than simply identify and prioritize information for the purposes of setting behavioral goals and objectives, plan- ning instructional interventions, and being able to evaluate in the long run whether the learner has achieved the desired goals and objectives. Good assessments ensure that optimal learn- ing can occur with the least amount of stress and anxiety for the learner. Assessment pre- vents needless repetition of known material, saves time and energy on the part of both the learner and the educator, and helps to establish positive communication between the two par- ties (Haggard, 1989). Furthermore, it increases the motivation to learn by focusing on what the patient or staff member feels is most important to know or to be able to do.

Why, then, is this first step in the education process so often overlooked or only partially car- ried out? Lack of time is the number one reason that nurse educators shortchange the assess- ment phase (Haddad, 2003; Lee & Lee, 2013; Marcum, Ridenour, Shaff, Hammons, & Taylor, 2002). Such factors as shortened hospital stays

and limited contact with patients and families in other healthcare settings, combined with the tighter schedules of nursing staff as a result of increased practice demands, have reduced the amount of time available for instruction. Because time constraints are a major concern when car- rying out patient or staff education, nurses must become skilled in accurately conducting assess- ments of the three determinants of learning in order to have reserve time for actual teaching. In addition, many nurses, although expected and required by their nurse practice acts to in- struct others, are unfamiliar with the principles of teaching and learning. The nurse in the role of educator must become better acquainted and comfortable with all the elements of instructional design, particularly with the assessment phase because it serves as the foundation for the rest of the educational process.

Assessment of the learner includes at- tending to the three determinants of learning (Haggard, 1989):

1. Learning needs—what the learner needs and wants to learn.

2. Readiness to learn—when the learner is receptive to learning.

3. Learning style—how the learner best learns.

▸ Assessing Learning Needs

Learning needs are defined as gaps in knowl- edge that exist between a desired level of per- formance and the actual level of performance (HealthCare Education Associates, 1989). In other words, a learning need is the gap between what someone knows and what someone needs or wants to know. Such gaps may arise because of a lack of knowledge, attitude, or skill.

Of the three determinants of learning, nurse educators must identify learning needs first so that they can design an instructional plan to address any deficits in the cognitive, affective, or psychomotor domains. Once the

122 Chapter 4 Determinants of Learning

educator discovers what needs to be taught, he can determine when and how learning can op- timally occur.

Of course, not every individual perceives a need for education. Often, learners are un- aware of what they do not know or want to know. Consequently, it is up to the educator to assist learners in identifying, clarifying, and pri- oritizing their needs and interests. Once these aspects of the learner are determined, the in- formation gathered can, in turn, be used to set objectives and plan appropriate and effective teaching and learning approaches for educa- tion to begin at a point suitable to the learner rather than stemming from an unknown or inappropriate place.

Differences often exist between the per- ception of needs identified by patients versus the needs identified by the health profession- als caring for them. In one study of a conve- nience sample of 365 cardiac patients who had recent major coronary interventions performed, their preferences for learning after the inter- vention were different from what 166 cardiac nurses perceived as important for the patient to learn (Mosleh, Eshah, & Almalik, 2017). Other authors have also substantiated comparative incongruence in the perception of learning needs by patients and providers (Ançel, 2012; Kilonzo & O’Connell, 2011; Roy, Gasquoine, Caldwell, & Nash, 2015; Wu, Tung, Liang, Lee, & Yu, 2014; Yonaty & Kitchie, 2012).

According to well-known experts in behav- ioral and social sciences (Bloom, 1968; Bruner, 1966; Carroll, 1963; Kessels, 2003; Ley, 1979; Skinner, 1954), most learners—90–95% of them—can master a subject with a high degree of success if given sufficient time and appropri- ate support. It is the educator’s task to facilitate the determination of what exactly needs to be learned and to identify approaches for present- ing information in a way that the learner will best understand. Recent evidence of success at mastery learning is illustrated by Roberts, In- gram, Flack, and Jones Hayes (2013) when they implemented this type of learning in a nurs- ing education program. The authors witnessed

an increase in the National Council Licensure Examination (NCLEX) scores among a diverse student population.

The following are important steps in the assessment of learning needs:

1. Identify the learner. Who is the audi- ence? If the audience is one individ- ual, is there a single need or do many needs have to be fulfilled? Is there more than one learner? If so, are their needs congruent or diverse? The develop- ment of formal and informal educa- tion programs for patients and their families, nursing staff, or students must be based on accurate identifi- cation of the learner. For example, an educator may believe that all parents of children with asthma need a for- mal class on potential hazards in the home. This perception may be based on the educator’s interaction with a few patients and may not be true of all families. Similarly, the manager of a healthcare agency might request an inservice workshop for all staff on documentation of infection control because of an isolated incident in- volving one staff member’s failure to appropriately follow established infection control procedures. This break in protocol may or may not in- dicate that everyone needs to have an update on policies and procedures.

2. Choose the right setting. Establishing a trusting environment helps learners feel a sense of security in confiding information, believe their concerns are taken seriously and are consid- ered important, and feel respected. Ensuring privacy and confidentiality is recognized as essential to establishing a trusting relationship.

3. Collect data about the learner. Once the learner is identified, the educator can determine characteristic needs of the population by exploring typical

Assessing Learning Needs 123

and needs motivates them to learn because they are invested in planning for a program specifically tailored to their unique circumstances. Also, the learner is important to include as a source of information because, as noted previously, the educator may not always perceive the same learning needs as the learner.

5. Involve members of the healthcare team. Other health professionals likely have insight into patient or family needs or the educational needs of the nursing staff or students resulting from their frequent contacts with both consumers and caregivers. Nurses are not the sole educators of these individuals; thus they must remember to collaborate with other members of the healthcare team for a richer assessment of learning needs. This consideration is especially important because time for assessment is often limited. In addition to other health professionals, organizations such as the American Heart Association, the American Diabetes Association, and the American Cancer Society are ex- cellent sources of health information.

6. Prioritize needs. A list of identified needs can become endless and seemingly impossible to accomplish. Maslow’s (1970) hierarchy of human needs can help the educator prioritize so that the learner’s basic needs are attended to first and foremost before higher needs are addressed. For example, learning about a low-sodium diet likely cannot occur if a patient faces problems with basic physiological needs such as pain and discomfort; the latter needs should be addressed before any other higher order learning is expected to occur.

Setting priorities for learning is often difficult when the nurse edu- cator is faced with many learning

health problems or issues of interest to that population. Subsequently, a literature search can assist the educa- tor in identifying the type and extent of content to be included in teaching sessions as well as the educational strategies for teaching a specific pop- ulation based on the analysis of needs. For example, systematic reviews offer an excellent way to become aware of the published research about learning needs of specific populations. One recent article (Nightingale, Friedl, & Swallow, 2015) reviewed 23 stud- ies that identified parents’ learning needs about managing their child’s chronic long-term health condition. Moore et al. (2013) reviewed stud- ies about the palliative and support- ive care needs of patients diagnosed with high-grade glioma and their care givers. These systematic reviews identified key themes related to pa- tient education, such as the need for consistent well-delivered information around disease sequelae, treatment, and resources available for patients and their significant others.

4. Collect data from the learner. Learn- ers are usually the most important source of needs assessment data about themselves. Allow patients and/or family members to identify what is important to them, what they perceive their needs to be, which types of social support systems are available, and which type of assis- tance these supports can provide. If the audience for teaching consists of staff members or students, solicit information from them as to those areas of practice in which they feel they need new or additional infor- mation (Cannon, Watson, Roth, & LaVergne, 2014; Winslow et al., 2016). Actively engaging learners in defining their own problems

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Often, healthcare providers believe that more education is necessary when something goes wrong, when something is not being done, when a patient is not following a prescribed regimen, or when a staff member does not adhere to a protocol. In such instances, always look for other nonlearning needs. For example, the nurse may discover that the patient is not taking his medication and may begin a teaching plan without adequate assessment. The patient may already understand the importance of taking a prescribed medication, know how to administer it, and be willing to follow the regimen, but his financial resources may not be sufficient to purchase the medication. In this case, the patient does not have a learning need but rather requires social or financial support to obtain the medication.

7. Determine availability of educational resources. The educator may iden- tify a need, but it may be useless to

needs in several areas. Prioritizing the identified needs helps the patient or staff member to set realistic and achievable learning goals. Choosing which information to cover is im- perative, and nurse educators must make choices deliberately. Educators should prioritize learning needs based on the criteria in BOX 4-1 (HealthCare Education Associates, 1989, p. 23) to foster maximum learning.

Without good assessment, a common mistake is to provide more information than the patient wants or needs. To avoid this problem, the nurse must discriminate between information that patients need to know versus information that is nice for them to know. Often, highly technical information merely serves to confuse and distract patients from the essential information they need to carry out their regimen (Hansen & Fisher, 1998; Kessels, 2003).

Education in and of itself is not always the answer to a problem.

BOX 4-1 Criteria for Prioritizing Learning Needs

■ Mandatory: Needs that must be learned for survival or situations in which the learner’s life or safety is threatened. Learning needs in this category must be met immediately. For example, a patient who has experienced a recent heart attack needs to know the signs and symptoms and when to get immediate help. The nurse who works in a hospital must learn how to do cardiopulmonary resuscitation or be able to carry out correct isolation techniques for self-protection.

■ Desirable: Needs that are not life dependent but that are related to well-being or the overall ability to provide high-quality care in situations involving changes in institutional procedure. For example, it is important for patients who have cardiovascular disease to understand the effects of a high-fat diet on their condition. It is desirable for nurses to update their knowledge by attending an inservice program when hospital management decides to focus more attention on the appropriateness of patient education materials in relation to the patient populations being served.

■ Possible: Needs for information that is nice to know but not essential or required or situations in which the learning need is not directly related to daily activities. For example, the patient who is newly diagnosed as having diabetes mellitus most likely does not need to know about self-care issues that arise in relationship to traveling across time zones or staying in a foreign country because this information does not relate to the patient’s everyday activities.

Data from HealthCare Education Associates. (1989). Managing hospital education. Laguna Niguel, CA: Author.

Assessing Learning Needs 125

assessment process, Rankin, Stallings, and London (2005) suggest the edu- cator should emphasize the following important points with respect to time- management issues: • Although close observation and

active listening take time, it is much more efficient and effective to take the time to do a good initial assessment upfront than to waste time by having to go back and uncover information that should have been obtained before beginning instruction.

• Learners must be given time to offer their own perceptions of their learning needs if the educator expects them to take charge and become actively involved in the learning process. Learners should be asked what they want to learn first, because this step allays their fears and makes it easier for them to move on to other necessary content (McNeill, 2012). This approach also shows that the nurse cares about what the learner believes is important and, in the case of an adult, meets his or her need to be self-directed (Inott & Kennedy, 2011).

• Assessment can be conducted anytime and anywhere the ed- ucator has formal or informal contact with learners. Data collection does not have to be restricted to a specific, predeter- mined schedule. With patients, many potential opportunities for assessment arise, such as when giving a bath, serving a meal, making rounds, and distributing medications. For staff, assessments can be made when stopping to talk in the

proceed with interventions if the proper educational resources are not available, are unrealistic to obtain, or do not match the learner’s needs. In this case, it may be better to focus on other identified needs. For example, a patient who has asthma needs to learn how to use an inhaler and peak-flow meter. The nurse educa- tor may determine that this patient learns best if the nurse first gives a demonstration of the use of the in- haler and peak-flow meter and then allows the patient the opportunity to perform a return demonstration. If the proper equipment is not available for demonstration/return demonstration at that moment, it might be better for the nurse educator to concentrate on teaching the signs and symptoms the patient might experience when having poor air exchange than it is to cancel the encounter altogether. Thereafter, the educator would work immediately on obtaining the necessary equipment for future encounters.

8. Assess the demands of the organization. This assessment yields information that reflects the climate of the orga- nization. What are the organization’s philosophy, mission, strategic plan, and goals? The educator should be familiar with standards of perfor- mance required in various employee categories, along with job descrip- tions and hospital, professional, and agency regulations. If, for example, the organization is focused on health promotion versus trauma care, then there likely will be a different educa- tional focus or emphasis that dictates learning needs of both consumers and employees.

9. Take time-management issues into account. Because time constraints are a major impediment to the

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Informal Conversations Often learning needs are discovered during impromptu conversations that take place with other healthcare team members involved in the care of the client and between the nurse and the patient or his or her family. The nurse educa- tor must rely on active listening to pick up cues and information regarding learning needs. Staff can provide valuable input about their learning needs by responding to open-ended questions.

Structured Interviews The structured interview is perhaps the form of needs assessment most commonly used to solicit the learner’s point of view. The nurse educator asks the learner direct and often pre- determined questions to gather information about learning needs. As with the gathering of any information from a learner in the assess- ment phase, the nurse should strive to estab- lish a trusting environment, use open-ended questions, choose a setting that is free of dis- tractions, and allow the learner to state what are believed to be the learning needs.

It is important to remain nonjudgmental when collecting information about the learner’s strengths, beliefs, and motivations. Nurses can take notes with the learner’s permission so that important information is not lost. The telephone is a good tool to use for an interview if it is im- possible to ask questions in person. The major drawback of a telephone interview is the inabil- ity on the part of the nurse educator to perceive nonverbal cues from the learner.

Interviews yield answers that may reveal uncertainties, conflicts, inconsistencies, un- expected problems, anxieties, fears, and pres- ent knowledge base. Examples of questions that nurse educators can ask patients as learn- ers are as follows:

■ What do you think caused your problem? ■ How severe is your illness? ■ What does your illness/health mean to you? ■ What do you do to stay healthy?

hallway or while enjoying lunch or break time together.

• Informing a patient ahead of time that the educator wishes to spend time discussing prob- lems or needs gives the person advance notice to sort out his or her thoughts and feelings. In one large metropolitan teaching hospital, this strategy proved effective in increasing patient understanding and satisfaction with transplant discharge infor- mation (Frank-Bader et al., 2011). Patients and their families were informed that a specific topic would be discussed on a specific day. Knowing what to expect each day allowed them to review the appropriate handouts ahead of time and prepare questions. It gave patients and family members the time they needed to identify areas of confusion or concern.

• Minimizing interruptions and distractions during planned as- sessment interviews maximizes productivity. In turn, the educator might accomplish in 15 minutes what otherwise might have taken an hour in less directed, more frequently interrupted circumstances.

▸ Methods to Assess Learning Needs

The nurse in the role of educator must obtain objective data about the learner as well as sub- jective data from the learner. This section de- scribes various methods that educators can use to assess learner needs and these methods should be used in combination to yield the most reli- able information (Haggard, 1989).

Methods to Assess Learning Needs 127

under discussion. However, if the purpose of the focus group is to solicit attitudes about a certain subject or to discuss ethical issues, for example, it may not be necessary or recom- mended to have a homogeneous group. Focus groups are ideal during the initial stage of in- formation gathering to provide qualitative data for a complete assessment of learning needs and can be a rich source of information when ex- ploring sensitive nursing issues (Papastavrou & Andreou, 2012). Andrews and Ford (2013) used focus groups of clinical facilitators to as- certain what their learning needs were in re- lation to their professional development. In another study (Samia, Hepburn, & Nichols, 2012) five focus groups explored the learning needs of 26 family caregivers who took care of individuals diagnosed with dementia.

Questionnaires Nurse educators can obtain learners’ written re- sponses to questions about learning needs by us- ing questionnaires. Checklists are one of the most common forms of questionnaires. They are easy to administer, provide more privacy compared to interviews, and yield easy-to-tabulate data. Learners seldom object to this method of ob- taining information about their learning needs. Sometimes learners may have difficulty rating themselves and may need the educator to clar- ify terms or provide additional information to help them understand what is being assessed. The educator’s role is to encourage learners to make as honest a self-assessment as possible. Be- cause checklists usually reflect what the nurse educator perceives as needs, a space should be provided for the learner to add any other items of interest or concern.

One example of a highly reliable and valid self-assessment tool is the Patient Learning Needs Scale (Redman, 2003). This instrument is designed to measure patients’ perceptions of learning needs to manage their health care at home following a medical illness or surgical procedure (Bubela et al., 2000). This scale also has been used internationally with reliability,

■ Which results do you hope to obtain from treatments?

■ What are your strengths and limitations as a learner?

■ How do you learn best?

If the learner is a staff member or student, the following questions could be asked:

■ What do you think are your biggest chal- lenges to learning?

■ Which skill(s) do you need help in performing? ■ Which obstacles have you encountered

in the past when you were learning new information?

■ What do you see as your strengths and limitations as a learner?

■ How do you learn best?

These types of questions help to determine the needs of the learner and serve as a foun- dation for beginning to plan an educational intervention.

Focus Groups Focus groups involve getting together a small number (4 to 12) of potential learners (Bre- itrose, 1988; Duke University, 2005) to de- termine areas of educational need by using group discussion to identify points of view or knowledge about a certain topic. With this approach, a facilitator leads the discussion by asking open-ended questions intended to en- courage detailed discussion. It is important for facilitators to create a safe environment so that participants feel free to share sensitive infor- mation in the group setting (Shaha, Wenzel, & Hill, 2011). In research focus groups, having a facilitator who is not known to members of the group can help to prevent feelings of coercion or conflict of interest. This also should be the case for focus groups assessing learning needs, because participants may fear that sharing in- formation about their areas of weakness may be held against them in the future. The groups of potential learners in most cases should be ho- mogeneous, with similar characteristics such as age, gender, and experience with the topic

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basis, development, and psychometric properties when evaluating the adequacy of any question- naire or test (Waltz, Strickland, & Lenz, 2010).

Observations Observing health behaviors in several differ- ent time periods can help the educator draw conclusions about established patterns of be- havior that cannot and should not be drawn from a single observation. For example, watch- ing the learner perform a skill more than once is an excellent way of assessing a psychomotor need. Are all steps performed correctly? Does the learner have any difficulty manipulating various pieces of equipment? Does the learner require prompting? Learners may believe they can accurately perform a skill or task (e.g., walk- ing with crutches, changing a dressing, giving an injection), but by observing the skill perfor- mance the educator can best determine whether additional learning may be needed.

Learners who can observe a videotape of themselves performing a skill can more easily identify their learning needs. In this process, which is known as reflection on action (Grant, 2002), the learner identifies what was done well and what could have been done better in his or her actual performance. Landry, Smith, and Swank (2006) provide evidence to support this method of assessing learning needs in their study measuring mothers’ critiques of their own video- taped responsive behaviors in the home setting that would facilitate their infants’ development.

Documentation Initial assessments, progress notes, nursing care plans, staff notes, and discharge planning forms can provide information about the learning needs of patients. Nurse educators need to follow a consistent format for reviewing charts so that they review each chart in the same manner to identify learning needs based on the same infor- mation. Also, documentation by other members of the healthcare team, such as physical thera- pists, social workers, respiratory therapists, and

validity, and cultural appropriateness tested (Eshah, 2011; Temiz, Ozturk, Ugras, Oztekin, & Sengul, 2016).

Tests Giving written pretests before planned teaching can help identify the knowledge levels of po- tential learners regarding certain subjects and can assist in identifying their specific learning needs before instruction begins. In addition, this approach prevents the educator from re- peating already known material in the teaching plan. Furthermore, pretest results are useful to the educator after the completion of teaching when pretest scores are compared with posttest scores to determine to what extent learning has taken place.

The Diabetes Knowledge Test is an exam- ple of a tool used to assess learning needs for self- management of diabetes (Panja, Starr, & Colleran, 2005). When investigating this tool, researchers compared patients’ diabetes knowl- edge with their glycemic control. The findings demonstrated an inverse linear relationship be- tween performance on this diabetes test and HbA1c values. This test is available from the Michigan Diabetes Research and Training Cen- ter (http://diabetesresearch.med.umich.edu /Tools.php). Redman (2003) describes this and many other measurement instruments for pa- tient education that measure knowledge and learning assessment.

The educator must always consider the re- ported characteristics of the self-administered questionnaire or test before using it. Specific criteria to consider include what the purpose of the tool is (i.e., if it is relevant to what the nurse educator plans to assess), whether the results will be meaningful, whether each of the measured constructs is well defined, whether adequate testing of the instrument has been con- ducted, whether the instrument has been used in a similar setting, and whether the instrument has been used with a population equivalent to the audience being tested by the educator. The edu- cator needs to consider the purpose, conceptual

Methods to Assess Learning Needs 129

need in terms of the actual charting? Is a new intervention being implemented? Does the re- cord indicate some inconsistency with imple- mentation of an intervention?

Rules and Regulations A thorough knowledge of hospital, professional, and healthcare requirements helps to identify possible learning needs of staff. The educator should monitor new rules of practice arising from changes occurring within an institution or external to the organization that may have implications for the delivery of care.

Self-Assessment In addition to the methods identified by Williams (1998), self-assessment is an important area to consider when assessing the learning needs of nursing students and staff. Grant (2002), in an article about physician learning needs, identifies the significance of staff self-assessment of needs through reflection on action as well as through diaries, journals, and log books. She also cites the importance of peer review in the assessment process and, most important, the need to rec- ognize that needs assessment and learning are part of daily professional life in medicine. The strengths, limitations, opportunities, threats/ barriers (SLOT/B) approach or strengths, weak- nesses, opportunities, and threats (SWOT) anal- ysis, which has been recommended as a method for self-assessment of nursing students’ learning needs (Sherwin & Stevenson, 2011), is another useful assessment method that promotes pro- fessional self-reflection.

Gap Analysis Other methods to assess learning needs are the gap analysis and the Delphi technique. A gap analysis is an organized method to identify dif- ferences between desired and actual knowledge. Data gathered are then used to determine what differences exist that will need an education in- tervention. Nurse educators can then use appro- priate interventions for improvement, address

nutritionists, can yield valuable insights with respect to the needs of the learner.

Assessing the Learning Needs of Nursing Staff Williams (1998) specifically addresses the im- portance of identifying the learning needs of staff nurses using the methods described in this section. He addresses the assumptions of learn- ing needs assessments, provides practical advice about designing a survey needs assessment, and outlines implementation issues that must be considered prior to conducting an assessment.

The following are methods that can be used to determine the learning needs of staff.

Written Job Descriptions A written description of what is required to ef- fectively carry out job responsibilities can reflect the potential learning needs of staff. Such infor- mation forms the basis for establishing content in an orientation program for new staff, for ex- ample, or for designing continuing education opportunities for experienced staff members.

Formal and Informal Requests Often staff are asked for ideas for educational programs, and these ideas reflect what they per- ceive as needs. When conducting a formal edu- cational program, the educator must verify that these requests are congruent with the needs of other staff members.

Quality Assurance Reports Trends found in incident reports indicating safety violations or errors in procedures are a source of information in establishing learning needs of staff that education can address.

Chart Audits Educators can identify trends in practice through chart auditing. Does the staff have a learning

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staff member, or student asks a question, the time is prime for learning. Readiness to learn occurs when the learner is receptive, willing, and able to participate in the learning process. It is the re- sponsibility of the educator to discover through assessment exactly when patients or staff are ready to learn, what they need or want to learn, and how to adapt the content to fit each learner.

To assess readiness to learn, the educator must first understand what needs to be taught, collect and validate that information, and then apply the same methods used previously to assess learning needs, including making observations, conducting interviews, gathering information from the learner as well as from other health- care team members, and reviewing documen- tation. The educator must perform these tasks before the time when actual learning is to occur.

No matter how important the information is or how much the educator feels the recipient of teaching needs the information, if the learner is not ready, then the information will not be absorbed. The educator, in conjunction with the learner, must determine what needs to be learned and what the learning objectives should be to establish which domain and at which level these objectives should be classified (refer to Chapter 10). Otherwise, both the educator’s and the learner’s time could very well be wasted be- cause the established objectives may be beyond the readiness of the learner.

Timing—that is, the point at which teaching should take place—is very important. Anything that affects physical or psychological comfort can affect a learner’s ability and willingness to learn. Consequently, a learner who is not receptive to information at one time may be more receptive to the same information at another time. Because the nurse often has limited contact with patients and family members as a result of short hospi- tal stays or short visits in the outpatient setting, teaching must be brief and basic. Timing also be- comes an important factor when working with nursing staff. Readiness to learn is based on the current demands of practice and must correspond to the constant changes in health care. Adults— whether they are patients, family, nursing staff,

the needs of the learner, and thus may satisfy the learner, which is more likely to result in a change in behavior (DeSilets, Dickerson, & Lavin, 2013).

Another way to identify gaps in knowledge is to use the Delphi technique, which is a struc- tured process using a series of questionnaires or rounds that provides information about the specific need(s) (Keeney, Hasson, & McKenna, 2001). The questionnaires are given to experts in the subject who return the questionnaires anon- ymously. The experts are chosen experienced professionals who can provide an informed view or opinion on the issue that is needed (Nworie, 2011). The process continues with another series of questionnaires until group consensus about the educational need is reached. Although Del- phi is a useful method to use for assessing learn- ing needs, as with any tool the nurse educator must consider the reliability and validity of the instrument (Keeney et al., 2001).

Educators can use these assessment meth- ods to collect data on staff at multiple levels, from registered nurses to nursing assistants who are typically the target audiences for in- service programs at an institution. Any plans for educational activities need to consider the participants’ personal preferences, mandates from administration, expectations of accred- iting agencies, and/or trends in the profession, which may meet the needs of the individual or entity who organizes the education activity but not necessarily address the needs of the learner. These approaches to needs assessment are useful because they benefit all involved and justify the resources required for the assessment process.

▸ Readiness to Learn Once the educator has identified learning needs, the next step is to determine the learn- er’s readiness to receive information. Readi- ness to learn can be defined as the time when the learner demonstrates an interest in learning the information necessary to maintain optimal health or to become more skillful in a job. Of- ten, educators have noted that when a patient,

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ability, complexity of task, environmental effects, health status, and gender—because they affect the degree or extent to which learning will occur.

Measures of Ability Ability to perform a task requires fine and/or gross motor movements, sensory acuity, ad- equate strength, flexibility, coordination, and endurance. Each developmental stage in life is characterized by physical and sensory abilities or is affected by individual disabilities. For ex- ample, walking on crutches is a psychomotor skill for which a patient must have the physi- cal ability to be ready to learn. If a person has a visual deficit, the educator can make available eyeglasses or a magnifying glass so that the pa- tient can, for example, see the lines on a piece of equipment such as a spirometer. If the edu- cator is conducting an inservice workshop on lifting and transfer activities, staff must have the endurance required to return demonstrate this skill. Creating a stimulating and accepting en- vironment by using instructional tools to match learners’ physical and sensory abilities encour- ages readiness to learn.

Complexity of Task Variations in the complexity of the task affect the extent to which the learner can master the behavioral changes in the cognitive, affective, and psychomotor domains. The more com- plex the task, the more difficult it is to achieve. Psychomotor skills, once acquired, are usually retained better and longer than learning in the other domains (Greer, Hitt, Sitterly, & Slebod- nick, 1972). Once ingrained, psychomotor, cog- nitive, and affective behaviors become habitual and may be difficult to alter. For example, if the learner has been performing a psychomotor skill over a long period of time and then the proce- dural steps of the task change, the learner must unlearn those steps and learn the new way. This requirement may increase the complexity of the task and put additional physical demands on the learner by lengthening the time the learner

or students—are eager to learn when the subject of teaching is relevant and applicable to their ev- eryday concerns.

Before teaching can begin, the educator must find the time to first take a PEEK (Licht- enthal, 1990) at the four types of readiness to learn—physical readiness, emotional readiness, experiential readiness, and knowledge readiness. These four types may either be obstacles or en- hancers to learning (BOX 4-2).

Physical Readiness The educator needs to consider five major com- ponents of physical readiness—measures of

BOX 4-2 Take Time to Take a PEEK at the Four Types of Readiness to Learn

P = Physical Readiness ■ Measures of ability ■ Complexity of task ■ Environmental effects ■ Health status ■ Gender

E = Emotional Readiness ■ Anxiety level ■ Support system ■ Motivation ■ Risk-taking behavior ■ Frame of mind ■ Developmental stage

E = Experiential Readiness ■ Level of aspiration ■ Past coping mechanisms ■ Cultural background ■ Locus of control

K = Knowledge Readiness ■ Present knowledge base ■ Cognitive ability ■ Learning disabilities ■ Learning styles

Reproduced from Lichtenthal, C. (1990). A self-study model on readiness to learn. Unpublished manuscript. Reprinted with permission from Cheryl Lichtenthal Harding.

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Healthy learners have energy available for learning. In such a case, readiness to learn about health-promoting behaviors is based on their perception of self-responsibility. The extent to which an individual perceives illness to poten- tially affect future well-being influences that per- son’s desire to learn preventive and promotion measures. If learners perceive a threat to their quality of life, they likely will seek more infor- mation to try to control the negative effects of an illness (Bubela & Galloway, 1990).

Learners who are acutely ill tend to focus their energies on the physiological and psy- chological demands of their illness. Learning is minimal in such persons because most of these individuals’ energy is needed for the demands of the illness and gaining immediate relief. Any learning that may occur should be related to treatments, tests, and minimizing pain or other discomforts. As these patients improve and the acute phase of illness diminishes, they can then focus on learning follow-up management and the avoidance of complications.

Educators must assess the readiness to learn of acutely ill patients by observing their energy levels, anxiety, and comfort status. Physical and emotional stress affects a person’s ability to learn (Gross, 2013; Sandi & Pinelo-Nava, 2007). Improvement in physical status usually results in more receptivity to learning. However, medica- tions that induce side effects such as drowsiness, mental depression, impaired depth perception, decreased ability to concentrate, and learner fa- tigue also reduce task-handling capacity. For example, giving a patient a sedative prior to a learning experience may result in less appre- hension, but cognitive and psychomotor abili- ties may be impaired.

In contrast to acute illness, chronic illness has no time limits and is of long-term duration. Models of how people deal with chronic illness also are useful as frameworks for understanding readiness to learn (Lubkin & Larsen, 2013). The physiological and psychological demands vary in chronic illness and are not always predict- able. Patients may go through different stages in dealing with their illness, which is similar

needs to adjust to doing something in a new way. Older adults, in particular, develop elab- orate cognitive schemas over the years; when they are faced with information contrary to their preexisting knowledge and beliefs, they find the effort to change difficult, confusing, and time consuming (Kessels, 2003).

Environmental Effects An environment conducive to learning helps to hold the learner’s attention and stimulate inter- est in learning. Unfavorable conditions, such as extremely high levels of noise or frequent inter- ruptions, can interfere with a learner’s accuracy and precision in performing cognitive and man- ual dexterity tasks. Intermittent noise tends to have greater disruptive effects on learning than the more rapidly habituated steady-state noise. McDonald, Wiczorek, and Walker (2004) exam- ined background noise and interruption to de- termine their effects on college students learning health information. The results of their research suggest that distraction, including noise, during health teaching adversely affects readiness to learn.

Older adults, in particular, need more time to react and respond to stimuli. Increased inabil- ity to receive, process, and transmit information is a characteristic of aging. Environmental de- mands that make older persons feel rushed to perform tasks in a short time frame can over- whelm them. When an activity is self-paced, older learners respond more favorably.

Health Status The amounts of energy available and the indi- vidual’s present comfort level are factors that significantly influence that individual’s readi- ness to learn. Energy-reducing demands associ- ated with the body’s response to illness require the learner to expend large amounts of phys- ical and psychic energy, leaving little reserve for actual learning. Nurse educators must seri- ously consider a person’s health status, whether well, acutely ill, or chronically ill, when assess- ing for readiness.

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traditionally have taken on the role of caregivers and, therefore, are more open to health promo- tion teaching. In addition, women traditionally have more frequent contacts with health provid- ers while bearing and raising children. Men, by comparison, tend to be less receptive to health- care interventions and are more likely to be risk takers. A good deal of this behavior is thought to be socially induced. Changes are beginning to be seen in the health-seeking behavior of men and women as a result of the increased focus of people of all sexes on healthier lifestyles and the blend- ing of gender roles in the home and workplace.

Emotional Readiness Learners must be emotionally ready to learn. Like physical readiness, emotional readiness in- cludes several factors that need to be assessed. These factors include anxiety level, support sys- tem, motivation, risk-taking behavior, frame of mind, and developmental stage.

Anxiety Level Anxiety influences a person’s ability to perform at cognitive, affective, and psychomotor levels. In particular, it affects patients’ ability to con- centrate and retain information (Kessels, 2003; Sandi & Pinelo-Nava, 2007; Stephenson, 2006). The level of anxiety may or may not be a hin- drance to the learning of new skills; some degree of anxiety is a motivator to learn, but anxiety that is too low or too high interferes with read- iness to learn. On either end of the continuum, mild or severe anxiety may lead to inaction on the part of the learner. If anxiety is low, the in- dividual is not driven to take steps to promote his or her health or prevent diseases. Moderate anxiety, however, drives someone to undertake action. As the level of anxiety increases, emo- tional readiness peaks and then begins to de- crease in an inversely U-shaped curvilinear manner based on the Yerkes–Dodson law (Ley, 1979), as shown in FIGURE 4-1. A moderate level of anxiety is best for success in learning and also is considered the optimal time for teaching.

to the adjustment stages of a person experi- encing a loss (Boyd, Gleit, Graham, & Whit- man, 1998). If the learner is in the avoidance stage, readiness to learn likely will be limited to simple explanations because the patient’s en- ergy is concentrated on denial. Over time, en- ergy levels stabilize and become redirected as awareness of the realities of the situation in- crease. Readiness to learn may be indicated by the questions the patient asks. Exploring an- other perspective, Telford, Kralik, and Koch (2006) encourage health professionals to lis- ten carefully to their patients’ stories of how they experience the illness rather than attempt to categorize patients into specific stages. Lis- tening to patient stories may provide clues as to individuals’ readiness to learn.

Burton (2000) describes the Corbin and Strauss (1991) chronic illness trajectory frame- work. This framework reflects the continual na- ture of adaptation required in living with chronic illness. In contrast to the Corbin and Strauss model, Patterson (2001) describes a shifting perspectives model that suggests living with chronic illness is an ongoing and continually dy- namic process. This model provides an expla- nation of variations in attention to symptoms over time. Individuals’ perspectives shift in the degree to which illness is in the foreground or background of their world. It is important for nurse educators to understand this cycle when assessing readiness to learn, because they can- not assume that an approach that worked at one time will be just as effective at another time. The receptivity to learning and practicing self-care measures of a person who is chronically ill is not static but rather fluctuates over time.

Gender Research suggests that women are generally more receptive to medical care and take fewer risks with their health than do men (Ashton, 1999; Bertakis, Rahman, Helms, Callahan, & Robbins, 2000; Harris, Jenkins, & Glaser, 2006; Rosen, Tsai, & Downs, 2003; Stein & Nyamathi, 2000). This difference may arise because women

134 Chapter 4 Determinants of Learning

FIGURE 4-1 Effect of anxiety on emotional readiness to learn. Data from Ley, P. (1979). Memory for medical information. British Journal of Social & Clinical Psychology, 18(2), 245–255.

Optimal Time for Learning

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Anxiety Level

Fear is a major contributor to anxiety and, therefore, negatively affects readiness to learn in any of the learning domains. The performance of a task in and of itself may be fear inducing to a patient because of its very nature or mean- ing. For example, learning self-administration of a medication by injection may produce fear for the patient because of the necessity of self- inflicted pain and the perceived danger of the needle breaking off into the skin. A staff mem- ber or nursing student, in contrast, may have real difficulty mastering a skill because of the fear of harming a patient or of failing to do a procedure correctly.

Fear also may lead patients to deny their illness or disability, which interferes with their ability to learn. If a situation is life threaten- ing or overwhelming, anxiety will be high and readiness to learn will be diminished. Although teaching may be imperative for survival, learn- ing usually can take place only if instructions are simple and are repeated over and over again. In such circumstances, families and support persons also should be educated to reinforce information and assist with caregiving responsi- bilities. In later stages of adaptation, acceptance of illness or disability allows the individual to be more receptive to learning because anxiety levels are less acute.

Discovering which stressful events or ma- jor life changes the learner is experiencing gives the educator clues about that person’s emotional readiness to learn. The nurse must first identify the source and level of anxiety. High stress levels can be moderated by encouraging the person to participate in activities such as support groups and the use of relaxation techniques such as im- agery and yoga (Stephenson, 2006). After anxi- ety levels have been moderated and anxiety has been lessened, education is an excellent inter- vention to spur someone to take action when dealing with a stressful life event.

Support System The availability and strength of a support sys- tem also influence emotional readiness and are closely tied to how anxious an individual might feel. Members of the patient’s support system who are available to assist with self-care activ- ities at home should be present during at least some of the teaching sessions so that they can learn how to help the patient if the need arises. Kitchie’s (2003) descriptive correlational study suggests that families and friends are important for medication adherence among older adults who experience chronic illness. Although the ed- ucator should not draw any conclusions about causal relationships from this type of study, the educator’s assessment benefits from incorporat- ing questions about the learner’s social network. Social support is important in buffering the ef- fects of stressful events (Gavan, 2003; Kitchie, 2003). A strong positive support system can de- crease anxiety, whereas the lack of one can in- crease anxiety levels.

Health professionals often act as sources of social and emotional support to clients. Epstein and Street (2007) describe the significance of fostering healing relationships with patients and responding to patients’ emotions as fundamen- tal functions of patient–clinician communica- tion in cancer care. Street, Makoul, Arora, and Epstein (2009) identify the importance of clini- cians in enhancing patients’ abilities to manage emotions in one of their several recommended

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teacher–learner interactions is a cue to motiva- tion. The learner who is ready to learn shows an interest in what the nurse educator is doing by demonstrating a willingness to participate or to ask questions. Prior learning experi- ences, whether they be past accomplishments or failures, are reflected in the current level of motivation demonstrated by the learner for ac- complishing the task at hand.

Risk-Taking Behavior Taking risks is intrinsic in the activities people perform daily. Indeed, many activities are done without thinking about the outcome. According to Joseph (1993), some patients, by the very na- ture of their personalities, take more risks than others do. The educator can assist patients in developing strategies that help reduce the level of risk associated with their choices. If patients participate in activities that may shorten their life span rather than complying with a recom- mended treatment plan, for example, the educa- tor must be willing to teach these patients how to recognize certain body symptoms and then what to do if they have them.

Understanding staff willingness to take risks helps the nurse educator understand why some learners may be hesitant to try new approaches to delivering care. Wolfe (1994) states that taking risks can be threatening when the outcomes are not guaranteed. Educators can, however, help in- dividuals learn how to take risks. First, the per- son must decide to take the risk. The next step is to develop strategies to minimize the risk. Then, the learner needs to develop worst-case, best- case, and most-probable-case scenarios. Last, the learner must decide whether the worst-case scenario developed is acceptable.

Frame of Mind Frame of mind involves concern about the here and now versus the future. If survival is of pri- mary concern, readiness to learn will be focused on the present to meet basic human needs. According to Maslow (1970), physical needs

pathways to improved health outcomes. Beddoe (1999) describes the unique opportunity that nurses have in providing emotional support to patients. She labels this opportunity as the reachable moment—the time when a nurse truly connects with the client by directly meet- ing the individual on mutual terms. The reach- able moment allows for the mutual exchange of concerns and a sharing of possible interven- tion options without the nurse being inhibited by prejudice or bias. When the client feels emo- tionally supported, the stage is set for the teach- able moment because it is then that the person is most receptive to learning.

Motivation Emotional readiness is strongly associated with motivation, which is a willingness to take action. Knowing the motivational level of the learner assists the educator in determining when that person is ready to learn. The nurse educator must be cognizant of the fact that motivation to learn is based on many varied theories of mo- tivation and, thus, be careful to link a specific theory’s concepts or constructs to the appro- priate method of assessment and subsequent educational interventions. For example, Cook and Artino (2016) point out that if an educa- tor is using Bandura’s Social-Cognitive (Self- Efficacy) theory in the assessment of motivation to learn, then an appropriate intervention is to help learners develop accurate self-efficacy be- liefs (perceptions of competence) by provid- ing interactive interventions for mastery of the knowledge or skills, give credible attributional feedback, and assist learners in connecting ex- ternal and self-administered rewards to make progress toward achievement of their goals. As- sessment of emotional readiness involves ascer- taining the level of motivation, not necessarily the reasons for the motivation. A learner may be motivated to learn for many reasons, and al- most any reason to learn is a valid one.

The level of motivation reflects what learners perceive as an expectation of them- selves or others. Interest in informal or formal

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them to cope better with real-life tasks. They see learning as relevant when they can apply new knowledge to help them solve immediate problems. Children, in contrast, desire to learn for learning’s sake and actively seek out experi- ences that give them pleasure and comfort. Erik- son’s (1963, 1968, 1997) well-accepted theory of the eight stages of psychosocial learning is most relevant to an individual’s emotional readiness.

Experiential Readiness Experiential readiness refers to the learner’s past experiences with learning and includes four elements: level of aspiration, past coping mechanisms, cultural background, and locus of control. The educator should assess whether pre- vious learning experiences have been positive or negative in overcoming problems or accom- plishing new tasks. Someone who has had neg- ative experiences with learning is not likely to be motivated or willing to take a risk to change behavior or acquire new behaviors. See Chap- ters 6, 7, and 8 for elaboration on these elements.

Level of Aspiration The extent to which someone is driven to achieve is related to the type of short- and long-term goals established—not by the educator but by the learner. Previous failures and past successes influence the goals that learners set for them- selves. Early successes are important motiva- tors in learning subsequent skills. Satisfaction, once achieved, elevates the level of aspiration, which in turn increases the probability of con- tinued performance output in undertaking fu- ture endeavors to change behavior.

Past Coping Mechanisms Educators must explore the coping mechanisms that learners have been using to understand how they have dealt with previous problems. Once these mechanisms are identified, the ed- ucator needs to determine whether past cop- ing strategies have been effective and, if so,

such as food, warmth, comfort, and safety as well as psychosocial needs of feeling accepted and secure must be met before someone can fo- cus on higher order learning. People from lower socioeconomic levels, for example, tend to con- centrate on immediate, current concerns be- cause they are trying to satisfy everyday needs.

Ramanadhan and Viswanath (2006) used national data from the 2003 Health Infor- mation National Trends survey to examine information-seeking behaviors of adults. They found that a significant percentage of persons diagnosed with a serious disease, such as cancer, report that they do not seek or receive health information beyond that given by healthcare providers. Furthermore, compared to seekers of health information, nonseeker patients are more likely to come from the lowest income and ed- ucation groups and are less attentive about get- ting health information from the media. Also, older individuals, although they gather infor- mation from a variety of sources, tend to make health decisions primarily based on information provided by the healthcare professional (Cutilli, 2010). These findings have implications for ed- ucators when deciding on the best method for reaching various segments of the population.

Children regard life in the here and now be- cause they are developmentally focused on what makes them happy and satisfied. This perspec- tive affects their willingness to learn health in- formation. In addition, their thinking is concrete rather than abstract. Adults who have reached self-actualization and those whose basic needs are met are most ready to learn health promo- tion tasks and are said to have a more futuris- tic orientation.

Developmental Stage Each task associated with human development produces a peak time for readiness to learn, known as a teachable moment (Hansen & Fisher, 1998; Hotelling, 2005; Tanner, 1989; Wag- ner & Ash, 1998). Unlike children, adults can build on meaningful past experiences and are strongly driven to learn information that helps

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determined that the learner understands what they are saying and that they understand and respect the learner’s culture.

Locus of Control Educators can determine whether readiness to learn is prompted by internal or external stim- uli in ascertaining the learner’s previous life pat- terns of responsibility and assertiveness. When patients are internally motivated to learn, they have what is called an internal locus of control; that is, they are ready to learn when they feel a need to know about something. This drive to learn comes from within the learner. Usually, this type of learner indicates a need to know by asking questions. Remember that when someone asks a question, the time is prime for learning. If patients have an external locus of control—that is, they are externally motivated—then some- one other than themselves must encourage the learner to want to know something. The respon- sibility often falls on the educator to motivate the patient to want to learn.

Knowledge Readiness Knowledge readiness refers to the learner’s pres- ent knowledge base, the level of cognitive abil- ity, the existence of any learning disabilities and/ or reading problems, and the preferred style of learning. Nurse educators must assess these components to determine readiness to learn and should plan teaching accordingly. See Chapters 5, 7, 9, and 10 for further elaboration on these components that affect knowledge readiness.

Present Knowledge Base How much someone already knows about a specific subject or how proficient that person is at performing a task is an important factor to determine before designing and implement- ing instruction. If educators make the mistake of teaching subject material that has already been learned, they risk at the very least induc- ing boredom and lack of interest in the learner

whether they work well in the present learn- ing situation.

Cultural Background The educator’s knowledge about other cultures and sensitivity to behavioral differences between cultures are important so that the educator can avoid teaching in opposition to cultural beliefs. Assessment of what an illness means to the pa- tient from the patient’s cultural perspective is imperative in determining readiness to learn. Remaining sensitive to cultural influences al- lows the educator to bridge the gap, when nec- essary, between the medical healthcare culture and the patient’s culture. Building on the learn- er’s knowledge base or belief system (unless it is dangerous to well-being), rather than attempt- ing to change it or claim it is wrong, encourages rather than dampens readiness to learn.

Language is also a part of culture and may prove to be a significant obstacle to learning if the educator and the learner do not speak the same language fluently. Assessing whether the learner understands English well enough to be able to express herself so that others understand is the first step. Obtaining the services of a qual- ified interpreter is necessary if the learner and nurse do not speak the same language. Enlisting the help of someone other than a trained inter- preter (such as a family member or friend) to bridge language differences may negatively in- fluence learning, although this effect depends on such issues as the sensitivity of the topic and the need for privacy. In some instances, the pa- tient may not want family members or associ- ates to know about a health concern or illness.

Medical terminology in and of itself may be a foreign language to many patients, even if they are from a nondominant culture or their primary language is the same as or different from that of the educator. In addition, some- times a native language does not have an equiv- alent word to describe the terms that are being used in the teaching situation. Differences in language compound cultural barriers. Educa- tors should not start teaching unless they have

138 Chapter 4 Determinants of Learning

allows them to contribute positively to the re- inforcement of self-care activities.

Learning and Reading Disabilities Learning disabilities, which may be accompa- nied by low-level reading skills, are not neces- sarily indicative of an individual’s intellectual abilities, but they do require educators to use special or innovative approaches to instruc- tion to sustain or bolster readiness to learn. In- dividuals with low literacy skills and learning disabilities become easily discouraged unless the educator recognizes their special needs and seeks ways to help them accommodate or over- come their problems with encoding words and comprehending information.

Learning Styles A variety of preferred styles of learning exist, and assessing how someone learns best and likes to learn helps the educator to select appropri- ate teaching approaches. Knowing the teaching methods and materials with which a learner is most comfortable or, conversely, those that the learner does not tolerate well allows the educator to tailor teaching to meet the needs of individuals with different styles of learning, thereby increas- ing their readiness to learn. The next section pro- vides further information about learning styles.

▸ Learning Styles Learning styles refer to the ways in which and conditions under which learners most efficiently and most effectively perceive, process, store, and recall what they are attempting to learn (James & Gardner, 1995) and their preferred approaches to different learning tasks (Cassidy, 2004; Furnham, 2012). Keefe (1979) further defined learning style as the way that learners learn that takes into ac- count the cognitive, affective, and physiological factors affecting how learners perceive, interact with, and respond to the learning environment.

or at the extreme insulting the learner, which could produce resistance to further learning. The nurse educator must always find out what the learner knows prior to teaching and build on this knowledge base to encourage readiness to learn. In teaching patients, the educator also must consider how much information the pa- tient wants to receive. Some patients want to know the details to make informed decisions about their care, whereas others prefer a more general and less in-depth approach and can be overwhelmed by the provision of too much information.

Cognitive Ability The extent to which information can be pro- cessed is indicative of the learner’s capabilities. The educator must match the level of behav- ioral objectives to the cognitive ability of the learner. The learner who is capable of under- standing, memorizing, recalling, or recogniz- ing subject material is functioning at a lower level in the cognitive domain than the learner who demonstrates problem solving, concept formation, or application of information. For example, nursing staff or students who can an- swer questions about cardiopulmonary resus- citation (CPR) on a written test demonstrate an understanding of the subject, but this does not necessarily mean that they can transfer this knowledge to perform CPR in the clinical set- ting. Patients who can identify risk factors of hypertension (a low level of functioning in the cognitive domain) may struggle with general- izing this information to incorporate a low- salt diet in their lifestyle.

Individuals with cognitive impairment present a special challenge to the educator and require simple explanations and step-by-step instruction with frequent repetition. Nurse ed- ucators should be sure to make information meaningful to those persons with cognitive im- pairments by teaching at their level and commu- nicating in ways that learners can understand. Enlisting the help of members of the patient’s support system by teaching them requisite skills

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instrument administration, educators can validate learning style and choose methods and materi- als for instruction to support a variety of learner preferences. They can then direct patients, stu- dents, or staff toward the ways they learn best.

Using the learning style approach to instruc- tion has exciting implications. Understanding and recognizing various styles can influence de- cision making about planning, implementing, and evaluating educational programs.

▸ Learning Style Models and Instruments

The identification and application of informa- tion about learning styles continues to be an emerging movement but also controversial. In a recent search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) limited to the last 5 years located over 300 pub- lished articles dealing with this topic and its ap- plication to nursing and health care. To date, researchers have defined learning styles differ- ently, although the concepts in each definition are often overlapping.

This chapter does not attempt to include all available instruments but rather highlights those commonly cited in recent reviews and in health sciences research literature that refer to the psychometric properties of each tool. These instruments are believed to be the most useful to nurse educators for assessment purposes.

Before using any learning style instru- ment, it is important to determine the reliabil- ity and validity of the tool and to realize that a totally inclusive instrument that measures all domains of learning—cognitive, affective, and psychomotor—does not exist. Therefore, it is best to use more than one measurement tool for assessment. Also, the educator should not rely heavily on these instruments because they are intended not for diagnosis but rather to validate what the learner perceives in comparison to what the educator perceives. When approached from this perspective, these instruments will help the

Learning style models are based on the premise that certain characteristics of learning are biological in origin, whereas others are socio- logically developed resulting from environmental influences. No learning style is inherently better or worse than another. Recognizing that people have different approaches to learning helps the nurse educator understand the differences in ed- ucational interests and needs of diverse popula- tions. Accepting the diversity of such styles can help educators create an atmosphere for learning characterized by experiences that encourage ev- ery individual to reach his or her full potential. Understanding learning styles also can help edu- cators make deliberate decisions about program development and instructional design (Arndt & Underwood, 1990; Chapman & Calhoun, 2006; Churchill, 2008; Coffield, Moseley, Hall, & Ecclestone, 2004b; Jessee, O’Neill, & Dosch, 2006; Morse, Oberer, Dobbins, & Mitchell, 1998; Vaughn & Baker, 2008).

Determining Learning Styles Three mechanisms to determine learning style are observation, interviews, and administration of learning style instruments. By observing the learner in action, the educator can ascertain how the learner grasps information and solves prob- lems. For example, when doing a math calcu- lation, does the learner write down every step or just the answer? In an interview, the educa- tor can ask the learner about preferred ways of learning as well as the environment most com- fortable for learning. Is group discussion or self-instruction preferable? Does the learner pre- fer hands-on activities or reading instructions? Is a warm or cold room more conducive to con- versation? Simply asking the question, “How do you learn best?” can yield valuable information on this front. Finally, the educator can admin- ister learning style instruments, such as those described in the next section.

Educators should use all three techniques to determine learning style. Assessment is fore- most in the educational process. Once data are gathered through interview, observation, and

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individuals perceive and gather information to solve problems, complete assigned tasks, relate to others, and meet the daily challenges of life.

Most individuals have a dominant side of the brain. Gondringer (1989) reports that most learners have left-brain dominance and that only approximately 30% have right-brain dominance. This preference may reflect the fact that the West- ern world is geared toward rewarding left-brain skills to the extent that right-brain skills go un- developed. However, educators need to employ teaching methods that enable the learner to use both sides of the brain. For example, to stimu- late the development of left-brain thinking, the nurse educator should provide a structured en- vironment by relying on specific objectives and a course outline. To stimulate the development of the right brain, the educator should provide a more unstructured, free-flowing environment that allows for creative opportunities. By em- ploying teaching strategies aimed at helping the learner use both brain hemispheres, the educa- tor facilitates more effective and efficient learn- ing. Lillyman, Gutteridge, and Berridge (2011) use storyboarding in helping students use both the right and left brain to reflect on end of life issues. Misch (2016) uses humor to encourage students to use the right brain along with the left brain so that critical components of care can be addressed in successful patient, family, and healthcare team interactions. Such whole-brain thinking allows the learner to realize the best of both worlds in developing his or her thought processes. Duality of thinking is what educators should strive to teach to encourage learners to reach their full learning potential.

As Gardner (1999a) points out, the brain does not exist in isolation but rather is con- nected to the entire body. He argues that for the brain to be more than an organ, consider- ation must be given to many variables—such as mental processes, feelings, desires, and cultural influences—that are important in the develop- ment and expression of a person’s learning style. What learners choose to learn is influenced by the set of values both educators and learners bring to the teaching–learning situation.

nurse educator in developing a more personal- ized form of instruction.

Right-Brain/Left-Brain and Whole-Brain Thinking Although not technically a model, right-brain/ left-brain thinking, along with whole-brain think- ing, adds to the understanding of brain func- tions that are associated with learning. About 40 years ago, Roger Sperry and his research team established that, in many ways, the brain op- erates as two brains (Herrmann, 1988; Sperry, 1977), with each hemisphere having separate and complementary functions. The left hemi- sphere of the brain was found to be the vocal and analytical side, which is used for verbaliza- tion and for reality-based and logical thinking. The right hemisphere was found to be the emo- tional, visual–spatial, and nonverbal side, with thinking processes that are intuitive, subjective, relational, holistic, and time free. Sperry and his colleagues discovered that learners can use both sides of the brain because of a connector between the two hemispheres called the corpus callosum. Although significant information in current neu- roscience research indicates the two-brain model oversimplifies cognitive functioning (Dietrich & Kanso, 2010; Mihov, Denzler, & Förster, 2010), it nonetheless gives educators yet another approach to better understanding the learner.

There is no correct or wrong side of the brain to use in information processing. Instead, each hemisphere gathers the same sensory in- formation but handles the information in dif- ferent ways. One hemisphere may take over and inhibit the other in processing information, or the task may be divided between the two sides, with each handling the part best suited to its way of processing information.

Recognizing that one side of the brain may be better equipped for certain kinds of tasks than for others, educators can find the most effective way to present information to learners who have a dominant brain hemisphere (BOX 4-3). Accord- ing to Sperry’s theory, brain hemisphericity is linked to cognitive learning style or the way

Learning Style Models and Instruments 141

BOX 4-3 Examples of Hemisphere Functions

Left-Hemisphere Functions ■ Thinking is critical, logical, convergent,

focal ■ Analytical ■ Prefers talking and writing ■ Responds to verbal instructions and

explanations ■ Recognizes/remembers names ■ Relies on language in thinking and

remembering ■ Solves problems by breaking them into

parts, then approaches the problem sequentially, using logic

■ Good organizational skills, neat ■ Likes stability, willing to adhere

to rules ■ Conscious of time and schedules ■ Algebra is the preferred math ■ Not as good at interpreting body

language ■ Controls emotions

Right-Hemisphere Functions ■ Thinking is creative, intuitive, divergent,

diffuse ■ Synthesizing ■ Prefers drawing and manipulating

objects ■ Responds to written instructions and

explanations ■ Recognizes and remembers faces ■ Relies on images in thinking and

remembering ■ Solves problems by looking at the whole

and the configurations, then approaches the problem through patterns, using hunches

■ Loose organizational skills, sloppy ■ Likes change, uncertainty ■ Frequently loses contact with time and

schedules ■ Geometry is the preferred math ■ Good at interpreting body language ■ Free with emotions

Instruments to Measure Right-Brain/Left-Brain and Whole-Brain Thinking Two instruments are used to measure right- and left-brain dominance. The first, called the brain preference indicator (BPI), consists of a set of questions used to determine hemispheric functioning. The BPI instrument reveals a gen- eral style of thought that results in a consistent pattern of behavior in all areas of the individu- al’s life. Although the reliability and validity of this instrument have not been reported, it does provide a starting point for the educator to un- derstand his or her own right- or left-brain pref- erences. More information about the BPI can be found in Whole-Brain Thinking by Wonder and Donovan (1984).

The other instrument available for wide- spread commercial use is the Herrmann Brain Dominance Instrument (HBDI). Herrmann’s (1988) model incorporates theories on growth and development and considers learning styles as learned patterns of behavior. The HBDI classifies learners in terms of the following four modes, with each quadrant correspond- ing to a brain structure and different prefer- ences for thinking:

■ Quadrant A (left brain, cerebral): logical, analytical, quantitative, factual, critical

■ Quadrant B (left brain, limbic): sequential, organized, planned, detailed, structured

■ Quadrant C (right brain, limbic): emotional, interpersonal, sensory, kinesthetic, symbolic

■ Quadrant D (right brain, cerebral): visual, holistic, innovative

The author suggests that his HBDI is psy- chometrically sound, although very few inde- pendent studies of its reliability and validity have been conducted (Coffield et al., 2004b). The HBDI has been used mostly in the business world, with minimal validation in the health sciences. More information about this model is available at Herrmann International’s website (http://www.herrmannsolutions.com).

142 Chapter 4 Determinants of Learning

To date, sex-related differences in behavior have been documented in the literature (Speck et al., 2000), but the underlying neuroanatomic processes remain unclear (Gur et al., 1999) and the significance of these research findings for the educator is difficult to gauge. Garity (1985) sug- gests that these individual differences in charac- teristics and interpersonal behavior can be used as a basis for understanding different learning styles and can facilitate the way educators work with learners, structure the learning task, and structure the environment (BOX 4-4). It must be noted that the findings of these studies were conducted on cisgender people and may not be applicable to transgender people.

Field-Independent/Field- Dependent Perception An extensive series of studies by Witkin, Oltman, Raskin, and Karp (1971b) identified two styles of learning in the cognitive domain, which are based on the bipolar distribution of character- istics of how learners process and structure in- formation in their environment. These authors hypothesized that learners have preference styles for certain environmental cues. A field- independent person perceives items as separate or differentiated from the surrounding field; a field-dependent person’s perception is influ- enced by or immersed in the surrounding field.

Field-independent individuals have inter- nalized frames of reference such that they expe- rience themselves as separate or differentiated from others and the environment. They are less sensitive to social cues, are not affected by criti- cism, favor an active participant role, and are eager to test their ideas or opinions in a group.

Field-dependent individuals, by compari- son, are more externally focused and as such are socially oriented, more aware of social cues, able to reveal their feelings, and are more dependent on others for reinforcement. They have a need for extrinsic motivation and externally defined objectives and learn better if the material has a social context. They are more easily affected by criticism; take a passive, spectator role; and change their opinions in the face of peer pressure.

Field independence/dependence is thought to be related to hemispheric brain processes (Chall & Mirsky, 1978). The studies cited in Sex and the Brain (Durden-Smith & deSimone, 1983) reveal that the right hemisphere in males tends to be more dominant than the left hemisphere; the opposite is true for females. Males tend to have better visual–spatial abilities, whereas fe- males tend to have better linguistic skills. Al- though females generally do not do as well as males on tests of spatial ability, men should be measured only against other men, and women against women, to reduce the differential test effect on the sexes.

BOX 4-4 Characteristics of Field- Independent and Field-Dependent Learners

Field-Independent Learners ■ Are not affected by criticism ■ Will not conform to peer pressure ■ Are less influenced by external feedback ■ Learn best by organizing their own material ■ Have an impersonal orientation to the world ■ Place emphasis on applying principles ■ Are interested in new ideas or concepts

for own sake ■ Provide self-directed goals, objectives, and

reinforcement ■ Prefer lecture method

Field-Dependent Learners ■ Are easily affected by criticism ■ Will conform to peer pressure ■ Are influenced by feedback (grades and

evaluations) ■ Learn best when material is organized ■ Have a social orientation to the world ■ Place emphasis on facts ■ Prefer learning to be relevant to own

experience ■ Need external goals, objectives, and

reinforcements ■ Prefer discussion method

Learning Style Models and Instruments 143

His findings show a significant positive correla- tion between the GEFT and the OTSES scores, supporting the notion that field-independent students tend to be more confident with online technologies. Thus field-dependent students may need more assistance with web-based courses, and the educator may need to find other meth- ods of instruction for their learning to be more successful and less anxiety producing.

Noble, Miller, and Heckman (2008) ad- ministered the GEFT to more than 800 students enrolled in 10 healthcare programs and found that nursing students were classified as more field dependent than students in other health- related disciplines. The authors suggested that the nursing students might be at risk of aca- demic failure because of their cognitive pro- cessing requirements and so recommended that instructional strategies tailored to their needs be incorporated into the nursing curriculum.

Flynn and associates (1999) found a sig- nificant association between the number of interruptions and distractions in an ambu- latory care pharmacy and dispensing errors (incorrect label information). As the distrac- tions (field background elements) increased, more errors occurred. Field-dependent phar- macists tended to become more distracted and to fill prescriptions inaccurately. Consider- ation of field independence/dependence can be useful for the educator who is involved with teaching in a clinical setting characterized by constant distractions.

Educators also can use the GEFT instrument to determine whether a learner sees the whole first (global, field independent) and then the individual parts (specific, field dependent), or vice versa. The field-independent person wants to know the end result of teaching and learning prior to concentrating on the individual parts of the process, whereas the field-dependent per- son wants to know the individual parts in se- quence prior to looking at the expected overall outcome of teaching–learning efforts.

The GEFT has been reasonably well val- idated in predicting academic performance (Oltman, Raskin, Witkin, & Karp, 1978). This

Instrument to Measure Field Independence/Field Dependence Witkin, Oltman, Raskin, and Karp (1971a) de- vised a tool called the Group Embedded Figures Test (GEFT) to measure field independence/ dependence—that is, how a person’s perception of an item is influenced by the context in which it appears. Bonham (1988) notes that the GEFT, which takes approximately 30 minutes to com- plete, is designed to determine a person’s ability to find simple geometric figures within complex drawings. Witkin’s work is based on 35 years of psychological research on more than 2,000 in- dividuals. Educators must keep in mind that the GEFT is based on psychological research when they attempt to apply findings broadly to the educational setting (Witkin, Moore, & Olt- man, 1977). Bonham (1988) points out in her analysis of learning style instruments that the GEFT measures the ability to do something, not the manner (style) in which that task is done. There is no way to tell whether a person could choose which style is most effective in a given situation (Shipman & Shipman, 1985; Witkin & Goodenough, 1981). Older adults generally do not do well on tests in which speed is import- ant (Botwinick, 1978; Santrock, 2017), and be- cause this assessment tool is a timed test, age bias is a concern (Santrock, 2017).

The best time to use the GEFT seems to be when the educator wants to measure field inde- pendence, not field dependence, in determining the extent to which learners are able to ignore distractions from other persons who may of- fer incorrect information or ideas. The results could help individuals understand why they may have trouble with certain learning experiences (Bonham, 1988). For example, Deture (2004) designed a study to identify those learner attri- butes that can be used to predict student success in web-based distance education courses. He administered the GEFT and the Online Technol- ogies Self-Efficacy Scale (OTSES) to community college students to determine their entry-level con- fidence with computer skills for online learning.

144 Chapter 4 Determinants of Learning

3. Sociological patterns (such as the desire to work alone or in groups, or a combination of these two ap- proaches), which are thought to be socioculturally based

4. Physical elements (such as perceptual strength, intake, time of day, and mobility), which are also biological in nature and relate to the way learners function physically

5. Psychological elements (such as the way learners process and react to in- formation), which are also biological in nature

Environmental Elements Sound. Individuals react to sound in different ways. Some learners need complete silence, others are capable of blocking out sounds around them, and still others require sound in their environ- ment for learning. Cognizant of the effect of sound on learning, the educator should permit learners to study either in silent areas or while

instrument is available for purchase from Mind Garden (http://www.mindgarden.com).

Dunn and Dunn Learning Styles In 1967, Rita Dunn and Kenneth Dunn set out to develop a user-friendly model that would assist educators in identifying characteristics that allow individuals to learn in different ways (Dunn & Dunn, 1978). Their model includes motivational factors, social interaction patterns, and physiological and environmental elements. These researchers identified five basic stimuli (as shown in FIGURE 4-2) that affect a person’s ability to learn:

1. Environmental elements (such as sound, light, temperature, and de- sign), which are biological in nature

2. Emotional elements (such as motiva- tion, persistence, responsibility, and structure), which are developmental and emerge over time as an outgrowth of experiences that have happened at home, school, play, or work

FIGURE 4-2 Dunn and Dunn’s learning style options. Courtesy of the Association for Supervision and Curriculum Development. Dunn, R. (1983). Can students identify their own learning styles? Educational Leadership, 40(5), 60–62. Reprinted by permission of the Association for Supervision and Curriculum Development. All rights reserved.

SOUND LIGHT

PEERS SELF PAIR TEAM ADULT

TEMPERATURE DESIGN Environmental

Emotional

Sociological

Physical

Psychological

Stimuli Elements

STRUCTURE

M T THW F

ANALYTIC

GLOBAL

PERCEPTUAL INTAKE TIME MOBILITY

IMPULSIVE

REFLECTIVE

RESPONSIBILITYPERSISTENCEMOTIVATION

VARIED

HEMISPHERIC PREFERENCE

SOUND LIGHT

PEERS SELF PAIR TEAM ADULT

TEMPERATURE DESIGN

STRUCTURE

M T THW F

ANALYTIC

GLOBAL

PERCEPTUAL INTAKE TIME MOBILITY

IMPULSIVE

REFLECTIVE

RESPONSIBILITYPERSISTENCEMOTIVATION

VARIED

HEMISPHERIC PREFERENCE

Learning Style Models and Instruments 145

Persistence. Learners differ in their preference for completing tasks in one sitting versus taking periodic breaks and returning to the task later. By giving learners in advance the objectives and a time interval for completion of a task, those with long attention spans can get the job done in a block of time, whereas those whose attention span is short can take the opportunity for breaks without feeling guilty or rushed.

Responsibility. A desire to do what the learner thinks is expected is related to the concept of con- formity or following through on what an educator asks or tells the learner to do. Learners with low responsibility scores usually are nonconforming; that is, they do not like to do something simply because someone asks them to do it. Knowing this, the educator should give them choices and allow learners to select different ways to complete the assignment. When given appropriate choices, the nonconformist will likely be more willing to meet the educator’s expectations.

Structure. This refers to either the preference for receiving specific directions, guidance, or rules prior to carrying out an assignment or the preference for doing an assignment without structure in the learner’s own way. Structure should vary in the amount and kind that is provided, depending on the learner’s ability to make responsible decisions and the requirements of the task.

Sociological Elements Learning Alone. Some learners prefer to study by themselves, whereas others prefer to learn with a friend or colleague. When learners prefer to be with others, group discussion and role playing can facilitate learning. For learners who do not do well learning with others because they tend to socialize or are unable to concentrate, self-instruction, one-to-one interaction, or lecture-type methods are the best approaches.

Presence of an Authority Figure. Some learners feel more comfortable when someone with authority or recognized expertise is present

listening to music on headsets to prevent them from interfering with those who need quiet.

Light. Some learners work best under bright lights, whereas others need dim or low lighting. The educator should provide lighting conducive to learning by moving furniture around to establish both well-lit and dimly lit areas and permitting learners to sit where they are most comfortable.

Temperature. Some learners have difficulty thinking or concentrating if a room is too hot or, conversely, if it is too cold. The educator needs to make learners aware of the temperature of the environment and encourage them to wear lighter or heavier clothing as necessary. If windows are available, they should be opened to permit variable degrees of temperature in the room to accommodate different comfort levels.

Design. Dunn and Dunn established that when learners are seated on wooden, steel, or plastic chairs, 75% of the total body weight is supported on only 4 square inches of bone. This results in fatigue, discomfort, and the need for frequent body position changes (Dunn & Dunn, 1987). Also, some learners are more relaxed and can learn better in an informal environment by being able to position themselves in a lounge chair, on the floor, on pillows, or on carpeting. Others cannot learn in an informal environment because it makes them drowsy. If possible, the educator should vary the furniture in the classroom to allow some students to sit either more formally or informally while learning.

Emotional Elements Motivation. A desire to achieve increases when learning success increases. Unmotivated learners need short learning assignments that enhance their strengths. Motivated learners, by comparison, are eager to learn and should be told exactly what they are required to do, with resources available so that they can pace their own learning.

146 Chapter 4 Determinants of Learning

Intake. Some learners need to eat, drink, chew, or bite objects while concentrating; others prefer no intake until after they have finished studying. A list of rules needs to be established to satisfy the oral needs of those who prefer intake while learning so that their behavior does not disturb others or interfere with building rules and reg- ulations of the institution or agency.

Time of Day. Some learners perform better at one time of day than another. The four time-of-day preferences can be placed on a continuum, and the educator needs to identify these preferences with an effort toward structuring teaching and learning to occur during the times that are most suitable for the learner:

■ Early-morning learners: Their ability to concentrate and focus energies on learning is high in the early hours of the day but wanes as the day progresses.

■ Late-morning learners: Their concentration and energy curve peaks around noontime, when their ability to perform is at its height.

■ Afternoon learners: Their concentration and energy are highest in the mid- to late afternoon, when performance is at its peak.

■ Evening learners: Their ability to concen- trate and focus energies is greatest at the end of the day.

Dunn (1995) contends that among adults, the majority fall on the two extremes of the time-of- day continuum: 55% are morning people and 28% work best in the evening. Many adults experience energy lows in the afternoon. Conversely, school- aged children have high energy levels in the late morning and early afternoon. Approximately 13% of high school students work best in the evening.

This time sensitivity means that it may be easier or more difficult for a person to learn a new skill or behavior at certain times of the day than at other times. To enhance learning poten- tial, the educator should try to schedule teach- ing during the learner’s best time of day.

Mobility. This refers to how still the learner can sit and for how long a period. Some learners need

during learning. Others become nervous, feel stifled, and have trouble concentrating. Depending on the style of the learner, either one-to-one interaction or self-study may be the appropriate approach.

Variety of Ways. Some learners are flexible and can learn as well alone as they can with authority figures and peer groups. These learners are versatile in their style of learning and would benefit from having different opportunities as opposed to routine approaches.

Physical Elements Perceptual Strengths. Four types of learners are distinguished in this category: (a) those with auditory preferences, who learn best while listening to verbal instruction; (b) those with visual preferences, who learn best from reading or observation; (c) those with tactile prefer- ences, who learn best when they can underline as they read, take notes when they listen, and otherwise keep their hands busy; and (d) those with kinesthetic preferences, who absorb and retain information best when allowed to per- form whole-body movement or participate in simulated or real-life experiences.

Auditory learners should be introduced to new information first by hearing about it, followed by receiving verbal feedback for re- inforcement of the information. Lecture and group discussion are the instructional meth- ods best suited to this learning style. Visual learners learn more easily by viewing, watch- ing, and observing. Simulation and demon- stration methods of instruction are, therefore, most beneficial to their learning. Tactile learn- ers learn through touching, manipulating, and handling objects, so they remember more when they write, doodle, draw, or move their fingers. The use of models and computer-assisted in- struction is most suitable for this learning style. Kinesthetic learners learn more easily by doing and experiencing. They profit most from op- portunities for field trips, role play, interview- ing, and participating in return demonstration.

Learning Style Models and Instruments 147

in the identification of how individuals prefer to function, learn, concentrate, and perform in their educational activities. It is available in three different forms: for grades 3–5; for grades 6–12; and in an adult version, called the Productiv- ity Environmental Preference Survey (PEPS). Dunn and Dunn stress that the PEPS is not in- tended to be used as an indicator of underlying psychological factors, value systems, or the qual- ity of attitudes. This instrument yields informa- tion concerned with the patterns through which learning occurs but does not assess the finer as- pects of an individual’s skills, such as the ability to outline procedures and to organize, classify, or analyze new material. It indicates how peo- ple prefer to learn, not the abilities they possess.

What has evolved since the model was first developed is a highly tested and continuously re- vised instrument that is valid and reliable as re- ported by those who like and use this instrument (Dunn & Griggs, 2003). However, others high- light major problems with the design and reli- ability of the instrument (Coffield et al., 2004b).

Jung and Myers–Briggs Typology Carl G. Jung (1921/1971), a Swiss psychiatrist, developed a theory that explains personality sim- ilarities and differences by identifying attitudes of people (extraverts and introverts) along with opposite mental functions, which are the ways people perceive or prefer to take in and make use of information from the world around them. Jung proposed that people are likely to operate in a variety of ways depending on the circum- stances. Despite these situational adaptations, every individual tends to develop comfortable patterns, which dictate behavior in certain pre- dictable ways. Jung used the word type to iden- tify these styles of personality.

According to Jung, everyone uses these op- posing perceptions to some degree when dealing with people and situations, but each person pre- fers one way of looking at the world. Individuals become more skilled in arriving at a decision in either a thinking or feeling way, and can func- tion as extraverts at one time and as introverts at

to move about, whereas others can sit for hours engaged in learning. For those who require mo- bility, it is necessary to provide opportunity for movement by assigning them to less restrictive sections of the room. During workshops or any type of group learning, nurse educators should give frequent 30- to 60-second breaks during which participants can stand. This is a good time to have the participants turn to one another and share one thing that they have learned during that time.

Psychological Elements Global Versus Analytic. Some learners are global in their thinking and learn best by ob- taining meaning from a broad, overall concept before focusing on the details in the surround- ing environment. Other learners are analytical in their thinking and learn sequentially in a step-by-step process.

Hemispheric Preference. Learners who pos- sess right-brain preference tend to learn best in environments that have low illumination, background music, casual seating, and tactile instructional resources. Learners with left-brain preference require the opposite type of environ- ment, characterized by bright lighting, quiet setting, formal seating, and visual or auditory instructional resources.

Impulsivity Versus Reflectivity. Impulsive learn- ers prefer opportunities to participate verbally in groups and tend to answer questions spontaneously and without consciously processing their thinking. Reflective learners seldom volunteer information unless they are asked to do so, prefer to contem- plate information, and tend to be uncomfortable participating in group discussions (Dunn, 1984).

Instrument to Measure the Dunn and Dunn Learning Style Inventory The Dunn and Dunn learning style inventory is a self-report instrument that is widely used

148 Chapter 4 Determinants of Learning

people, experiences, and situations. They like to clarify thoughts and ideas through talking and doing. Those persons who operate more comfortably in an extraverted way think aloud.

Individuals with a preference for introversion are more interested in the internal world of their minds, hearts, and souls. They like to brew over thoughts and actions, reflecting on them until they become more personally meaningful. Those persons who operate more comfortably in an introverted way are often thoughtful, reflective, and slow to act because they need time to translate internal thoughts to the external world. Their thoughts are well formulated before they are willing to share them with others.

2. Sensing–Intuition (S–N) describes perception as coming directly through the five senses or indirectly by way of the unconscious. This pair of oppo- site preferences explains how people understand what is experienced.

People who prefer sensing ex- perience the world through their senses—vision, hearing, touch, taste, and smell. They observe what is real, what is factual, and what is happen- ing. For these individuals, seeing or experiencing is believing. The sensory

another time, but they tend to develop patterns that are most typical and comfortable.

Isabel Myers and her mother, Katherine Briggs, became convinced that Jung’s theories had an application for increasing human un- derstanding (Myers, 1980). In addition to Jung’s dichotomies, Myers and Briggs discovered an- other dichotomy (Myers, 1987) and thus made explicit one underdeveloped aspect of Jung’s model (FIGURE 4-3). According to Myers and Briggs, an individual reaches a conclusion about or becomes aware of something through a pref- erence of judging or perceiving.

By combining the different preferences, Myers and Briggs identified 16 personality types, each with its own strengths and interests (FIGURE 4-4). People can be classified into the 16 personality types based on four constructs:

1. Extraversion–Introversion (E–I) re- flects an orientation to either the out- side world of people and things or to the inner world of concepts and ideas. This pair of opposite prefer- ences describes the extent to which behavior is determined by attitudes toward the world. Jung invented the terms from Latin words mean- ing “outward turning” (extraversion) and “inward turning” (introversion).

Individuals who prefer extraver- sion operate comfortably and suc- cessfully by interacting with things external to themselves, such as other

FIGURE 4-3 Myers–Briggs dichotomous dimensions or preferences.

Extraversion (E) Introversion (I)

Intuition (N)

Feeling (F)

Perception (P)

Sensing (S)

Thinking (T)

Judgment (J)

FIGURE 4-4 Myers–Briggs types. Modified and reproduced from Myers, I. B. (1998). Introduction to type® (3rd ed.). Palo Alto, CA: Consulting Psychologists Press. Copyright 1998 by Consulting Psychologists Press, Inc. All rights reserved. Further reproduction is prohibited without the Publisher’s written consent.

ISTJ

ISTP

ESTP

ESTJ

ISFJ

ISFP

ESFP

ESFJ

INFJ

INFP

ENFP

ENFJ

INTJ

INTP

ENTP

ENTJ

Learning Style Models and Instruments 149

of something. The extremes of this continuum are a preference for judg- ing, which is the desire to regulate and bring closure to circumstances in life, and a preference for perceiv- ing, which is the desire to be open minded and understanding.

Instrument to Measure the Myers–Briggs Personality Types Myers and Briggs developed an instrument called the Myers–Briggs Type Indicator (MBTI) that permits people to learn about their own type of behavior and understand themselves better with respect to the way in which they interact with others. Although the MBTI is not a learning style instrument per se, it does measure differ- ences in personality types, which are combina- tions of the four dichotomous preferences. The MBTI is a forced-choice, self-report inventory.

The MBTI can be useful for the educator to understand in which ways learners perceive and judge information and how they prefer to learn. Logical, detailed individuals (sensing–thinking type), for example, may have difficulty commu- nicating with persons who are more holistically oriented (intuitive–feeling type). What each party values and believes most and how they go about learning or dealing with information differ and may lead to misunderstandings and conflicts (Bargar & Hoover, 1984). Findings of signifi- cant differences between medical graduates and the general adult population in Great Britain in three of the four basic personality dimensions of the MBTI, as well as in combinations of percep- tion and judgment, suggest potential points for miscommunication between physicians and pa- tients (Clack, Allen, Cooper, & O’Head, 2004). Another example of how these two preferences function is that the preferred learning style of sensing–thinking learners emphasizes hands-on experience, demonstration, and application of concepts, whereas intuition–feeling learners pre- fer emphasis on the theoretical concerns before they can concentrate on the practical applica- tions. Examples of how the MBTI results affect learning are listed in BOX 4-5.

functions allow the individual to observe carefully, gather facts, and focus on practical actions.

Conversely, those people who prefer intuition tend to read between the lines, focus on meaning, and attend to what might be. Those with intuition preferences view the world through possibilities and relationships and are tuned into subtleties of body language and tones of voice. This kind of perception leads them to examine problems and issues in creative and original ways.

3. Thinking–Feeling (T–F) is the ap- proach used by individuals to arrive at judgments through objective versus subjective processes. Thinking types analyze information, data, situations, and people and make decisions based on logic. They are careful and slow in the analysis of the data because accu- racy and thoroughness are important to them. They trust objectivity and put faith in logical predictions and rational arguments. Thinking types explore and weigh all alternatives, and the final decision is reached imper- sonally, unemotionally, and carefully.

For individuals with a feeling preference, the approach to decision making takes place through a sub- jective, perceptive, empathetic, and emotional perspective. Individuals who prefer feeling search for the effect of a decision on themselves and others. They consider alternatives and examine evidence to develop a personal reaction and commitment. They believe the decision-making process is complex and not totally objective. Circumstantial evidence is extremely important, and these individuals see the world as gray rather than black and white.

4. Judging–Perceiving (J–P) is the way by which an individual reaches a conclusion about or becomes aware

150 Chapter 4 Determinants of Learning

BOX 4-5 Myers–Briggs Types: Examples of Learning

Extraversion ■ Likes group work ■ Dislikes slow-paced learning ■ Likes action and to experience things as the way to learn ■ Offers opinions without being asked ■ Asks questions to check on the expectations of the educator

Sensing ■ Practical ■ Realistic ■ Observant ■ Learns from an orderly sequence of details

Thinking ■ Low need for harmony ■ Finds ideas and things more interesting than people ■ Analytical ■ Fair

Judging ■ Organized ■ Methodical ■ Work oriented ■ Controls the environment

Introversion ■ Likes quiet space ■ Dislikes interruptions ■ Likes learning that deals with thoughts and ideas ■ Offers opinions only when asked ■ Asks questions to allow understanding of the learning activity

Intuition ■ Always likes something new ■ Imaginative ■ Sees possibilities ■ Prefers the whole concept versus details

Feeling ■ Values harmony ■ More interested in people than things or ideas ■ Sympathetic ■ Accepting ■ Perceiving

Perceiving ■ Open ended ■ Flexible ■ Play oriented ■ Adapts to the environment

Learning Style Models and Instruments 151

the learning cycle, learners tend to rely more on feelings than on a systematic approach to prob- lems and situations. Learners who fall into this category like interacting with people, benefit from specific experiences, and are sensitive to others. They learn from feeling. In contrast, at the AC stage, learners rely on logic and ideas rather than on feelings to deal with problems or situations. People who fall into this category use systematic planning and logical analysis to solve problems. They learn by thinking.

The process dimension also has two op- posing orientations: Some learners process in- formation through reflective observation (RO mode), whereas others process information through active experimentation (AE mode). At the RO stage of the learning cycle, learners rely on objectivity, careful judgment, personal thoughts, and feelings to form opinions. People who fall into this category look for the meaning of things by viewing them from different per- spectives. They learn by watching and listening. At the AE stage of the learning cycle, however, learning is active, and learners like to experi- ment to get things done. They prefer to influ- ence or change situations and see the results of their actions. They enjoy involvement and are risk takers. They learn by doing.

Kolb describes each learning style as a com- bination of the four basic learning modes (CE, AC, RO, and AE), identifying separate learn- ing style types that best define the strengths and weaknesses of a learner. The learner predom- inantly demonstrates characteristics of one of four style types: diverger, assimilator, converger, or accommodator. These learning styles are dis- cussed here as they appear in clockwise order in FIGURE 4-5, starting with the diverger.

The diverger combines the learning modes of CE and RO. People with this learning style are good at viewing concrete situations from many points of view. They like to observe, gather in- formation, and gain insights rather than take action. Working in groups to generate ideas ap- peals to them. They place a high value on un- derstanding for knowledge’s sake and like to personalize learning by connecting information

Since its initial development in the 1920s, the MBTI instrument has undergone several revisions, with mixed reviews on its reliability and validity (Capraro & Capraro, 2002; Coffield et al., 2004b). Schoessler, Conedera, Bell, Mar- shall, and Gilson (1993) discuss the use of the MBTI to develop a continuing education de- partment for nursing. Hardy and Smith (2001) explain how they restructured their nursing orientation program to match preceptor and orientee based on teaching and learning traits identified through individual MBTI scores. Stil- well, Wallick, Thal, and Burleson (2000) iden- tify how the MBTI is useful for understanding how some aspects of personality relate to med- ical graduates’ choice of medical specialty ar- eas. The MBTI instrument and MBTI products are available from CPP (https://www.cpp.com).

Kolb’s Experiential Learning Model David Kolb (1984), a management expert from Case Western Reserve University, developed his learning style model in the early 1970s. Kolb believed that knowledge is acquired through a transformational process, which is continu- ously created and recreated. In this model, the learner is not a blank slate but rather approaches a topic to be learned with preconceived ideas. Kolb’s theory on learning style is that it is a cu- mulative result of past experiences, heredity, and the demands of the present environment. These factors combine to produce different in- dividual orientations to learning.

Kolb’s model, known as the cycle of learn- ing, includes four modes of learning that reflect two major dimensions: perception and process- ing. He hypothesizes that learning results from the way learners perceive as well as how they process what they perceive.

The dimension of perception involves two opposite perceptual viewpoints: Some learners perceive through concrete experience (CE mode), whereas others perceive through abstract con- ceptualization (AC mode). At the CE stage of

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problems. Learners with this style prefer tech- nical tasks rather than dealing with social and interpersonal issues. Kolb postulates that indi- viduals with this learning style have skills that are important for specialist and technology ca- reers. The convergent thinker learns best, for example, through demonstration/return demon- stration methods of teaching accompanied by handouts and diagrams.

The accommodator combines the learning modes of AE and CE. People with this learning style learn best by hands-on experience and en- joy new and challenging situations. They act on intuition and gut feelings rather than on logic. These risk takers like to explore all possibilities and learn by experimenting with materials and objects. Accommodative thinkers are perhaps the most challenging to educators because they demand new and exciting experiences and are willing to take risks that might endanger their safety. Role play, gaming, and computer simu- lations, for example, are methods of teaching most preferred by this style of learner.

Among every group of learners, approxi- mately 25% will fall into each of the four catego- ries. Kolb believes that understanding a person’s learning style, including its strengths and weak- nesses, represents a major step toward increasing

with something familiar in their experiences. They have active imaginations, enjoy being involved, and are sensitive to feelings. Diver- gent thinkers learn best, for example, through group discussions and participating in brain- storming sessions.

The assimilator combines the learning modes of RO and AC. People with this learn- ing style demonstrate the ability to understand large amounts of information by putting it into concise and logical form. They are less inter- ested in people and more focused on abstract ideas and concepts. They are good at inductive reasoning, value theory over practical applica- tion of ideas, and need time to reflect on what has been learned and how information can be integrated into their past experiences. They rely on knowledge from experts. Assimilative think- ers learn best, for example, through lecture, one-to-one instruction, and self- instruction methods with ample reading materials to sup- port their learning.

The converger combines the learning modes of AC and AE. People with this learning style type find practical application for ideas and theories and are able to use deductive reason- ing to solve problems. They like structure and facts, and they look for specific solutions to

FIGURE 4-5 Kolb’s learning style inventory. Reproduced from Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall. © 1984. Reprinted by permission of Pearson Education, Inc., New York, NY.

Accommodator Diverger

Converger Assimilator

Active Experimentation (AE) “Doing”

Reflective Observation (RO) “Watching”

Concrete Experience (CE) “Feeling”

Abstract Conceptualization (AC) “Thinking”

Learning Style Models and Instruments 153

Instrument to Measure Kolb’s Experiential Learning Styles The Learning Style Inventory (LSI) is a 20-item, self-report questionnaire that requires respon- dents to rank four sentence endings correspond- ing to each of the four learning modes. Eight of the 20 items on the questionnaire assess learning flexibility. A scoring process reduces the ranking evidence to four mode scores (CE, RO, AC, and AE), which are further reduced to two dimension scores (concrete–abstract and reflective–active). Two combinations of dimension scores measure the learner’s preference for abstractness versus concreteness (AC–CE) and for action versus re- flection (AE–RO). The predominant score in- dicates the learner’s style (diverger, assimilator, converger, or accommodator).

The Kolb model is popular in the healthcare field and has been the subject of many studies. Some scholars believe that this model’s validity has not been demonstrated (Coffield et al., 2004b; Schenck & Cruickshank, 2015). Kolb argues oth- erwise and states that the LSI has internal con- sistency reliability (Cronbach alpha = .81) and internal and external validity (Kolb & Kolb, 2013). A considerable body of research positively re- ports on Kolb’s model. The LSI (version 4.0) can be obtained from Experience Based Learning Sys- tems, Inc. (http://learningfromexperience.com/).

4MAT System McCarthy (1981) developed a model based on previous research on learning styles and brain functioning. She used Kolb’s model combined with Sperry’s right-brain/left-brain research findings to create the 4MAT system (FIGURE 4-6).

McCarthy’s model describes four types of learners:

■ Type 1/Imaginative: Learners who demand to know why. These learners like to listen, speak, interact, and brainstorm.

■ Type 2/Analytical: Learners who want to know what to learn. These learners are most comfortable observing, analyzing, classifying, and theorizing.

learning power and helping learners to get the most from their learning experiences. By using different teaching strategies to address these four learning styles, specific modes of learning can be matched, at least some of the time, with the educator’s methods of teaching. If the educator predominantly uses only one method of teach- ing, such as the lecture, then 75% of all learn- ers will be selectively excluded.

When teaching groups of learners, the in- structor may want to begin with activities best suited to the divergent thinker and progress se- quentially to include activities for the assimila- tor, converger, and accommodator, respectively (Arndt & Underwood, 1990). This pattern works because learners must first have foundational knowledge of a subject before they can test in- formation. Otherwise, they operate from a level of ignorance. Put simply, they must first have familiarity with facts and ideas before they can explore and test concepts.

Kolb’s four learning styles were expanded to nine distinct styles (Kolb & Kolb, 2005). These additional learning styles were incorporated to help better explain the uniqueness of individual learning styles. Added to the original accommo- dator, diverger, assimilator, and converger were the new Northerner, Easterner, Southerner, and Westerner. These were created by dividing the AC–CE and AE–RO scores at the 30th percen- tile and 60th percentile of the total norm group and plotting them on the Nine-Region Learning Style Type Grid (Kolb & Kolb, 2005). According to Kolb and Kolb (2005) the Northerner empha- sizes feeling (CE) while balancing acting (AE) and reflecting (RO), the Easterner emphasizes reflecting (RO) while balancing feeling (CE) and thinking (AC), the Southerner emphasizes thinking (AC) while balancing acting (AE) and reflecting (RO), and the Westerner emphasizes acting (AE) while balancing feeling (CE) and thinking (AC). The ninth style, a balancing learn- ing style, was also identified that integrates AC and CE and AE and RO. This was added to re- duce some of the confusion that occurred with those individuals who did not fit perfectly into one of the four learning styles.

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The next quadrant is Type 2, in which learn- ing also begins with the right brain to make observations and integrate data with present knowledge. Learners then engage the left brain to think about new theories and concepts rel- ative to these observations. They ask, “What is it I am supposed to be learning? What is the relationship?”

In the third quadrant, Type 3 learners be- gin with the left brain by working with defined concepts and then shift to the right brain to ex- periment with what is to be learned. They ask, “How does this work? How can I figure this out?”

Finally, Type 4 learners begin with the left brain by analyzing the practicality of what has been learned. They then move to the right brain to show mastery through application and shar- ing of findings with others. They ask, “If I learn this, what can I do with it? Can I apply it?”

The learning sequence is circular and cyclic, beginning at Type 1 and moving to Type 4, which is characteristic of a higher level and greater complexity of learning. According to

■ Type 3/Common sense: Learners who want to know how to apply the new learning. These learners are happiest when experimenting, manipulating, improving, and tinkering.

■ Type 4/Dynamic: Learners who ask, What if? These learners enjoy modifying, adapting, taking risks, and creating.

McCarthy defines the learning process as a natural sequence from Type 1 to Type 4. Educa- tors can address all four learning styles by teach- ing sequentially, thereby attending to all types of learners. Learners are then able to work with their own strongest learning style, while at the same time developing the ability through expo- sure to work in the other quadrants.

To use this sequence, learners begin in the first quadrant of the 4MAT system, known as Type 1, and engage the right brain by sensing and feeling their way through an experience. Eventually, they move to the left brain to analyze what they have experienced. They ask, “Why is this important? Why should I try to learn this?”

FIGURE 4-6 McCarthy’s 4MAT system. Reproduced from Guild, P. B., & Garger, S. (1998). Marching to different drummers. Alexandria, VA: Association for Supervision and Curriculum Development.

Concrete Experience

Abstract Conceptualization

right ri gh

rightrig ht

left

le ft

left

Reflective Observation

Active Experimentation

TYPE FOUR:

IF? WHY?

TYPE ONE:

TYPE TWO:TYPE THREE:

HOW? WHAT?

left

Learning Style Models and Instruments 155

properties of the 4MAT system, including the learning type measure, it appears to have face validity. There seems to be no direct criticism of the 4MAT model, and it is accepted by many ed- ucators as a useful approach for presenting new information. Tsai (2004) conducted a study that compared two instructional methods (4MAT and traditional) in relation to learning achieve- ment, satisfaction, and retention in a nursing course at a Taiwan college. The researcher used the two different instructional methods in two identical courses. That is, one course used the 4MAT and the other used the traditional. The research found that the learners’ achievement, retention, and satisfaction were improved with the 4MAT system.

Gardner’s Eight Types of Intelligence Most models and measurement instruments on learning style focus on the adult as learner. How- ever, children also have their own way of learn- ing that can be assessed from the standpoint of every individual’s unique pattern of growth and neurological functioning. Psychologist Howard Gardner (1983) developed a theory focused on the multiple kinds of intelligence in children. Gard- ner based his theory on findings from brain re- search, developmental work, and psychological testing. He identified seven kinds of intelligence located in different parts of the brain: linguistic, logical-mathematical, spatial, musical, bodily- kinesthetic, interpersonal, and intrapersonal. Later, Gardner (1999b) identified an eighth kind of intelligence, called naturalistic. Each learner possesses all eight kinds of intelligence, albeit in different proportions. Gardner (2006) also is considering another kind of intelligence, called existential. In this kind of intelligence individ- uals seem to possess the ability to contemplate phenomena or questions beyond sensory data. Thus, they tend to be able to tackle questions about human existence, such as the meaning of life, why people die, and how did we get on earth.

this model, it is important for the educator to begin by stimulating Type 1 learning, which includes personal meaning for the learner to make the learning experience relevant and to answer the why question. Next, it is essential to introduce new knowledge based on accurate information to answer the what question. The third step in sequential learning is to deal with reality in a practical manner through application of knowledge to enable learners to answer the how question. Finally, in the fourth step, the learning experience must allow the learner to be inno- vative and inspiring and to create new dynamic possibilities so that the if question is answered.

By using this sequential approach to learn- ing, the educator can instill personal meaning and motivation related to what is to be learned (Type 1), assist the learner in the acquisition of the new knowledge and concepts (Type 2), al- low for active experimentation (Type 3), and provide the opportunity for more complex syn- thesis and extension through practical applica- tion (Type 4). Through use of the 4MAT system, each learning style has an opportunity to exert itself at least part of the time. A recent quality improvement project used the framework of the 4MAT system to provide a structured approach to patient education designed to improve ad- herence to a skin care regimen during radia- tion treatment (Bauer, Magnan, & Laszewski, 2016). Although the results were not signifi- cantly different between the control group and the group that received skin care education us- ing the 4MAT system, the authors did find in- creased nurse and patient satisfaction for those involved in the 4MAT system of education.

Instrument to Measure the 4MAT System McCarthy’s consulting and publishing com- pany has its own website (http://aboutlearning .com). The 4MAT instructional design and the learning-type measurement instrument is a 26-point questionnaire. Although there is lit- tle published information on the psychometric

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Often, musically intelligent children learn best with music playing in the background.

Bodily-kinesthetic intelligence involves the basal ganglia and cerebellum of the brain in addi- tion to other brain structures. Children with this type of intelligence learn by processing knowledge through bodily sensations, such as moving around or acting things out. It is difficult for these learners to sit still for long periods of time. They are good at sports and have highly developed fine-motor coordination. Use of body language to communi- cate and copying people’s behaviors or movements come easily for this group of learners.

Interpersonal intelligence involves the pre- frontal lobes of the brain. Children with high interpersonal intelligence understand people, no- tice others’ feelings, tend to have many friends, and are gifted in social skills. They learn best in groups and gravitate toward activities that in- volve others in problem solving.

Intrapersonal intelligence also involves the prefrontal lobes of the brain. Children with this type of intelligence have strong personali- ties, prefer the inner world of feelings and ideas, and like being alone. They are very private in- dividuals, desire a quiet area to learn, and pre- fer to be by themselves to learn. They tend to be self-directed and self-confident. They learn well with independent, self-paced instruction.

Naturalistic intelligence refers to sensing abilities in making patterns and connections to elements in nature. Children with high nat- uralistic intelligence can distinguish and cate- gorize objects or phenomena in nature. They enjoy subjects, shows, and stories that deal with animals or naturally occurring phenomena and are keenly aware of their surroundings and sub- tle changes in their environment.

Educators should always approach children from the perspective of these different intelli- gences (Armstrong, 1987). For nurses, it can of- ten be difficult to assess the preferred learning style of a child when he or she is facing an ill- ness or surgery. Asking some key questions of the child or parents may give the educator some clues about how to approach the child: Which

Linguistic intelligence seems to reside in Broca’s area of the left side of the brain. Chil- dren with a tendency to display this type of in- telligence have highly developed auditory skills and think in words. They like writing, telling stories, spelling words, and reading, and they can recall names, places, and dates. These chil- dren learn best by verbalizing, hearing, or see- ing words. Word games or crossword puzzles are an excellent method for helping these chil- dren to learn new material.

Logical-mathematical intelligence in- volves both sides of the brain. The right side of the brain deals with concepts, and the left side remembers symbols. The children who are strong in this intelligence explore patterns, categories, and relationships. In the adolescent years, they are able to engage in logical think- ing with a high degree of abstraction. As learn- ers, they question many things and ask where, what, and when. A question such a learner might ask is, “If people are always supposed to be good to each other, then why do people always say they are sorry?” Children who rate high in logical-mathematical intelligence can do arithmetic problems quickly in their heads, like to learn by using computers, and do ex- periments to test concepts they do not under- stand. They enjoy strategy board games such as chess and checkers.

Spatial intelligence is related to the right side of the brain. Children with high spatial intelligence learn by images and pictures. They enjoy such activities as building blocks, jigsaw puzzles, and daydreaming. They like to draw or do other art activities, can read charts and di- agrams, and learn with visual methods such as videos or photographs.

Musical intelligence also is related to the right side of the brain. Musically intelligent chil- dren can be found singing a tune, indicating when a note is off key, playing musical instru- ments with ease, dancing to music, and keep- ing time rhythmically. They also are sensitive to sounds in the environment, such as the sound of walking on snow on a cold winter morning.

Learning Style Models and Instruments 157

need to research the facts and then convey these findings to others.

■ Naturalist: Provide pet therapy, allow the child to engage in outside activities that are a form of exercise (e.g., gardening or nature walks), or offer videos that feature nature, science, or animals.

Although Gardner’s theory of multiple in- telligences was originally designed for use with children, several recent articles have addressed its application with adults. For example, Sheahan, While, and Bloomfield (2015) conducted an ex- ploratory trial that used a control group and an intervention group that benefited from multi- ple intelligences teaching approaches. The pur- pose was for teaching clinical skills to first-year undergraduate nursing students. Students were assessed for their preferred learning style. The results of this study support the use of multi- ple intelligences as teaching approaches for the various preferred ways of learning. Many edu- cators see the theory as simple common sense— that children (and adults) have varied talents and learn in different ways even though there is little evidence supporting the multiple intel- ligences theory (Gardner, 2004; Waterhouse, 2006). Additional information about Gardner’s theory is available for purchase at his website (http://www.howardgardner.com).

Instrument to Measure Multiple Intelligences Although Howard Gardner does not believe indi- viduals need be tested to find out their preferred style of learning, he does refer to an instrument called Multiple Intelligences Developmental As- sessment Scales (MIDAS™) created by C. Branton Shearer (http://www.miresearch.org/).

VARK Learning Styles Fleming and Mills (1992) have identified four categories or preferences—visual, aural, read/ write, and kinesthetic (VARK)—that seem to reflect the learning style experiences of their

subjects does the child excel in or like best? Which kinds of hobbies does the child have? What ex- cites this child? Which kinds of toys does the child play with? Which inner qualities does the child possess, such as courage, playfulness, cu- riosity, friendliness, or creativity? Which talents does the child possess?

By using Gardner’s theory of the eight intel- ligences, the educator can assess each child’s style of learning and tailor teaching accordingly. For example, if the educator wants to assist a child in learning about a kidney disorder, then the educa- tor can use one of the following eight approaches, depending on the child’s style of learning:

■ Linguistic: Practice quizzing the child orally on the different parts of the kidney, the disease itself, and different ways to take care of himself or herself.

■ Spatial: Have a diagram or chart that al- lows the child to associate different colors or shapes with concepts. Storytelling that illustrates a child with the same chronic illness can be used.

■ Bodily-kinesthetic: Have a kidney model available that can be felt, taken apart, and manipulated. Have the child identify tactile features of the kidney or act out appropriate behavior.

■ Logical-mathematical: Group concepts into categories, starting with simple generaliza- tions or health behaviors. Reasoning works well in showing the child the consequences of actions.

■ Musical: Teach self-care or the material to be learned by putting information into a song. Soft music also serves as a relaxing influence on the child.

■ Interpersonal: Have a group of children play a card game such as a version of Old Maid that matches health information with medical pictures or pictures of healthcare activities and procedures.

■ Intrapersonal: Suggest that the child become active by writing to friends, family, or local and state government officials to advocate for kidney disease research. Such learners

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intended this questionnaire to be diagnostic in nature. Educators may find VARK scores to be an excellent way to help open a dialogue with learners on the differences that exist in the way individuals prefer to learn. Leite et al. do not recommend the VARK as a research tool until other sources of psychometric evidence are col- lected. However, researchers continue to use the VARK to measure whether an educational in- tervention is successful (Bhagat, Vyas, & Singh, 2015; Stirling & Alquraini, 2017).

The VARK questionnaire is easy to use and can readily be applied in the healthcare setting. In a pilot study, Koonce, Giuse, and Storrow (2011) used the VARK assessment to tailor health information materials for emer- gency department patients who were hyper- tensive. Although there were no significant differences in changes in quiz scores on a hy- pertensive knowledge assessment between the experimental and control group, patients who received the learning style–tailored information reported higher levels of satisfaction with the intervention materials. The authors hypothe- sized that the lack of significant differences be- tween the two groups may have been a result of the presence of high baseline hypertension knowledge scores.

▸ Interpretation of the Use of Learning Style Models and Instruments

Learning style is an important concept, but ed- ucators must exercise caution when assessing styles so as not to ignore other factors that are equally important to teaching and learning, such as readiness and capabilities to learn, educa- tional background, and rates of learning. Learn- ing styles, which vary from person to person, also differ from capabilities. The style by which someone learns describes how that individual

students. The VARK model technically focuses on a person’s preference for taking in and put- ting out information. According to Fleming and Mills, an individual learns most effectively and comfortably by one of the following ways:

■ Visual learners like graphical representa- tions such as flowcharts with step-by-step directions.

■ Aural learners enjoy listening to lectures, often need directions read aloud, and prefer to discuss topics and form study groups.

■ Read/write learners like the written word, as evidenced by reading or writing, with refer- ences to additional sources of information.

■ Kinesthetic learners enjoy doing hands-on activities, such as role play and return demonstration.

Fleming also stresses that the VARK was designed to be a starting place for both educa- tors and learners to have a conversation about the different strategies for teaching and learn- ing that individuals can use as appropriate for them (Fleming and Baume, 2006). The VARK is a way to communicate. Fleming (2012) also believes that knowledge of VARK will encour- age educators to teach in styles that are not their own preferred way of teaching. Fleming and Bonwell (2013) contend that the VARK should act as a catalyst for reflection by learners about their preferences and learning strategies.

Instrument to Measure the VARK The VARK questionnaire (version 7.8) provides users with a profile of their learning preferences for taking in and giving out information. This instrument consists of 16 questions with four options or modalities, and the learner can se- lect more than one option for each question. The VARK is available for free as either an on- line or printable version (http://vark-learn.com).

Some evidence supports the validity of the VARK scores, suggesting that this instrument may be used as a low-stakes diagnostic tool by students and teachers (Leite, Svinicki, & Shi, 2010), although Fleming and Mills (1992) never

Interpretation of the Use of Learning Style Models and Instruments 159

process allows the educator to approach each learner holistically by recognizing that not all learners process information in precisely the same way (Arndt & Underwood, 1990).

Research indicates that learning style pref- erences prevail over time, although they may fluctuate depending on the context in which learners are operating at any given moment. The concept of matching styles implies that in- dividuals are static, which contradicts the pur- pose of education. Learners need to experience some discomfort before they can grow. Educa- tors need to generate dynamic disequilibrium rather than create an environment that is too harmonious (Bhagat et al., 2015; Joyce, 1984).

When selecting a learning style instrument, the educator must first evaluate the instrument for validity, reliability, and applicability to the population for which it is intended. In addition, the ease of administering the instrument as well as analyzing the results needs to be taken into consideration. Also, educators must adhere to copyright laws, which means that they must purchase the instrument or obtain the author’s permission before using the tool.

For purposes of assessment, the nurse ed- ucator is encouraged to use multiple learning style models and instruments. If the educator focuses on only one model, the possibility arises that the educator may be trying to make learn- ers fit into a specific style type that does not suit them—a forced choice with no options. Given the teaching–learning situation, the educator may find certain learning style models and in- struments to be more appropriate than others in providing strategies for dealing with needs, problems, or unique circumstances.

Of course, it may not always be practical to administer learning style instruments because of considerations such as cost, time, accessibility, or appropriateness for a specific population. There- fore, educators should follow these general guide- lines when assessing individual learning styles:

■ Become familiar with the different models and instruments available and the various

processes stimuli, whereas that individual’s ca- pabilities define how much and how well the person processes the information (Thompson & Crutchlow, 1993). Another caution to keep in mind is that much of the advice offered with re- spect to using learning styles consists of “logical deductions from the various theories of learn- ing style, rather than conclusions drawn from empirical research” (Coffield, Moseley, Hall, & Ecclestone, 2004a, p. 125).

Some learning theorists advocate that learn- ing style be matched with a similar teaching style for learners to attain an optimal level of achievement. Understanding learning styles helps educators think about how to modify their instructional methods so to best pres- ent different content and to reach the wid- est variety of learners. However, research in this area is clouded by inconsistent findings (Coffield et al., 2004b; Cuevas, 2015; Nor- man, 2009; Scott, 2005; Willingham, Hughes, & Dobolyi, 2015). After reviewing the liter- ature, Pashler, McDaniel, Rohrer, and Bjork (2008), Rogowsky, Calhoun, and Tallal (2015), and Bhagat et al. (2015) concluded that there is insufficient evidence to justify this approach. Cuevas (2014) believes learning styles are no more than a myth and suggests cognitive sci- entists and educators consider an alternative theory, dual coding, which is more strongly supported by empirical research. Dual coding refers to the idea that two separate pathways exist, one verbal and one visual, for encoding information into memory. Instead, these au- thors suggest that educators should be more concerned with matching their instruction to the content they are teaching.

It may be that learning occurs not so much because teacher and learner styles are a perfect match, but because the educator uses a variety of teaching approaches rather than relying on just one, so that learners feel less stressed and more confident. As a result, learners are more satis- fied overall with their learning experience and hence more motivated to learn. Application of learning style theory to facilitate the education

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learn in the best or most comfortable way. Un- derstanding how someone prefers to learn as- sists the educator in choosing diverse teaching methods and materials to meet the needs of both that learner and all learners.

▸ State of the Evidence Interwoven into each section of this chapter are examples of specific published research about the determinants of learning. This chapter’s frame- work for assessing the evidence to be included in support of the three determinants of learning is based on the framework suggested by Lohr (2004). She cites four dimensions of evidence that nurse educators need to consider when as- sessing the available evidence:

1. Level of evidence (study design). 2. Quality of evidence (concern with

bias). 3. Relevance of evidence (implying ap-

plicability). 4. Strength of evidence (precision, re-

producibility, and attributability).

For this chapter, using this framework was helpful in deciding what is considered ap- propriate evidence, where the evidence comes from (e.g., refereed journals as opposed to In- ternet commercial sites), and whether all the evidence counts (or counts in the same way when there are several articles from which to choose). Most of the literature about the deter- minants of learning is descriptive in nature or consists of expert opinion, and many studies lack the scientific rigor needed to provide ev- idence of strength. These studies were not in- cluded in this chapter.

The research included in this chapter sup- ports the importance of conducting an edu- cational assessment. However, the deficit of evidence on the process and criteria for assess- ment is striking when compared to the number of studies that provide evidence for the effec- tiveness of different teaching methodologies.

ways in which styles are classified so that they are easier to recognize.

■ Identify key elements of an individual’s learn- ing style by observing and asking questions to verify observations. Then, initially match teaching methods and instructional materials to those unique qualities. For example, the following questions could elicit valuable information: Do you prefer to attend lec- tures or group discussions? Which do you like best, reading or viewing a film? Would you like me to demonstrate this skill first, or would you rather learn by doing while I talk you through the procedure?

■ Always allow learners the opportunity to say when a teaching method or instructional material is not working for them.

■ Encourage learners to become aware of their learning styles so as to increase understanding from both the educator’s and the learner’s perspectives. Everyone should realize that a variety of learning modalities exist and that no one style is better than another.

■ Be cautious about saying that certain teaching methods are always more effective for certain styles. Remember that everyone is unique, circumstances may alter preferences, and many factors influence learning.

■ Prompt learners to expand their style ranges rather than to seek only comfortable experiences.

■ Provide learning choices that enable learners to operate, at least some of the time, in the style by which they prefer to learn.

■ When possible, use a team of educators who have varied teaching styles to present new and complex information in different ways to ensure mastery of information.

Educators must exercise caution when us- ing any of these instruments to assess learning style. They should avoid placing too much em- phasis or reliance on these tools to categorize learners. The goal should not be to stereotype learners as to style but rather to ensure that each learner is given an equal opportunity to

State of the Evidence 161

the educator can then choose the teaching ap- proaches and learning activities best suited for an individual.

Identifying and prioritizing learning needs require the educator to discover what the learner feels is important and the educator knows to be important. Once needs are established and agreed upon, the educator must assess the learner’s readiness to learn based on the phys- ical, emotional, experiential, and knowledge components specific to each learner. Assess- ing learning styles by interviewing, observing, and using instrument measurement can reveal how individuals best learn as well as how they prefer to learn.

By accepting the diversity of needs, read- iness levels, and styles among learners, the ed- ucator can create a versatile atmosphere and facilitate optimal experiences that encourage all learners to reach their full potential. Whoever the audience may be, nurse educators should select teaching interventions and learning ac- tivities most beneficial for the learner based on the three determinants of learning.

Review Questions 1. How would you define the term determi-

nants of learning? 2. What are the seven methods to assess

patient learning needs? 3. What is meant by the term readiness to

learn? 4. What are the four types of readiness to

learn? 5. What are the components of each type

of readiness to learn? 6. What is the definition of the term learn-

ing style? 7. Which models and instruments are

available to determine someone’s learning style?

8. What does each of the eight learning style models and instruments measure?

9. What evidence is available to support the determinants of learning?

Many of the current scientifically designed studies do not consider all the determinants of learning before examining the benefits of various teaching interventions. Every learner has different learning needs, readiness to learn, and learning styles, which may account for the paucity of experimental research in this area. Even though very few systemic reviews that pertained to learning styles were found, the ev- idence suggests that learning style instruments should be used with caution.

The amount of research-based evidence about the three determinants of learning sug- gests that educational assessment is not an easy area in which to conduct research. It is essential to acknowledge this limitation and to remem- ber that nursing research, as compared to other sciences, is still young and has attracted a much smaller number of investigators.

Even though much more evidence is needed, the available evidence on conducting an educa- tional assessment substantiates its importance and provides direction for the nurse as educa- tor. Conducting a needs assessment on all three determinants of learning is essential before any educational intervention is performed.

▸ Summary This chapter stresses the importance of the as- sessment phase of learning because the educator must be aware of and know how to determine learning needs, readiness to learn, and individ- ual learning styles prior to planning for any ed- ucational encounter.

Learning is a complex concept that is not directly seen but rather can be inferred from permanent changes that occur in the learner’s behavior in the cognitive, psychomotor, and af- fective domains. Educators should not define behavioral objectives for these three domains until they establish the needs of the learner, the learner’s readiness to learn, and the ways in which the learner best learns. Based on the findings from assessment of these determinants,

162 Chapter 4 Determinants of Learning

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CASE STUDY You are a member of the interdisciplinary team working with Barbara Lund, a 36-year-old woman recovering from a recent surgical resection of a malignant thoracic spinal cord tumor. Mrs. Lund has a supportive husband and a 2-year-old son. Mrs. Lund’s husband, James, states, “I am really worried about Barbara because she was quite distressed for about 6 months prior to this surgery over the death of her father. I fear the surgery may have pushed her over the edge.” Currently, 2 week’s status post resection, Mrs. Lund is beginning to ask team members questions about her prognosis and potential functional abilities. She says, “I remember my surgeon trying to explain the surgery to me, but honestly, I didn’t really understand much of what he told me. I am a bit naive when it comes to anything medical.” Mrs. Lund appears quite anxious about the cancer diagnosis and about how she will be able to continue caring for her son.

1. What are two methods you might use to assess Mrs. Lund’s learning needs? List the advantages and disadvantages of each method.

2. Describe the criteria your team, in conjunction with Mrs. Lund’s perceptions, will use to prioritize her learning needs. Give examples of specific learning needs that will likely be a priority.

3. Which major clues indicate Mrs. Lund’s readiness to learn? Using the PEEK model, identify potential obstacles that might interfere with her readiness to learn.

4. According to the VARK model, how will knowledge of Mrs. Lund’s learning preference(s) affect your team’s instructional approach? Choose one VARK learning preference for Mrs. Lund and describe the instructional approach your team will use to support this preference.

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168 Chapter 4 Determinants of Learning

Developmental Stages of the Learner Susan B. Bastable Gina M. Myers

CHAPTER HIGHLIGHTS

■ Developmental Characteristics ■ The Developmental Stages of Childhood

• Infancy (First 12 Months of Life) and Toddlerhood (1–2 Years of Age) • Early Childhood (3–5 Years of Age) • Middle and Late Childhood (6–11 Years of Age) • Adolescence (12–19 Years of Age)

■ The Developmental Stages of Adulthood • Young Adulthood (20–40 Years of Age) • Middle-Aged Adulthood (41–64 Years of Age) • Older Adulthood (65 Years of Age and Older)

■ The Role of the Family in Patient Education ■ State of the Evidence

KEY TERMS

pedagogy object permanence causality precausal thinking animistic thinking egocentric causation syllogistic reasoning

conservation causal thinking propositional reasoning egocentrism imaginary audience personal fable andragogy

dialectical thinking ageism geragogy crystallized intelligence fluid intelligence

169

CHAPTER 5

When planning, designing, implement-ing, and evaluating an educational program, the nurse as educator must carefully consider the characteristics of learn- ers with respect to their developmental stage in life. The more heterogeneous the target au- dience, the more complex the development of an educational program to meet the diverse needs of the population. Conversely, the more homogeneous the population of learners, the more straightforward the approach to teaching.

An individual’s developmental stage signifi- cantly influences the ability to learn. Pedagogy, andragogy, and geragogy are three different ori- entations to learning in childhood, young and middle adulthood, and older adulthood, respec- tively. To meet the health-related educational needs of learners, a developmental approach must be used. Three major stage-range factors associated with learner readiness—physical, cognitive, and psychosocial maturation—must be considered at each developmental period throughout the life cycle.

For many years, developmental psychologists have explored the various patterns of behavior characteristic of specific stages of development. Educators, more than ever before, acknowledge the effects of growth and development on an individual’s willingness and ability to make use of instruction. This chapter has specific impli- cations for nurses educating patients, staff, and students as teaching plans must address stage- specific competencies of the learner. In this chap- ter, therefore, the distinct life stages of learners are examined from the perspective of physical,

cognitive, and psychosocial development. Also, this chapter emphasizes the role of the nurse in assessment of stage-specific learner needs, the role of the family in the teaching–learning process, and the teaching strategies specific to meeting the needs of learners at various devel- opmental stages of life.

A deliberate attempt has been made to min- imize reference to age as the criterion for cat- egorization of learners. Research on life-span development shows that chronological age per se is not the only predictor of learning ability (Crandell, Crandell, & Vander Zanden, 2012; Santrock, 2017). At any given age, one finds a wide variation in the acquisition of abilities related to the three fundamental domains of development: physical (biological), cognitive, and psychosocial (emotional–social) maturation. Age ranges, such as those included after each developmental stage heading in this chapter, are intended to be used as merely approximate age-strata reference points or general guidelines; they do not imply that chrono- logical ages necessarily correspond perfectly to the various stages of development (Newman & Newman, 2015). Thus, the term developmental stage is the perspective used, based on the con- firmation from research that human growth and development are sequential but not always spe- cifically age related (Kail & Cavanaugh, 2015).

Recently, it has become clear that develop- ment is contextual. Even though the passage of time has traditionally been synonymous with chronological age, social and behavioral psy- chologists have begun to consider the many other changes occurring over time that affect

OBJECTIVES

After completing this chapter, the reader will be able to

1. Identify the physical, cognitive, and psychosocial characteristics of learners that influence learning at various stages of growth and development.

2. Recognize the role of the nurse as educator in assessing stage-specific learner needs according to maturational levels.

3. Determine the role of the family in patient education. 4. Discuss appropriate teaching strategies effective for learners at different developmental stages.

170 Chapter 5 Developmental Stages of the Learner

the dynamic relationship between a human’s bi- ological makeup and the environment. It is now understood that three important contextual in- fluences act on and interact with the individual to produce development (Crandell et al., 2012; Santrock, 2017):

1. Normative age-graded influences are strongly related to chronological age and are similar for individuals in a specific age group, such as the biolog- ical processes of puberty and meno- pause and the sociocultural processes of transitioning to different levels of formal education or to retirement.

2. Normative history-graded influences are common to people in a certain age cohort or generation because they have been uniquely exposed to similar historical circumstances, such as the Vietnam War, the age of computers, or the terrorist events of September 11, 2001.

3. Normative life events are the unusual or unique circumstances, positive or negative, that are turning points in individuals’ lives that cause them to change direction, such as a house fire, serious injury in an accident, win- ning the lottery, divorce, or an un- expected career opportunity.

Although this chapter focuses on the patient as the learner throughout the life span, nurses and nurse educators can apply the stage-specific characteristics of adulthood and the associated principles of adult learning presented herein to any audience of young, middle, or older adult learners, whether the nurse is instructing the public in the community, preparing students in a nursing education program, or providing con- tinuing education to staff nurses or colleagues.

▸ Developmental Characteristics

As noted earlier, actual chronological age is only a relative indicator of someone’s physical,

cognitive, and psychosocial stage of development. Unique as every individual is in the world, how- ever, some typical developmental trends have been identified as milestones of normal progres- sion through the life cycle. When dealing with the teaching–learning process, it is imperative to examine the developmental phases as individuals progress from infancy to senescence to fully ap- preciate the behavioral changes that occur in the cognitive, affective, and psychomotor domains.

As influential as age can be to learning read- iness, it should never be examined in isolation. Growth and development interact with expe- riential background, physical and emotional health status, and personal motivation, as well as numerous environmental factors such as stress, the surrounding conditions, and the available support systems, to affect a person’s ability and readiness to learn.

Musinski (1999) describes three phases of learning: dependence, independence, and inter- dependence. These passages of learning ability from childhood to adulthood, labeled by Covey (1990) as the “maturity continuum,” are identi- fied as follows.

■ Dependence is characteristic of the infant and young child, who are totally depen- dent on others for direction, support, and nurturance from a physical, emotional, and intellectual standpoint (unfortunately, some adults are considered stuck in this stage if they demonstrate manipulative behavior, do not listen, are insecure, or do not accept responsibility for their own actions).

■ Independence occurs when a child develops the ability to physically, intellectually, and emotionally care for himself or herself and make his or her own choices, including taking responsibility for learning.

■ Interdependence occurs when an individ- ual has sufficiently advanced in maturity to achieve self-reliance, a sense of self-esteem, and the ability to give and receive, and when that individual demonstrates a level of respect for others. Full physical matu- rity does not guarantee simultaneous emo- tional and intellectual maturity.

Developmental Characteristics 171

If the nurse as educator is to encourage learn- ers to take responsibility for their own health, learners must be recognized as an important source of data regarding their health status. Be- fore any learning can occur, the nurse must as- sess how much knowledge the learner already possesses with respect to the topic to be taught. With the child as client, for example, new con- tent should be introduced at appropriate stages of development and should build on the child’s previous knowledge base and experiences.

The major question underlying the plan- ning for educational experiences is: When is the most appropriate or best time to teach the learner? The answer is when the learner is ready. The teachable moment, as defined by Havighurst (1976), is that point in time when the learner is most receptive to a teaching situation. It is im- portant to realize that the teachable moment need not be a spontaneous and unpredictable event. That is, the nurse as educator does not always have to wait for teachable moments to occur; the teacher can actively create these opportunities by taking an interest in and attending to the needs of the learner, as well as using the present situ- ation to heighten the learner’s awareness of the need for health behavior changes (Hinkle, 2014; Lawson & Flocke, 2009). When assessing readi- ness to learn, the nurse educator must determine not only whether an interpersonal relationship has been established, prerequisite knowledge and skills have been mastered, and the learner exhibits motivation, but also whether the plan for teaching matches the learner’s developmen- tal level (Crandell et al., 2012; Leifer & Hartston, 2013; Polan & Taylor, 2015; Santrock, 2017).

▸ The Developmental Stages of Childhood

Pedagogy is the art and science of helping chil- dren to learn (Knowles, 1990; Knowles, Holton, & Swanson, 2015). The different stages of child- hood are divided according to what develop- mental theorists and educational psychologists

define as specific patterns of behavior seen in definitive phases of growth and development. One common attribute observed throughout all phases of childhood is that learning is subject centered. This section reviews the developmen- tal characteristics in the four stages of child- hood and the teaching strategies to be used in relation to the physical, cognitive, and psycho- social maturational levels indicative of learner readiness (TABLE 5-1).

Infancy (First 12 Months of Life) and Toddlerhood (1–2 Years of Age) The field of growth and development is highly complex, and at no other time is physical, cog- nitive, and psychosocial maturation so change- able as during the very early years of childhood. Because of the dependency of members of this age group, the focus of instruction for health maintenance of children is geared toward the parents, who are considered the primary learn- ers rather than the very young child (Callans, Bleiler, Flanagan, & Carroll, 2016; Crandell et al., 2012; Santrock, 2017). However, the older tod- dler should not be excluded from healthcare teaching and can participate to some extent in the education process.

Physical, Cognitive, and Psychosocial Development At no other time in life is physical maturation so rapid as during the period of development from infancy to toddlerhood (London et al., 2017). Exploration of self and the environment becomes paramount and stimulates further phys- ical development (Crandell et al., 2012; Kail & Cavanaugh, 2015). Patient education must focus on teaching the parents of very young children the importance of stimulation, nutrition, the practice of safety measures to prevent illness and injury, and health promotion (Polan & Taylor, 2015).

172 Chapter 5 Developmental Stages of the Learner

TA B

LE 5

-1 S

ta ge

-A pp

ro pr

ia te

Te ac

hi ng

S tra

te gi

Le ar

ne r

Ge ne

ra l C

ha ra

ct er

is ti

cs Te

ac hi

ng S

tr at

eg ie

s N

ur si

ng In

te rv

en ti

on s

In fa

nc y–

To dd

le rh

oo d

A p

p ro

xi m

at e

ag e:

Bi rt

h –2

y ea

rs C

o g

n it

iv e

st ag

e: Se

n so

ri m

o to

r Ps

yc h

o so

ci al

s ta

g e:

Tr u

st v

s. m

is tr

u st

ir th

–1 2

m o

) A

u to

n o

m y

vs . s

h am

e an

d o

u b

t (1

–2 y

D ep

en d

en t

o n

e n

vi ro

n m

en t

N ee

d s

se cu

ri ty

Ex p

lo re

s se

lf an

d e

n vi

ro n

m en

t N

at u

ra l c

u ri

o si

O ri

en t

te ac

h in

g t

o c

ar eg

iv er

U se

re p

et it

io n

a n

d im

it at

io n

o f

in fo

rm at

io n

St im

u la

te a

ll se

n se

s Pr

o vi

d e

p h

ys ic

al s

af et

y an

d e

m o

ti o

n al

cu ri

ty A

llo w

p la

y an

d m

an ip

u la

ti o

n o

f o b

je ct

W el

co m

e ac

ti ve

in vo

lv em

en t

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e al

lia n

ce s

En co

u ra

g e

p h

ys ic

al c

lo se

n es

s Pr

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d e

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at io

n A

n sw

er q

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ti o

n s

an d

n ce

rn s

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fo r

in fo

rm at

io n

o n

c h

ild ’s

st re

n g

th s/

lim it

at io

n s

an d

li ke

s/ d

is lik

Ea rl

y Ch

ild ho

A p

p ro

xi m

at e

ag e:

3– 5

ye ar

s C

o g

n it

iv e

st ag

e: Pr

eo p

er at

io n

al Ps

yc h

o so

ci al

s ta

g e:

In it

ia ti

ve v

s. g

u ilt

Eg o

ce n

tr ic

Th in

ki n

g p

re ca

u sa

l, co

n cr

et e,

li te

ra l

Be lie

ve s

ill n

es s

se lf-

ca u

se d

a n

p u

n it

iv e

Li m

it ed

s en

se o

f t im

e Fe

ar s

b o

d ily

in ju

ry C

an n

o t

g en

er al

iz e

A n

im is

ti c

th in

ki n

g (o

b je

ct s

p o

ss es

s lif

e o

r h

u m

an c

h ar

ac te

ri st

ic s)

C en

tr at

io n

(f o

cu s

is o

n o

n e

ch ar

ac te

ri st

ic o

f a n

o b

je ct

) Se

p ar

at io

n a

n xi

et y

M o

ti va

te d

b y

cu ri

o si

ty A

ct iv

e im

ag in

at io

n , p

ro n

e to

fe ar

s Pl

ay is

h is

/h er

w o

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w ar

m , c

al m

a p

p ro

ac h

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t ru

st U

se re

p et

it io

n o

f i n

fo rm

at io

n A

llo w

m an

ip u

la ti

o n

o f o

b je

ct s

an d

u ip

m en

t G

iv e

ca re

w it

h e

xp la

n at

io n

R ea

ss u

re n

o t

to b

la m

e se

lf Ex

p la

in p

ro ce

d u

re s

si m

p ly

a n

d b

ri ef

ly Pr

o vi

d e

sa fe

, s ec

u re

e n

vi ro

n m

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p o

si ti

ve re

in fo

rc em

en t

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u ra

g e

q u

es ti

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s to

re ve

p er

ce p

ti o

n s/

fe el

in g

s U

se s

im p

le d

ra w

in g

s an

d s

to ri

es U

se p

la y

th er

ap y,

w it

h d

o lls

a n

d p

u p

p et

s St

im u

la te

s en

se s:

V is

u al

, a u

d it

o ry

, t ac

ti le

, m

o to

W el

co m

e ac

ti ve

in vo

lv em

en t

Fo rg

e al

lia n

ce s

En co

u ra

g e

p h

ys ic

al c

lo se

n es

s Pr

o vi

d e

d et

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d in

fo rm

at io

n A

n sw

er q

u es

ti o

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an d

n ce

rn s

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fo r

in fo

rm at

io n

o n

c h

ild ’s

st re

n g

th s/

lim it

at io

n s

an d

li ke

s/ d

is lik

(c on

tin u

es )

The Developmental Stages of Childhood 173

Le ar

ne r

Ge ne

ra l C

ha ra

ct er

is ti

cs Te

ac hi

ng S

tr at

eg ie

s N

ur si

ng In

te rv

en ti

on s

M id

dl e

A nd

L at

e Ch

ild ho

A p

p ro

xi m

at e

ag e:

6– 11

y ea

rs C

o g

n it

iv e

st ag

e: C

o n

cr et

e o

p er

at io

n s

Ps yc

h o

so ci

al s

ta g

e: In

d u

st ry

v s.

in fe

ri o

ri ty

M o

re re

al is

ti c

an d

o b

je ct

iv e

U n

d er

st an

d s

ca u

se a

n d

e ffe

ct D

ed u

ct iv

e/ in

d u

ct iv

e re

as o

n in

g W

an ts

c o

n cr

et e

in fo

rm at

io n

A b

le t

o c

o m

p ar

e o

b je

ct s

an d

e ve

n ts

Va ri

ab le

r at

es o

f p h

ys ic

al g

ro w

th R

ea so

n s

sy llo

g is

ti ca

lly U

n d

er st

an d

s se

ri o

u sn

es s

an d

n se

q u

en ce

s o

f a ct

io n

s Su

b je

ct -c

en te

re d

fo cu

s Im

m ed

ia te

o ri

en ta

ti o

En co

u ra

g e

in d

ep en

d en

ce a

n d

a ct

iv e

p ar

ti ci

p at

io n

Be h

o n

es t,

al la

y fe

ar s

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lo g

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la n

at io

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llo w

t im

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q u

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o n

s U

se a

n al

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ie s

to m

ak e

in vi

si b

le p

ro ce

ss es

al Es

ta b

lis h

ro le

m o

d el

s R

el at

e ca

re t

o o

th er

c h

ild re

n’ s

ex p

er ie

n ce

s; c

o m

p ar

e p

ro ce

d u

re s

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s u

b je

ct -c

en te

re d

fo cu

s U

se p

la y

th er

ap y

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vi d

e g

ro u

p a

ct iv

it ie

s U

se d

ia g

ra m

s, m

o d

el s,

p ic

tu re

s, d

ig it

m ed

ia , p

ri n

te d

m at

er ia

ls , a

n d

c o

m p

u te

r, ta

b le

t, o

r sm

ar tp

h o

n e

ap p

lic at

io n

s as

ju n

ct s

to v

ar io

u s

te ac

h in

g m

et h

o d

W el

co m

e ac

ti ve

in vo

lv em

en t

Fo rg

e al

lia n

ce s

En co

u ra

g e

p h

ys ic

al c

lo se

n es

s Pr

o vi

d e

d et

ai le

d in

fo rm

at io

n A

n sw

er q

u es

ti o

n s

an d

n ce

rn s

A sk

fo r

in fo

rm at

io n

o n

c h

ild ’s

st re

n g

th s/

lim it

at io

n s

an d

li ke

s/ d

is lik

TA B

LE 5

-1 S

ta ge

-A pp

ro pr

ia te

Te ac

hi ng

S tra

te gi

(c on

tin u

ed )

174 Chapter 5 Developmental Stages of the Learner

A do

le sc

en ce

A p

p ro

xi m

at e

ag e:

12 –1

9 ye

ar s

C o

g n

it iv

e st

ag e:

Fo rm

al o

p er

at io

n s

Ps yc

h o

so ci

al s

ta g

e: Id

en ti

ty v

s. ro

le c

o n

fu si

o n

A b

st ra

ct , h

yp o

th et

ic al

t h

in ki

n g

C an

b u

ild o

n p

as t

le ar

n in

g R

ea so

n s

b y

lo g

ic a

n d

u n

d er

st an

d s

sc ie

n ti

fic p

ri n

ci p

le s

Fu tu

re o

ri en

ta ti

o n

M o

ti va

te d

b y

d es

ire fo

r so

ci al

ce p

ta n

ce Pe

er g

ro u

p im

p o

rt an

t In

te n

se p

er so

n al

p re

o cc

u p

at io

n ,

ap p

ea ra

n ce

e xt

re m

el y

im p

o rt

an t

(im ag

in ar

y au

d ie

n ce

) Fe

el s

in vu

ln er

ab le

, i n

vi n

ci b

le /

im m

u n

e to

n at

u ra

l l aw

s (p

er so

n al

b le

)

Es ta

b lis

h t

ru st

, a u

th en

ti ci

ty K

n o

w t

h ei

r ag

en d

a A

d d

re ss

fe ar

s/ co

n ce

rn s

ab o

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tc o

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f i lln

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in p

la n

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d p

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rr an

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p ee

r g

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s in

p er

so n

r vi

rt u

al ly

(e .g

., b

lo g

s, s

o ci

al n

et w

o rk

in g

, p

o d

ca st

s, o

n lin

e vi

d eo

s) U

se a

u d

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s, ro

le p

la y,

c o

n tr

ac ts

, re

ad in

g m

at er

ia ls

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vi d

e fo

r e xp

er im

en ta

tio n

a n

d fl

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lo re

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n d

fin

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p o

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et er

m in

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ti o

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ve ls

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p ec

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m in

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sp o

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s En

g ag

e in

1 :1

t ea

ch in

g w

it h

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t p

ar en

ts p

re se

n t,

b u

t w

it h

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sc en

t’s p

er m

is si

o n

in fo

fa m

ily o

f c o

n te

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co ve

re d

Yo un

g A

du lt

ho od

A p

p ro

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at e

ag e:

20 –4

0 ye

ar s

C o

g n

it iv

e st

ag e:

Fo rm

al o

p er

at io

n s

Ps yc

h o

so ci

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ta g

e: In

ti m

ac y

vs . i

so la

ti o

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to n

o m

o u

s Se

lf- d

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ed U

se s

p er

so n

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an ce

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in te

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it h

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m o

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b le

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it ic

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p et

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-b as

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en te

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s D

ra w

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m ea

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cu s

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f a p

p lic

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co u

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w t

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er ia

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p p

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la yi

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a n

d h

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s- o

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lo re

e m

o ti

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in an

ci al

, an

d p

h ys

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s u

p p

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s ys

te m

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m o

ti va

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r in

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t Id

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fy p

o te

n ti

al o

b st

ac le

s an

d s

tr es

so rs

(c on

tin u

es )

The Developmental Stages of Childhood 175

Le ar

ne r

Ge ne

ra l C

ha ra

ct er

is ti

cs Te

ac hi

ng S

tr at

eg ie

s N

ur si

ng In

te rv

en ti

on s

M id

dl e-

A ge

d A

du lt

ho od

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p ro

xi m

at e

ag e:

41 –6

4 ye

ar s

C o

g n

it iv

e st

ag e:

Fo rm

al o

p er

at io

n s

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h o

so ci

al s

ta g

e: G

en er

at iv

it y

vs . s

el f-

ab so

rp ti

o n

a n

d s

ta g

n at

io n

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se o

f s el

f w el

l d ev

el o

p ed

C o

n ce

rn ed

w it

h p

h ys

ic al

c h

an g

es A

t p

ea k

in c

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p lo

re s

al te

rn at

iv e

lif es

ty le

s R

ef le

ct s

o n

c o

n tr

ib u

ti o

n s

to fa

m ily

d s

o ci

et y

R ee

xa m

in es

g o

al s

an d

v al

u es

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st io

ns a

ch ie

ve m

en ts

a nd

s uc

ce ss

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as c

o n

fid en

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a b

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s to

m o

d ify

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p o

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ss es

s p

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al s

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tr es

s ca

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b y

m id

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cr is

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su es

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vi d

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fo rm

at io

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it h

li fe

n ce

rn s

an d

p ro

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m s

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lo re

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o ti

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al , f

in an

ci al

, an

d p

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p p

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s ys

te m

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m o

ti va

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l f o

r in

vo lv

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t Id

en ti

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b st

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s an

d s

tr es

so rs

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er A

du lt

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p ro

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ag e:

65 y

ea rs

a n

d o

ve r

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g n

it iv

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ag e:

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al o

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at io

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ta g

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o in

te g

ri ty

v s.

d es

p ai

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g n

it iv

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h a

n g

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re as

ed a

b ili

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k ab

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, p

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at io

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s h

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cr ea

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ti o

n t

im e

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ea se

d t

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u lu

s p

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ft er

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cu se

s o

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as t

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c o

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ex am

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as t

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ex p

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n ce

s M

ak e

in fo

rm at

io n

re le

va n

t a n

d m

ea n

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en t

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se (s

lo w

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io n

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ri tt

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xa m

s U

se v

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al e

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an g

e an

d c

o ac

h in

g Es

ta b

lis h

re tr

ie va

l p la

n (u

se o

n e

o r

se ve

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lu es

) En

co u

ra g

e ac

ti ve

in vo

lv em

en t

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e xp

la n

at io

n s

b ri

ef U

se a

n al

o g

ie s

to il

lu st

ra te

a b

st ra

in fo

rm at

io n

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lv e

p ri

n ci

p al

c ar

eg iv

er s

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u ra

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p ar

ti ci

p at

io n

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vi d

e re

so u

rc es

fo r

su p

p o

(r es

p it

e ca

re )

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es s

co p

in g

m ec

h an

is m

s Pr

o vi

d e

w ri

tt en

in st

ru ct

io n

s fo

r re

in fo

rc em

en t

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vi d

e an

ti ci

p at

o ry

p ro

b le

so lv

in g

(w h

at h

ap p

en s

if . .

TA B

LE 5

-1 S

ta ge

-A pp

ro pr

ia te

Te ac

hi ng

S tra

te gi

es (

co n

tin u

ed )

176 Chapter 5 Developmental Stages of the Learner

S e

n so

ry /m

o to

r d

e fi

ci ts

A u

d it

o ry

c h

an g

es H

ea ri

n g

lo ss

, e sp

ec ia

lly h

ig h

-p it

ch ed

n es

, c o

n so

n an

ts (S

, Z , T

, F , a

n d

G ),

an d

r ap

id s

p ee

ch Vi

su al

c h

an g

es Fa

rs ig

h te

d (n

ee d

s g

la ss

es t

o re

ad )

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se s

b ec

o m

e o

p aq

u e

(g la

p ro

b le

m )

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le r

p u

p il

si ze

(d ec

re as

ed v

is u

ad ap

ta ti

o n

t o

d ar

kn es

s) D

ec re

as ed

p er

ip h

er al

p er

ce p

ti o

n Ye

llo w

in g

o f l

en se

s (d

is to

rt s

w -t

o n

e co

lo rs

: b lu

e, g

re en

, v io

le t)

D is

to rt

ed d

ep th

p er

ce p

ti o

n Fa

ti g

u e/

d ec

re as

ed e

n er

g y

le ve

ls Pa

th o

p h

ys io

lo g

y (c

h ro

n ic

il ln

es s)

Sp ea

k sl

o w

ly , d

is ti

n ct

ly U

se lo

w -p

it ch

ed t

o n

es A

vo id

s h

o u

ti n

g U

se v

is u

al a

id s

to s

u p

p le

m en

t ve

rb al

st ru

ct io

n A

vo id

g la

re s,

u se

s o

ft w

h it

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vi d

e su

ff ic

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w h

it e

b ac

kg ro

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d s

an d

b la

ck p

ri n

t U

se la

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le tt

er s

an d

w el

l- sp

ac ed

p ri

n t

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id c

o lo

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d in

g w

it h

p as

te l b

lu es

, g

re en

s, p

u rp

le s,

a n

d y

el lo

w s

In cr

ea se

s af

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p re

ca u

ti o

n s/

p ro

vi d

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en vi

ro n

m en

t En

su re

a cc

es si

b ili

ty a

n d

fi t

o f p

ro st

h es

(i. e.

, g la

ss es

, h ea

ri n

g a

id )

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s es

si o

n s

sh o

rt Pr

o vi

d e

fo r

fr eq

u en

t re

st p

er io

d s

A llo

w fo

r ex

tr a

ti m

e to

p er

fo rm

Es ta

b lis

h re

al is

ti c

sh o

rt -t

er m

g o

al s

P sy

ch o

so ci

a l c

h a

n g

e s

D ec

re as

ed r

is k

ta ki

n g

Se le

ct iv

e le

ar n

in g

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m id

at ed

b y

fo rm

al le

ar n

in g

G iv

e ti

m e

to re

m in

is ce

Id en

ti fy

a n

d p

re se

n t

p er

ti n

en t

m at

er ia

l U

se in

fo rm

al t

ea ch

in g

s es

si o

n s

D em

o n

st ra

te re

le va

n ce

o f i

n fo

rm at

io n

t o

ai ly

li fe

A ss

es s

re so

u rc

es M

ak e

le ar

n in

g p

o si

ti ve

Id en

ti fy

p as

t p

o si

ti ve

e xp

er ie

n ce

s In

te g

ra te

n ew

b eh

av io

rs w

it h

fo rm

er ly

ta b

lis h

ed o

n es

The Developmental Stages of Childhood 177

to foster this aspect of development by talking with and listening to their child. As they progress through this phase, children begin to engage in fantasizing and make-believe play. Because they are unable to distinguish fact from fiction and have limited cognitive capacity for understand- ing cause and effect, the disruption in their rou- tine during illness or hospitalizations, along with the need to separate from parents, is very stress- ful for the toddler (London et al., 2017). Rou- tines give these children a sense of security, and they gravitate toward ritualistic ceremonial-like exercises when carrying out activities of daily living. Separation anxiety is also characteris- tic of this stage of development and is particu- larly apparent when children feel insecure in an unfamiliar environment. This anxiety is often compounded when they are subjected to med- ical procedures and other healthcare interven- tions performed by people who are strangers to them (London et al., 2017).

According to Erikson (1963), the noted au- thority on psychosocial development, the pe- riod of infancy is one of trust versus mistrust. During this time, children must work through their first major dilemma of developing a sense of trust with their primary caretaker. As the in- fant matures into toddlerhood, autonomy versus shame and doubt emerges as the central issue. During this period of psychosocial growth, tod- dlers must learn to balance feelings of love and hate and learn to cooperate and control willful desires (TABLE 5-2).

Children progress sequentially through ac- complishing the tasks of developing basic trust in their environment to reaching increasing lev- els of independence and self-assertion. Their newly discovered sense of independence often is expressed by demonstrations of negativism. Children may have difficulty in making up their minds, and, aggravated by personal and exter- nal limits, they may express their level of frus- tration and feelings of ambivalence in words and behaviors, such as by engaging in tem- per tantrums to release tensions (Falvo, 2011). With peers, play is a parallel activity, and it is not unusual for them to end up in tears because

Piaget (1951, 1952, 1976)—a noted expert in defining the key milestones in the cogni- tive development of children—labels the stage of infancy to toddlerhood as the sensorimotor period. This period refers to the coordination and integration of motor activities with sensory perceptions. As children mature from infancy to toddlerhood, learning is enhanced through sensory experiences and through movement and manipulation of objects in the environ- ment. Toward the end of the second year of life, the very young child begins to develop object permanence—that is, recognition that objects and events exist even when they cannot be seen, heard, or touched (Santrock, 2017). Motor ac- tivities promote toddlers’ understanding of the world and an awareness of themselves as well as others’ reactions in response to their own ac- tions. Encouraging parents to create a safe envi- ronment can allow their child to develop with a decreased risk for injury.

The toddler has the rudimentary capacity for basic reasoning, understands object perma- nence, has the beginnings of memory, and begins to develop an elementary concept of causality, which refers to the ability to grasp a cause-and- effect relationship between two paired, succes- sive events (Crandell et al., 2012). With limited ability to recall past happenings or anticipate future events, the toddler is oriented primarily to the here and now and has little tolerance for delayed gratification. The child who has lived with strict routines and plenty of structure has more of a grasp of time than the child who lives in an unstructured environment.

Children at this stage have short attention spans, are easily distracted, are egocentric in their thinking, and are not amenable to correc- tion of their own ideas. Unquestionably, they believe their own perceptions to be reality. Asking questions is the hallmark of this age group, and cu- riosity abounds as they explore places and things. They can respond to simple, step-by-step com- mands and obey such directives as “give Grandpa a kiss” or “go get your teddy bear” (Santrock, 2017).

Language skills are acquired rapidly during this period, and parents should be encouraged

178 Chapter 5 Developmental Stages of the Learner

the child and parents can adversely affect their readiness to learn. See Chapter 4 on factors in- fluencing readiness to learn.

Although teaching activities primarily are directed to the main caregiver(s), children at this developmental stage in life have a great capacity for learning. Toddlers are capable of some degree of understanding procedures and interventions that they may experience. Because of the young child’s natural tendency to be intimidated by un- familiar people, it is imperative that a primary nurse is assigned and time is taken to establish a relationship with the child and parents. This approach not only provides consistency in the teaching–learning process but also helps to re- duce the child’s fear of strangers. Parents should be present whenever possible during formal and informal teaching and learning activities to allay

they have not yet learned about tact, fairness, or rules of sharing (Miller & Stoeckel, 2016; Po- lan & Taylor, 2015).

Teaching Strategies Patient education for infancy through toddler- hood need not be illness related. Usually less time is devoted to teaching parents about ill- ness care, and considerably more time is spent teaching aspects of normal development, safety, health promotion, and disease prevention. When the child becomes ill or injured, the first prior- ity for teaching interventions would be to as- sess the parents’ and child’s anxiety levels and to help them cope with their feelings of stress related to uncertainty and guilt about the cause of the illness or injury. Anxiety on the part of

TABLE 5-2 Erikson’s Nine Stages of Psychosocial Development

Developmental Stages Psychosocial Stages Strengths

Infancy Trust versus mistrust Hope

Toddlerhood Autonomy versus shame and doubt

Will

Early childhood Initiative versus guilt Purpose

Middle and late childhood Industry versus inferiority Competence

Adolescence Identity versus role confusion Fidelity

Young adulthood Intimacy versus isolation Love

Middle-aged adulthood Generativity versus self- absorption and stagnation

Care

Older adulthood Ego integrity versus despair Wisdom

Very old age (late 80s and beyond) Hope and faith versus despair Wisdom and transcendence

Data from Ahroni, J. H. (1996). Strategies for teaching elders from a human development perspective. Diabetes Educator, 22(1), 47–52; Crandell, T. L., Crandell, C. H., & Vander Zanden, J. W. (2012). Human development (10th ed.). New York, NY: McGraw-Hill.

The Developmental Stages of Childhood 179

■ Perform procedures on a teddy bear or doll first to help the child anticipate what an experience will be like.

■ Allow the child something to do—squeeze your hand, hold a Band-Aid, sing a song, cry if it hurts—to channel his or her response to an unpleasant experience.

■ Keep teaching sessions brief (no longer than about 5 minutes each) because of the child’s short attention span.

■ Cluster teaching sessions close together so that children can remember what they learned from one instructional encounter to another.

■ Avoid analogies and explain things in straight- forward and simple terms because children take their world literally and concretely.

■ Individualize the pace of teaching according to the child’s responses and level of attention.

For Long-Term Learning ■ Focus on rituals, imitation, and repetition

of information in the form of words and actions to hold the child’s attention. For example, practice washing hands before and after eating and toileting.

■ Use reinforcement as an opportunity for children to achieve permanence of learning through practice.

■ Employ the teaching methods of gaming and modeling as a means by which children can learn about the world and test their ideas over time.

■ Encourage parents to act as role models, be- cause their values and beliefs serve to re- inforce healthy behaviors and significantly influence the child’s development of atti- tudes and behaviors.

Early Childhood (3–5 Years of Age) Children in the preschool years continue with development of skills learned in the earlier years of growth. Their sense of identity becomes clearer, and their world expands to encompass

stress, which could be compounded by separa- tion anxiety (London et al., 2017).

Ideally, health teaching should take place in an environment familiar to the child, such as the home or daycare center. When the child is hos- pitalized, the environment selected for teaching and learning sessions should be as safe and secure as possible, such as the child’s bed or the playroom, to increase the child’s sense of feeling protected.

Movement is an important mechanism by which toddlers communicate. Immobility re- sulting from illness, hospital confinement, or disability tends to increase children’s anxiety by restricting activity. Nursing interventions that promote children’s use of gross motor abilities and that stimulate their visual, auditory, and tac- tile senses should be chosen whenever possible.

Developing rapport with children through simple teaching helps to elicit their cooperation and active involvement. The approach to chil- dren should be warm, honest, calm, accepting, and matter of fact. A smile, a warm tone of voice, a gesture of encouragement, or a word of praise goes a long way in attracting children’s attention and helping them adjust to new circumstances. Fundamental to the child’s response is how the parents respond to healthcare personnel and medical interventions.

The following teaching strategies are sug- gested to convey information to members of this age group. These strategies feed into chil- dren’s natural tendency for play and their need for active participation and sensory experiences.

For Short-Term Learning ■ Read simple stories from books with lots

of pictures. ■ Use dolls and puppets to act out feelings

and behaviors. ■ Use simple audiotapes with music and

videotapes with cartoon characters. ■ Role play to bring the child’s imagination

closer to reality. ■ Give simple, concrete, nonthreatening ex-

planations to accompany visual and tactile experiences.

180 Chapter 5 Developmental Stages of the Learner

mechanical forces. They often believe that they can influence natural phenomena, and their be- liefs reflect animistic thinking—the tendency to endow inanimate objects with life and conscious- ness (Pidgeon, 1977; Santrock, 2017).

Preschool children are very curious, can think intuitively, and pose questions about al- most anything. They want to know the reasons, cause, and purpose for everything (the why), but are unconcerned at this point with the process (the how). Fantasy and reality are not well dif- ferentiated. Children in this cognitive stage mix fact and fiction, tend to generalize, think magically, develop imaginary playmates, and believe they can control events with their thoughts. At the same time, they do possess self-awareness and realize that they are vul- nerable to outside influences (Crandell et al., 2012; Santrock, 2017).

The young child also continues to have a lim- ited sense of time. For children of this age, being made to wait 15 minutes before they can do some- thing can feel like an eternity. They do, however, understand the timing of familiar events in their daily lives, such as when breakfast or dinner is eaten and when they can play or watch their fa- vorite television program. As they begin to un- derstand and appreciate the world around them, their attention span (ability to focus) begins to lengthen such that they can usually remain quiet long enough to listen to a song or hear a short story read (Santrock, 2017).

In the preschool stage, children begin to develop sexual identity and curiosity, an inter- est that may cause considerable discomfort for their parents. Cognitive understanding of their bodies related to structure, function, health, and illness becomes more specific and differ- entiated. They can name external body parts but have only an ill-defined concept of the lo- cation of internal organs and the specific func- tion of body parts (Raven, 2016).

Explanations of the purpose and reasons for a procedure remain beyond the young child’s level of reasoning, so any explanations must be kept very simple and matter of fact (Pidgeon, 1985). Children at this stage have a fear of body

involvement with others external to the family unit. Children in this developmental category acquire new behaviors that give them more in- dependence from their parents and allow them to care for themselves more autonomously. Learning during this developmental period occurs through interactions with others and through mimicking or modeling the behaviors of playmates and adults (Crandell et al., 2012; Santrock, 2017).

Physical, Cognitive, and Psychosocial Development The physical maturation during early childhood is an extension of the child’s prior growth. Fine and gross motor skills become increasingly more refined and coordinated so that children can carry out activities of daily living with greater independence (Crandell et al., 2012; Kail & Cavanaugh, 2015; Santrock, 2017). Although their efforts are more coordinated, supervi- sion of activities is still required because they lack judgment in carrying out the skills they have developed.

The early childhood stage of cognitive de- velopment is labeled by Piaget (1951, 1952, 1976) as the preoperational period. This stage, which emphasizes the child’s inability to think things through logically without acting out the situa- tion, is the transitional period when the child starts to use symbols (letters and numbers) to represent something (Crandell et al., 2012; San- trock, 2017; Snowman & McCown, 2015).

Children in the preschool years begin to de- velop the capacity to recall past experiences and anticipate future events. They can classify ob- jects into groups and categories but have only a vague understanding of their relationships. The young child continues to be egocentric and is essentially unaware of others’ thoughts or the existence of others’ points of view. Thinking re- mains literal and concrete—they believe what is seen and heard. Precausal thinking allows young children to understand that people can make things happen, but they are unaware of causation as the result of invisible physical and

The Developmental Stages of Childhood 181

Teaching Strategies The nurse’s interactions with preschool children and their parents are often sporadic, usually oc- curring during occasional well-child visits to the pediatrician’s office or when minor medical prob- lems arise. During these interactions, the nurse should take every opportunity to teach parents about health promotion and disease prevention measures, to provide guidance regarding normal growth and development, and to offer instruc- tion about medical recommendations related to illness or disability. Parents can be a great asset to the nurse in working with children in this de- velopmental phase, and they should be included in all aspects of the educational plan and the ac- tual teaching experience. Parents can serve as the primary resource to answer questions about chil- dren’s disabilities, their idiosyncrasies, and their favorite toys—all of which may affect their abil- ity to learn (Bedells & Bevan, 2016; Hussey & Hirsh, 1983).

Children’s fear of pain and bodily harm is uppermost in their minds, whether they are well or ill. Because young children have fantasies and active imaginations, it is most important for the nurse to reassure them and allow them to express their fears openly (Heiney, 1991). Nurses need to choose their words carefully when describing procedures and interventions and keep expla- nations simple (Miller & Stoeckel, 2016). Pre- school children are familiar with many words, but using terms such as cut and knife is fright- ening to them. Instead, nurses should use less threatening words such as fix, sew, and cover up the hole. Band-Aids is a much more understand- able term than dressings, and bandages are of- ten thought by children to have magical healing powers (Miller & Stoeckel, 2016).

Although still dependent on family, the young child has begun to have increasing con- tact with the outside world and is usually able to interact more comfortably with others. Never- theless, significant adults in a child’s life should be included as participants during teaching ses- sions. They can provide support to the child,

mutilation and pain, which not only stems from their lack of understanding of the body but also is compounded by their active imagination. Their ideas regarding illness also are primi- tive with respect to cause and effect; illness and hospitalization are thought to be a punishment for something they did wrong, either through omission or commission (London et al., 2017). Children’s attribution of the cause of illness to the consequences of their own transgressions is known as egocentric causation (Polan & Taylor, 2015; Richmond & Kotelchuck, 1984).

Erikson (1963) has labeled the psychosocial maturation level in early childhood as the period of initiative versus guilt. Children take on tasks for the sake of being involved and on the move (Table 5-2). Excess energy and a desire to dom- inate may lead to frustration and anger on their part. They show evidence of expanding imagi- nation and creativity, are impulsive in their ac- tions, and are curious about almost everything they see and do. Their growing imagination can lead to many fears—of separation, disapproval, pain, punishment, and aggression from others. Loss of body integrity is the preschool child’s greatest threat, which significantly affects his or her willingness to interact with healthcare per- sonnel (Poster, 1983; Vulcan, 1984).

In this phase of development, children be- gin interacting with playmates rather than just playing alongside one another. Appropriate so- cial behaviors demand that they learn to wait for others, give others a turn, and recognize the needs of others. Play in the mind of a child is equivalent to the work performed by adults. Play can be as equally productive as adult work and is a means for self-education about the phys- ical and social world (Ormrod, 2012). It helps the child act out feelings and experiences to mas- ter fears, develop role skills, and express joys, sorrows, and hostilities. Through play, children in the preschool years also begin to share ideas and imitate parents of the same sex. Role play- ing is typical of this age as the child attempts to learn the responsibilities of family members and others in society (Santrock, 2017).

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■ Use storybooks to emphasize the humanity of healthcare personnel; to depict relation- ships between the child, parents, and others; and to help the child identify with certain situations.

For Long-Term Learning ■ Enlist the help of parents, who can play a

vital role in modeling a variety of healthy habits, such as practicing safety measures and eating a balanced diet; offer them access to support and follow-up as the need arises.

■ Reinforce positive health behaviors and the acquisition of specific skills.

Middle and Late Childhood (6–11 Years of Age) In middle and late childhood, children have progressed in their physical, cognitive, and psy- chosocial skills to the point where most begin formal training in structured school systems. They approach learning with enthusiastic an- ticipation, and their minds are open to new and varied ideas.

Children at this developmental level are mo- tivated to learn because of their natural curios- ity and their desire to understand more about themselves, their bodies, their world, and the in- fluence that different things in the world have on them (Whitener et al., 1998). This stage is a period of great change for them, when attitudes, values, and perceptions of themselves, their so- ciety, and the world are shaped and expanded. Visions of their own environment and the cul- tures of others take on more depth and breadth (Santrock, 2017).

Physical, Cognitive, and Psychosocial Development The gross- and fine-motor abilities of school- aged children become increasingly more coordi- nated so that they have the ability to control their movements with much greater dexterity than ever

substitute as the teacher if their child is reluctant to interact with the nurse, and reinforce teach- ing at a later point in time. The primary care- takers, usually the mother and father, are the recipients of most of the nurse’s teaching efforts. They are the learners who will assist the child in achieving desired health outcomes (Callans et al., 2016; Kaakinen, Gedaly-Duff, Coehlo, & Hanson, 2010; Whitener, Cox, & Maglich, 1998).

The following specific teaching strategies are recommended.

For Short-Term Learning ■ Provide physical and visual stimuli because

language ability is still limited, both for expressing ideas and for comprehending verbal instructions.

■ Keep teaching sessions short (no more than 15 minutes) and scheduled sequentially at close intervals so that information is not forgotten.

■ Relate information needs to activities and ex- periences familiar to the child. For example, ask the child to pretend to blow out candles on a birthday cake to practice deep breathing.

■ Encourage the child to participate in selecting between a limited number of teaching–learning options, such as play- ing with dolls or reading a story, which promotes active involvement and helps to establish nurse–client rapport.

■ Arrange small-group sessions with peers to make teaching less threatening and more fun.

■ Give praise and approval, through both verbal expressions and nonverbal gestures, which are real motivators for learning.

■ Give tangible rewards, such as badges or small toys, immediately following a suc- cessful learning experience to encourage the mastery of cognitive and psychomotor skills.

■ Allow the child to manipulate equipment and play with replicas or dolls to learn about body parts. Special kidney dolls, ostomy dolls with stomas, or orthopedic dolls with splints and tractions provide opportunities for hands-on experience.

The Developmental Stages of Childhood 183

and use sarcasm as well as to employ well- developed language skills for telling jokes, con- veying complex stories, and communicating increasingly more sophisticated thoughts (Snow- man & McCown, 2015).

Nevertheless, thinking remains quite lit- eral, with only a vague understanding of abstrac- tions. Early in this phase, children are reluctant to exchange magical thinking for reality think- ing. They cling to cherished beliefs, such as the existence of Santa Claus or the tooth fairy, for the fun and excitement that the fantasy pro- vides them, even when they have information that proves contrary to their beliefs.

Children passing through elementary and middle schools have developed the ability to concentrate for extended periods, can toler- ate delayed gratification, are responsible for independently carrying out activities of daily living, have a good understanding of the en- vironment around them, and can generalize from experience (Crandell et al., 2012). They understand time, can predict time intervals, are oriented to the past and present, have some grasp and interest in the future, and have a vague appreciation for how immediate actions can have implications over the course of time (Kail & Cavanaugh, 2015). Special interests in topics of their choice begin to emerge, and they can pursue subjects and activities with devotion to increase their talents in selected areas.

Children at this cognitive stage can make de- cisions and act in accordance with how events are interpreted, but they understand only to a lim ited extent the seriousness or consequences of their choices. Children in the early period of this de- velopmental phase know the functions and names of many common body parts, whereas older chil- dren have a more specific knowledge of anatomy and can differentiate between external and in- ternal organs with a beginning understanding of their complex functions (Raven, 2016).

As part of the shift from precausal think- ing to causal thinking, the child begins to in- corporate the idea that illness is related to cause and effect and can recognize that germs create disease. Illness is thought of in terms of social consequences and role alterations, such as the

before. Involvement in all kinds of curricular and extracurricular activities helps them to fine tune their psychomotor skills. Physical growth during this phase is highly variable, with the rate of de- velopment differing from child to child. Toward the end of this developmental period, girls more than boys on average begin to experience prepu- bescent bodily changes and tend to exceed the boys in physical maturation. Growth charts, which monitor the rate of growth, are a more sensitive indicator of health or disability than actual size (Crandell et al., 2012; Santrock, 2017).

Piaget (1951, 1952, 1976) labeled the cogni- tive development in middle and late childhood as the period of concrete operations. During this time, logical, rational thought processes and the ability to reason inductively and deductively develop. Children in this stage can think more objectively, are willing to listen to others, and selectively use questioning to find answers to the unknown. At this stage, they begin to use syllogistic reasoning—that is, they can con- sider two premises and draw a logical conclusion from them (Bara, Bucciarelli, & Johnson-Laird, 1995; Elkind, 1984; Steegen & De Neys, 2012). For example, they comprehend that mammals are warm blooded and whales are mammals, so whales must be warm blooded.

Also, children in this age group are intel- lectually able to understand cause and effect in a concrete way. Concepts such as conservation, which is the ability to recognize that the prop- erties of an object stay the same even though its appearance and position may change, are beginning to be mastered. For example, they realize that a certain quantity of liquid is the same amount whether it is poured into a tall, thin glass or into a short, squat one (Snowman & McCown, 2015). Fiction and fantasy are sepa- rate from fact and reality. The skills of memory, decision making, insight, and problem solving are all more fully developed (Protheroe, 2007).

Children in this developmental phase can engage in systematic thought through inductive reasoning. They have the ability to classify objects and systems, express concrete ideas about rela- tionships and people, and carry out mathemat- ical operations. Also, they begin to understand

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them from one another (Table 5-2). They be- gin to establish their self-concept as members of a social group larger than their own nuclear family and start to compare their own family’s values with those of the outside world.

The school environment for children of this age facilitates their development of a sense of responsibility and reliability. With less depen- dency on family, they extend their intimacy to include special friends and social groups (New- man & Newman, 2015; Santrock, 2017). Rela- tionships with peers and adults external to the home environment become important influ- ences in their development of self-esteem and their susceptibility to social forces outside the family unit. School-aged children fear failure and being left out of groups. They worry about their inabilities and become self-critical as they compare their own accomplishments to those of their peers. They also fear illness and dis- ability that could significantly disrupt their ac- ademic progress, interfere with social contacts, decrease their independence, and result in loss of control over body functioning.

Teaching Strategies It is important to follow sound educational prin- ciples with the child and family, such as iden- tifying individual learning styles, determining readiness to learn, and accommodating special learning needs and abilities to achieve positive health outcomes. Given their increased ability to comprehend information and their desire for active involvement and control of their lives, it is very important to include school-aged children in patient education efforts as these “hands-on” experiences are important sources of learning (Hayes, 2015). The nurse in the role as educa- tor should explain illness, treatment plans, and procedures in simple, logical terms in accor- dance with the child’s level of understanding and reasoning. Although children at this stage of development can think logically, their abil- ity to engage in abstract thought remains lim- ited. Therefore, teaching should be presented in concrete terms with step-by-step instruc- tions (Pidgeon, 1985; Whitener et al., 1998). It

realization that they will miss school and out- side activities, people will feel sorry for them, and they will be unable to maintain their usual routines (Banks, 1990; Koopman, Baars, Chap- lin, & Zwinderman, 2004).

Marin (2010) found that concepts of ill- ness in children vary depending on socioeco- nomic status (SES) and ethnicity, although she found no differences in their thinking based on gender. Children from lower SES levels and mi- nority backgrounds had a less sophisticated un- derstanding of the causes of illness compared with those children from higher SES levels and those belonging to the majority population. She suggested that this may be a result of edu- cational, cultural, and language differences and that healthcare professionals should consider a child’s ethnicity and SES when communicating symptoms and causes of illness based on cul- tural health beliefs and practices.

Also, research indicates that systematic dif- ferences exist in children’s reasoning skills with respect to understanding body functioning and the cause of illness resulting from their expe- riences with illness. Children suffering from chronic diseases have been found to have more sophisticated conceptualization of illness causal- ity and body functioning than do their healthy peers. Piaget (1976) postulated that experience with a phenomenon catalyzes a better under- standing of it.

Conversely, the stress and anxiety result- ing from having to live with a chronic illness or disability can interfere with a child’s general cognitive performance. Chronically ill children have a less refined understanding of the physi- cal world than healthy children do, and the for- mer often are unable to generalize what they learned about a specific illness to a broader un- derstanding of illness causality (Perrin, Sayer, & Willett, 1991). Thus, illness may act as an in- trusive factor in overall cognitive development (Bell, Bayliss, Glauert, Harrison, & Ohan, 2016).

Erikson (1963) characterized school-aged children’s psychosocial stage of life as industry versus inferiority. During this period, children begin to gain an awareness of their unique tal- ents and the special qualities that distinguish

The Developmental Stages of Childhood 185

children. The school nurse can play a vital role in providing education to the school-aged child to meet these goals (American Academy of Pedi- atrics Council on School Health, 2016). In sup- port of this teaching–learning process, Healthy People 2020 has introduced the topic area “Early and Middle Childhood,” which recommends providing formal health education in the school setting (USDHHS, 2014). The school nurse is afforded the opportunity to educate children not only in a group when teaching a class but also on a one-to-one basis when encountering an individual child in the office for a certain problem or need.

The specific conditions that may come to the attention of the nurse in caring for children at this phase of development include problems such as behavioral disorders, hyperactivity, learn- ing disorders, obesity, diabetes, asthma, and en- uresis. Extensive teaching may be needed to help children and parents understand a condition particularly related to them and learn how to overcome or deal with it (Edelman et al., 2013).

The need to sustain or bolster their self- image, self-concept, and self-esteem requires that children be invited to participate, to the extent possible, in planning for and carrying out learning activities (Snowman & McCown, 2015). For young children receiving an x-ray or other imaging procedure, for example, it would be beneficial to have them initially simulate the experience by positioning a doll or stuffed ani- mal under the machine as the technician explains the procedure. This strategy allows them to par- ticipate and can decrease their fear. Because of children’s fears of falling behind in school, be- ing separated from peer groups, and being left out of social activities, teaching must be geared toward fostering normal development despite any limitations that may be imposed by illness or disability (Falvo, 2011; Leifer & Hartston, 2013).

Children in middle and late childhood are used to the structured, direct, and formal learn- ing in the school environment; consequently, they are receptive to a similar teaching– learning approach when hospitalized or confined at home. The following teaching strategies are

is imperative that the nurse observe children’s reactions and listen to their verbal feedback to confirm that information shared has not been misinterpreted or confused.

To the extent feasible, parents should be informed of what their child is being taught. Teaching parents directly is encouraged so that they may be involved in fostering their child’s independence, providing emotional support and physical assistance, and giving guidance re- garding the correct techniques or regimens in self-care management. Siblings and peers also should be considered as sources of support. In attempting to master self-care skills, children thrive on praise from others who are important in their lives as rewards for their accomplish- ments and successes (Hussey & Hirsh, 1983; Santrock, 2017).

Education for health promotion and health maintenance is most likely to occur in the school system through the school nurse, but the par- ents as well as the nurse outside the school setting should be told which content is being addressed. Information then can be reinforced and expanded when in contact with the child in other care settings. Numerous opportunities for nurses to teach the individual child or groups of children about health promotion and disease and injury prevention are available in schools, physicians’ offices, community centers, outpa- tient clinics, or hospitals. Health education for children of this age can be very fragmented be- cause of the many encounters they have with nurses in a variety of settings (Edelman, Mandle, & Kudzma, 2013).

The school nurse is in an excellent posi- tion to coordinate the efforts of all other pro- viders to avoid duplication of teaching content or the giving of conflicting information as well as to provide reinforcement of learning. Accord- ing to Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2014), health promotion regarding healthy eating and weight status, exercise, sleep, and prevention of injuries, as well as avoidance of tobacco, alcohol, and drug use, are just a few examples of objec- tives intended to improve the health of American

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a means of interpreting the results of nurs- ing interventions specific to the child’s own condition.

■ Provide time for clarification, validation, and reinforcement of what is being learned.

■ Select individual instructional techniques that provide opportunity for privacy—an increasingly important concern for this group of learners, who often feel quite self- conscious and modest when learning about bodily functions.

■ Employ group teaching sessions with oth- ers of similar age and with similar problems or needs to help children avoid feelings of isolation and to assist them in identifying with their own peers.

■ Prepare children for procedures and in- terventions well in advance to allow them time to cope with their feelings and fears, to anticipate events, and to understand what the purpose of each procedure is, how it relates to their condition, and how much time it will take.

■ Encourage participation in planning for procedures and events because active in- volvement helps the child to assimilate in- formation more readily.

■ Provide much-needed nurturance and sup- port, always keeping in mind that young children are not just small adults. Praise and rewards help motivate and reinforce learning.

For Long-Term Learning ■ Help school-aged children acquire skills

that they can use to assume self-care re- sponsibility for carrying out therapeutic treatment regimens on an ongoing basis with minimal assistance.

■ Assist them in learning to maintain their own well-being and prevent illnesses from occurring.

Research suggests that lifelong health attitudes and behaviors begin in the early child- hood phase of development and remain intra- personally consistent throughout the stage of middle to late childhood (USDHHS, 2014).

suggested when caring for children in this de- velopmental stage of life (Edleman et al., 2013; Falvo, 2011; Hayes, 2015; Leifer & Hartston, 2013; Snowman & McCown, 2015).

For Short-Term Learning ■ Allow school-aged children to take re-

sponsibility for their own health care be- cause they are not only willing but also capable of manipulating equipment with accuracy. Because of their adeptness in re- lation to manual dexterity, mathematical operations, and logical thought processes, they can be taught, for example, to apply their own splint or use an asthma inhaler as prescribed.

■ Teaching sessions can be extended to last up to 30 minutes each because the increased cognitive abilities of school-aged children make possible the attention to and the re- tention of information. However, lessons should be spread apart to allow for com- prehension of large amounts of content and to provide opportunity for the practice of newly acquired skills between sessions.

■ Use diagrams, models, pictures, digital me- dia, printed materials, and computer, tab- let or smartphone applications as adjuncts to various teaching methods because the increased facility these children have with language (both spoken and written) and mathematical concepts allows them to work with more complex instructional tools.

■ Choose audiovisual and printed materials that show peers undergoing similar proce- dures or facing similar situations.

■ Clarify any scientific terminology and med- ical jargon used.

■ Use analogies as an effective means of pro- viding information in meaningful terms, such as “Having a chest x-ray is like having your picture taken” or “White blood cells are like police cells that can attack and de- stroy infection.”

■ Use one-to-one teaching sessions as a method to individualize learning rele- vant to the child’s own experiences and as

The Developmental Stages of Childhood 187

Today’s adolescents comprise the generational cohort Generation Z, or Gen Z. They excel with self-directed learning and thrive on the use of technology (Shatto & Erwin, 2016).

Physical, Cognitive, and Psychosocial Development Adolescents vary greatly in their biological, psy- chological, social, and cognitive development. From a physical maturation standpoint, they must adapt to rapid, dramatic, and significant bodily changes, which can temporarily result in clumsiness and poorly coordinated movement. Alterations in physical size, shape, and function of their bodies, along with the appearance and development of secondary sex characteristics, bring about a significant preoccupation with their appearance and a strong desire to express sex- ual urges (Crandell et al., 2012; Santrock, 2017). And, according to neuroscience research, ado- lescent brains are different than adult brains in the way they process information, which may explain that adolescent behaviors, such as im- pulsiveness, rebelliousness, lack of good judg- ment, and social anxiety, stem from biological reasons more than environmental influences (Packard, 2007).

Piaget (1951, 1952, 1976) termed this stage of cognitive development as the period of for- mal operations. Adolescents have attained a new, higher order level of reasoning superior to ear- lier childhood thoughts. They are capable of ab- stract thought and the type of complex logical thinking described as propositional reason- ing, as opposed to syllogistic reasoning. Their ability to reason is both inductive and deductive, and they can hypothesize and apply the prin- ciples of logic to situations never encountered before. Adolescents can conceptualize and inter- nalize ideas, debate various points of view, un- derstand cause and effect, comprehend complex explanations, imagine possibilities, make sense out of new data, discern relationships among objects and events, and respond appropriately to multiple-step directions (Aronowitz, 2006; Crandell et al., 2012).

The development of cognitive understanding of health and illness has been shown to follow a systematic progression parallel to the stage of general cognitive development (Koopman et al., 2004). As the child matures, beliefs about health and illness become less concrete and more ab- stract, less egocentric, and increasingly differ- entiated and consistent.

Motivation, self-esteem, and positive self- perception are personal characteristics that in- fluence health behavior. Research has shown that the higher the grade level of the child, the greater the understanding of illness and an awareness of body cues. Thus, children become more actively involved in their own health care as they progress developmentally (Farrand & Cox, 1993; Whitener et al., 1998). Teaching should be directed at assisting them to incorporate positive health actions into their daily lives. Because of the importance of peer influence, group activities are an effec- tive method of teaching health behaviors, at- titudes, and values.

Adolescence (12–19 Years of Age) Adolescence marks the transition from child- hood to adulthood. During this prolonged and very change-filled time, many adolescents and their families experience much turmoil. How ad- olescents think about themselves and the world significantly influences many healthcare issues facing them, from anorexia to obesity. Teenage thought and behavior give insight into the eti- ology of some of the major health problems of this group of learners (Elkind, 1984). Adoles- cents are known to be among the nation’s most at-risk populations (Ares, Kuhns, Dogra, & Kar- mik, 2015). Most recently, Healthy People 2020 identified “Adolescent Health” as a new topic area, with objectives focused on interventions to promote health as well as mitigate the risks as- sociated with this population (USDHHS, 2014).

For patient education to be effective, an understanding of the characteristics of the ad- olescent phase of development is crucial (Ack- ard & Neumark-Sztainer, 2001; Ormrod, 2012).

188 Chapter 5 Developmental Stages of the Learner

it also leads teenagers to believe they are cloaked in an invisible shield that will protect them from bodily harm despite any risks to which they may subject themselves (Alberts, Elkind, & Ginsberg, 2007; Jack, 1989; Oswalt, 2010). They can un- derstand implications of future outcomes, but their immediate concern is with the present.

Recent research, however, reveals that ado- lescents 15 years of age and older are not as sus- ceptible to the personal fable as once thought (Cauffman & Steinberg, 2000). Although chil- dren in the mid- to late-adolescent period appear to be aware of the risks they take, it is import- ant, nevertheless, to recognize that this popu- lation continues to need support and guidance (Brown, Teufel, & Birch, 2007).

Erikson (1968) has identified the psychoso- cial dilemma adolescents face as one of identity versus role confusion. Children in this age group indulge in comparing their self-image with an ideal image (Table 5-2). Adolescents find them- selves in a struggle to establish their own iden- tity, match their skills with career choices, and determine their self. They work to emancipate themselves from their parents, seeking indepen- dence and autonomy so that they can emerge as more distinct individual personalities.

Teenagers have a strong need for belonging to a group, friendship, peer acceptance, and peer support. They tend to rebel against any actions or recommendations by adults whom they con- sider authoritarian. Their concern over personal appearance and their need to look and act like their peers drive them to conform to the dress and behavior of this age group, which is usually contradictory, nonconformist, and in opposi- tion to the models, codes, and values of their parents’ generation. Conflict, toleration, stereo- typing, or alienation often characterizes the rela- tionship between adolescents and their parents and other authority figures (Hines & Paulson, 2006). Adolescents seek to develop new and trusting relationships outside the home but re- main vulnerable to the opinions of those whom they emulate (Santrock, 2017).

Adolescents demand personal space, con- trol, privacy, and confidentiality. To them, illness,

Formal operational thought enables ado- lescents to conceptualize invisible processes and make determinations about what others say and how they behave. With this capacity, teenagers can become obsessed with what they think as well as what others are thinking, a characteris- tic known as adolescent egocentrism. They be- gin to believe that everyone is focusing on the same things they are—namely, themselves and their activities. Elkind (1984) labels this belief as the imaginary audience, a type of social thinking that has considerable influence over an adolescent’s behavior. The imaginary audi- ence explains the pervasive self-consciousness of adolescents, who, on the one hand, may feel embarrassed because they believe everyone is looking at them and, on the other hand, desire to be looked at and thought about because this attention confirms their sense of being special and unique (Crandell et al., 2012; Oswalt, 2010; Santrock, 2017; Snowman & McCown, 2015).

Adolescents are able to understand the con- cept of health and illness, the multiple causes of diseases, the influence of variables on health status, and the ideas associated with health pro- motion and disease prevention. Parents, health- care providers, and the Internet are all potential sources of health-related information for ado- lescents. At this developmental stage, adoles- cents recognize that illness and disability are processes resulting from a dysfunction or non- function of a part or parts of the body and can comprehend the outcomes or prognosis of an illness. They also can identify health behaviors, although they may reject practicing them or be- gin to engage in risk-taking behaviors because of the social pressures they receive from peers as well as their feelings of invincibility (Ormrod, 2012). Elkind (1984) labels this second type of social thinking as the personal fable. The per- sonal fable leads adolescents to believe that they are invulnerable—other people grow old and die, but not them; other people may not realize their personal ambitions, but they will.

This personal fable has value in that it al- lows individuals to carry on with their lives even in the face of all kinds of dangers. Unfortunately,

The Developmental Stages of Childhood 189

largely ignored by the healthcare system glob- ally (Patton et al., 2016). Thus, the educational needs of adolescents are broad and varied. The potential topics for teaching are numerous, rang- ing from sexual adjustment, contraception, and venereal disease to accident prevention, nutri- tion, substance abuse, and mental health.

Healthy teens have difficulty imagining themselves as sick or injured. Those with an illness or disability often comply poorly with medical regimens and continue to indulge in risk-taking behaviors. Because of their preoc- cupation with body image and functioning and the perceived importance of peer acceptance and support, they view health recommendations as a threat to their autonomy and sense of control.

Probably the greatest challenge to the nurse responsible for teaching the adolescent, whether healthy or ill, is to be able to develop a mutu- ally respectful, trusting relationship (Brown et al., 2007). Adolescents, because of their well-developed cognitive and language abili- ties, can participate fully in all aspects of learn- ing, but they need privacy, understanding, an honest and straightforward approach, and un- qualified acceptance in the face of their fears of embarrassment, losing independence, identity, and self-control (Ackard & Neumark-Sztainer, 2001). The American Academy of Pediatrics Committee on Adolescence (2016) cites avail- ability, visibility, quality, confidentiality, afford- ability, flexibility, and coordination as important factors in providing education effectively to the adolescent population.

The existence of an imaginary audience and personal fable can contribute to the exacer- bation of existing problems or cause new ones. Adolescents with disfiguring disabilities, who as young children exhibited a great deal of spirit and strength, may now show signs of depression and lack of will. For the first time, they look at themselves from the standpoint of others and reinterpret behavior once seen as friendly as ac- tually condescending. Teenagers may fail to use contraceptives because the personal fable tells them that other people will get pregnant or get venereal disease, but not them. Teenagers with

injury, disability, and hospitalization mean de- pendency, loss of identity, a change in body image and functioning, bodily embarrassment, confine- ment, separation from peers, and possible death. The provision of knowledge alone is, therefore, not sufficient for this population. Because of the many issues apparent during the adolescent period, the need for coping skills is profound and can influence the successful completion of this stage of development (Grey, Kanner, & Lacey, 1999; Hoffman, 2016; Williams & McGillicuddy-De Lisi, 1999; Zimmer-Gembeck & Skinner, 2008). Some developmentalists are ex- tending the uppermost age range of the ado- lescent period to 24 years of age because it has been determined that many young people in this stage do not meet the typical psychosocial milestones until well into their second decade of life (Newman & Newman, 2015).

Teaching Strategies Although most individuals at this phase of de- velopment remain relatively healthy, an esti- mated 20% of U.S. teenagers have at least one serious health problem, such as asthma, learn- ing disabilities, eating disorders (e.g., obesity, anorexia, or bulimia), diabetes, a range of dis- abilities resulting from injury, or psychological problems resulting from depression or phys- ical and/or emotional maltreatment. In addi- tion, adolescents are considered at high risk for teen pregnancy, the effects of poverty, drug or alcohol abuse, and sexually transmitted diseases such as venereal disease and AIDS. The three leading causes of death in this age group are ac- cidents, homicide, and suicide (Kochanek, Xu, Murphy, Minino, & Kung, 2011; London et al., 2017). More than 50% of all adolescent deaths are a result of accidents, and most of these inci- dents involve motor vehicles (Santrock, 2017).

Despite these potential threats to their well-being, adolescents use medical services the least frequently of all age groups. Compounding this problem is the realization that adolescent health has not been a priority in the past and the health issues of this population have been

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■ Share decision making whenever possible, because control is an important issue for adolescents.

■ Include adolescents in formulating teaching plans related to teaching strategies, expected outcomes, and determining what needs to be learned and how it can best be achieved to meet their needs for autonomy.

■ Suggest options so that they feel they have a choice about courses of action.

■ Give a rationale for all that is said and done to help adolescents feel a sense of control.

■ Approach them with respect, tact, open- ness, and flexibility to elicit their attention and encourage their responsiveness to teaching–learning situations.

■ Expect negative responses, which are com- mon when their self-image and self-integrity are threatened.

■ Avoid confrontation and acting like an authority figure. Instead of directly contra- dicting adolescents’ opinions and beliefs, acknowledge their thoughts and then ca- sually suggest an alternative viewpoint or choices, such as “Yes, I can see your point, but what about the possibility of . . .?”

For Long-Term Learning ■ Accept adolescents’ personal fable and

imaginary audience as valid, rather than challenging their feelings of uniqueness and invincibility.

■ Acknowledge that their feelings are very real because denying them their opinions simply will not work.

■ Allow them the opportunity to test their own convictions. Let them know, for example, that although some other special people may get away without taking medication, others cannot. Suggest, if medically feasible, setting up a trial period with medications scheduled further apart or in lowered dos- ages to determine how they can manage.

Although much of patient education should be done directly with adolescents to re- spect their right to individuality, privacy, and

chronic illnesses may stop taking prescribed medications because they feel they can manage without them to prove to others that they are well and free of medical constraints; other peo- ple with similar diseases need to follow thera- peutic regimens, but not them.

Adolescents’ language skills and ability to conceptualize and think abstractly give the nurse as educator a wide range of teaching methods and instructional tools from which to choose (Brown et al., 2007). The following teaching strat- egies are suggested when caring for adolescents.

For Short-Term Learning ■ Use one-to-one instruction to ensure con-

fidentiality of sensitive information. ■ Choose peer-group discussion sessions as

an effective approach to deal with health topics such as smoking, alcohol and drug use, safety measures, obesity, and teenage sexuality. Adolescents benefit from being exposed to others who have the same con- cerns or who have successfully dealt with problems like theirs.

■ Use face-to-face or computer group discus- sion, role playing, and gaming as methods to clarify values and solve problems, which feed into the teenager’s need to belong and to be actively involved. Getting groups of peers together in person or virtually (e.g., blogs, social networking, podcasts, online videos) can be very effective in helping teens confront health challenges and learn how to significantly change behavior (Snowman & McCown, 2015).

■ Employ adjunct instructional tools, such as complex models, diagrams, and specific, detailed written materials, which can be used competently by many adolescents. Using technology is a comfortable approach to learning for adolescents, who generally have facility with technological equipment after years of academic and personal experience with telecommunications in the home and at school.

■ Clarify any scientific terminology and medical jargon used.

The Developmental Stages of Childhood 191

to being an independent, self-directed human being.

2. He or she accumulates a growing reservoir of previous experience that serves as a rich resource for learning.

3. Readiness to learn becomes increas- ingly oriented to the developmental tasks of social roles.

4. Adults are best motivated to learn when a need arises in their life situ- ation that will help them satisfy their desire for information.

5. Adults learn for personal fulfillment such as self-esteem or an improved quality of life.

A limitation of Knowles’s assumptions about child versus adult learners is that they are derived from studies conducted on healthy people. Ill- ness and injury, however, have the potential to significantly change the cognitive and psycho- logical processes used for learning (Best, 2001).

The period of adulthood constitutes three major developmental stages—the young adult stage, the middle-aged adult stage, and the older adult stage (Table 5-1). Although adulthood, like childhood, can be divided into various devel- opmental phases, the focus for learning is quite different. Whereas a child’s readiness to learn de- pends on physical, cognitive, and psychosocial development, adults have essentially reached the peak of their physical and cognitive capacities.

The emphasis for adult learning revolves around differentiation of life tasks and social roles with respect to employment, family, and other activities beyond the responsibilities of home and career (Boyd, Gleit, Graham, & Whit- man, 1998). In contrast to childhood learning, which is subject centered, adult learning is prob- lem centered. The prime motivator to learn in adulthood is being able to apply knowledge and skills for the solution of immediate problems. Unlike children, who enjoy learning for the sake of gaining an understanding of themselves and the world, adults must clearly perceive the rel- evancy of acquiring new behaviors or chang- ing old ones for them to be willing and eager to

confidentiality, teaching effectiveness may be enhanced by including their families to some extent (Brown et al., 2007). The nurse as edu- cator can give guidance and support to families, helping them to better understand adolescent be- havior (Hines & Paulson, 2006). Parents should be taught how to set realistic limits and at the same time foster the adolescent’s sense of inde- pendence. Through prior assessment of poten- tial sources of stress, teaching both the parents and the adolescent (as well as siblings) can be en- hanced. Because of ambivalence the adolescent feels while in this transition stage from child- hood to adulthood, healthcare teaching, to be effective, must consider the learning needs of the adolescent as well as the parents (Ackard & Neumark-Sztainer, 2001; Falvo, 2011).

▸ The Developmental Stages of Adulthood

Andragogy, the term used by Knowles (1990) to describe his theory of adult learning, is the art and science of teaching adults. Education within this framework is more learner cen- tered and less teacher centered; that is, instead of one party imparting knowledge to another, the power relationship between the educator and the adult learner is much more horizontal (Curran, 2014). The concept of andragogy has served for years as a useful framework in guid- ing instruction for patient teaching and for con- tinuing education of staff. Recently, based on emerging research and theory from a variety of disciplines, Knowles and colleagues (2015) dis- cussed new perspectives on andragogy that have refined and strengthened the core adult learn- ing principles that Knowles originally proposed.

The following basic assumptions about Knowles’s framework have major implications for planning, implementing, and evaluating teaching programs for adults as the individ- ual matures:

1. The adult’s self-concept moves from one of being a dependent personality

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further learning. Adults already have a rich re- source of stored information on which to build a further understanding of relationships be- tween ideas and concepts (Conlan, Grabowski, & Smith, 2015). Compared to children, adults grasp relationships more quickly, but they do not tolerate learning isolated facts as well. TABLE 5-3 highlights the main differences between teach- ing children and teaching adults.

learn. In the beginning of any teaching– learning encounter, therefore, adults want to know how they will benefit from their efforts at learning (Knowles et al., 2015).

In contrast to the child learner, who is de- pendent on authority figures for learning, the adult is much more self-directed and indepen- dent in seeking information. For adults, past ex- periences are internalized and form the basis for

TABLE 5-3 Process Elements of Andragogy

Element Pedagogical Approach Andragogical Approach

1. Preparing Learners Minimal Provide information Prepare for participation Help develop realistic expectations Begin thinking about content

2. Climate Authority oriented Formal Competitive

Relaxed, trusting Mutually respectful Informal, warm Collaborative, supportive Openness and authenticity Humanness

3. Planning By instructor Mechanism for mutual planning by learners and facilitator

4. Diagnosis of Needs By instructor By mutual assessment

5. Setting of Objectives By instructor By mutual negotiation

6. Designing Learning Plans

Logic of subject matter Content units

Sequenced by readiness Problem units

7. Learning Activities Transmittal techniques

Experiential techniques (inquiry)

8. Evaluation By instructor Mutual rediagnosis of needs Mutual measurement of program

Reproduced from Knowles, M. S., Holton, E. F., & Swanson, R. A. (2015). The adult learner: The definitive classic in adult education and human resource development (8th ed.). London: Routledge: Taylor and Francis Group. Copyright © 2015 by Routledge. Reproduced with permission of Taylor & Francis Books UK.

The Developmental Stages of Adulthood 193

clear and identifiable objectives. Continuing education for them is episodic and occurs as a recurring pattern throughout their lives as they realize the need for or an interest in expanding their knowledge and skills. Adults attend night courses or professional workshops to build their expertise in a specific subject or for advancement in their profes- sional or personal lives.

2. Activity-oriented learners select ed- ucational activities primarily to meet social needs. The learning of content is secondary to their need for human contact. Although they may choose to participate in support groups, special-interest groups, or self-help groups, or attend academic classes because of an interest in a topic be- ing offered, they join essentially out of their desire to be around others and converse with people in similar circumstances—retirement, parent- ing, divorce, or widowhood. Their drive is to alleviate social isolation or loneliness.

3. Learning-oriented learners view themselves as perpetual students who seek knowledge for knowl- edge’s sake. They are active learn- ers throughout their lives and tend to join groups, classes, or organiza- tions with the anticipation that the experience will be educational and personally rewarding.

In most cases, all three types of learners ini- tiate the learning experience for themselves. In planning educational activities for adults, it is important to determine their motives for want- ing to be involved. That is, it is advantageous for the nurse educator to understand the purpose and expectations of the individuals who partici- pate in continuing education programs. Armed with that knowledge, the nurse educator can best serve learners in the role of facilitator for

Because adults already have established ideas, values, and attitudes, they also tend to be more resistant to change. In addition, adults must overcome obstacles to learning very differ- ent from those faced by children. For example, they have the burden of family, work, and social responsibilities, which can diminish their time, energy, and concentration for learning. Also, their need for self-direction may present prob- lems because various stages of illness, as well as the healthcare setting in which they may find themselves, can force dependency. Anxiety, too, may negatively affect their motivation and abil- ity to learn, especially if the content is perceived as difficult (Kinkead, Miller, & Hammett, 2016). Furthermore, some adults may feel too old or too out of touch with the formal learning of the school years to learn new things. If past experi- ences with learning were not positive, they may also shy away from assuming the role of learner for fear of the risk of failure (Boyd et al., 1998).

Although nurse educators can consider adult learners as autonomous, self-directed, and independent, these individuals often want and need structure, clear and concise specifics, and direct guidance. As such, Taylor, Marienau, and Fiddler (2000) label adults as “paradoxi- cal” learners.

Only recently has it been recognized that learning is a lifelong process that begins at birth and does not cease until the end of life. Growth and development are a process of becoming, and learning is inextricably a part of that process. As a person matures, learning is a significant and continuous task to maintain and enhance one- self (Knowles, 1990; Knowles et al., 2015). Social scientists now recognize that adulthood “is not a single monolithic stage sandwiched between ado- lescence and old age” (Crandell et al., 2012, p. 403).

A variety of reasons explain why adults pursue learning throughout their lives. Basi- cally, three categories describe the general ori- entation of adults toward continuing education (Knowles et al., 2015; Miller & Stoeckel, 2016):

1. Goal-oriented learners engage in ed- ucational endeavors to accomplish

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the formal operations stage of cognitive devel- opment (Piaget, 1951, 1952, 1976). These ex- periences add to their perceptions, allow them to generalize to new situations, and improve their abilities to critically analyze, solve prob- lems, and make decisions about their personal, occupational, and social roles. Their interests for learning are oriented toward those experi- ences that are relevant for immediate applica- tion to problems and tasks in their daily lives. Young adults are motivated to learn about the possible implications of various lifestyle choices (Crandell et al., 2012).

Erikson (1963) describes the young adult’s stage of psychosocial development as the period of intimacy versus isolation. During this time, individuals work to establish trusting, satisfy- ing, and permanent relationships with others (Table 5-2). They strive to make commitments to others in their personal, occupational, and social lives. As part of this effort, they seek to maintain the independence and self-sufficiency they worked to obtain in adolescence.

Young adults face many challenges as they take steps to control their lives. Many of the events they experience are happy and growth promoting from an emotional and social per- spective, but they also can prove disappointing and psychologically draining. The new experi- ences and multiple decisions young adults must make regarding choices for a career, marriage, parenthood, and higher education can be quite stressful. Young adults realize that the avenues they pursue will affect their lives for years to come (Santrock, 2017).

Teaching Strategies Based on the paucity of literature on health teaching of individuals who belong specifi- cally to this age cohort, young adulthood is the life-span period that has received the least atten- tion by nurse educators. At this developmental stage, prior to the emergence of the chronic dis- eases that characterize the middle-age and older years, young adults are generally very healthy and tend to have limited exposure to health

referral or resource information, thereby em- bracing the adults’ state of independence and interdependence (Musinski, 1999).

Obviously, there are many differences be- tween child and adult learners (Table 5-1 and Table 5-3). As the following discussion clearly reveals, there also are differences in the char- acteristics of adult learners within the three de- velopmental stages of adulthood.

Young Adulthood (20–40 Years of Age) The transition from adolescence to becoming a young adult has been termed emerging adulthood. Early adulthood is composed of the cohort cur- rently between 20 and 34 years of age, who be- long to the millennial generation, as well as the cohort currently aged 35 to 40, who are known as Generation X. Both generations exhibit their own characteristic traits and present different challenges to the nurse educator (Fishman, 2016). These two age cohorts encompass approximately 140 million Americans and are more ethnically diverse than ever (Crandell et al., 2012; Fry, 2016).

Young adulthood is a time for establishing long-term, intimate relationships with other peo- ple, choosing a lifestyle and adjusting to it, de- ciding on an occupation, and managing a home and family. These decisions lead to changes in the lives of young adults that can be a potential source of stress for them. It is a time when inti- macy and courtship are pursued and spousal and/ or parental roles are developed (Santrock, 2017).

Physical, Cognitive, and Psychosocial Development During this period, physical abilities for most young adults are at their peak, and the body is at its optimal functioning capacity (Crandell et al., 2012). The cognitive capacity of young adults is fully developed, but with maturation, they con- tinue to accumulate new knowledge and skills from an expanding reservoir of formal and in- formal experiences. Young adults continue in

The Developmental Stages of Adulthood 195

promotion, more money, or more time to pursue outside activities (Crandell et al., 2012; Miller & Stoeckel, 2016).

When young adults are faced with acute or chronic illnesses or disabilities, many of which may significantly alter their lifestyles, they are stimulated to learn to maintain their indepen- dence and return to normal life patterns. It is likely they will view an illness or disability as a serious setback to achieving their immediate or future life goals.

Because adults typically desire active participa- tion in the educational process, whenever possible it is important for the nurse as educator to allow them the opportunity for mutual collaboration in health education decision making. They should be encouraged, as Knowles (1990) suggested, to select what to learn (objectives), how they want material to be presented (teaching methods and tools), and which indicators will be used to de- termine the achievement of learning goals (eval- uation). Also, it must be remembered that adults bring to the teaching–learning situation a variety of experiences that can serve as the foundation on which to build new learning. Consequently, it is important to draw on their personal expe- riences to make learning relevant, useful, and motivating. Young adults tend to be reluctant to expend the resources of time, money, and energy to learn new information, skills, and attitudes if they do not see the content of instruction as rel- evant to their current lives or anticipated prob- lems (Collins, 2004; Knowles et al., 2015).

Teaching strategies must be directed at en- couraging young adults to seek information that expands their knowledge base, helps them con- trol their lives, and bolsters their self-esteem. Whether they are well or ill, young adults need to know about the opportunities available to learning. Making them aware of health issues and learning opportunities can occur in a vari- ety of settings, such as physicians’ offices, stu- dent health services, health fairs, community and outpatient clinics, or hospitals. In all cases, these educational opportunities must be convenient and accessible to them in terms of their lifestyle with respect to work and family responsibilities.

professionals. Their contact with the health- care system is usually for preemployment, col- lege, or presport physicals; for a minor episodic complaint; or for pregnancy and contraceptive care (Orshan, 2008). At the same time, young adulthood is a crucial period for the establish- ment of behaviors that help individuals to lead healthy lives, both physically and emotionally. Many of the choices young adults make, if not positive ones, will be difficult to modify later. As Havighurst (1976) points out, this stage is full of “teachable moment” opportunities and healthcare providers must take advantage of ev- ery opportunity to promote healthy behaviors with this population (Hinkle, 2014).

Health promotion is the most neglected as- pect of healthcare teaching at this stage of life. Yet, many of the health issues related to risk factors and stress management are important to deal with to help young adults establish pos- itive health practices for preventing problems with illness in the future. The major factors that need to be addressed in this age group are healthy eating habits, regular exercise, and avoid- ing drug abuse. Such behaviors will reduce the incidence of high blood pressure, elevated cho- lesterol, obesity, smoking, and overuse of alco- hol and drugs (Santrock, 2017).

The nurse as educator must find a way of reaching and communicating with this audi- ence about health promotion and disease pre- vention measures. Readiness to learn does not always require the nurse educator to wait for it to develop. Rather, such readiness can be ac- tively fostered through experiences the nurse creates. Knowledge of the individual’s lifestyle can provide cues to concentrate on when de- termining specific aspects of education for the young adult. For example, if the individual is planning marriage, then establishing healthy relationships, family planning, contraception, and parenthood are potential topics to address during teaching (Orshan, 2008). The motiva- tion for adults to learn comes in response to internal drives, such as need for self-esteem, a better quality of life, or job satisfaction, and in response to external motivators, such as job

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the average life expectancy has increased by 30 years (Crandell et al., 2012; Santrock, 2017).

Thus, the concept of what has been thought of as middle age is being nudged upward. As more people live longer, middle age is now com- ing later in life than ever before. Adults are no longer considered to be “over the hill” when they celebrate their 40th birthday. Middle age for many healthy adults is starting later and last- ing longer. Remember, chronological age is one factor, but biological, psychological, and social age also must be considered (Newman & New- man, 2015; Santrock, 2017).

During middle age, many individuals are highly accomplished in their careers, their sense of who they are is well developed, their children are grown, and they have time to share their tal- ents, serve as mentors for others and pursue new or latent interests. This stage is a time for them to reflect on the contributions they have made to family and society, relish in their achieve- ments, and reexamine their goals and values (Newman & Newman, 2015).

Physical, Cognitive, and Psychosocial Development During this stage of maturation, physiologi- cal changes begin to take place. Skin and mus- cle tone decreases, metabolism slows down, body weight tends to increase, endurance and energy levels lessen, hormonal changes bring about a variety of symptoms, and hearing and visual acuity start to diminish. All these physical changes and others affect middle-aged adults’ self- image, ability to learn, and motivation for learn- ing about health promotion, disease prevention, and maintenance of health (Crandell et al., 2012).

The ability to learn from a cognitive stand- point remains at a steady state for middle-aged adults as they continue in what Piaget (1951, 1952, 1976) labeled the formal operations stage of cognitive development. He maintained that cognitive development stopped with this fourth stage (meaning the ability to perform abstract thinking). However, over the years the critics of Piaget’s theory have begun to assert the existence

Relevant, applicable, and practical information is what adults desire and value—they want to know “what’s in it for me,” according to Collins (2004).

Because they tend to be very self-directed in their approach to learning, young adults do well with written patient education materials and audiovisual tools, including computer-assisted instruction, that allow them to self-pace their learning independently. Group discussion is an attractive method for teaching and learning because it provides young adults with the op- portunity to interact with others of similar age and in similar situations, such as in parenting groups, prenatal classes, exercise classes, or mar- ital adjustment sessions. Although assessment prior to teaching helps to determine the level at which to begin teaching, no matter what the content, the enduring axiom is to make learning easy and relevant. To facilitate learning, present concepts logically from simple to complex and establish conceptual relationships through spe- cific application of information (Collins, 2004; Musinski, 1999).

Middle-Aged Adulthood (41–64 Years of Age) Just as adolescence is the link between childhood and adulthood, so midlife is the transition pe- riod between young adulthood and older adult- hood. Middle-aged Americans make up about one fourth of the population, and this current cohort has typically been labeled the baby-boom generation. Although middle-aged adulthood was once one of the most neglected age peri- ods, baby boomers, who now make up this co- hort, are receiving increasingly more attention from developmental psychologists and health- care providers. This emphasis is occurring not only because they constitute the largest cohort of any current generation but also because cur- rent middle-aged adults are the best educated, most affluent generation in history, and they have the potential to enjoy a healthier life than ever before because of medical discoveries that can stave off the aging process. In just one century,

The Developmental Stages of Adulthood 197

served as mentors. During this time, individu- als often become oriented away from self and family and toward the larger community. New social interests and leisure activities are pursued as they find more free time from family respon- sibilities and career demands. As they move to- ward their retirement years, individuals begin to plan for what they want to do after culminating their career. This transition sparks their interest in learning about financial planning, alternative lifestyles, and ways to remain healthy as they approach the later years (Crandell et al., 2012).

Teaching Strategies Depending on individual situations, middle- aged adults may be facing either a more relaxed lifestyle or an increase in stress level because of midlife crisis issues such as menopause, obvious physical changes in their bodies, responsibility for their own parents’ declining health status, or concern about how finite their life really is. They may have regrets and feel they did not achieve the goals or live up to the values they had set for themselves in young adulthood or the ex- pectations others had of them as young adults. Santrock (2017) cites research indicating that this stage in life is not so much seen as a crisis but rather as a period of midlife consciousness.

When teaching members of this age group, the nurse must be aware of their potential sources of stress, the health risk factors associated with this stage of life, and the concerns typical of mid- life. Misconceptions regarding physical changes such as menopause are common. Stress may in- terfere with middle-aged adults’ ability to learn or may be a motivational force for learning (Merriam & Bierema, 2014). Those who have lived healthy and productive lives are often mo- tivated to contact health professionals to ensure maintenance of their healthy status. Such con- tacts represent an opportune time for the nurse educator to reach out to assist these middle-aged adults in coping with stress and maintaining optimal health status. Many need and want in- formation related to chronic illnesses that can arise at this phase of life (Orshan, 2008).

of postformal operations. That is, adult thought processes go beyond logical problem solving to include what is known as dialectical thinking. This type of thinking is defined as the ability to search for complex and changing understand- ings to find a variety of solutions to any given sit- uation or problem. In other words, middle-aged adults see the bigger picture (Crandell et al., 2012).

For many adults, the accumulation of life experiences and their proven record of accomplishments often allow them to come to the teaching–learning situation with confi- dence in their abilities as learners. However, if their past experiences with learning were min- imal or not positive, their motivation likely will not be at a high enough level to easily facilitate learning. Physical changes, especially with re- spect to hearing and vision, may impede learn- ing as well (Santrock, 2017).

Erikson (1963) labels this psychosocial stage of adulthood as generativity versus self-absorption and stagnation. Midlife marks a point at which adults realize that half of their potential life has been spent. This realization may cause them to question their level of achievement and suc- cess. Middle-aged adults, in fact, may choose to modify aspects of their lives that they per- ceive as unsatisfactory or adopt a new lifestyle as a solution to dissatisfaction.

Developing concern for the lives of their grown children, recognizing the physical changes in themselves, dealing with the new role of be- ing a grandparent, and taking responsibility for their own parents whose health may be fail- ing are all factors that may cause adults in this cohort to become aware of their own mortal- ity (Table 5-2). During this time, middle-aged adults may either feel greater motivation to fol- low health recommendations more closely or— just the opposite—may deny illnesses or abandon healthy practices altogether (Falvo, 2011).

The later years of middle adulthood are the phase in which productivity and contributions to society are valued. They offer an opportunity to feel a real sense of accomplishment from hav- ing cared for others—children, spouse, friends, parents, and colleagues for whom adults have

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Most older people have at least one chronic condition, and many, especially in the later years, have multiple conditions. On average, they are hospitalized longer than persons in other age categories and require more teaching overall to broaden their knowledge of self-care. In addi- tion, it is approximated by the USDHHS that as of 2016, the educational profile of older Ameri- cans is as follows: 54% of Hispanics, 77% of Black Americans, 80% of those of Asian descent, and 90% of Caucasians older than 65 years of age have a high school education; this percentage is 84% for the aggregate. These numbers have increased significantly since 1970, when only 28% of older adults had a high school diploma. However, currently, only 28% of them have a college degree at the bachelor’s level or higher (USDHHS, 2016). Lower educational levels in some ethnic groups, sensory impairments, the disuse of literacy skills once learned, and cog- nitive changes in the population of older adults may contribute to their decreased ability to read and comprehend written materials (Best, 2001).

For these reasons, their patient education needs are generally greater and more complex than those for persons in any of the other de- velopmental stages. Numerous studies have documented that older adults can benefit from health education programs. Their compliance, if they are given specific health directions, can be quite high. Given the considerable health- care expenditures for older people, education programs to improve their health status and re- duce morbidity would be a cost-effective mea- sure (Behm et al., 2014; Best, 2001; Mauk, 2014; Robnett & Chop, 2015).

Because American society values physical strength, beauty, social networking, produc- tivity, and integrity of body and mind, people fear the natural losses that accompany the ag- ing process. Growing older is a normal event, yet the inevitable continuation of human de- velopment that results in biological, psycho- logical, and social changes with the passage of time is a reminder of mortality. Nurses and nurse educators must recognize that a signifi- cant number of older persons respond to these

Adult learners need to be reassured or com- plimented on their learning competencies. Rein- forcement for learning is internalized and serves to reward them for their efforts. Teaching strat- egies for learning are similar in type to teach- ing methods and instrumental tools used for the young adult learner, but the content is dif- ferent to coincide with the concerns and prob- lems specific to this group of learners.

Older Adulthood (65 Years of Age and Older) The percentage of middle-aged adults in the United States has tripled since 1900, and in 2011, the first wave of baby boomers turned 65 years of age. Older persons constitute approxi- mately 15% of the U.S. population now, but by 2030, the number of those older than age 65 will increase to 21%, or approximately 74 mil- lion Americans. Those aged 85 and older make up the fastest-growing segment of the popu- lation in the country today, and that segment is expected to more than triple by 2060, ris- ing to approximately 20 million (Federal In- teragency Forum on Aging-Related Statistics, 2016). With more than 45% of the 2010 fed- eral budget allocated for Medicare, Medicaid, and Social Security, a considerable portion of this country’s fiscal resources is used for pro- grams that support those 65 years and older (Crandell et al., 2012).

Some developmentalists have in recent years begun to categorize older adults into distinct di- visions based on different age ranges. For ex- ample, Santrock (2017) identifies three groups of older adults: the young-old (65–74 years of age), the old-old (75–84 years of age), and the oldest-old (85 years and older). Newman and Newman (2015) have identified the last stages of aging into two categories: later adulthood (60–75 years) and elderhood (75 years until death). These new distinctions acknowledge a shift in health and productivity levels of peo- ple in the later years according to biological and social trends.

The Developmental Stages of Adulthood 199

create obstacles to learning unless nurses under- stand them and can adapt appropriate teaching interventions to meet the older person’s needs. The following discussion of physical, cognitive, and psychosocial maturation is based on find- ings reported by numerous authors (Ahroni, 1996; Best, 2001; Crandell et al., 2012; Gavan, 2003; Hinkle, 2014; Mauk, 2014; Santrock, 2017; Weinrich & Boyd, 1992).

Physical, Cognitive, and Psychosocial Development With advancing age, so many physical changes occur that it becomes difficult to establish nor- mal boundaries. As a person grows older, nat- ural physiological changes in all systems of the body are universal, progressive, decremental, and intrinsic. Alterations in physiological func- tioning can lead secondarily to changes in learn- ing ability. The senses of sight, hearing, touch, taste, and smell are usually the first areas of de- creased functioning noticed by adults (Miller & Stoeckel, 2016).

The sensory perceptive abilities that relate most closely to learning capacity are visual and auditory changes. Hearing loss, which is very common beginning in the late 40s and 50s, in- cludes diminished ability to discriminate high- pitched, high-frequency sounds. Visual changes such as cataracts, macular degeneration, re- duced pupil size, decline in depth perception, and presbyopia may prevent older persons from being able to see small print, read words printed on glossy paper, or drive a car. Yellowing of the ocular lens can produce color distortions and diminished color perceptions.

Other physiological changes affect organ functioning and result in decreased cardiac output, lung performance, and metabolic rate; these changes reduce energy levels and lessen the ability to cope with stress. Nerve conduction velocity also is thought to decline by as much as 15%, influencing reflex times and muscle re- sponse rates. The interrelatedness of each body system has a total negative cumulative effect on individuals as they grow older.

changes by viewing them as challenges rather than defeats. Many aspects of older adulthood can be pleasurable, such as becoming a grand- parent and experiencing retirement that gives one time to pursue lifelong interests, as well as freedom to explore new avenues of endeavor (Santrock, 2017).

Ageism describes prejudice against the older adult. This discrimination based on age, which exists in most segments of American society, perpetuates the negative stereotype of aging as a period of decline (Gavan, 2003; Miller & Stoeckel, 2016). Ageism, in many re- spects, can be compared to the discriminatory attitudes of racism and sexism (Crandell et al., 2012). This bias interferes with interactions be- tween the older adult and younger age groups and must be counteracted because it “prevents older people from living lives as actively and happily as they might” (Ahroni, 1996, p. 48). Given that the aging process is universal, even- tually everyone is potentially subject to this type of prejudice. New research that focuses on healthy development and positive lifestyle ad- aptations, rather than on illnesses and impair- ments in the older adult, can serve to reverse the stereotypical images of aging. Education to inform people of the significant variations that occur in the way that individuals age and education to help the older adult learn to cope with irreversible losses can combat the preju- dice of ageism as well (Crandell et al., 2012).

The teaching of older persons, known as geragogy, is different from teaching younger adults (andragogy) and children (pedagogy). For teaching to be effective, geragogy must ac- commodate the normal physical, cognitive, and psychosocial changes that occur during this phase of growth and development (Best, 2001; Miller & Stoeckel, 2016). Until recently, little had been written about the special learning needs of older adults that acknowledged the physiologi- cal and psychological aging changes that affect their ability to learn.

Age changes, which begin in young and middle adulthood, progress significantly at this older adult stage of life. These changes often

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remains strong, such as the ability to clearly and accurately remember something from their youth.

4. Increased test anxiety. People in the older adult years are especially anx- ious about making mistakes when per- forming; when they do make an error, they become easily frustrated. Because of their anxiety, they may take an in- ordinate amount of time to respond to questions, particularly on tests that are written rather than verbal.

5. Altered time perception. For older persons, life becomes more finite and compressed. Issues of the here and now tend to be more important, and some adhere to the philosophy, “I’ll worry about that tomorrow.” This way of thinking can be detrimental when applied to health issues because it serves as a vehicle for denial or delay in taking appropriate action.

Despite the changes in cognition caused by aging, most research supports the premise that the ability of older adults to learn and remem- ber is virtually as good as ever if special care is taken to slow the pace of presenting information, to ensure relevance of material, and to give ap- propriate feedback when teaching (FIGURE 5-1).

Erikson (1963) labels the major psycho- social developmental task at this stage in life as ego integrity versus despair. This phase of older adulthood includes dealing with the re- ality of aging, the acceptance of the inevitabil- ity that all persons die, the reconciling of past failures with present and future concerns, and developing a sense of growth and purpose for those years remaining (Table 5-2). The most common psychosocial tasks of aging involve changes in lifestyle and social status based on the following circumstances.

■ Retirement ■ Illness or death of spouse, relatives, and

friends ■ The moving away of children, grandchil-

dren, and friends

Aging affects the mind as well as the body. Cognitive ability changes with age as perma- nent cellular alterations invariably occur in the brain itself, resulting in an actual loss of neurons, which have no regenerative powers. Physiological research has demonstrated that people have two kinds of intellectual ability— crystallized and fluid intelligence. Crystal- lized intelligence is the intelligence absorbed over a lifetime, such as vocabulary, general in- formation, understanding social interactions, arithmetic reasoning, and ability to evaluate experiences. This kind of intelligence increases with experience as people age. However, it is important to understand that crystallized in- telligence can be impaired by disease states, such as the dementia seen in Alzheimer’s dis- ease. Fluid intelligence is the capacity to per- ceive relationships, to reason, and to perform abstract thinking. This kind of intelligence de- clines as degenerative changes occur.

The decrease in fluid intelligence results in the following specific changes:

1. Slower processing and reaction time. Older persons need more time to process and react to information, es- pecially as measured in terms of rela- tionships between actions and results. However, if the factor of speed is re- moved from intelligence tests, for example, older people can perform as well as younger people. In per- formance of activities of daily living when speed is not a factor, older adults can demonstrate their true abilities to function well and inde- pendently (Kray & Lindenberger, 2000).

2. Persistence of stimulus (afterimage). Older adults can confuse a previous symbol or word with a new word or symbol just introduced.

3. Decreased short-term memory. Older adults sometimes have difficulty re- membering events or conversations that occurred just hours or days before. However, long-term memory often

The Developmental Stages of Adulthood 201

vary from less frequent to no more frequent than the incidence rate found in middle adult- hood. This situation arises because older adults overall have fewer economic hardships and in- creased religiosity. However, depressive symp- toms do increase in the oldest-old and are thought to be associated with more physical disability, more cognitive impairment, and lower socio- economic status.

For those who experience major depres- sion (the “common cold” of mental disorders), the most likely predictors are a previous history of depression, lack of perceived social support, poor health, disability, and losing members of the established social network (Santrock, 2017). These losses, which signify a threat to one’s own autonomy, independence, and decision making, result in isolation, financial insecurity, dimin- ished coping mechanisms, and a decreased sense of identity, personal value, and societal worth. With aging, some individuals, particularly the oldest-old, begin to question their perception of a meaningful life—that is, the potential for further enjoyment, pleasure, and satisfaction. Depressive symptoms in the oldest-old, espe- cially men, are thought to be associated with more physical disability, more cognitive impair- ment, and lower socioeconomic status (Federal Interagency Forum on Aging-Related Statistics, 2016; Santrock, 2017).

■ Relocation to an unfamiliar environment such as an extended-care facility or senior residential living center

After Erikson’s death in 1994, a ninth stage of psychosocial development, hope and faith versus despair was published by his wife in the book The Life Cycle Completed (Erikson & Erikson, 1998). This new final stage was de- veloped from notes that Erikson left behind, along with the conversations he had with his wife. It addresses those individuals reaching their late 80s and older, identifying that aging individuals need to accept greater assistance as their bodies age. The goal is to find a renewed awareness of self in accordance with this need for additional care while eventually achieving a new sense of wisdom that is less materialis- tic and moves the individual beyond physical limits (Crandell et al., 2012; Erikson & Erikson, 1998). Although this additional stage has been published for some time, it has not been incor- porated into the literature discussing Erikson’s stages of development. However, Brown and Lowis (2003) conducted a study that did provide some evidence of a distinct differentiation be- tween stages eight and nine in aging individuals.

Depression, grief, loneliness, and isolation, once thought to be common traits among older adults, have now been found by researchers to

FIGURE 5-1 Learning in the older adult. Data from Mauk, K. L. (2014). Gerontological nursing: Competencies for care (3rd ed.). Burlington, MA: Jones & Bartlett Learning; Rendon, D. C., Davis, D. K., Gioiella, E. C., & Tranzillo, M. J. (1986). The right to know, the right to be taught. Journal of Gerontological Nursing, 12(12), 36.

Learning Influences in the Older Adult

– Sensory perceptions (hearing, seeing, touching) – Energy level – Memory – Affect – Risk-taking ability – Response time – Cultural background – Disability – Stress – Health literacy level

Maximizing Learning in the Older Adult

– Personalized goals – Cueing – Positive reinforcement – Pacing with rest periods – Rehearsing – Time for questions – Relaxed environment – Flexibility – Provide purpose of teaching – Establish rapport – Material easy to read

Older Adult

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gained over the years. Negative coping mechanisms indicate an individual’s focus on losses and show that his or her thinking is immersed in the past. The emphasis in teaching is on exploring alternatives, determining realistic goals, and supporting large and small accomplishments.

5. Meaning of life. For well-adapted older persons, having realistic goals allows them the opportunity to enjoy the smaller pleasures in life, whereas less well-adapted individuals may be frustrated and dissatisfied with per- sonal inadequacies. Health teaching must be directed at ways older adults can maintain optimal health so that they can derive pleasure from their leisure years.

Teaching Strategies Learning in older adults can be affected by such sociological, psychological, and cognitive factors as retirement, economics, mental status, and in- formation processing abilities (Crandell et al., 2012; Miller & Stoeckel, 2016; Santrock, 2017). Understanding older persons’ developmental tasks allows nurses to alter how they approach both well and ill individuals in terms of coun- seling, teaching, and establishing a therapeu- tic relationship. Nurses must be aware of the possibility that older patients may delay medi- cal attention. Decreased cognitive functioning, sensory deficits, lower energy levels, and other factors may prevent early disease detection and intervention. A decline in psychomotor per- formance affects older adults’ reflex responses and their ability to handle stress. Coping with simple tasks becomes more difficult. Chronic illnesses, depression, and literacy levels, partic- ularly among the oldest-old, have implications with respect to how they care for themselves (eating, dressing, and taking medications) as well as the extent to which they understand the nature of their illnesses (Best, 2001; Katz, 1997; Mauk, 2014; Phillips, 1999).

Separate from biological aging but closely related are the many sociocultural factors that affect how older adults see themselves as com- petent individuals (Crandell et al., 2012; Leifer & Hartston, 2013; Newman & Newman, 2015; Santrock, 2017). The following traits regarding personal goals in life and the values associated with them are significantly related to motiva- tion and learning:

1. Independence. The ability to provide for their own needs is the most important aim of most older per- sons, regardless of their state of health. Independence gives them a sense of self-respect, pride, and self-functioning so as not to be a burden to others. Health teaching is the tool to help them maintain or regain independence.

2. Social acceptability. Winning approval from others is a common goal of many older adults. It is derived from health, a sense of vigor, and feeling and think- ing young. Despite declining phys- ical attributes, the older adult often has residual fitness and functioning potentials. Health teaching can help to channel these potentials.

3. Adequacy of personal resources. Resources, both external and internal, are important considerations when assessing the older adult’s current health and wellness status. Life pat- terns, which include habits, physical and mental strengths, and economic situation, should be assessed to de- termine how to incorporate teaching to complement existing regimens and resources (financial and support system) with new required behaviors.

4. Coping mechanisms. The ability to cope with change during the aging process is indicative of the person’s readiness for health teaching. Pos- itive coping mechanisms allow for self-change as older persons draw on life experiences and knowledge

The Developmental Stages of Adulthood 203

amount of contacts older adults have with significant others remains constant over time. Successful aging depends on an ex- tended family support network.

Crandell et al. (2012) also point out that American culture is preoccupied with youthful- ness and has distorted notions about late adult- hood that perpetuate negative views of this generation. There is no typical older adult—not all individuals in this age group are unhealthy, unhappy, fearful, institutionalized, or disengaged; dwell on their own mortality; or find themselves in financial straits. Stereotypes can have a very powerful impact on older adults in both a pos- itive and negative way, affecting their physical and cognitive functioning. Positive stereotypes can bring out the best in a person, whereas neg- ative ones can lead to fulfillment of a pessimis- tic state (Bennett & Gaines, 2010).

Nurse educators may not even be aware of their stereotypical attitudes toward older adults. Furthermore, healthcare providers make assump- tions about older clients that cause them to over- look problems that could be treatable (Gavan, 2003). To check their assumptions, nurses can think about the last time they gave instructions to an older patient and ask themselves the fol- lowing questions.

■ Did I talk to the family and ignore the pa- tient when I described some aspect of care or discharge planning?

■ Did I tell the older person not to worry when he or she asked a question? Did I say, “Just leave everything up to us”?

■ Did I eliminate information that I normally would have given to a younger patient?

■ Did I attribute a decline in cognitive func- tioning to the aging process without considering common underlying causes in mental deterioration, such as effects of medication interactions, fluid imbalances, poor nutrition, or sensory impairments?

All health professionals must remember that older people can learn, but their abilities and needs differ from those of younger persons.

In working with older adults, reminiscing is a beneficial approach to use to establish a thera- peutic relationship. Memories can be quite pow- erful. Talking with older persons about their experiences—marriage, children, grandchildren, jobs, community involvement, and the like—can be very stimulating. Furthermore, their answers will give the nurse insight into their humanness, their abilities, and their concerns.

Too many times nurses and other health professionals believe the adage, “You can’t teach an old dog new tricks.” Gavan (2003) warns that it is easy to fall into the habit of believing the myths associated with the intelligence, person- ality traits, motivation, and social relations of older adults. She outlined the following prev- alent myths that must be dispelled to prevent harmful outcomes in the older adult when these myths are assumed to be true:

Myth No. 1: Senility. Intelligence test scores indicate that many older adults maintain their cognitive functioning well into their 80s and 90s. Mental decline is not always caused by the aging process itself but rather by disease processes, medication interactions, sensory deficits, dehydration, and malnutrition.

Myth No. 2: Rigid Personalities. Personality traits, such as agreeableness, satisfaction, and extraversion, remain stable throughout the older adult years. Although diversity in personality traits among individuals in the older population exists as it does in all other stages of life, labeling older adults as cranky, stubborn, and inflexible does a disservice to them.

Myth No. 3: Loneliness. As mentioned earlier, the belief that older adults are more fre- quently vulnerable to depression, isolation, and feelings of being lonely has not been upheld by research, which indicates that their satisfaction with life continues at a steady level throughout the period of adulthood.

Myth No. 4: Abandonment. It is untrue that older adults are abandoned by their children, siblings, or good friends. The

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limited, it may be beneficial to schedule addi- tional time, if possible, to allow for a more re- laxed environment. Individual and situational variables such as motivation, life experiences, educational background, socioeconomic sta- tus, health or illness status, and motor, cogni- tive, and language skills may all influence the ability of the older adult to learn.

A recent report found that 59% of those persons older than age 65 are engaged in some type of computer use (Smith, 2014). Thus, although many older adults routinely use com- puters, a good number do not. Assuming the client has the computer skills necessary to look up healthcare information or engage in self- education can derail learning. As the popula- tion continues to age, computer use will be more prevalent and preferred by clients who have been comfortable using technology to increase their knowledge (Mauk, 2014). However, despite the cognitive comfort some aging clients have with technology, the nurse may need to suggest adap- tive devices for the computer to accommodate the physical changes of aging.

Some of the more common aging changes that affect learning and the teaching strategies specific to meeting the needs of the older adult are summarized in Table 5-1. When teaching older persons, abiding by the following spe- cific tips can create an environment for learning that considers major changes in their physical, cognitive, and psychosocial functioning (Best, 2001; Crandell et al., 2012; Doak, Doak, & Root, 1996; Katz, 1997; Phillips, 1999; Robnett & Chop, 2015; Ruholl, 2003; Santrock, 2017; Weinrich & Boyd, 1992):

Physical Needs 1. To compensate for visual changes,

teaching should be done in an envi- ronment that is brightly lit but with- out glare. Visual aids should include large print, well-spaced letters, and the use of primary colors. The edu- cator should wear bright colors and a visible name tag. Use white or off- white, flat matte paper and black print

The process of teaching and learning is much more rewarding and successful for both the nurse and the patient if it is tailored to fit the older adult’s physical, cognitive, motivational, and social differences.

Because changes during aging vary con- siderably from one individual to another, it is essential to assess each learner’s physical, cog- nitive, and psychosocial functioning levels be- fore developing and implementing any teaching plan (Miller & Stoeckel, 2016). Keep in mind that older adults have an overall lower educa- tional level of formal schooling than does the remainder of the population. Also, they were raised in an era when consumerism and health education were practically nonexistent. As a re- sult, older people may feel uncomfortable in the teaching–learning situation and may be reluc- tant to ask questions.

As the older population becomes more educated and in tune with consumer activism in the health field, these individuals will likely have an increased desire to actively participate in decision making and demand more detailed and sophisticated information. Nurse educa- tors must take steps to support older clients in making decisions affecting their health (Mauk, 2014). This increased participation by clients can assist in managing chronic diseases, pro- moting quality and safety in healthcare organi- zations, and ensuring effective redesign of care and treatment-related processes (Longtin et al., 2010). Further, the involvement of clients in de- ciding the course of their own care is supported by Healthy People 2020 (USDHHS, 2014).

Health education for older persons should be directed at promoting their involvement and changing their attitudes toward learning (Ahroni, 1996; Weinrich & Boyd, 1992). A cli- mate of mutual respect in which they are made to feel important for what they once were as well as for what they are today should be cul- tivated. Interaction needs to be supportive, not judgmental.

Interventions work best when they take place in a casual, informal atmosphere. In the primary care setting, where time is often

The Developmental Stages of Adulthood 205

determine whether you are speaking too softly, too fast, or not distinctly enough. When addressing a group, microphones are useful aids.

Be alert to nonverbal cues from the audience. Participants who are having difficulty with hearing your message may try to compensate by leaning forward, turning the good ear to the speaker, or cupping their hands to their ears. Ask older per- sons to repeat verbal instructions to be sure they heard and interpreted correctly the entire message.

3. To compensate for musculoskeletal problems, decreased efficiency of the cardiovascular system, and reduced kidney function, keep sessions short, schedule frequent breaks to allow for use of bathroom facilities, and allow time for stretching to relieve painful, stiff joints and to stimulate circula- tion. Provide pain medication and encourage the learner to follow his or her usual pain management routine. Also, provide comfortable seating.

4. To compensate for any decline in cen- tral nervous system functioning and decreased metabolic rates, set aside more time for the giving and receiv- ing of information and for the prac- tice of psychomotor skills. Also, do not assume that older persons have the psychomotor skills necessary to handle technological equipment for self-paced learning, such as comput- ers and mouse, ear buds instead of headsets, MP3 players, and DVD players. In addition, they may have difficulty with independently apply- ing prostheses or changing dress- ings because of decreased strength and coordination. Be careful not to misinterpret the loss of energy and motor skills as a lack of motivation.

5. To compensate for the impact of hear- ing and visual changes on computer

for posters, diagrams, and other writ- ten materials.

Because of older persons’ diffi- culty in discriminating certain shades of color, avoid blue, blue–green, and violet hues. Keep in mind that tasks that require recognizing different shades of color, such as test strips measur- ing the presence of sugar in the urine, may present learning difficulties for older patients. Color distortions can have an especially devastating effect on learning if, for example, the type of pills are referred to by color in guiding patients to take medications as pre- scribed. Green, blue, and yellow pills may all appear gray to older persons.

Accommodations should be made to meet older adults’ physical needs, such as arranging seats so that the learner is reasonably close to the instructor and to any visual aids that may be used. For patients who wear glasses, be sure they are readily accessible, lenses are clean, and frames are properly fitted.

2. To compensate for hearing losses, eliminate extraneous noise, avoid cov- ering your mouth when speaking, directly face the learner, and speak slowly. These techniques assist the learner who may be seeking visual confirmation of what is being said.

Low-pitched voices are heard best, but be careful not to drop your voice at the end of words or phrases. Do not shout, because it distorts sounds and the decibel level is usually not a problem for individuals with hearing impairments. The intensity of sound seems to be less important than the pitch and rate of auditory stimuli.

Word speed should not exceed 140 words spoken per minute. If the learner uses hearing aids, be sure he or she has working batteries. Ask for feedback from the learner to

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and react to information and to see relationships between concepts. Re- search has shown that older adults can learn anything if new informa- tion is tied to familiar concepts drawn from relevant past experiences.

When teaching, nurses should avoid presenting long lists by divid- ing a series of directions for action into short, discrete, step-by-step mes- sages and then waiting for a response after each one. For instance, to give directions about following different menus depending on exercise levels, they can use an active voice to per- sonalize the message. For example, instead of saying, “Use menu A if not active; use menu B if somewhat

use, be sure that the speakers on the computer are working well and use headphones to block background noise. The computer screen should be clean and free of glare, offer good resolution, and provide large-enough print. Further, clients with arthritis may need to learn alternative ways to use the mouse (Mauk, 2014). TABLE 5-4 outlines specific strate- gies that can assist older adults to overcome problems associated with computer use.

Cognitive Needs 1. To compensate for a decrease in fluid

intelligence, provide older persons with more opportunities to process

TABLE 5-4 Problems That Can Be Overcome by Older Adults Using Computers

Age Change Effect on Computer Use Possible Solutions

Hearing Sound from computer may not be heard

Use earphones to enhance hearing and eliminate background noise. Speak slowly and clearly.

Vision Vision declines, need for bifocal glasses, viewing monitor may be difficult, problems with glaucoma and light/colors

Adjust monitor’s tilt to eliminate glare. Change size of font to 14. Make sure contrast is clear. Change the screen resolution to promote color perception.

Motor control tremors

May affect use of keyboard or control of mouse, may not be able to hold the mouse and consistently click correct mouse buttons

Highlight area and press Enter. Avoid double clicking.

Arthritis May not be able to hold the mouse and consistently click correct mouse buttons

Highlight area and press Enter. Teach how to use options on keyboard.

Attention span

Problems with inability to focus and making correct inferences

Priming—introduce concept early on. Repetition is key to retention. Use cheat sheets.

The Developmental Stages of Adulthood 207

learned it. Confirm patients’ level of knowledge before beginning to teach. Basic information should be understood before progressing to more complex information.

4. Convincing older persons of the use- fulness of what the educator is teach- ing is only half the battle in getting them motivated. Nurse educators may also have to convince patients that the information or technique they are teaching is correct. Anything that is entirely strange or that upsets estab- lished habits is likely to be far more difficult for older adults to learn. Information that confirms existing beliefs (cognitive schema) is better remembered than that which con- tradicts these beliefs. Patients with chronic illnesses frequently have es- tablished schemas about their medical conditions that they have embraced for years.

As perception slows, the older person’s mind has more trouble ac- commodating to new ways than does the mind of a younger person. Find out about older persons’ health hab- its and beliefs before trying to change their ways or teach something new. For example, many older adults were taught as children that pain is a sign that something is wrong and they should always stop whatever they are doing if it causes pain. Educa- tors need to identify this belief be- fore trying to teach them that they sometimes need to move through their pain to avoid stiffness and joint contractures.

5. Arrange for brief teaching sessions because a shortened attention span (attentional narrowing) requires sched- uling a series of sessions to provide sufficient time for learning. In addi- tion, if the material is relevant and focused on the here and now, older

active; use menu C if very active,” they should say, “You should use menu A if you are not active.” Then wait for the learner’s response, which might be, “That’s what I should eat if I’m not very active?” The nurse educa- tor can follow up with the response, “That’s right. And if you are some- what active, you should. . .”

Older persons tend to confuse previous words and symbols with a new word or symbol being in- troduced. Again, nurse educators can wait for a response before they introduce a new concept or word definition. For decreased short-term memory, coaching and repetition are very useful strategies that assist with recall. Memory also can be enhanced by involving the learner in devising ways to remember how or when to perform a procedure. Because many older adults expe- rience test anxiety, try to explain procedures simply and thoroughly, reassure them, and, if possible, give verbal rather than written tests.

2. Be aware of the effects of medica- tions and energy levels on concentra- tion, alertness, and coordination. Try to schedule teaching sessions before or well after medications are taken and when the person is rested. For example, the patient who has just returned from physical therapy or a diagnostic procedure will likely be too fatigued to attend to learning.

3. Be certain to ask what an individual already knows about a healthcare issue or technique before explaining it. Repetition for reinforcement of learning is one thing; repeating in- formation already known may seem patronizing. Nurse educators should never assume that because someone has been exposed to information before that the individual, in fact,

208 Chapter 5 Developmental Stages of the Learner

FIGURE 5-2 A basic gerontological teaching–learning model for nursing. Reproduced from Rendon, D. C., Davis, D. K., Gioiella, E. C., & Tranzillo, M. J. (1986). The right to know, the right to be taught. Journal of Gerontological Nursing, 12(12), 36. Reproduced with permission of SLACK Incorporated.

Elements of Learning Process

Apprehending: Registering

Stimuli, Attending, Perceiving

Acquiring: Relevance

and Coding

Storage: Primary

to Secondary Memory

Retrieval Recall and Transfer

Repetition, Rehearsing

Overlearning

Associative Cues

Nursing Strategies to Facilitate Learning

L E

A R

N IN

L E

A R

N IN

R E

M E

M B

E R

IN G

R E

M E

M B

E R

IN G

Environmental Manipulation, Rest Periods,

Relaxation Techniques, Reduced Stimulus

Overload

Pacing, Reduce Task Complexity,

Organize, Personalized

Learner Goals

FIGURE 5-2 presents strategies to meet the cognitive needs of older adults.

Psychosocial Needs 1. Assess family relationships to de-

termine how dependent the older person is on other members for financial and emotional support. In turn, nurse educators can explore the level of involvement by family members in reinforcing the lessons they are teaching and in giving assistance with self-care measures. Do family members help the older

persons are more likely to be atten- tive to the information being pre- sented. If procedures or treatments are perceived as stressful or emo- tionally threatening, attentional nar- rowing occurs.

6. Recognize that the process of con- ceptualizing and the ability to think abstractly become more difficult with aging. Conclude each teach- ing session with a summary of the information presented and allow for a question-and-answer period to correct any misconceptions.

The Developmental Stages of Adulthood 209

Self-paced instructional tools may be very appropriate, but it is important to know the client’s previous learning techniques, mental and physical abilities, and comfort levels with certain approaches before assigning any such tools. Many older adults grew up in a time when technology was very different than it is today, and those who have always learned by reading and discussion may not like electronic devices. Introducing new teaching methods and tools, such as the use of computer and interactive video formats, without adequate instructions on how to operate these techni- cal devices, may inhibit learning by increas- ing anxiety and frustration levels and may adversely affect self-esteem.

Games, role play, demonstration, and re- turn demonstration can be used to rehearse problem-solving and psychomotor skills if these methods, and the tools used to complement them, are designed appropriately to accommo- date the various developmental characteristics of this age group. For example, speed or com- petition should not be factors in the games cho- sen, and plenty of time should be reserved for return demonstrations. These teaching methods stimulate learning and can offer active learn- ing opportunities to put knowledge into prac- tice. Written materials, if appropriate in terms of literacy level and visual impairments in the older adult, are excellent adjuncts to augment, supplement, and reinforce verbal instructions.

▸ The Role of the Family in Patient Education

The role of the family is considered one of the key variables influencing positive patient care outcomes. The primary motives in patient edu- cation for involving family members in the care delivery and decision-making process are to de- crease the stress of hospitalization, reduce costs of care, increase satisfaction with care, reduce hospital readmissions, and effectively prepare the patient for self-care management outside

person to function independently, or do they foster dependency? With permission of the patient, include family members in teaching sessions and enlist their support.

2. Determine availability of resources. A lack of resources can sabotage any teaching plan, especially if the recommendations include expecting older adults to carry out something they cannot afford or lack the means to do, such as buying or renting equipment, having transportation to get to therapy or teaching ses- sions, purchasing medications, and the like.

3. Encourage active involvement of older adults to improve their self- esteem and to stimulate them both mentally and socially. Teaching must be directed at helping them find meaningful ways to use talents acquired over their lifetime. Estab- lishing a rapport based on trust can provide them contact with others to bolster their sense of self-worth.

4. Identify coping mechanisms. There is no other time in the life cycle that carries with it the number of develop- mental tasks associated with adapta- tion to loss of roles, social and family contacts, and physical and cognitive capacities that this time does. Teach- ing must include offering construc- tive methods of coping.

The older person’s ability to learn may be affected by the methods and materials chosen for teaching. One-to-one instruction provides a nonthreatening environment for older adults in which to meet their individual needs and goals. This teaching approach helps them to compen- sate for their special deficits and promotes their active participation in learning. Group teaching also can be a beneficial approach for fostering social skills and maintaining contact with oth- ers through shared experiences.

210 Chapter 5 Developmental Stages of the Learner

In patient education, the nurse may be tempted to teach as many family members as possible. Realistically, it is difficult to coordi- nate the instruction of so many different peo- ple. The more individuals involved, the greater the potential for misunderstanding of instruc- tion. The family must make the deliberate deci- sion as to who is the most appropriate person to take the primary responsibility as the caregiver.

The nurse educator must determine how caregivers feel about the role of providing sup- portive care and about learning the necessary information. They must also explore caregiver learning style preferences, cognitive abilities, fears and concerns, and current knowledge of the sit- uation. The family and the nurse may perceive the patient problem differently (Mauk, 2014). Such difference must be identified so that ef- fective teaching can be provided. The caregiver needs similar information to what the patient is given to provide support, feedback, and re- inforcement of self-care consistent with pre- scribed regimens of care. In some situations, a secondary caregiver is identified and also must be considered when teaching.

Sometimes the family members need more information than the patient to compensate for any sensory deficits or cognitive limitations the patient may have. Anticipatory teaching with family caregivers can reduce their anxiety, un- certainty, and lack of confidence. What the fam- ily is to do is important, but what the family is to expect also is essential information to be shared during the teaching–learning process (Haggard, 1989). The greatest challenge for caregivers is to develop confidence in their ability to do what is right for the patient. Education is the means to help them confront this challenge (Reinhard et al., 2012).

The family can be the educator’s great- est ally in preparing the patient for discharge and in helping the patient to become indepen- dent in self-care. The patient’s family is per- haps the single most significant determinant of the success or failure of the education plan and achievement of successful aging (Capezuti, 2014; Gavan, 2003; Haggard, 1989). Rankin and

the healthcare setting. Family caregivers pro- vide critical emotional, physical, and social support to the patient (Gavan, 2003; James & Hughes, 2016; Reeber, 1992; Reinhard, Levine, & Samis, 2012).

Future projections indicate that the num- ber of Americans who need long-term services and supports (LTSS) in the home will continue to grow at a significant rate, more than doubling from 12 million today to 27 million by 2050. According to federal statistics, 20% of individ- uals over 65 years of age need assistance from an informal caregiver with at least one activity of daily living, such as medication administra- tion, and for those over 85 years of age, this per- centage increases to 41%. Based on 2013 data, it is estimated that the approximate value of ser- vices provided to adults by family caregivers is $470 billion annually (James & Hughes, 2016).

The role of family caregivers is central to the quality of care for older adults in the com- munity. Although the physical, emotional, and financial toll on caregivers can be great (James & Hughes, 2016), including the family members in the teaching–learning process helps to ensure that the situation is a win-win scenario for both the clients and the nurse educators. Fam- ily role enhancement and increased knowledge on the part of the family have positive benefits for the learners as well as the teachers. Patients derive increased satisfaction and greater inde- pendence in self-care, and nurses experience increased job satisfaction and personal gratifi- cation in helping patients to reach their poten- tial and achieve successful outcomes (Barnes, 1995; Gavan, 2003).

Numerous nursing, life-span development, and educational psychology theories provide the conceptual frameworks for understanding the dynamics and importance of family relationships as influential in achieving teaching–learning out- comes. Although a great deal of attention has been given to the ways in which young and ad- olescent families function, unfortunately min- imal attention has been paid to the dynamics of the complex interactions that characterize the aging family (Gavan, 2003).

The Role of the Family in Patient Education 211

up-to-date information on performance stan- dards and guidelines for a program of health- care activities for children. However, updated information in the healthcare literature on the application of new approaches to foster child health is sorely needed.

To bolster general understanding of the physical, cognitive, and psychosocial (emo- tional) traits of human development across the life span, plenty of excellent resources, well grounded by research evidence, exist in the fields of psychology in general and edu- cational psychology, in particular. However, much of the educational psychology litera- ture focuses extensively on the application of teaching and learning principles only to pre- school and K–12 classrooms. Understandably, life-span developmental scientists do not spe- cifically consider health education of well indi- viduals with respect to disease prevention, risk reduction, and health promotion efforts or to health promotion, maintenance, and rehabil- itation measures for persons who are acutely and chronically ill. The application and trans- lation of developmental characteristics to the teaching and learning aspects of healthcare delivery are the responsibility of nurses and other healthcare providers. Much more inves- tigation is needed to demonstrate how to effec- tively teach clients at different developmental stages based on their learning needs, learning styles, and readiness to learn, thereby ensur- ing achievement of the most positive client- centered outcomes possible.

Malcolm Knowles’s original 1973 the- ory about adult learning and his subsequent modifications and clarifications of his theory (Knowles, 1990; Knowles et al., 2015) seem to be well accepted and have stood the test of time. Piaget’s theory on cognitive development also has been accepted and extensively applied over the years, but recent critics of Piaget have challenged the assumptions underlying his the- ory with respect to the last stage of develop- ment (formal operations). Today, psychologists speculate that a fifth and qualitatively higher level of thinking follows adolescence, a stage

Stallings’s 2001 model for patient and family education serves as a foundation for assessing the family profile to determine the family mem- bers’ understanding of the actual or potential health problem(s), the resources available to them, their ways of functioning, and their ed- ucational backgrounds, lifestyles, and beliefs.

Education is truly the most powerful tool nurse educators possess to ensure optimal care and the transfer of power to the patient–family dyad. It is imperative that attention be focused on both the assumed and the expected respon- sibilities of family caregivers. The role of the family has been stressed in each developmen- tal section in this chapter. Table 5-1 outlines appropriate interventions for the family at dif- ferent stages in the life cycle.

▸ State of the Evidence In an extensive review of the literature, a signif- icant number of studies, from both primary and secondary sources, that were carried out by nurses and other healthcare professionals were found to support the application of teaching and learn- ing principles to the education of middle-aged and older adult clients in various healthcare set- tings. However, current nursing and healthcare research focusing specifically on patient educa- tion approaches applicable to the age cohorts of children, adolescents, and the young adult pop- ulation, as well as instructional needs of family members as caregivers, is lacking.

For example, the article by Richmond and Kotelchuck (1984), written more than 3 decades ago, remains an excellent and thorough exam- ination of health maintenance in children, in- cluding children’s cognitive understanding of health and disease, their psychological control over health, parental and media influences on health behaviors, the impact of school health education, and the role of health professionals in the management of childhood illness and health services for children. Currently, the Na- tional Resource Center for Health and Safety in Child Care and Early Education (2017) publishes

212 Chapter 5 Developmental Stages of the Learner

(2016), highlight the different experiences, val- ues, beliefs, and needs of learners from varied generational backgrounds.

Although there has been an upsurge of in- terest in educational strategies and techniques for teaching and learning as they apply to cer- tain population groups in the broad health- care arena, much more research needs to be done regarding the creative leadership role of the nurse educator functioning as facilita- tor rather than teacher of patients and family members (at all stages of development) and of nursing students and staff (Donner, Levo- nian, & Slutsky, 2005). Research has only be- gun to scratch the surface of how teaching and learning are affected by situational variables, such as chronic illness, acute illness, disability, or wellness; by personality traits, such as mo- tivation and learning styles; by temperament responses, such as anxiety and attention span; and by sociocultural influences, such as gender, economic status, and educational background.

Another area requiring further explora- tion is the role of family and other support systems on the success of educational endeav- ors to help Americans of all ages maintain and improve their health status. Much more ev- idence from research needs to be conducted on family structure and the many changing relationships in society that promote or hin- der teaching and learning of clients in various healthcare settings.

The national initiatives of Healthy Peo- ple 2020, as well as pending policy goals at local and state levels, will not be realized unless a better understanding is gained of the impact of physical, cognitive, psychological/emotional, and sociocultural changes that occur across the life course that can serve as a guideline for teaching and learning in nursing and health- care practice.

▸ Summary For nurses, it is important to understand the specific and varied tasks associated with each

postulated as the postformal operations period of adulthood. Vygotsky’s sociocultural theory adds another dimension to understanding cog- nitive development that was not addressed by Piaget (Crandell et al., 2012; Santrock, 2017). A contemporary interpretation of Vygotsky’s theory to the classroom is the current inter- est in collaborative group learning with peers (McLeod, 2007).

Erikson’s theory of the eight stages of psy- chosocial development, whereby individu- als face unique stage-related tasks (crises that must be resolved to reduce one’s vulnerabil- ity and enhance one’s potential), is still recog- nized as elucidating the unique turning points in life that require successful completion for healthy, normal development to occur. Although Erikson’s theory continues to be widely applied to the field of life-span development, the ex- istence of a ninth stage of development, hope and faith versus despair, has received relatively little attention in the literature. More research is needed to confirm the existence of this fi- nal stage of psychosocial development, which addresses the unique tasks of the oldest-old (Erikson & Erikson, 1998).

Recently, increased attention has been paid to the appropriateness of teaching methods and instructional materials (especially as they relate to multimedia technology) for college-aged stu- dents and adult learners to meet their expecta- tions for lifelong learning. Given the fact that the population is steadily aging, nurses are caring for an increasingly older audience of learners. Many of today’s nursing students are somewhat older than the traditional college-aged students, and nursing staff are adult continuing-education learners. It is gratifying to witness the acknowl- edgment of these population changes through an emphasis on studying generational differ- ences in learner preferences, modes of infor- mation processing, and memory and recall with respect to the impact of standard versus newer technological methods and tools for the effec- tive delivery of instruction. The literature, such as the articles written by Billings and Kowalski (2004), Fishman (2016), and Shatto and Erwin

Summary 213

facilitator of the learning process. In conjunc- tion with these adult learners, nurse educators can establish objectives and learner-centered ap- proaches that challenge the educator’s creativ- ity to foster self-direction, motivation, interest, and active participation for independence and interdependence in learning.

Review Questions 1. What are the seven stages of development? 2. Define pedagogy, andragogy, and

geragogy. 3. Who is the expert in cognitive develop-

ment? What are the terms or labels used by this expert to identify the key cognitive milestones?

4. Who is the expert in psychosocial de- velopment? What are the terms or labels used by this expert to identify the key psychosocial milestones?

5. What are the salient or prominent char- acteristics at each stage of development that influence the ability to learn?

6. What are three main teaching strategies for each stage of development?

7. How do people you know in each stage of development compare with what you have learned about physical, cognitive, and psychosocial characteristics at the various developmental stages?

8. What is the role of the family in the teaching and learning process in each stage of development?

9. How does the role of the nurse vary when teaching individuals at different stages of development?

developmental stage to individualize the ap- proach to education in meeting the needs and desires of clients and their families. Assessment of physical, cognitive, and psychosocial matura- tion within each developmental period is cru- cial in determining the appropriate strategies to facilitate the teaching–learning process. The younger learner is, in many ways, very differ- ent from the adult learner. Issues of dependency, extent of participation, rate of and capacity for learning, and situational and emotional obsta- cles to learning vary significantly across the var- ious phases of development.

Readiness to learn in children is very sub- ject centered and highly influenced by their physical, cognitive, and psychosocial matu- ration. By comparison, motivation to learn in adults is very problem centered and more oriented to psychosocial tasks related to roles and expectations of work, family, and commu- nity activities.

For client education to be effective, the nurse in the role of educator must create an environ- ment conducive to learning by presenting infor- mation at the learner’s level, inviting participation and feedback, and identifying whether paren- tal, family, and/or peer involvement is appropri- ate or necessary. Nurses are the main source of health information. In concert with the client, they must facilitate the teaching–learning pro- cess by determining what needs to be taught, when to teach, how to teach, and who should be the focus of teaching based on the develop- mental stage of the learner.

When nursing students and staff are the audience of learners, the educator also is re- sponsible for assuming the leadership role as

CASE STUDY Your local primary care network is developing a new program that focuses on a family-centered approach to diabetes management. Expected patient outcomes of the program are to reduce hospitalizations and days off from work or school. Your role as a nursing consultant to this program is to help the team develop a comprehensive, family-oriented educational program that covers important diabetes topics

(continues)

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such as pathophysiology, nutrition, and exercise. Maurice, a member of the team, suggests, “Let’s do our teaching with all the family members together in a group.” Lina, another team member, states, “We should separate the family members into similar age groups for the teaching—that way, we can better keep their interest.” You suggest that the team integrate Maurice’s and Lina’s suggestions and plan a total of five teaching sessions, with four of the sessions grouping participants according to developmental stages and the final session grouping families together. Participants range from 6 to 75 years of age.

1. Describe how you will determine the different age range groupings of the participants for the first four sessions. Explain the different age ranges, cognitive and psychosocial stages, and general characteristics of each group.

2. Choose two different developmental stage groupings and give examples of teaching strategies you will use with each group for the specific teaching sessions. Explain why you chose these strategies for the individuals with diabetes and their families.

3. What are some advantages to grouping participants by developmental stages? What are some disadvantages?

CASE STUDY (continued)

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218 Chapter 5 Developmental Stages of the Learner

Compliance, Motivation, and Health Behaviors of the Learner Mary Ann Wafer With grateful acknowledgment in memoriam to Eleanor Richards, PhD, RN, former Chair and Associate Professor at the State University of New York (SUNY) at New Paltz, for her contributions as the original author of this chapter.

CHAPTER HIGHLIGHTS

■ Compliance and Adherence • Perspectives on Compliance • Noncompliance and Nonadherence • Locus of Control

■ Motivation • Motivational Factors • Motivational Axioms • Assessment of Motivation • Motivational Strategies

■ Selected Models and Theories • Health Belief Model • Health Promotion Model (Revised) • Self-Efficacy Theory • Protection Motivation Theory • Stages of Change Model • Theory of Reasoned Action and Theory of Planned Behavior • Therapeutic Alliance Model

(continues)

219

CHAPTER 6

■ Models for Health Education • Similarities and Dissimilarities of Models • Educator Agreement with Model Conceptualizations • Functional Utility of Models • Integration of Models for Use in Education

■ The Role of Nurse as Educator in Health Promotion • Facilitator of Change • Contractor • Organizer • Evaluator

■ State of the Evidence

CHAPTER HIGHLIGHTS (continued)

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the terms compliance, adherence, and motivation relative to behaviors of the learner. 2. Discuss compliance, adherence, and motivation concepts and theories. 3. Identify incentives and obstacles that affect motivation to learn. 4. State axioms of motivation relevant to learning. 5. Assess levels of learner motivation. 6. Outline strategies that facilitate motivation and improve compliance and adherence. 7. Compare selected health behavior frameworks and their influence on learning. 8. Recognize the role of the nurse as educator in health promotion.

The concepts of compliance, adherence, and motivation are used implicitly or explicitly in many health behavior mod- els. This chapter discusses these concepts as

they relate to health behaviors of the learner and presents an overview of selected theories and models for consideration in the teaching– learning process. The nurse as educator needs

KEY TERMS

compliance adherence noncompliance nonadherence locus of control (LOC) motivation hierarchy of needs motivational incentives motivational axioms

concept mapping motivational interviewing (MI) READS OARS health belief model (HBM) health promotion model

(HPM) self-efficacy theory protection motivation theory

stages of change model theory of reasoned action

(TRA) theory of planned behavior

(TPB) therapeutic alliance model concordance educational contracting

220 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

to understand which factors promote or hinder the acquisition and application of knowledge and what drives the learner to learn.

Factors that determine health behaviors and outcomes are complex. Knowledge alone does not guarantee that the learner will engage in health-promoting behaviors or that the de- sired outcomes will be achieved. The most well- thought-out educational program or plan of care cannot achieve the prescribed goals if the learner is not understood in the context of com- plex factors associated with compliance, adher- ence, and motivation.

▸ Compliance and Adherence

The terms compliance and adherence are often used interchangeably in the literature to refer to a patient’s effort to follow healthcare advice (Brown & Bussell, 2011; Robinson, Callister, Berry, & Dearing, 2008). However, these terms imply different views about the healthcare provider— patient relationship. Compliance is defined as the “extent to which the patient’s behavior (in terms of taking medications, following diets or execut- ing other lifestyle changes) coincides with the clinical advice” (Sackett & Haynes, 1976, p. 11). According to the Merriam-Webster dictionary (2015b), compliance means “the act or process of complying to a desire, demand, proposal, or regimen or to coercion; a disposition to yield to others.” Defined as such, it has an authoritative undertone. Specifically, when applied to health care, it implies that the healthcare provider or ed- ucator is viewed as the authority, and the patient or learner is in a submissive role, passively fol- lowing recommendations. Many nurses object to this hierarchical stance because they believe that patients have the right to make their own healthcare decisions and not necessarily follow predetermined courses of action set by health- care professionals.

Adherence, according to the World Health Organization, is “the extent to which a person’s

behavior corresponds with agreed recommen- dations from a health care provider” (Sabaté, 2003, p. 3), such as taking medication, follow- ing a diet, and/or executing lifestyle changes. Mihalko et al. (2004) define adherence as “level of participation achieved in a behavioral regimen once an individual has agreed to the regimen” (p. 448), and Hernshaw and Lidenmeyer (2006) describe adherence as the degree to which the patient follows the plan of care formulated in con- junction with the healthcare provider. Further- more, the Merriam-Webster dictionary (2015a) defines adherence as “the act, action, or qual- ity of adhering: steady or faithful attachment,” suggesting the need for the patient to attach and commit to the healthcare regimen. These definitions address the need for patients to be involved in treatment decisions, which is quite different from passively following the healthcare providers’ prescriptions. The presumption with adherence is that the patient agrees with a rec- ommendation put forth (Brown & Bussell, 2011).

During the 1990s, the terminology in the literature began to shift from compliance to adherence (Gardner, 2015), supporting a more inclusive and active patient role. The term adher- ence is considered more patient centered than compliance (Vlasnik, Aliotta, & DeLor, 2005) because it supports the patient’s right to choose whether to follow treatment recommendations.

Both compliance and adherence refer to the ability to maintain health-promoting regimens, which are determined by the health- care provider or in conjunction with the health- care provider, respectively. It is possible, though, for an individual to initially comply with a reg- imen but not necessarily be committed to it. For example, a patient who is experiencing sleep disturbances may comply for a short pe- riod of time with medication as directed. The same patient, however, may not continue to adhere to the regimen for an extended time, even though his sleep disturbances continue. In this situation, there is temporary support of the plan but no commitment to follow through. Because both compliance and adherence are terms commonly used in the measurement of

Compliance and Adherence 221

health outcomes, they are often used synony- mously in the literature despite the differences in social connotations between the terms (Gardner, 2015). In this chapter, these terms are used interchangeably.

Perspectives on Compliance Theories and models of compliance, as de- scribed by Eraker, Kirscht, and Becker (1984) and Leventhal and Cameron (1987), can be viewed from various perspectives and are use- ful in explaining or describing compliance from a multidisciplinary approach, including psychology and education. These theories and models are as follows:

1. Biomedical theory, which links com- pliance with patient characteristics such as demographics, severity of disease, and complexity of treat- ment regimen.

2. Behavioral/social learning theory, which focuses on external factors that influence the patient’s adher- ence, such as rewards, cues, con- tracts, and social supports.

3. Communication models, which at- tempt to explain compliance based on the communication between the patient and healthcare profes- sional. These models address aspects such as the feedback loop of send- ing, receiving, comprehen ding, re- taining, and accepting information.

4. Rational belief theory, which sug- gests that patients decide to com- ply or not comply by weighing the benefits of treatment and the risks of disease through cost-benefit logic.

5. Self-regulatory systems, in which patients are seen as problem solv- ers whose regulation of behavior is based on perception of illness, cog- nitive skills, and past experiences that affect their ability to plan and cope with illness.

Although these theories and models shed some light on the very complex issue of com- pliance, most sources agree that each of them has limitations and no one theory or model alone has proved to be superior to the others (Heiby, Lukens, & Frank, 2005; Munro, Lewin, Swart, & Volmink, 2007). In recent years, re- searchers have attempted to use a multivariate approach to explaining compliance. For exam- ple, Heiby et al. (2005) have proposed the health compliance-II model, which incorporates vari- ables from several theories and models. Fur- ther research is needed to identify a model that incorporates some of the multiple variables de- scribed subsequently.

Low compliance with making healthy life- style changes is frequently seen in people who have chronic diseases. This is because positive outcomes resulting from behavioral change are not often immediate and, therefore, individuals become frustrated and nonadherent to health plans that offer mainly long-term benefits, not short-term gratifications. A web-based behavior motivational tool, grounded in social cognitive theories, has been developed to help increase pa- tient compliance. Entertaining gaming techniques are used to encourage change in behaviors by creating scenarios and “information interven- tions based on predefined rules to achieve effec- tive compliance” (Lin, Ramakrishnan, Chang, Spraragen, & Zhu, 2013, p. 58).

Noncompliance and Nonadherence Noncompliance describes resistance of the individual to follow a predetermined regimen. It often results in blaming behavior when pa- tient goals are not achieved (Yach, 2003) and condemns a patient’s behavior as flawed for the inability to conform to treatment (Ofri, 2012; Robinson et al., 2008). Ward-Collins (1998) notes that noncompliance can be a highly sub- jective judgmental term sometimes used syn- onymously with the terms noncooperative and disobedient. Helme and Harrington (2004) stud- ied patients who were noncompliant with their

222 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

diabetes regimen and found that although most people admitted their failure to comply with their healthcare plan, many offered excuses or justi- fications, and some denied that noncompliance had occurred. Even though in this study partic- ipants had nothing to lose by admitting their noncompliance, many felt the need to explain or deny their failure to follow orders.

Many studies on patient noncompliance have been conducted, and yet, the question of why patients are noncompliant remains largely unanswered, primarily because of the complex- ity of the issue. Noncompliance can be related to patient issues such as knowledge or motiva- tion, health illiteracy, treatment factors such as side effects, disease issues such as prognosis, lifestyle issues such as transportation, socio- demographic factors such as social and eco- nomic status, and psychosocial variables such as depression and fear (Chesanow, 2014; Quan, 2016; Rosner, 2006).

The expectation of total compliance in all spheres of behavior and at the specified times prescribed is unrealistic. In some situations, noncompliant behavior may be desirable and could be viewed as a necessary defensive re- sponse to stressful situations. The learner may use time-outs as the intensity of the learning sit- uation is maintained or escalates. This mecha- nism of temporary withdrawal from the learning situation may prove to be beneficial. Follow- ing withdrawal, the learner could reengage, feeling renewed and ready to continue with an educational program or regimen. Viewed in this way, noncompliance is not always an obstacle to learning and does not always carry a nega- tive connotation (Rosner, 2006).

Nonadherence occurs when the patient does not follow treatment recommendations that are mutually agreed upon (Resnik, 2005). It can be intentional or unintentional and, according to the World Health Organization, can be deter- mined by the interplay of five sets of factors or dimensions—socioeconomically related, patient related, condition related, therapy related, and healthcare team or system related (Sabaté, 2003). Patient factors that contribute to nonadherence

include stress, forgetfulness, substance abuse, having multiple medical conditions, uncertainty about health beliefs and practices, and real or perceived stigma associated with the conditions of being treated (DiMatteo, 2004; Pignone & Salazar, 2014). A patient’s nonadherence to med- ical treatment recommendations can affect their health status as well as the healthcare system.

Noncompliance confers an unnecessary health risk and can result in increased med- ical expenditures (Heiby et al., 2005; Martin, Williams, Haskard, & DiMatteo, 2005). For ex- ample, a patient’s nonadherence to medications for diabetes has been identified as contributory to health complications and preventable hos- pitalizations (Schwartz et al., 2017). In many disease conditions, including diabetes, approxi- mately 40% of patients were at high risk because of nonadherence resulting from factors such as misunderstanding, forgetting, or ignoring rec- ommended health regimens (Martin et al., 2005; Quan, 2016). Specifically related to medication noncompliance or nonadherence, 50% of pre- scription drugs are taken incorrectly or not at all, 75% of patients do not always take their medi- cations as directed, 125,000 deaths per year are attributed to poor medication compliance, and poor drug compliance is estimated to cost the healthcare system $290 billion per year through unnecessary hospitalizations, rehospitalizations, and premature death (Chesanow, 2014).

Research, as evidenced by the multidisci- plinary healthcare literature, has focused on the compliance or adherence and noncompliance or nonadherence of healthcare consumers to their healthcare plans (Chesanow, 2014; Jin, Sklar, Min Sen Oh, & Chuen Li, 2008; Jimmy & Jose, 2011). The number of studies on the level of compli- ance reflects the importance of this concept to practice. This phenomenon may result from an emphasis on cost-effective health care, as seen, for example, in shorter lengths of hospital stays when there is less time to teach. Also, related to the educator role is the fact that the successes of educational programs in a fiscally cost- conscious system ultimately are linked to measurement of patient compliance relative to outcomes.

Compliance and Adherence 223

3. Others external: Others such as fam- ily, friends, and associates are pow- erful influences

4. Doctors external: Doctors have power to control outcomes

As an example of the influence of HLOC, Brincks, Feaster, Burns, and Mitrani (2010) in- vestigated how it affects the patient–provider relationship. They found that a powerful oth- ers HLOC (doctors external) resulted in HIV patients demonstrating a trusting, positive re- lationship with physicians. Janowski, Kurpas, Kusz, Mroczek, and Jedynak (2013) examined HLOC and acceptance of illness in patients with chronic diseases and found health-related be- haviors were significantly positively correlated with all categories (dimensions) of HLOC re- gardless of specific diagnosis, but they also found sociodemographic factors (age, gender, educa- tion, marital status) were crucial in determining frequency of health behaviors in these patients.

Many researchers in the health profes- sions have studied the link between locus of control and compliance with therapeutic reg- imens. Given the complexity of the phenom- enon of LOC characterized by the interplay of many factors that make up individuals’ cognitive and psychosocial behaviors, the re- sults in this area have been somewhat mixed. Some investigators have found a significant correlation and others an insignificant rela- tionship between LOC and adherence to rec- ommended treatments in patients with both acute and chronic conditions, such as ortho- pedic problems, hypertension, diabetes, obe- sity, and schizophrenia (Combes & Feral, 2011; Epstein, Kale, & Weisshaar, 2014; Indelicato et al., 2017; Lee, Ahn, & Kim, 2008; Morowatishari- fabad, Mahmoodabad, Baghianimoghadam, & Tonekaboni, 2010; O’Hea et al., 2009; Omeje & Nebo, 2011; Porto, Machado, Martins, Galato, & Piovezan, 2014; Rosno, Steele, Johnston, & Aylward, 2008; Tahar et al., 2015). Although the literature remains inconclusive as to the nature of the relationship between compliance in inter- nal versus external LOC, Shillinger (1983) and Nguyen (2016) suggest that different teaching

Locus of Control The authoritative aspect of compliance im- plies that the educator attempts to control, in some degree, decision making on the part of the learner. Some models of compliance have attempted to balance the issue of con- trol by using terms such as mutual contract- ing (Steckel, 1982) or consensual regimen (Fink, 1976).

One way to view the issue of control in the learning situation is through the concept of locus of control (Rotter, 1954) or health lo- cus of control (Wallston, Wallston, & DeVellis, 1978). Locus of control (LOC) refers to an in- dividual’s sense of responsibility for his or her own behavior and the extent to which motiva- tion to act originates from within the person (internal) or is influenced by others (exter- nal). Health locus of control (HLOC) spe- cifically relates LOC to health behaviors and describes an individual’s belief that health is dependent on internal and external factors. Through objective measurement, individuals can be categorized as internals, whose health behavior is self-directed, or externals, for whom others are viewed as more powerful in influ- encing health outcomes. Externals believe that fate or some other powerful outside force(s) determines life’s course, whereas internals be- lieve that they control their own destiny. For instance, an external might say, “Osteoporosis runs in my family, and it will catch up with me.” An internal might say, “Although there is a his- tory of osteoporosis in my family, I will have necessary screenings, eat an appropriate diet, and do weight-bearing exercise to prevent or control this problem.”

Recently, four dimensions to the concept of HLOC that expand on Rotter’s (1954) original concept of LOC have been identified by Combes and Feral (2011). The four dimensions are:

1. Internal: Power originates from within and is related to personal abilities

2. Chance external: Fate is a powerful outside influence

224 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

social sciences. The major premises of Maslow’s motivation theory are integrated wholeness of the individual and a hierarchy of goals. Ac- knowledging the complexity of the concept of motivation, Maslow noted that not all behav- ior is motivated and that behavior theories are not synonymous with motivation. Many deter- minants of behavior other than motives exist, and many motives can be involved in one be- havior. Using the principles of a hierarchy of needs—physiological, safety, love/belonging, esteem, and self-actualization—Maslow noted the relatedness of needs, which are organized by their level of potency. Some individuals are highly motivated, whereas others are weakly motivated. When a need is quite well satisfied, then the next potent need emerges. An exam- ple of the hierarchy of basic needs is the pow- erful need to satisfy hunger. This need may be met by the nurse assisting the poststroke patient with feeding. The nurse–patient interaction may also satisfy the next most potent needs, those of love/belonging and esteem.

Relationships exist between motivation and learning; between motivation and behavior; and among motivation, learning, and behavior. Each theory presented in this chapter attempts to ad- dress the complex and somewhat elusive qual- ity of motivation.

Motivational Factors Factors that influence motivation can serve as either incentives or obstacles to achieving de- sired behaviors. Both creating incentives and decreasing obstacles to motivation pose a chal- lenge for the nurse as educator. The cognitive (thinking processes), affective (emotions and feelings), and psychomotor (skill behavior) domains as well as the social circumstances of the learner can be influenced by the educator, who can act as either a motivational facilita- tor or blocker.

Motivational incentives, which are those factors that influence motivation in the direc- tion of a desired goal, need to be considered in the context of the individual. What may be a

and coaching strategies are indicated for inter- nals versus externals.

▸ Motivation Motivation, from the Latin word movere, means to set into motion. Motivation is defined as “an internal state that arouses, directs, and sustains human behavior” (Glynn, Aultman, & Owens, 2005, p. 150) and as a willingness of the learner to embrace learning, with readiness as evidence of motivation (Redman, 2007). According to Kort (1987), motivation is the result of both in- ternal and external factors and not the result of external manipulation alone. Implicit in moti- vation is movement in the direction of meeting a need or toward reaching a goal. Motivation is the desire to reduce some drive (drive reduc- tion). Hence, satisfied, complacent, and sati- ated individuals have little motivation to learn and to change.

Lewin (1935), an early field theorist, con- ceptualized motivation in terms of positive or negative movement toward goals. Once an indi- vidual’s equilibrium is disturbed, such as in the case of illness, forces of approach and avoidance may come into play. Lewin noted that if avoid- ance endured in an approach–avoidance con- flict, there would be negative movement away from a goal. His theory implies the existence of a critical time factor relative to motivation. This time factor, however, is generally not a serious consideration in motivational models of health behavior or motivational research.

Ideally, the nurse educator’s role is to facilitate the learner’s approach toward a desired goal and to prevent untimely delays. For example, nurs- ing staff may request an inservice program about evidence-based practice. The inservice nurse ed- ucator may delay this request to the point that the staff loses interest in the topic. Although un- timely delays may be beyond the control of the educator, every effort should be made to capi- talize on the staff ’s desire and readiness to learn.

Maslow (1943) developed a theory of hu- man motivation that is still widely used in the

Motivation 225

well. Emerging interest about male–female be- havioral and learning differences indicates the need for in-depth research on gender-related characteristics that affect motivation to learn.

Environmental Influences Physical characteristics of the learning environ- ment, accessibility and availability of human and material resources, and different types of behav- ioral rewards all combine to influence the moti- vational level of the individual. The environment can create, promote, or detract from a state of learning receptivity. Pleasant, comfortable, and adaptable individualized surroundings, for ex- ample, can promote a state of readiness to learn. Conversely, noise, confusion, interruptions, and lack of privacy can interfere with the capacity to concentrate and to learn.

The factors of accessibility and availability of resources include physical and psychologi- cal aspects. Can the client physically access a health facility, and once there, will the health- care personnel be psychologically available to the client? Psychological availability refers to whether the healthcare system is flexible and sensitive to patients’ needs. It includes factors such as promptness of services, sociocultural competence, emotional support, and communi- cation skills. Attitude influences the client’s en- gagement with the healthcare system.

The way in which the healthcare system is perceived by the client affects the client’s willingness to participate in health- promoting behaviors. Behavioral rewards permeate the foundations of the learner’s motivation. Re- wards can be extrinsic, such as praise or ac- knowledgment from the educator or caretaker. Alternatively, they can be intrinsically based, taking the form of feelings of a personal sense of fulfillment, gratification, or self-satisfaction.

Relationship Systems Family or significant others in the support sys- tem; cultural identity; work, school, and com- munity roles; and teacher–learner interaction are all relationship-based factors that influence

motivational incentive for one learner may be a motivational obstacle to another. For example, a nurse assigned to work with a woman who is elderly may be motivated to care for her when other staff nurses on the unit hold older adults in high regard. Another nurse may be motiva- tionally blocked by the same emotional domain because previous experiences with older women, such as a grandmother, were unrewarding. Fa- cilitating or blocking factors that shape motiva- tion to learn can be classified into three major categories, which are not mutually exclusive:

1. Personal attributes, which consist of physical, developmental, and psy- chological components of the indi- vidual learner

2. Environmental influences, which include the physical and attitudi- nal climate

3. Relationship systems, such as those of significant other, family, commu- nity, and teacher–learner interaction

Personal Attributes Personal attributes of the learner—such as developmental stage, age, gender, emotional readiness, values and beliefs, sensory func- tioning, cognitive ability, educational level, actual or perceived state of health, and se- verity or chronicity of illness—can shape an individual’s motivation to learn. Functional ability to achieve behavioral outcomes is de- termined by an individual’s physical, emo- tional, and cognitive status. The individual’s perception of disparity between the current and expected states of health can be a moti- vating factor in health behavior and can drive readiness to learn.

The learner’s views about the complexity or extent of changes that are needed can shape motivation. Values, beliefs, and natural curiosity can be firmly entrenched and enduring factors that also can shape desire to learn new behaviors. Other factors, such as sensory input and pro- cessing of information and short-term and long- term memory, can affect motivation to learn as

226 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

level, the learner who has low anxiety is not very driven to act. Thus, a moderate state of anxiety can be comfortably managed and is known to be most effective in promoting learning (Kes- sels, 2003; Ley, 1979; Stephenson, 2006).

For example, a patient who has been recently diagnosed with breast cancer and who has a high level of anxiety will not respond at an optimal level of retention of information when instructed about treatment options. When the nurse as- sists the patient in reducing anxiety through techniques such as guided imagery, use of hu- mor, words of reassurance, or relaxation tapes, the patient will respond with a higher level of information retention.

Learner Readiness Desire to move toward a goal and readiness to learn are factors that influence motivation. Desire cannot be imposed on the learner. It can, however, be significantly influenced by external forces and be promoted by the nurse as educator. Incentives are specific to the in- dividual learner. An incentive for one individ- ual can be a deterrent to another. For example, suggesting a method of weight reduction that includes physical exercise may be an incen- tive for one client and totally unappealing for another. Incentives in the form of reinforc- ers and rewards can be tangible or intangible, external or internal.

Acting as a facilitator to the learner, the nurse as educator offers positive perspectives and encouragement, which shape the desired behavior toward goal attainment. By ensuring that learning is stimulating, making informa- tion relevant and accessible, and creating an environment conducive to learning, educators can enhance motivation to learn.

Realistic Goals Goals that are within a person’s grasp and pos- sible to achieve will likely be something toward which an individual will work. In contrast, goals that are significantly beyond the person’s reach are frustrating and counterproductive.

an individual’s motivation. The interactional as- pects of motivation are perhaps the most salient because the learner always exists in the context of interlocking relationship systems. Individuals are viewed in the context of family/community/ cultural systems that have lifelong effects on the choices that individuals make, including healthcare seeking and healthcare decision making. These significant-other systems may have an even greater influence on health out- comes than commonly acknowledged, and the nurse, when in the role of educator, needs to consider the health-promoting use of these systems. Collectively, these factors interact to address the motivation of the learner. They are not comprehensive theory constructs but rather forces that act on motivation, serving to facilitate or block the desire to learn.

Motivational Axioms Axioms are premises on which an under- standing of a phenomenon is based. The nurse as educator needs to understand the prem- ises involved in promoting motivation of the learner. Motivational axioms are rules that set the stage for motivation. They include (1) the state of optimal anxiety, (2) learner read- iness, (3) realistic goal setting, (4) learner sat- isfaction/success, and (5) uncertainty-reducing or uncertainty-maintaining dialogue.

State of Optimal Anxiety Learning occurs best when a state of moderate anxiety exists. In this optimal state for learning, the learner’s ability to observe, focus attention, learn, and adapt is operative (Peplau, 1979). Perception, concentration, abstract thinking, and information processing are enhanced. Behavior is directed at a learning or challeng- ing situation. Above this optimal level, at high or severe levels of anxiety, the learner becomes increasingly self-absorbed (Shapiro, Boggs, Melamed, & Graham-Pole, 1992), and the abil- ity to perceive the environment, concentrate, and learn is reduced. If at less than the optimal

Motivation 227

Uncertainty (as well as certainty) can be a motivating factor in the learning situation. Individuals may have ongoing internal dia- logues that can either reduce or maintain un- certainty. Individuals carry on self-talk; they think things through. When a person wants to change a state of health, behaviors often follow a dialogue that examines uncertainty, such as “If I stop smoking, then my chances of getting lung cancer will be reduced.” When the proba- ble outcome of health behaviors is more uncer- tain, behaviors may maintain uncertainty. The person might say, “I am not sure that I need this surgery because the survival rates are no differ- ent for those who had this surgery and those who did not.” Some learners may maintain cur- rent behaviors, given probabilities of treatment outcomes, thereby maintaining uncertainty.

Mishel (1990) reconceptualizes the con- cept of uncertainty in illness. She views uncer- tainty as a necessary and natural rhythm of life rather than an adverse experience. Uncertainty in sufficient concentration influences choices and decision making, and it can capitalize on receptivity or readiness for change. Premature uncertainty reduction can be counterproduc- tive to the learner who has not sufficiently ex- plored alternatives. For example, when a staff nurse is uncertain about positions for catheter- izing a female patient who is debilitated and is presented with alternatives, then a thinking dia- logue is carried out. If the decision to use a spe- cific position is not premature, then uncertainty will promote exploration of alternative positions.

Assessment of Motivation How does the nurse know when the learner is motivated? Redman (2001) views motivational assessment as a part of general health assess- ment and states that it includes such areas as level of knowledge, client skills, decision-making capacity of the individual, and screening of target populations for educational programs. The educator can pose several questions of the learner, such as those focusing on previous at- tempts, curiosity, goal setting, self-care ability,

Setting unrealistic goals that lead to loss of valuable time can set the stage for the learner to give up.

Setting realistic goals by determining what the learner wants to change is a motivat- ing factor. The belief that one can achieve the task set before him or her facilitates behavior geared toward achieving that goal. Goals should parallel the extent to which behavioral changes are needed. Determining what the learner wants to change is a critical factor in setting realistic goals. Mutual goal setting between the learner and the educator reduces the negative effects of hidden agendas or the sabotaging of edu- cational plans.

Learner Satisfaction/Success The learner is motivated by success. Success is self-satisfying and feeds the learner’s self-esteem. In a cyclical process, success and self-esteem escalate, moving the learner toward accom- plishment of additional goals. When a learner feels good about step-by-step accomplish- ments, motivation is enhanced. For example, in the instructor–student relationship, evalu- ations can be a valuable method of promoting learner success. Clinical evaluations, when fo- cused on demonstration of positive behaviors, can encourage movement toward performance goals. Focusing on successes as a means of pos- itive reinforcement promotes learner satisfac- tion and instills a sense of accomplishment. Conversely, focusing on weak clinical perfor- mance can reduce students’ self-esteem.

Uncertainty Reduction or Maintenance Uncertainty is a common experience in the healthcare arena. Healthcare consumers and health professionals alike are often asked to make decisions about treatments and care op- tions whose outcomes are unclear. An individ- ual’s response to this type of uncertainty may vary depending on the individual’s character- istics (Politi, Han, & Col, 2007).

228 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

motivators; Ajzen and Fishbein’s (1980) intent and attitude; Becker, Drachman, and Kirscht’s (1974) notion of likelihood of engaging in ac- tion; Pender’s (1996) commitment to a plan of action; and Barofsky’s (1978) focus on alliance in the learning situation. Additionally, the pres- ence of cognitions in the form of facilitative beliefs proposed by Wright, Watson, and Bell (1996) provides a comprehensive and multidi- mensional assessment. This multidimensional guide allows for assessment of the level of learner motivation. If responses to dimensions are pos- itive, the learner is likely to be motivated.

Assessment of learner motivation involves the judgment of the educator because teaching– learning is a two-way process. Motivation can be assessed through both subjective and objective means. A subjective means of assessing level of motivation is through dialogue. By being pres- ent and using therapeutic communication skills, the nurse can obtain verbal information from the patient, such as “I really want to maintain my weight” or “I want to be able to take care of myself.” Both statements indicate an energized desire with direction of movement toward a pos- itive health outcome. Nonverbal cues also can indicate motivation, such as when the nurse sees the patient reading about healthy diets. Like- wise, a staff member or student may express a verbal desire to know more about a specific ad- vanced procedure. A nonverbal motivational cue might be expressed by the staff member or student carefully observing a senior nurse or clinical specialist performing an advanced tech- nique, for example.

Measurement of motivation is another aspect to be considered. Subjective self-reports indicate the level of motivation from the learner’s perspective. If desired, self-report measurements could be developed for educational programs. Objective measurement of motivation—an indirect measurement—can be quantified through observation of expected behaviors, which are the consequence of motivation. Be- haviors that can be observed as the learner moves toward achieving preset realistic goals can serve as objective measures of motivation.

stress factors, survival issues, and life situations. Motivational assessment of the learner needs to be comprehensive, systematic, and concep- tually based. Cognitive, affective, physiologi- cal, experiential, environmental, and learning relationship variables need to be considered. BOX 6-1 shows parameters for a comprehensive motivational assessment of the learner.

These multitheory-based parameters incorporate several perspectives, including Bandura’s (1986) construction of incentive

BOX 6-1 Comprehensive Parameters for Motivational Assessment of the Learner

Cognitive Variables ■ Capacity to learn ■ Readiness to learn

• Expressed self-determination • Constructive attitude • Expressed desire and curiosity • Willingness to contract for behavioral

outcomes ■ Facilitating beliefs

Affective Variables ■ Expressions of constructive emotional state ■ Moderate level of anxiety

Physiological Variables ■ Capacity to perform required behavior

Experiential Variables ■ Previous successful experiences

Environmental Variables ■ Appropriateness of physical environment ■ Social support systems

• Family • Group • Work • Community resources

Educator–Learner Relationship System

■ Prediction of positive relationship

Motivation 229

Motivational strategies for the nurse as ed- ucator are extrinsically generated using specific incentives. The critical question for the nurse as educator to ask is, “Which specific behavior, un- der which circumstances, in which time frame, may be desired by this learner?” Strategizing be- gins with a systematic assessment of learner mo- tivation, like that outlined in Box 6-1. When a variable is absent or reduced, incentive strate- gizing is likely to move the individual away from the desired outcome. When considering strat- egies to improve learner motivation, Maslow’s (1943) hierarchy of needs also can be taken into consideration. An appeal can be made to the innate need for the learner to succeed, known as achievement motivation (Atkinson, 1964).

In an educational setting, clear communi- cation, including clarification of directions and expectations, is critical. Organization of mate- rial in a way that makes information meaning- ful to the learner, environmental mani pulation, positive verbal feedback, and provision of op- portunities for success are motivational strate- gies proposed by Haggard (1989). Reducing or eliminating barriers to achieve goals is an im- portant aspect of maintaining motivation.

One model developed by Keller (1987), known as the attention, relevance, confidence, and satisfaction (ARCS) model, focuses on creating and maintaining motivational strate- gies that can be used for designing instruction. This model emphasizes strategies that the edu- cator can apply to effect changes in the learner by creating a motivating learning environment:

■ Attention introduces opposing positions, case studies, and variable instructional presentations.

■ Relevance capitalizes on the learners’ ex- periences, usefulness, needs, and personal choices.

■ Confidence deals with learning require- ments, level of difficulty, expectations, at- tributions, and sense of accomplishment.

■ Satisfaction pertains to timely use of a new skill, use of rewards, praise, and self- evaluation.

Motivational Strategies Finding the spark that motivates the learner to learn is challenging to the educator. The ques- tion remains, how does an educator motivate a seemingly unmotivated individual or help a mo- tivated person to remain motivated? As noted earlier, incentives viewed as appeals or induce- ments to motivation can be either intrinsically or extrinsically generated. Incentives and mo- tivation are both stimuli to action. Bandura (1986), for example, associates motivation with incentives. He notes, however, that intrinsic (in- ternal) motivation, although highly appealing, is elusive. Only rarely does motivation occur without extrinsic (external) influence. Green and Kreuter (1999) note that “strictly speaking we can appeal to people’s motives, but we can- not motivate them” (p. 30). Extrinsic incentives are used for motivational strategizing in the ed- ucational situation.

Cognitive evaluation theory (Ryan & Deci, 2000) posits that knowing how to foster mo- tivation is essential because educators can- not rely on intrinsic motivation to promote learning. They note, however, that autonomy and competence are intrinsic motivators that can be enhanced by selected teaching strate- gies. One contemporary nursing educational strategy suggested that a way to promote mo- tivation is concept mapping, which enables the learner to integrate previous learning with newly acquired knowledge through diagram- matic “mapping.” As a motivational technique, concept mapping facilitates the acquisition of complex new knowledge through visual links that acknowledge previous learning. Learner interest is sustained by perceived compe- tence and autonomy. Concept mapping, as a less instructor-regulated learning activity, promotes interest and value on behalf of the learner. A review of the health professions’ literature indicates that students and faculty find concept mapping to be a valuable learn- ing exercise (Hunter Revell, 2012; Taylor & Littleton-Kearney, 2011; Torre et al., 2007; Wil- kes, Cooper, Lewin, & Batts, 1999).

230 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

the client’s own reasons and values for change (Miller, 2004).

According to Miller (2010), the theoret- ical underpinnings of MI include Festinger’s (1957) cognitive dissonance theory, Bem’s (1967) self-perception theory, and Bandura’s (1977b) self-efficacy theory. Carl Rogers’s (1951) work on nondirective counseling and the FRAMES set of data about the effective components of brief in- terventions for change (Bien, Miller, & Tonigan, 1993) also provide foundational relevancy for this counseling method (Miller, 2010), as does self- determination theory (Markland, Ryan, Tobin, & Rollnick, 2005). The MI approach integrates well with two health behavior models discussed later in this chapter: the transtheoretical model of change (Prochaska & DiClemente, 1982) and the therapeutic alliance model (Barofsky, 1978).

MI was initially used in substance abuse treatment with adults, where it was developed as a reaction to the confrontational methods used in that field in the 1970s and 1980s. In this counseling approach, the nurse as educator avoids telling a patient what he or she needs to do. Rather, the interview is a collaborative ven- ture between nurse and patient whereby a posi- tive atmosphere is created through a partner-like relationship. The nurse guides rather than di- rects the patient. This approach stands in con- trast to the classic relationship of expert provider and passive recipient (Miller, 2004) that is often seen in the traditional medical model. With MI, the learner has more autonomy and the nurse is less of an authority figure. Nurses can ask patients useful questions that guide the direc- tion of this counseling approach, such as what changes are most important to them, how con- fident they are in being able to make changes, what do they see as the benefits or drawbacks in making changes in their lives, and how might their lives be different if they carried through with one or more of changes (Rollnick, Butler, Kinnersley, Gregory, & Marsh, 2010)?

According to Miller and Rollnick (2013), the spirit of MI includes collaboration (as opposed to confrontation), evocation (as opposed to edu- cation), and autonomy (as opposed to authority).

In motivational strategizing, it would also be beneficial to consider Damrosch’s (1991) pro- posal that client health beliefs, personal vulner- ability, efficacy of proposed change, and ability to effect the change are important in patient ed- ucation efforts.

Beliefs are a major construct proposed by Wright et al. (1996) as the heart of healing in families. Facilitating beliefs can promote a de- sired change, whereas constraining beliefs can restrict options. Challenging constraining be- liefs and promoting facilitating beliefs are, there- fore, offered as motivational strategies.

An understanding of the individual’s men- tal representations or beliefs also is foundational to the commonsense model in the representa- tional approach to patient education (Leventhal & Diefenbach, 1991). Beliefs constitute an un- deracknowledged and understudied phenom- enon that needs to be further developed in the education literature in terms of motivational strategizing.

Motivational interviewing (MI) is an- other motivational strategy the nurse edu- cator can use with learners (Droppa & Lee, 2014). It is a client-centered, directive coun- seling method in which clients’ intrinsic mo- tivation to change is enhanced by exploring and resolving their ambivalence toward behav- ior change (Miller & Rollnick, 2013). The pur- pose of MI is strengthening the motivation of an individual to change. MI is a useful collab- orative communication technique that facili- tates engagement of patients in changing health behaviors (Howard & Williams, 2016). Collab- orative conversations are arranged in MI in a way that facilitates an individual talking one- self into changing (Miller & Rollnick, 2013). Dart (2011) states that “motivational interview- ing fits perfectly into the nursing profession” (p. 23) and represents a caring, respectful tool with which to promote behavior change. MI is a rapidly diffusing, empirically supported approach to health behavior change (Antiss, 2009). Both as an assessment strategy and as an intervention, MI supports client self- esteem and self-efficacy though emphasis on

Motivation 231

Avoiding arguments decreases instances of confrontation, which usually make patients feel defensive. Defensiveness often leads to fur- ther resistance rather than instilling motivation for change. When the urge to argue arises, the nurse should instead change strategies to help the patient self-identify important issues and problem areas.

Developing discrepancy involves helping patients understand how their current behavior is inconsistent with their personal goals and/or values. This realization acts as a source of moti- vation for change by the patient. The objective is for patients, rather than the nurse, to identify why change is necessary after seeing the inconsis- tencies between their behaviors and their goals.

Supporting self-efficacy involves building the patient’s confidence that change is possible. The nurse can do this by providing support and recognition for small steps the patient has made toward his or her goals, helping the patient set reachable goals, and demonstrating belief in the patient’s ability to succeed.

In addition, the MI approach includes spe- cific strategies that the nurse can use for build- ing motivation to change in the early phases of treatment and continuing throughout the treat- ment. Miller and Rollnick (2013) suggest the mnemonic OARS to describe these strategies:

1. Open-ended questioning 2. Affirmations of the positives 3. Reflective listening 4. Summaries of the interactions

Open-ended questions facilitate discussion between nurse and patient and encourage the patient to do most of the talking, particularly about the reasons why change is necessary or desirable. To encourage a patient-centered di- alogue, the nurse should avoid closed-ended questions for which a simple “yes” or “no” an- swer could limit further discussion (Levensky, Forcehimes, O’Donohue, & Beitz, 2007).

Affirming the positives involves the nurse making statements that support and encour- age the patient, particularly in areas where the patient may see only failure. Affirmations can

Because change is ultimately the patient’s re- sponsibility, this approach encourages motiva- tion for change to come from within rather than being imposed from the outside. Overall, MI is a form of patient empowerment, with the goal of helping patients gain control over the most important lifestyle management decisions af- fecting their well-being (Soderlund, Nilsen, & Kristensson, 2008). It consists of two phases: in the first phase, the nurse helps the patient enhance intrinsic motivation for change; in the second phase, commitment to change is strengthened (Miller, 2010; Miller & Rollick, 2013).

The five general principles of MI (Miller & Rollnick, 2013) are arranged to form the mne- monic READS, which helps nurses remember the key concepts of this approach. The follow- ing principles are not applied in a specific order, and all the techniques should be used through- out the interview:

1. Roll with resistance 2. Express empathy 3. Avoid argumentation 4. Develop discrepancy 5. Support self-efficacy

Rolling with resistance refers to a strategy of acknowledging to the patient that ambivalence is natural and, rather than oppose the resis- tance, the nurse “rolls” or flows with it. Resis- tance is expected and should not be viewed as a negative occurrence by the nurse. It can take several forms, including blaming, excusing, min- imizing, arguing, challenging, interrupting, and ignoring. When the patient displays resistance, the nurse should actively involve the patient in the process of problem solving and attempt to explore the reasons behind the resistance.

Expressing empathy communicates to pa- tients that they are understood and they are accepted as they are and where they are, which helps to facilitate change. As part of this tech- nique, it is important that the nurse not judge, criticize, or blame the patient. Specifically, the nurse needs to employ excellent active and re- flective listening skills throughout the interview to establish a therapeutic rapport.

232 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

the nurse has heard the patient. Summaries are important ways to emphasize significant parts of the discussion and to review the plan of action.

BOX 6-2 provides examples of OARS ques- tions and statements that the nurse educator might use in an MI session.

A growing body of literature explores the use of MI in health care. MI is being applied in a broad range of behavioral issues, includ- ing those related to alcohol abuse (Beckham, 2007), bipolar disorder (Laakso, 2012), cancer pain (Thomas et al., 2012), cardiovascular dis- ease (Brodie, Inoue, & Shaw, 2008; Hardcastle, Taylor, Bailey, & Castle, 2008; Paradis, Cossette, Frasure-Smith, Heppell, & Guertin, 2010; Thompson et al., 2011), chronic kidney disease

take the form of complimenting efforts made by the patient, acknowledging small successes, or stating appreciation and understanding (Lev- ensky et al., 2007). This approach promotes self-efficacy, builds rapport, and reinforces the efforts the patient is making toward change.

Reflective listening involves restating the patient’s own comments in a concise manner, which demonstrates that the nurse understands what the patient is saying. The goal of this tech- nique is to keep the conversation moving for- ward so the patient can see the need for change and begin to move in that direction.

Summarizing links and reinforces the infor- mation that has been discussed. It helps to build rapport with patients and demonstrates that

BOX 6-2 Examples of OARS Questions and Statements

Open-Ended Questions Could you share with me what has worked for you in the past when faced with a similar situation? What are your current plans to accomplish your goal? What do you believe you can accomplish at this time? How do you believe it will feel to accomplish your goal?

Affirmation You have worked very hard to get to this point. You should be commended for all your positive efforts in meeting your goals. It is obvious you have invested a lot into making these changes. You have faced many challenges along the way, but you did not give up and now you are reaping the rewards.

Reflection Previously you said you wanted to . . . but truly you are afraid of making the changes to reach that goal. On the one hand, you are happy with your current lifestyle, but on the other hand, you realize that some changes need to be made. You have worked on . . . in the past and have been unsuccessful and now you are afraid to try again because you could fail. Making a change is never easy, and you realize that you will have to put forth quite a bit of effort to accomplish your goals.

Summary Throughout our conversation, you have said you would like to . . . and will accomplish this by . . . in this amount of time. I would like to review what we talked about today. To summarize what you just said . . . We covered a lot today, and I would like to review what we discussed.

Motivation 233

effects across a wide range of problem domains, although it is more potent in some situations compared to others and it does not work in all cases” (p. 151). These authors also found that MI significantly increased patients’ engagement in treatment and their intention to change, and when MI was compared to other active treat- ments, the MI interventions took at least 100 fewer minutes of treatment on average yet pro- duced equal effects (Lundahl et al., 2010). Also, another major study found as few as one MI ses- sion may be effective in enhancing readiness to change behaviors to reach health goals (VanBu- skirk & Wetherell, 2014). These are particularly significant findings given that nurses have only a limited amount of time to spend with patients and need to be as efficient as possible in their interactions with patients.

Rubak et al. (2005), in their own meta- analysis of MI, reported that “motivational interviewing in a scientific setting effectively helps clients change their behavior and it out- performs traditional advice giving in approx- imately 80% of the studies” (p. 309). Their review also showed that MI can be effective even in brief encounters of 15 minutes and that more than one encounter increases the like- lihood of effect. All reviews suggest the need for further research into MI using improved research methodologies.

MI can be a useful tool for helping nurses as educators achieve success in one of their major roles—namely assisting patients to change neg- ative health behaviors. Nurses need to exercise patience when learning MI, however, because this approach requires them to adjust to a new way of thinking. They need to be open minded and willing to let go of the tendency to give ad- vice and offer expert opinions (Brobeck, Bergh, Odencrants, & Hildingh, 2011; Soderlund et al., 2008). With time and practice, nurses will also be able to let go of the “righting reflex,” which is the tendency to identify a problem and solve it for the patient (Rollnick et al., 2010; Rollnick, Miller, & Butler, 2008). Instead, they ideally will use MI to empower and motivate patients to do the work themselves.

(McCarley, 2009), colorectal screening (Corey, Gorsky, Schaper, & Newberry, 2009), depression (Interian, Rios, Martinez, Krejci, & Guarnaccia, 2010; Watkins et al., 2007), diabetes (Chen, Creedy, Lin, & Wollin, 2011; Huisman & de Gucht, 2009; Wang et al., 2010), obesity (Carels et al., 2007; Schelling et al., 2009), schizophrenia (Drymalski & Campbell, 2009; Tay, 2007), stroke educa- tion (Byers, Lamanna, & Rosenberg, 2010), to- bacco use disorders (Borrelli et al., 2005; Stotts, DeLaune, Schmitz, & Grabowski, 2004), and low back pain (Friedrich, Gittler, Arendasy, & Friedrich, 2005; Vong, Cheing, Chan, So, & Chan, 2011). Most of the current evidence re- lated to MI use comes primarily from studies with adults, but this technique may be particularly useful with the adolescent population because its collaborative, nonconfrontational approach fits well with the developmental need for iden- tity and autonomy that characterizes this stage of growth (Jackman, 2011).

Although study outcomes for MI are some- times inconsistent, several systematic reviews as well as meta-analysis reports reveal quite a few statistically significant results for the use of MI in the healthcare arena (Hettema, Steele, & Miller, 2005; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Lundahl et al., 2013; Martins & McNeil, 2009; O’Halloran et al., 2014; Rubak, Sandbaek, Lauritzen, & Christensen, 2005; Van- Buskirk & Wetherell, 2014). Martins and Mc- Neil (2009) suggested that MI is effective in diet and exercise, diabetes, and oral care. O’Hallo- ran et al. (2014) revealed MI with people who have chronic illnesses was a useful strategy in increasing their physical activity levels. VanBu- skirk and Wetherell (2014) discovered that MI can be applied to primary care populations. In a review of 72 MI studies, Hettema et al. (2005) uncovered small to medium effects for MI in improving health outcomes and found it to be a promising intervention in addressing addic- tive behaviors (except for smoking cessation).

Lundahl et al. (2010) performed a meta- analysis of 25 years of MI interviewing stud- ies, and their analyses strongly suggested that “MI exerts small, though significant, positive

234 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

to be relevant in explaining health behavior. This model is grounded on the supposition that it is possible to predict health behavior given three major interacting components: individual per- ceptions, modifying factors, and likelihood of action. FIGURE 6-1 shows the direction and flow of these components, each of which is further divided into subcomponents:

1. Individual perceptions: These include the subcomponents of perceived sus- ceptibility or perceived severity of a specific disease.

2. Modifying factors: These include the demographic variables (age, sex, race, ethnicity), sociopsychologi- cal variables (personality, locus of control, social class, peer and ref- erence group pressure), and struc- tural variables (knowledge about and prior contact with disease). These variables, in conjunction with cues to action (mass media, advice, re- minders, illness, reading material), influence the subcomponent of per- ceived threat of the specific disease.

3. Likelihood of action: This includes the subcomponents of perceived bene- fits of preventive action minus per- ceived barriers to preventive action.

These components and subcomponents are di- rected toward the likelihood of taking recom- mended preventive health action as the final phase of the model. In sum, individual percep- tions and modifying factors interact. An indi- vidual appraisal of the preventive action occurs, which is followed by a prediction of the likeli- hood of action.

The HBM has been the predominant explan- atory model since the 1970s for explaining dif- ferences in preventive health behaviors as well as use of preventive health services (Langlie, 1977). It stands out as one of the most frequently cited and researched psychosocial models to deter- mine health-related screening behavior (Wong et al., 2013). It has been used widely in health behavior research across disciplines such as

▸ Selected Models and Theories

Compliance, adherence, and motivation are concepts germane to health behaviors of the learner. The nurse as educator focuses on health education as well as the expected health be- haviors. Health behavior frameworks are blue- prints and, as such, serve as tools for the nurse as educator that can be used to maintain de- sired patient behaviors or promote changes (Syx, 2008). As a result, a familiarity with mod- els and theories that describe, explain, or pre- dict health behaviors can increase the range of health-promoting strategies for the nurse as educator. When the educator understands these frameworks, the principles inherent in each can be used either to promote compliance with a health regimen or to facilitate motiva- tion. This chapter presents an overview of the following models and theories: health belief model, health promotion model, self-efficacy theory, protection motivation theory, stages of change model, theory of reasoned action and theory of planned behavior, and therapeutic alliance model.

Health Belief Model The original health belief model (HBM) was developed in the 1950s from a social psychol- ogy perspective to examine why people did not participate in health screening programs (Rosenstock, 1974). This model was modified by Becker et al. (1974) to address compliance with therapeutic regimens. According to Ver- mandere et al. (2016), the Health Belief Model frequently guides the development of interven- tions related to health.

The HBM explains and predicts health be- haviors based on the patients’ beliefs about the health problem and the health behavior. The model relies on the assumptions that patients are willing to participate and that they believe that health is highly valued (Becker, 1990). Both these premises need to be present for the model

Selected Models and Theories 235

FIGURE 6-1 Health belief model used as a predictor of preventative health behavior. Reproduced from Becker, M. W., Drachman, R. H., & Kirscht, J. P. (1974). A new approach to explaining sick-role behavior in low-income populations. American Journal of Public Health, 64(3), 205–216. Copyright by American Public Health Association. Reprinted with permission.

INDIVIDUAL PERCEPTIONS

MODIFYING FACTORS LIKELIHOOD OF ACTION

Demographic Variables (age, sex, race, ethnicity, etc.) Sociopsychological Variables (personality, social class, peer and reference group pressure, etc.) Structural Variables (knowledge about the disease, prior contact with the disease, etc.)

Perceived Benefits of Preventive Action

minus

Perceived Barriers to Preventive Action

Likelihood of Taking Recommended Preventive

Health Action

Perceived Threat of Disease “X”

Mass Media Campaigns Advice from Others Reminder Postcard from Physician or Dentist Illness of Family Member or Friend Newspaper or Magazine Article

CUES TO ACTION

Perceived Susceptibility to Disease “X” Perceived Seriousness (Severity) of Disease “X”

medicine, psychology, social behavior, and ger- ontology to predict preventive health behavior and to explain sick-role behavior in acute and chronic illnesses. It has even been used to explain nursing students’ willingness to seek treatment for test anxiety (Markman, Balik, Braunstein- Bercovitz, & Ehrenfeld, 2011) and in evaluat- ing the impact of an H1N1 flu vaccine initiative (Jones et al., 2015).

Over time, research studies have supported the validity of the HBM. For instance, Jachna

and Forbes-Thompson (2005) studied health belief constructs in an assisted living facility and found that healthcare providers can in- fluence health beliefs relative to osteoporosis, which has implications for gerontology nurs- ing education. In China, Wang et al. (2013) successfully used a nursing intervention based on the HBM to enhance patients’ health beliefs and self-efficacy toward the disease manage- ment of COPD. Turner, Kivlahan, Sloan, and Haselkorn (2007) found that this model was

236 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

an understanding of whether people choose to engage in health-promoting behaviors (Pender, Murdaugh, & Parsons, 2002) and strongly sup- ports the partner relationship between health- care provider and patient (Stewart, 2012). Its emphasis on actualizing health potential and in- creasing the level of well-being using approach behaviors rather than avoidance of disease be- haviors distinguish this model as focusing on health promotion rather than disease prevention.

The sequence of major components and variables is outlined as follows:

1. Individual characteristics and experi- ences, which consist of two variables— prior related behavior and personal factors

2. Behavior-specific cognitions and af- fect, which consist of perceived ben- efits of action, perceived barriers to action, perceived self-efficacy, activity- related affect, interpersonal influ- ences, and situational influences

3. Behavioral outcomes, which consist of health-promoting behavior par- tially mediated by commitment to a plan of action and influenced by immediate competing demands and preferences

The HBM and the HPM share several schematic similarities and one major differ- ence, seen when Figures 6-1 and 6-2 are com- pared. Both models describe the use of factors or components that influence perceptions that may lead to positive health outcomes. How- ever, the HBM targets the likelihood of engag- ing in preventive health behaviors whereas the revised HPM targets the likelihood of engaging in health promotion activities. Support for the HPM has been demonstrated by many research studies on a number of different population groups (Buijs, Ross-Kerr, Cousins, & Wilson, 2003; Hjelm, Mufunda, Nambozi, & Kemp, 2003; Ho, Berggren, & Dahlborg- Lyckhage, 2010; Mohamadian et al., 2011; Rothman, Lourie, Brian, & Foley, 2005; Srof & Velsor- Friedrich, 2006). One conclusion supported by

effective in predicting adherence to a medication regimen among patients with multiple sclerosis. Saunders, Frederick, Silverman, and Papesh (2013) determined the HBM provided an ap- propriate framework for examining hearing behaviors. Johnson, Mues, Mayne, and Kiblawi (2008) emphasized the need for culturally rel- evant screening strategies as a response to the significance of sociocultural factors influenc- ing health-related beliefs and use of healthcare services. Findings from studies such as these, as well as from additional studies (Adams, Hall, & Fulghum, 2014; Baghianimoghadam et al., 2013; Griffin, 2011; Scarinci, Bandura, Hi- dalgo, & Cherrington, 2012), can be operation- alized through educational programs specific to high-risk populations. In a historical 10-year review of the HBM literature, Janz and Becker (1984) found that the model strongly predicted health behaviors, with perceived barriers being the most influential factor. As it applies today, the nurse as educator needs to take into con- sideration the availability of barrier-free edu- cational resources. In this technology-driven society, Dutta-Bergman (2004) suggests a re- lationship between health beliefs, information seeking, and active versus passive learners with implications for type of health education deliv- ery. Health educators, this author suggests, need to be concerned with consumer health-seeking behaviors in the technology age.

Health Promotion Model (Revised) The health promotion model (HPM), origi- nally developed by Pender in 1987 and revised in 1996, has been primarily used in the disci- pline of nursing (Pender, 1996). The purpose of the model is to assist nurses in understand- ing the major determinants of health behav- iors as a basis for behavioral counseling to promote healthy lifestyles (Pender, 2011). The HPM describes major components and vari- ables that influence health-promoting behav- iors (FIGURE 6-2). This model helps to provide

Selected Models and Theories 237

competency and capability relative to certain behaviors is a precursor to expected outcomes. FIGURE 6-3 shows an adaptation of Bandura’s ef- ficacy expectations model extended to include expected outcomes based on a person’s percep- tions of self-efficacy.

According to Bandura (1986, 1997), self- efficacy is cognitively appraised and processed through four principal sources of information:

1. Performance accomplishments, as evidenced in self-mastery of simi- larly expected behaviors

2. Vicarious experiences, such as ob- serving successful expected behav- ior through the modeling of others

the HPM literature is that perceived self-efficacy is an important determinant of participation in health-promoting behavior and achievement of an improved health-related quality of life (Ho et al., 2010; Mohamadian et al., 2011; Srof & Velsor-Friedrich, 2006).

Self-Efficacy Theory Developed from a social–cognitive perspective, self-efficacy theory is based on a person’s ex- pectations relative to a specific course of action (Bandura, 1977a, 1977b, 1986, 1997). It is a pre- dictive theory in the sense that it deals with the belief that one is competent and capable of ac- complishing a specific behavior. The belief of

FIGURE 6-2 Revised health promotion model. Reproduced from Pender, N. (1996). Health promotion in nursing practice (3rd ed.). Upper Saddle River, NJ: Prentice-Hall. ©1996. Reprinted by permission of Pearson Education, Inc., New York, NY.

Individual Characteristics

and Experiences

Behavior-Specific Cognitions and Affect

Behavioral Outcome

Perceived benefits of action

Perceived barriers to action

Commitment to a plan of action

Health- promoting behavior

Perceived self-efficacy

Activity-related affect

Interpersonal influences

(family, peers, providers); norms, support, models

Situational influences;

options, demand characteristics,

aesthetics

Immediate competing demands

(low control) and preferences (high control)

Prior related

behavior

Personal factors;

biological sociocultural

238 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

FIGURE 6-3 Determinants of expected outcomes using self-efficacy perceptions. Reproduced from Bandura, A. (1977b). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. © 1977. Reprinted by permission of Pearson Education, Inc., New York, NY.

MODE OF INDUCTION

SOURCE OF EFFICACY

INFORMATION

Cognitive Processes

Competency Perceptions

EXPECTED OUTCOMES

Effort

Persistence

Performance Accomplishments

Vicarious Experiences

Verbal Persuasion

Emotional ArousalSymbolic

Desensitization

Symbolic Exposure

Relaxation Biofeedback

Attribution

Interpretive Treatments

Self-Instruction

Exhortation

Suggestion

Live Modeling

Self-Instructed Performance

Performance Exposure

Performance Desensitization

Participant Modeling

Symbolic Modeling

3. Verbal persuasion by others, who present realistic beliefs that the in- dividual is capable of the expected behavior

4. Emotional arousal, resulting from self-judgment of physiological states of distress

Bandura (1986, 1997) notes that the most influential source of efficacy information is pre- vious performance accomplishments. Efficacy expectations—that is, expectations relative to a specific course of action—are induced through certain modes. Modes of induction include, but

are not limited to, desensitization, self-instruction, exposure, suggestion, and relaxation.

Self-efficacy has proved useful in predict- ing the course of health behavior. Kaewthum- manukul and Brown (2006) reviewed the literature from 11 studies and concluded that self- efficacy was the best predictor in an em- ployee physical activity program and could be used in occupational health nursing. Tung, Lu, and Cook (2010) used the transtheoreti- cal model of change to study cervical cancer screening among Taiwanese women and de- termined that reinforcement of self-efficacy was more important in this population than

Selected Models and Theories 239

(MacDonell et al., 2013). A threat to health is considered a stimulus to protection motivation. This linear theory includes sources of informa- tion (environmental and intrapersonal) that are cognitively processed by appraisal of threat and coping to engender protective motivation, which leads to intent and ultimately to action.

Influenced by crisis and self-efficacy the- ories, protection motivation theory has been used to test antecedents to health behaviors such as drug abuse, AIDS, smoking, sun protec- tion, and drinking behaviors. Wu, Stanton, Li, Galbraith, and Cole (2005) found that adolescent drug trafficking can be predicted by the overall level of health protection motivation. These au- thors suggest that the theory be considered in the design of drug-trafficking prevention pro- grams. Prentice-Dunn, McMath, and Cramer (2009) found that protection motivation the- ory was useful in creating “readiness to change” sun-protective intentions among young women.

Evidence-based research can uncover moti- vational information that can be used to inform health educators in the design of educational programs that specifically target high-risk in- dividuals or groups for selected risk behaviors. Protection motivation theory goes beyond the likelihood of action in the health belief model and self-efficacy intent to promote actual health behavior action.

Stages of Change Model Another model that sheds light on the phe- nomenon of health behaviors of the learner is the stages of change model, also known as the transtheoretical model (TTM) of behav- ioral change (Prochaska & DiClemente, 1982). Originating from the field of psychology, this model (BOX 6-3) was developed around addic- tive and problem behaviors. Prochaska (1996) notes that it encompasses six distinct time- related stages of change:

1. Precontemplation: Individuals have no current intention of changing. Strategies involve simple observa- tions, confrontation, or conscious- ness raising.

emphasizing the benefits of or decreasing the barriers to regular Pap screening. Callaghan (2005) studied relationships between self-care behaviors and self- efficacy in an older adult population (N = 235). She found a signifi- cant relationship between self-care behaviors in older women and self- efficacy, noting that nurses are in a key position to promote self-care and healthy aging. Strachan and Brawley (2009) studied the eating habits of university students and staff. They found that self-efficacy was a strong predictor of healthy eating among this population. Singleton, Bienemy, Hutchinson, Dellinger, and Rami (2011), in a descriptive cor- relational study of obesity in nursing students, identified that students who had higher body mass indexes (BMIs) had lower self-efficacy beliefs about regulating their exercise habits. In a study designed to measure the effective- ness of a training program for older adults in- tended to improve memory and self-efficacy, West, Bagwell, and Dark-Freudeman (2008) found that memory improvement could be predicted based on self-efficacy scores. Self- efficacy also has been linked with self- management of hypertension and diabetes mellitus (Jang & Yoo, 2012) and patient re- covery after acute injury (Connolly, Aitkin, & Tower, 2014).

The use of self-efficacy theory by the nurse as educator is particularly relevant in develop- ing educational programs. The behavior-specific predictions of this theory can be used for under- standing the likelihood of individuals participat- ing in existing or future educational programs. Educational strategies such as modeling, demon- stration, and verbal reinforcement parallel modes of self-efficacy induction.

Protection Motivation Theory Protection motivation theory explains be- havioral change in terms of threat and cop- ing appraisal (Prentice-Dunn & Rogers, 1986). These threat and coping appraisals embed- ded within the protection motivation theory are beneficial for understanding why individu- als participate in behaviors that are unhealthy

240 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

research has focused on its value in health pro- motion and the processes by which people de- cide to change (or not to change) behaviors.

The stages of change model has been used to investigate health behaviors, such as using sun protection (Prentice-Dunn et al., 2009), managing weight loss (Mastellos, Gunn, Felix, Car, & Majeed, 2014), and exercising (Lowther, Mutrie, & Scott, 2007). It also has been used as a method of outcome evaluation in continuing education for nurses (Randhawa, 2012). This popular model can be used with children and adults, which has implications for a variety of educational settings.

Theory of Reasoned Action and Theory of Planned Behavior The theory of reasoned action (TRA) emerged from a research program that began in the 1950s and is concerned with predicting and under- standing any form of human behavior within a social context (Ajzen & Fishbein, 1980). It is based on the premise that humans behave in a rational way that is consistent with their be- liefs (Fishbein, 2008). This theory suggests that a person’s behavior can be predicted by exam- ining the individual’s attitudes about the behav- ior as well as the individual’s beliefs about how others might respond to the behavior. For ex- ample, when using this theory to predict how a client might respond to a weight-reduction plan, it would be vital not only to consider the client’s beliefs about food and exercise but also to examine what the client thinks about how the people around him would view his attempts to lose weight. It is important to note that rea- soned action in this theory is not emotion free but rather based on beliefs that are influenced by emotion and mood (Fishbein, 2008). This theory is depicted as a sequential model in FIGURE 6-4.

In a two-pronged linear approach, spe- cific behavior is determined by (1) beliefs, at- titude toward the behavior, and intention; and (2) motivation to comply with influential persons (known as referents), subjective norm, and intention. The person’s intention to perform

2. Contemplation: Individuals accept or realize that they have a problem and begin to think seriously about changing it. Strategies involve in- creased consciousness raising.

3. Preparation: Individuals are plan- ning to act within the time frame of 1 month. Strategies include a firm and detailed plan for action.

4. Action: There is overt/visible modifi- cation of behavior. This is the busiest stage, and strategies include com- mitment to the change, self-reward, countering (substitute behaviors), creating a friendly environment, and supportive relationships.

5. Maintenance: Maintenance is a dif- ficult stage to achieve and may last 6 months to a lifetime. There are common challenges to this stage, in- cluding overconfidence, daily temp- tation, and relapse self-blame. The strategies in this stage are the same for the action stage.

6. Termination: This stage occurs when the problem no longer presents any temptation. However, some ex- perts note that termination does not occur; instead, maintenance simply becomes less vigilant.

The extent to which people are motivated and ready to change is an important construct. It is useful in health care to stage the client’s intentions and behaviors for change as well as to determine those strategies that will en- able completion of the specific stage. More re- cent use of the stages of change model in health

BOX 6-3 Six Stages of Change

■ Precontemplation ■ Contemplation ■ Preparation ■ Action ■ Maintenance ■ Termination

Selected Models and Theories 241

FIGURE 6-4 Theory of reasoned action: factors determining a person’s behavior. Reproduced from Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. © 1980. Reprinted by permission of Pearson Education, Inc., New York, NY.

The person’s beliefs that the behavior leads to certain outcomes and his evaluations of these outcomes

The person’s beliefs that specific individuals or groups think he should or should not perform the behavior and his motivation to comply with the specific referents

Note: Arrows indicate the direction of influence.

Attitude Toward the Behavior

Relative Importance of Attitudinal and

Normative Considerations

Subjective Norm

Intention Behavior

FIGURE 6-5 Theory of planned behavior. Reproduced from Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2),179–211. Copyright 1991, p. 182, with permission from Elsevier.

Behavioral Beliefs

Attitude toward the Behavior

Actual Behavioral

Control

Intention Behavior Normative

Beliefs Subjective

Norm

Control Beliefs

Perceived Behavioral

Control

can be measured by relative weights of attitude and subjective norm.

As the TRA began to be applied in the social sciences, Ajzen and other researchers realized the theory had several limitations (Godin & Kok, 1996). One of the strongest limitations was use of the theory with people

who felt they had little power over their be- haviors. To remedy this, in 1985, Ajzen pro- posed a new model—the theory of planned behavior (TPB). The TPB added a third ele- ment to the TRA model—the concept of per- ceived behavioral control (Ajzen, 1991). This theory is depicted in FIGURE 6-5.

242 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

adherent conformity but responsible self-care resulting from an alliance between the nurse and the patient.

Although not originally developed as an educational model, the usefulness of this model to the nurse as educator is nevertheless acknowledged in the partnership of learning. This interpersonal model is appropriate in the educational process when shifting the focus from the patient as a passive-dependent learner to the patient as an active learner. It serves as a guide to refocus education efforts on collab- oration rather than on compliance. The nurse as educator and the patient as learner form an alliance with the goal of self-care.

Hobden (2006), in a recent exploration of the concepts of compliance and adher- ence, notes that these terms have a negative connotation. Instead, this author suggests emphasizing the consultative process known as concordance, which is “consultation that allows mutual respect for the patient’s and pro- fessional’s beliefs, and allows negotiation to take place about the best course of action for the patient” (p. 258). She notes there is a shift in the balance of power from the professional to the patient. Although concordance should lead to improved health outcomes, the focus is on the process.

Kim, Boren, and Solem (2001) developed the Kim Alliance Scale (KAS), which was later revised by Kim, Kim, and Boren (2008) as the Kim Alliance Scale Refined (KAS-R) to measure

The TRA and the TPB have been used to determine nurses’ attitudes toward teaching particular health education topics (Kleier, 2004; Mullan & Westwood, 2010), as a framework in smoking prevention and intention studies (Hanson, 2005; McGahee, Kemp, & Tingen, 2000), for designing interventions to reduce heterosexual risk behavior (Tyson, Covey, & Rosenthal, 2014), to understand intentions to receive human papillomavirus vaccine (Fisher, Kohut, Salisbury, & Salvadori, 2013), and to study nursing care of individuals who are drug addicts (Natan, Beyil, & Neta, 2009). The TRA and TPB are useful theories in pre- dicting behaviors, which is particularly helpful for educators who want to understand the atti- tudinal context within which health behaviors are likely to change. Nurses as educators need to take beliefs, attitudinal factors, and subjec- tive norms into consideration when designing educational programs intended to change spe- cific health behaviors.

Therapeutic Alliance Model Barofsky’s (1978) therapeutic alliance model addresses a shift in power from the provider to a learning partnership in which collaboration and negotiation with the consumer are key. A thera- peutic alliance is formed between the caregiver and the care receiver in which the participants are viewed as having equal power. The client is viewed as active and responsible, with an out- come expectation of self-care. The shift toward self-determination and control over one’s own life is fundamental to this model (FIGURE 6-6).

The therapeutic alliance model compares the components of compliance, adherence, and alliance. According to Barofsky (1978), change is needed in treatment determinants—change from coercion in compliance and from con- forming in adherence to collaboration in alli- ance. The power in the relationship between the participants is equalized by alliance. The role of the patient is neither passive nor rebellious but rather active and responsible. The expected outcome is neither compliant dependence nor

FIGURE 6-6 Continuum of the therapeutic alliance model.

COMPLIANCE ADHERENCE THERAPEUTIC ALLIANCE

Dependency Conforming Self-Care

Key: Patient Power

Provider Power

Selected Models and Theories 243

Similarities and Dissimilarities of Models Models may be viewed as so similar that there would be a negligible difference in choosing one over the other, or they may be considered so dissimilar that one would be inappropriate for a specific educational purpose. A cursory comparative analysis of the different frame- works reveals that the health belief model and the health promotion model are similar. Each uses comparable salient factors of individual perceptions and competing variables. The dif- ferences appear in the models’ basic premises and outcomes. The health belief model em- phasizes susceptibility to disease and the like- lihood of preventive action, whereas the health promotion model emphasizes health potential and health-promoting behaviors.

The self-efficacy theory, the theory of rea- soned action, and the theory of planned be- havior are similar in that they focus on the predictions or expectations of specific behav- iors. These theories lend themselves more eas- ily to less complex model testing than either the health belief model or the health promo- tion model because the former theories are more linear in conceptualization. Specificity of behaviors may aid in targeting outcomes of educational programs.

The stages of change model is similar to self-efficacy theory, the theory of reasoned ac- tion, and the theory of planned behavior in the sense that these models focus on intent. The stages of change model, though, appears to be less complicated and does not account for per- sonal characteristics or experiences. It differs from self-efficacy theory, protection motiva- tion theory, the theory of reasoned action, and the theory of planned behavior in that change is time relevant, which has implications for ed- ucational interventions. Protection motivation theory is similar in construct to the theory of rea- soned action and the theory of planned behav- ior in the sense that information is cognitively processed, followed by intent or commitment to action and the health behavior.

the quality of the therapeutic alliance between patient and provider. The refined scale includes collaboration, integration, empowerment, and communication subscales. In these authors’ study, the KAS-R was shown to be valid and reliable and, when it was used to measure the relation- ship between therapeutic alliance and general patient satisfaction, therapeutic alliance was a significant predictor variable (36%) for patients’ general satisfaction. The link between therapeu- tic alliance and patient satisfaction underscores the significance of the quality of the provider– patient relationship.

As mentioned earlier, motivational inter- viewing may be combined with the therapeu- tic alliance model. Duran (2003) points out that successful MI takes place in an atmosphere in which the client feels understood and respected, and it is collaborative in nature, with the high- est priority placed on the client’s autonomy and freedom of choice.

The significance of the therapeutic alli- ance between caregiver and patient as it re- lates to adherence has been studied in patients with mental health issues (Ardito & Rabellino, 2011; Arnow et al., 2013; Byrne & Deane, 2011; Jaeger, Weißhaupt, Flammer, & Steinert, 2014; Sylvia et al., 2013). Del Re, Flückiger, Horvath, Symonds, and Wampold (2012) found that therapist behavior in the alliance partnership is more important than patient behavior in achieving the goal of improved outcomes. The therapeutic alliance also has been studied rel- ative to weight gain in patients with anorexia nervosa (Bourion-Bedes et al., 2013; Brown, Mountford, & Waller, 2013), although its im- pact has been mixed.

▸ Models for Health Education

Selection of models for educational use can be made based on the following considerations: (1) similarities and dissimilarities, (2) the nurse as educator’s agreement with model conceptu- alizations, and (3) functional utility.

244 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

The choice of a model, therefore, can be based on the educator’s level of agreement with salient factors in each framework.

Likelihood of action is best addressed by the health belief model, whereas attain- ing positive health outcomes is the focus of the protection motivation theory. Attitude and intention are best viewed through the theory of reasoned action and the theory of planned behavior. Belief in one’s capabilities is best addressed by self-efficacy theory, and the therapeutic alliance model is best used for reduction of noncompliance through an educator–learner collaboration. Staging the in- dividual’s readiness for change and developing strategies for interventions are helpful in de- signing educational programs with the stages of change model.

Through in-depth analysis of each model, the attention of the educator may be drawn to other factors as well. Ultimately, the model or models that fit best with the educator’s own be- liefs are more likely to be chosen.

Functional Utility of Models Model selection for educational purposes also can be based on functional utility. The follow- ing questions may be asked to determine func- tional utility:

■ Who is the target learner? ■ What is the focus of the learning? ■ When is the optimal time? ■ Where is the process to be carried out?

The question of who the learner is deals with whether the target learner is the individ- ual, family, or group. The health belief model, health promotion model, self-efficacy theory, protection motivation theory, stages of change model, theory of reasoned action, and theory of planned behavior can be used across the range of these target learners. The important notion for the nurse as educator to remem- ber is the probability of individual variation. Another consideration in terms of the target learner is the various categorical groups that

The health belief model, health promotion model, self-efficacy theory, protection motiva- tion theory, theory of reasoned action, and the theory of planned behavior are similar in that they acknowledge factors such as experiences, perceptions, or beliefs relative to the individual and factors external to the individual that can modify health behaviors. These frameworks also recognize the multidimensional nature, complexity, and probability of health behav- iors. One major difference between the health belief model and the protection motivation the- ory is that the latter includes a component of fear appraisal and focuses on a specific vulner- ability rather than general susceptibility to ill- ness (Prentice-Dunn & Rogers, 1986).

All the models acknowledge the impor- tance of the patient in decision making with respect to health behaviors. The differences relate to patient focus, the relative importance of modifying factors, specificity of behavior, and outcomes.

The most dissimilar model is the thera- peutic alliance model. Although it is relatively narrow in scope, its simplicity and parsimony are strengths. When this model is applied to the educational arena, the educator–learner relationship is the critical factor. Addressing potentially frustrating patient education situa- tions such as noncompliance, Hochbaum (1980) noted that patient educators, when frustrated, “are unable to understand the apparently irra- tional and self-destructive action of their pa- tients, and sometimes throw their hands up in despair, bedeviled by the seeming irrationality of the patient’s behavior. . . . But this behavior may be altogether rational from the patient’s perspective” (p. 7). Understanding of the patient as learner can be uncovered in the therapeutic alliance model.

Educator Agreement with Model Conceptualizations Nurses as educators have their own belief sys- tems, which may or may not agree with some of the tenets of each of the models presented.

Models for Health Education 245

Recent literature proposes model integra- tion. For example, Gebhardt and Maes (2001) advocate a multitheory approach to promote health behaviors. Cautioning against the use of unidirectional and nondynamic views of behavioral change, they propose an integra- tive approach using goal theories and stages of change. Poss (2001) developed a new model synthesizing the health belief model and the theory of reasoned action, noting that a syn- thesized model is appropriate for the study of persons from varying cultural backgrounds. Chiu (2005) investigated the previously un- tested Bruhn and Parcel (1982) model of chil- dren’s health promotion in adolescents with type 1 diabetes using structural equation mod- eling analysis. Finding only partial support for this model, she suggested a new model that would incorporate self-efficacy as well as lo- cus of control. The development of new mod- els or revision of older models is a necessary step in the evolution and delivery of health care, and it necessarily affects the educator who is concerned with motivational behav- iors of the learner.

Salient health promotion factors that nurse educators can use in a multitheory ap- proach to health education include, but are not limited to, level of knowledge, attitudes, values, beliefs, perceptions, level of anxi- ety, self-confidence, skills mastery, past ex- periences, intention, physiological capacity, sociocultural enablers, environment, educator– learner alliance, resources and reinforcements, mutual and realistic goal setting, hierarchy of needs, quality of life, and voluntary partici- pation in learning.

Developmental stages of the learner in- corporate principles of pedagogy (teaching children), andragogy (teaching adults), and geragogy (teaching older adults) to meet the needs of the learner. A more comprehensive and holistic model for the nurse as educator could emerge when learning is viewed along a unidirectional developmental continuum, in combination with salient health promo- tion factors.

can be distinguished, such as those considered at high risk and those diagnosed with acute or chronic illnesses.

The functional utility of the models also can be determined by the content needed, the timing of the educational experience, and the setting in which the learning is to take place. What is needed reflects the focus of the learn- ing and addresses the content to be taught, such as disease processes, specific disease treatment, adaptation techniques, promotion of wellness, expectations of specific health practices, or fo- cus on self-care.

The question of when deals with optimal timing and refers to the readiness of the learner, a mutually convenient time, and prevention of untimely delays in moving toward a desired goal. Although considered important in the context of health education, this critical factor has received little specific reference in terms of health pro- motion models. Except for the stages of change model, timing often is a neglected factor in the models discussed in this chapter. It is apparent that determining optimal time can be a motiva- tional incentive in terms of meeting the health needs of the learner.

Addressing the question of where the educa- tional process is to be carried out is another as- pect of functional utility. The home, workplace, school, institution, and specific community lo- cations are all options as settings. Every model discussed in this chapter lends itself to these di- verse settings.

Integration of Models for Use in Education Theories provide blueprints for interventions (Molisani, 2015). From the previous discussion, clearly the integration of various components of health behavior models is advantageous in the educational process. When salient factors are taken into consideration in relation to the spe- cific developmental stage of the learner, an inte- grated motivational model of learning in health promotion could emerge.

246 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

is needed because patients are expected to take increasingly more responsibility for and con- trol of the decisions that affect their own health. Educational contracting is the key to informed decision making.

When education is viewed in the context of the client, rather than the client in the con- text of education, learning is individualized. The fit between the client as learner and the nurse as educator has the capacity to facilitate learn- ing. Indeed, the goodness of fit between these two educational participants can be a motivat- ing factor. Do the client and the educator share an understanding of backgrounds or language? Is there a mutual understanding of goal setting? Are health beliefs respected?

A contract involves a trusting relationship. In a mutually satisfying teacher–learner rela- tionship system, trust is a key ingredient. The learner trusts that the nurse as educator pos- sesses a respectable, current body of theoreti- cally based and clinically applicable knowledge. The nurse needs to be approachable, trustworthy, and culturally sensitive because the learner’s own health status is often valued as a private matter. In turn, the nurse trusts that when the client enters into an agreement, the learner will demonstrate behaviors that are health promot- ing. Newman and Brown (1986) list the follow- ing elements as part of an ideal relationship that are still highly relevant today: both parties have trust and respect, the teacher assumes the learner can learn and is sensitive to individual needs, and both parties feel free to learn and make mistakes.

Organizer Organization of the learning situation, including manipulation of materials and space, sequential organization of content from simple to complex, and determination of the priority of subject mat- ter, are tasks taken on by the nurse when in the role of educator. Organization of learning mate- rial decreases obstacles to learning. Attendance at educational programs or individual sessions can be organized around the target learner as well as

▸ The Role of Nurse as Educator in Health Promotion

Nurses as educators are in a key position to promote healthy lifestyles. Combining content specific to the discipline of nursing, knowledge from educational theories, and health behav- ior models allows for an integrated approach to shaping the health behaviors of individu- als through education. The roles of the nurse as educator include facilitator of change, con- tractor, organizer, and evaluator.

Facilitator of Change The goal of the nurse as educator is, of course, to promote health. Health education and health promotion are integral to this effort. At the same time, the nurse as educator is an important fa- cilitator of change. When teaching is viewed as an intervention, it needs to be considered in the context of other nursing interventions that will effect change. As far back as 1987, deTor- nay and Thompson proposed that explaining, analyzing, dividing complex skills, demonstrat- ing, practicing, asking questions, and providing closure are effective in facilitating change in the learning situation.

Contractor Contracting has been a popular means of facil- itating learning. Informal or formal contracts can delineate and promote learning objectives. Similar in steps to the nursing process, edu- cational contracting involves stating mutual goals to be accomplished, devising an agreed-upon plan of action, evaluating the plan, and deriving alternatives. The plan of action needs to be as specific as possible and include the who, what, when, where, and how of the learning process. Responsibilities that are clearly stated aid in evaluating the plan and directing plan revisions.

In light of the changing healthcare system, a greater emphasis on patient–nurse partnerships

The Role of Nurse as Educator in Health Promotion 247

Carter and Kulbok (2002), in an integra- tive review of motivational research, conclude that no clear definition of motivation exists, that certain populations have been underrep- resented in motivational research, and that motivation may not be able to be effectively measured. They challenge researchers and prac- titioners to carefully examine the role of mo- tivation in influencing health behaviors. Zinn (2005) argues that there are insufficient data to explain why people take health risks and that more research concerning how an individual’s knowledge is shaped and how it affects health behaviors is needed. A clarion call has been sounded for both qualitative and quantitative conceptually grounded research to be infused into the teaching–learning process. Forums for evidence-based learning ought to be widely established and should include discussion rel- ative to compliance, motivation, and health be- haviors of the learner (Gleasman-DeSimone, 2012). Considering the persistence of the nurs- ing workforce shortage and the critical nursing faculty shortage, motivational factors should be a paramount focus of research in nursing education as well as patient education.

▸ Summary Critical components of this chapter included a discussion of the concepts of compliance, ad- herence, and motivation; assessment of the level of learner motivation; identification of incen- tives and obstacles that affect motivation; and discussion of axioms of motivation relevant to learning. Selected health behavior frameworks and their influence on learning were compared to one another. In support of the role of nurse as educator, strategies that facilitate health be- haviors of the learner were outlined and selected theories and models that influence compliance and motivation were addressed. The information and evidence presented in this chapter clearly indicate that when people are motivated and know that they can make a difference in their own lives, the foundation is set for change in their health behaviors.

significant others to facilitate the learning pro- cess and promote motivation to learn.

Evaluator Educational programs, like other healthcare projects, need to be accountable to the learner or consumer of the health service. This account- ability is ensured by evaluation in the form of outcomes. Self-evaluation, learner evaluation, organization evaluation, and peer evaluation are not new concepts. Indeed, evaluative pro- cesses are an integral part of all learning. Appli- cation of knowledge that improves the health of individuals, families, and groups is the evalua- tive measure of learning.

▸ State of the Evidence The evidence is less than adequate for imple- menting nursing interventions that specifi- cally address the variables of compliance and motivation as related to health behaviors of the learner. With the explosion of interest in evidence-based practice, additional conceptu- ally based research that identifies, describes, explains, and predicts health behaviors of the learner needs to be conducted.

Healthy People 2020 (U.S. Department of Health and Human Services, 2010) has estab- lished four major goals:

■ Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death

■ Achieve health equity, eliminate dispari- ties, and improve the health of all groups

■ Create social and physical environments that promote good health for all

■ Promote quality of life, healthy develop- ment, and healthy behaviors across all life stages

This document sets the stage for the nurse as educator to use theoretically based strate- gies to promote desirable health behaviors of the learner.

248 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

8. Which models/theories are used to fa- cilitate motivation, and which are used to promote compliance to a therapeutic healthcare regimen?

9. What are the basic concepts of each model or theory?

10. What are the similarities and differences among the models with respect to who the target audience is, what the focus of the learning is, and what the implications for education are?

11. What is the role of the nurse in shaping health behaviors of the learner?

Review Questions 1. How are the terms compliance, adherence,

and motivation defined? 2. How do the terms defined in question 1

relate to one another? 3. What are the three major motivational

factors? 4. Which axioms (premises) are involved

in promoting motivation of the learner? 5. What are the six parameters for a com-

prehensive motivational assessment of the learner?

6. What are the five general principles of MI?

7. What are seven major models or theo- ries used to describe, explain, or predict health behaviors?

CASE STUDY “Keeping our employees healthy is not only the right thing to do, it is good for the bottom line.” With this statement and a directive from the chief nursing officer, Marie DeSantis, RN, PhD, the staff in the Office of Human Resources at Longwood Skilled Nursing Facility developed a “Let’s Get Healthy” initiative for its 500 employees. Weight Watchers, a smoking cessation program, and yoga classes were brought on site and offered free of charge to all employees. Nicotine patches were offered at 50% of cost, and gym memberships were provided at a significant reduction in price. The cafeteria began offering healthy, low-calorie meals, and a walking club was started to support staff who chose to exercise before and after work or during lunch hours. Staff who were willing to submit an individual health plan and agreed to participate in one or more of the facility’s available health programs were offered a 10% discount on their health insurance premiums.

One year after the start of Let’s Get Healthy, the initiative is in trouble. Although it initially met with a great deal of enthusiasm, staff compliance has declined. Attendance at Weight Watchers and smoking cessation classes is episodic, and yoga classes were canceled because of lack of interest. Anecdotal information suggests that although the facility has renewed gym memberships for approximately 20% of the staff, few are using them on a regular basis. Convinced that Let’s Get Healthy is a good idea, Longwood has hired a health educator to evaluate the program and make recommendations for improvement.

1. Using one of the identified models and theories of adherence (health belief model, revised health promotion model, self-efficacy theory, protection motivation theory, stages of change model, theory of reasoned action and theory of planned behavior, or therapeutic alliance model), provide a possible explanation for why the staff members at Longwood Skilled Nursing Facility are not participating in the Let’s Get Healthy campaign.

2. Which motivational strategies did the human resources staff use in the Let’s Get Healthy initiative? Why do you think these strategies did not work?

3. Do you think that if a health education campaign had been offered in conjunction with the Let’s Get Healthy program, the results would have been different?

249Review Questions

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256 Chapter 6 Compliance, Motivation, and Health Behaviors of the Learner

Literacy in the Adult Client Population Susan B. Bastable Gina M. Myers Leigh Bastable Poitevent

CHAPTER HIGHLIGHTS

■ Definition of Terms • Literacy Relative to Oral Instruction • Literacy Relative to Computer Instruction

■ Scope and Incidence of the Problem ■ Trends Associated with Literacy Problems ■ Those at Risk ■ Myths, Stereotypes, and Assumptions ■ Assessment: Clues to Look For ■ Impact of Illiteracy on Motivation and Compliance ■ Ethical, Financial, and Legal Concerns ■ Readability of Printed Education Materials ■ Measurement Tools to Test Literacy Levels ■ Formulas to Measure Readability of Printed Education Materials

• Flesch–Kincaid Scale • Fog Index • Fry Readability Graph—Extended • SMOG Formula • Computerized Readability Software Programs

■ Tests to Measure Comprehension of Printed Education Materials • Cloze Procedure • Listening Test

(continues)

257

CHAPTER 7

■ Tests to Measure General Reading Skills and Health Literacy Skills of Clients • WRAT ( Wide Range Achievement Test) • REALM (Rapid Estimate of Adult Literacy in Medicine) • TOFHLA ( Test of Functional Health Literacy in Adults) • NVS (Newest Vital Sign) • eHEALS (eHealth Literacy Scale) • LAD (Literacy Assessment for Diabetes) • SAM (Instrument for Suitability Assessment of Materials)

■ Simplifying the Readability of Printed Education Materials ■ Teaching Strategies to Promote Health Literacy ■ State of the Evidence

CHAPTER HIGHLIGHTS (continued)

KEY TERMS

literacy numeracy literate illiterate

low literacy functional illiteracy health literacy medicalese

reading readability comprehension e-health literacy

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the terms literacy, illiteracy, health literacy, low literacy, functional illiteracy, reading, readability, comprehension, and numeracy.

2. Identify the magnitude of the literacy problem in the United States. 3. Describe the characteristics of those individuals at risk for having difficulty with reading and

comprehension of written and oral language. 4. Discuss common myths and assumptions about people with illiteracy. 5. Identify clues that are indicators of reading and writing deficiencies. 6. Assess the impact of illiteracy and low literacy on patient motivation and compliance with

healthcare regimens. 7. Recognize the role of the nurse as educator in the assessment of clients’ literacy skills. 8. Use specific formulas and tests to critically analyze the readability and comprehension levels of

printed materials and the reading skills of clients. 9. Describe specific guidelines for writing effective education materials.

10. Outline various teaching strategies useful in educating clients with low literacy skills. 11. Recognize the research and policymaking issues that must be addressed to solve the health

literacy problem.

258 Chapter 7 Literacy in the Adult Client Population

Over the past few decades, educators as well as government officials, employers, and media experts have focused interest on and expressed concern about literacy in the U.S. population. Adult illiteracy continues to be a major problem in this country despite public and private efforts at all levels to address the issue through testing of literacy skills and develop ment of literacy training programs.

Today, the fact remains that many individ uals do not possess the basic literacy abilities required to function effectively in a technolog ically complex society (Rampey et al., 2016). Many adult citizens have difficulty reading and comprehending information well enough to be able to perform such common tasks as filling out job and insurance applications, interpret ing bus schedules and road signs, completing tax forms, applying for a driver’s license, regis tering to vote, and ordering from a restaurant menu (ProLiteracy, 2017; Weiss, 2003).

In the early 1980s, President Ronald Reagan launched the National Adult Literacy Initiative, which was followed by the United Nations’ dec laration of 1990 as International Literacy Year (Belton, 1991; Wallerstein, 1992). In 1992, the U.S. Department of Education conducted the National Adult Literacy Survey (NALS), which revealed a shockingly high prevalence of illit eracy in the country (Weiss, 2003; Weiss et al., 2005; Zarcadoolas, Pleasant, & Greer, 2006). For many decades prior to this Literacy Volunteers of America and Laubach Literacy International served as advocates for the most marginalized adult population both in the United States and around the globe. Today, ProLiteracy (https:// proliteracy.org), which was formed in 2002 from the merger of these two entities, is the world’s largest organization targeting adult literacy. It supports 1,000 literacy programs across the United States and in 20 developing countries worldwide (ProLiteracy, 2017).

Particularly in the past 15 years resulting from the NALS report, nursing and the health profes sions literature has focused significant attention on the effects of patient illiteracy on healthcare

delivery and health outcomes. Today, the em phasis is on health literacy—that is, the extent to which Americans can read and comprehend health information well enough to function suc cessfully in a healthcare environment and make appropriate decisions for themselves. Although a great deal more research needs to be done on the causes and effects associated with poor health literacy as well as the methods available to screen and teach patients, much has been learned about the magnitude and consequences of the health literacy problem (Friedman & HoffmanGoetz, 2008; PaascheOrlow & Wolf, 2007a; Pignone, DeWalt, Sheridan, Berkman, & Lohr, 2005; Wu, Moser, DeWalt, Rayens, & Dracup, 2016).

Healthy People 2010 and Healthy People 2020 also identified limited health literacy as one of the nation’s top public health agenda concerns (U.S. Department of Health and Human Ser vices [USDHHS], 2000, 2014). In 2006, several agencies of USDHHS joined forces to establish a health literacy workgroup. In the fall of 2010, this highly diverse workgroup released the Na- tional Action Plan to Improve Health Literacy, also known as NAP or the “Action Plan” (Baur, 2011).

The NAP was created to provide guidance to organizations, professionals, policymak ers, communities, individuals, and families in identifying actions to take to improve the widespread pandemic of limited health liter acy facing not only the United States but other countries worldwide (USDHHS, 2010). The NAP is not just a report on the state of the problem—it is an urgent request to identify, select, and use strategies that have the great est potential to produce effective, measurable improvements in health literacy (Speros, 2011).

Nurses are in a unique position that enables them to act as advocates for and empower each client to obtain, understand, and act on infor mation provided to them. Many of the NAP strategies highlight actions that organizations or professions can take to further these goals. By focusing on health literacy issues and work ing together, nurses can improve the accessibil ity, quality, and safety of health care provided,

259Literacy in the Adult Client Population

reduce costs, and improve the health and quality of life for millions of people in the United States.

The NAP envisions a society that (1) provides everyone with access to accurate and actionable health information, (2) delivers personcentered health information and services, and (3) sup ports lifelong learning and skills to promote good health. Furthermore, the Action Plan high lights seven goals that will improve health liter acy (USDHHS, 2010):

1. Develop and disseminate health and safety information that is accurate, accessible, and actionable

2. Promote changes in the healthcare system that improve health infor mation, communication, informed decision making, and access to health services

3. Incorporate accurate, standardsbased, and developmentally appropriate health and science information and curricula in child care as well as ed ucation through the university level

4. Support and expand local efforts to provide adult education, English language instruction, and cultur ally and linguistically appropriate health information services in the community

5. Build partnerships, develop guidance, and change policies

6. Increase basic research and the devel opment, implementation, and evalu ation of practices and interventions to improve health literacy

7. Increase the dissemination and use of evidencebased health literacy practices and interventions

These goals cannot be achieved by a sin gle group or organization. Instead, meeting the goals of the NAP requires intense collaboration, both challenging and empowering individu als and communities to change the health sys tem to meet the needs of specific populations. TABLE 7-1 highlights the recent strides made in the United States in relation to health literacy.

With respect to the subject of literacy, the nurse educator’s attention specifically focuses on adult client populations. Literacy levels are not an issue in teaching staff nurses or nursing students because of their level of formal educa tion. However, literacy levels remain a concern if the audience for inservice programs includes less educated, more culturally and socioecono mically diverse support staff (Wong, 2012) or if a member of the audience has been diagnosed with a learning disability, such as dyslexia.

What must be particularly concerning to the healthcare industry are the numbers of consumers who are illiterate, functionally illiterate, or mar ginally literate. Researchers have discovered that people with poor reading and comprehension skills, as well as lower health literacy, have dis proportionately higher medical costs, increased number of hospitalizations and readmissions, and more perceived physical and psychosocial problems than do literate persons (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Eichler, Wi eser, & Brügger, 2009; McNaughton et al., 2015; Parnell, 2014; Sudore, Yaffe et al., 2006; Weiss, 2003; Weiss et al., 2005; Wu et al., 2016).

In today’s world of managed care, the literacy problem is perceived to have grave consequences. Clients are expected to assume greater responsibility for selfcare and health promotion, yet this expanded role depends on increased knowledge and skills. If people with low literacy abilities cannot fully benefit from the type and amount of information they are typically given, they cannot be expected to maintain health and manage independently. The result is a significant negative impact on the cost of health care and the quality of life (Dickens & Piano, 2013; Kogut, 2004; Levy & Royne, 2009; MacabascoO’Connell et al., 2011; Pignone et al., 2005; Weiss, 2014; Williams, Davis, Parker, & Weiss, 2002).

Traditionally, healthcare professionals have relied heavily on printed education mate rials (PEMs) as a costeffective and timeefficient means to communicate health messages. An as sumption was made that the written materials commonly distributed to patients were sufficient

260 Chapter 7 Literacy in the Adult Client Population

to ensure informed consent for tests and pro cedures, to promote compliance with treatment regimens, and to guarantee adherence to dis charge instructions.

Healthcare providers have begun to rec ognize that the scientific and technical ter minology inherent in the ubiquitous printed teaching aids constitutes a bewildering set of written instructions little understood by many people (Ache, 2009; McClure, Ng, Vitzthum, &

Rudd, 2016; Morrow, Weiner, Steinley, Young, & Murray, 2007). Kessels (2003) points out that 40% to 80% of medical information provided by health professionals is forgotten immediately, not just because medical terminology is too dif ficult to understand but also because delivery of too much information leads to poor recall. Furthermore, half of the information remem bered is incorrect (Parnell, 2014). Unless edu cation materials are written at a level and style

TABLE 7-1 Landmark Initiatives at the National Level in Support of Health Literacy

Healthy People 2010 (2000) Health objectives for the nation focused on health literacy (HL).

Priority Areas for National Action: Transforming Health Care Quality (Institute of Medicine [IOM] report; Adams & Corrigan, 2003)

HL listed as a cross-cutting priority for healthcare organizations.

Health Literacy: A Prescription to End Confusion (IOM report; Nielsen- Bohlman, Panzer, & Kindig, 2004)

Defined HL. Recommended government support and funding for research and HL initiatives. Recommended medical and nursing education programs incorporate HL in curricula and areas of competence.

U.S. Department of Education’s National Assessment of Adult Literacy (NAAL; results reported 2006)

Measured prevalence of inadequate HL in United States.

Surgeon General’s Workshop on Improving Health Literacy (2006)

Initiated dialog and HL with public and private entities and the Surgeon General’s office.

The Joint Commission Report, “What Did the Doctor Say?” (2007)

Established the link between HL, safety, and high-quality care.

Plain Writing Act (2010) Established that government documents issued to the public must be written clearly.

Patient Protection and Affordable Care Act (2010)

Included HL as law in specified programs.

National Action Plan to Improve Health Literacy (USDHHS, 2010)

Vision and goals set for a health literate society. Resources provided for communities to improve HL.

261Literacy in the Adult Client Population

Because it is difficult, if not impossible, to measure reading abilities on a populationwide basis, the number of years of schooling attended has been used to define literacy levels (Badaru deen & Sabharwal, 2010; Giorgianni, 1998). This method remains an imprecise means of estimating someone’s true reading skills. Many researchers have found that the reported grade level achieved in school is an inadequate predic tor of reading ability (Chew, Bradley, & Boyko, 2004; Doak et al., 1996; O’Bryant et al., 2007; Weiss, 2003; Winslow, 2001).

In the United States, the term literacy is generally defined as the ability to read and speak English (Andrus & Roth, 2002). In the 1992 NALS report, the U.S. Department of Ed ucation defined literacy as “the ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential” (National Center for Education Statistics, 1993, p. 6). NALS cate gorized literacy into three types of tasks: prose (reading newspapers, magazines, books), doc ument (interpreting insurance reports, consent forms), and quantitative (computing bills, taxes, paycheck stubs, calorie counts).

Most recently the NAP defined literacy as being able to demonstrate skills in reading, writing, basic math, interpreting speech, and comprehending information as well as skills in numeracy, which implies an aptitude with ba sic probability and numerical concepts (Baur, 2011). Overwhelmingly, those persons with lim ited literacy also have limited ability in numer acy (Andrus & Roth, 2002; Doak et al., 1996; Fisher, 1999; Williams et al., 1995).

Although no precise cutoff point defines the difference between literacy and illiteracy, the commonly accepted working definition of what is meant by literate is the ability to write and to read, understand, and interpret information written at the eighthgrade level or above. On the other end of the continuum, illiterate is defined as being unable to read or write at all or having reading and writing skills at the fourthgrade level or below.

Low literacy, also termed marginally lit- erate or marginally illiterate, refers to the ability

appropriate for their intended audiences, clients cannot be expected to be able or willing to ac cept responsibility for selfcare.

An essential prerequisite for implementing health education programs is to know the lit eracy skills of audiences for whom these pro grams are intended (Quirk, 2000). Yet calls for assessment of literacy and recommendations for appropriate interventions for clients with poor literacy skills have largely been ignored. Health professionals, including nurses, are sometimes reluctant to conduct a clinical assessment of literacy skill or place this information in the health record for fear of embarrassing or stig matizing the patient (PaascheOrlow & Wolf, 2007b). Therefore, even though illiteracy and low literacy are quite prevalent in the U.S. pop ulation, problems with literacy frequently con tinue to go undiagnosed (Doak, Doak, & Root, 1996; Zarcadoolas et al., 2006).

This chapter examines the magnitude of the literacy problem, the myths associated with it, and the factors that influence literacy levels. It emphasizes the important role that nurses play in assessing clients’ literacy skills and the effects of reading and health illiteracy on the wellbeing of the public. In addition, the for mulas and tests used to evaluate readability of printed tools and to assess clients’ comprehen sion and reading skills are reviewed, specific guidelines are put forth for writing effective health education materials, and teaching strat egies are recommended as a means for break ing down the barriers of illiteracy.

▸ Definition of Terms For many years, there was no clear agreement of what it meant to be literate in American so ciety. A literate person was loosely described as someone who possessed socially required and ex pected reading and writing abilities, such as being able to sign his or her name and read and write a simple sentence. Over time, performance on reading tests in school became the conventional method to measure gradelevel achievement.

262 Chapter 7 Literacy in the Adult Client Population

then compute the correct dose and frequency of taking the medication. He or she must be able to fill out lengthy health insurance forms, know when to vaccinate his or her child or have a mammogram, or give informed con sent for a lifesaving procedure. Although lit eracy and health literacy are closely related, they are different concepts (McCray, 2005). Health literacy is complex, such that even those people with strong reading and writ ing skills, high levels of education, and afflu ence can face challenges with health literacy. In fact, 45% of high school graduates have limited health literacy skills (USDHHS, 2010).

The CDC (2016) outlines the following common health literacy challenges facing many people:

1. They are not familiar with medical terms or how their bodies work.

2. They must be able to interpret or cal culate numbers or risks that could have health and safety consequences.

3. They are scared and confused when diagnosed with a serious illness.

4. They have health conditions that require high levels of complicated selfcare instructions.

5. They are voting on a critical local issue affecting the community’s health and are relying on unfamiliar technical information.

Health literacy level cannot be determined from stereotypes, generalizations, or assump tions, or by simply looking at a patient. Fur thermore, health literacy levels change over time with education, aging, social interactions, language, culture, and life experiences with health and disease (Baker, 2006; Nguyen et al., 2013; Speros, 2011). The Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs of the American Medical Association (1999) concluded that an individual’s func tional health literacy is likely to be significantly worse than his or her general literacy skills be cause of the complicated language used in the healthcare field, known as medicalese.

of adults to read, write, and comprehend infor mation between the fifth and eighthgrade lev els of difficulty. Persons with low literacy have trouble using commonly printed and written informa tion to meet their everyday needs, such as reading a TV schedule, taking a telephone message, or filling out a relatively simple appli cation form (Doak et al., 1996).

Functional illiteracy means that adults lack the fundamental reading, writing, and comprehension skills that are needed to per form the tasks of everyday life (Giorgianni, 1998; Vagvolgyi, Coldea, Dresler, Schrader, & Nuerk, 2016; Williams, Baker, Parker, & Nurss, 1998). They do not read well enough to under stand and interpret what they have read or use the information as it was intended (Doak et al., 1996). For example, someone who is function ally illiterate may be able to read the simple words on a label of a can of soup that directs them to “Pour soup into pan. Add one can water. Heat until hot.” However, they cannot comprehend the meaning and sequence of the words to carry through with these directions.

Conventional gradelevel definitions of liter acy are considered conservative because even an adult with the ability to read at the eighthgrade level will encounter difficulties in functioning in today’s advanced society. However, although an individual may have poor reading skills, this does not necessarily imply a lack of intelligence. Low literacy or illiteracy cannot be equated with IQ level. A person can be illiterate or low liter ate, yet intellectually be within at least normal IQ range (Doak et al., 1996).

Health literacy is defined by the Patient Protection and Affordable Care Act of 2010, Title V, as the “degree to which an individual has the capacity to obtain, communicate, pro cess, and understand basic health information and services to make appropriate health deci sions” (Centers for Disease Control and Pre vention [CDC], 2016, para. 1). Health literacy requires a person to do more than simply read patient education materials or make an appoint ment. A healthliterate individual must, for ex ample, be able to read a medication label and

Definition of Terms 263

usually three grade levels higher than compre hension scores (Fisher, 1999). Hirsch (2001) ad dresses the public’s confusion between reading in the sense of being able to decode words flu ently and reading in the sense of being able to comprehend the meaning of words.

Readability is defined as the ease with which written or printed information can be read. It is based on a measure of several different elements within a given text of printed material, such as the level of language being used and the layout and design of the page (Hasselkus, 2009). These variables influence with what degree of suc cess a group of readers will be able to read the style of writing of a selected printed passage.

Comprehension, in comparison, is the de gree to which individuals understand what they have read (Fisher, 1999; Koo, Krass, & Aslani, 2005). It is the ability to grasp the meaning of a message—to get the gist of it. A healthcare professional can determine whether compre hension of health instruction has occurred by noting whether clients are able to demonstrate correctly or recall in their own words the message that was received (Caplin & Saunders, 2015).

The ability to read does not, by itself, guar antee reading comprehension. Comprehension is affected by the amount, clarity, and com plexity of the information presented. If the el ements of logic, language, and experience in health instruction are compatible with and cul turally appropriate to the clients’ background, the message likely will be clear and relevant to them (Doak et al., 1996). Conversely, a mis match will likely make the message confusing, incomprehensible, and useless to the individual.

Illness, medication, treatment, or disrup tive life situations, all of which may cause stress and anxiety, have been found to interfere sig nificantly with comprehension. The ability to take in medical information, store it in mem ory, and recall it when necessary is affected by many other factors as well, such as the length of time between information disclosure and the need to remember the information, the nature of the information (how threatening), and the method of presentation (Doak et al., 1996; Doak,

Health literacy is a complex issue, and many variables have the potential to influence an in dividual’s capacity to obtain, process, and un derstand information. Some have suggested that “if health literacy is the ability to function in the health care environment, it must be de pendent upon the characteristics of both the individual and the health care system” (Baker, 2006, p. 878). Health literacy should be consid ered context specific and, as such, is influenced by the patient, the complexity of the condition and treatment, and the environment in which the treatment takes place (Volandes, 2007).

With the expectations, economics, and com plexities of the healthcare system today, which require individuals to take more responsibility for selfcare and symptom management, health literacy is becoming an important determinant of health status. Poor health literacy may lead to serious negative consequences, such as in creased morbidity and mortality, when a person is unable to read and comprehend instructions for medications, followup appointments, diet, procedures, and other regimens. Patients cannot be expected to be compliant, autonomous, and selfdirected in navigating the healthcare sys tem if they do not have the ability to follow basic instructions (Bennett, Chen, Soroui, & White, 2009; Davis et al., 2006). Further, low health lit eracy can result in more emergency department visits and hospital admissions and readmissions, with the elderly experiencing lower health sta tus with increased mortality (Stevens, 2015). It also affects use of preventive services such as mammography and flu vaccination and lessens the likelihood a person will take medications or follow health instructions correctly (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011).

Reading, readability, and comprehension also are terms frequently used when deter mining levels of literacy. Fisher (1999) defines reading or word recognition as “the process of transforming letters into words and being able to pronounce them correctly” (p. 57). Word recognition test scores, which can be mislead ing because they indicate only a person’s abil ity to identify words, not understand them, are

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health information can be provided verbally, and many clients prefer to learn in a facetoface en counter (Morrow et al., 2007). However, oral in struction alone is not a very successful method of teaching. “Written information is better re membered and leads to better treatment adher ence” (Kessels, 2003, p. 221).

Doak, Doak, and Root (1985) address the fact that there is no universally accepted way to test the degree of difficulty with oral lan guage. However, as these authors observe, “It is believed that some of the same characteristics that are critical for written materials will also af fect the comprehensibility of spoken language” (p. 40). Much more research needs to be done on “iloralacy,” or the inability to understand sim ple oral language, as a generic concept of illit eracy (Hirsch, 2001; Zarcadoolas et al., 2006).

Literacy Relative to Computer Instruction The literacy issue has traditionally been ex amined from the standpoint of readability and comprehension of printed materials. The use of computer technology has emerged as an in creasingly popular way to present information, making it an important dimension of the liter acy issue. To a much greater extent, educators and consumers are relying on computers as ed ucational tools, transforming the way health care information is accessed and shared. Clients who are well educated and career oriented are likely to own a computer and be computer lit erate. It is important to assess and accommo date those with limited resources, literacy skills, and technological knowhow so they are not left behind (Merriam & Bierema, 2014; Zarcadoo las et al., 2006).

Computers not only are used to convey instructional messages, but they also serve as valuable tools for accessing a wide array of ad ditional sources of health information. How ever, clients may not have the skills necessary to assess the quality and validity of the infor mation they discover. This new concern speaks

Doak, Friedell, & Meade, 1998; Kessels, 2003; Ley, 1979; Stephenson, 2006; Stevens, 2015).

Readability and comprehension, there fore, are particularly complex activities involv ing many variables with respect to both the reader and the actual written material (Doak et al., 1996; Fisher, 1999). Both are commonly determined by using one or more measurement formulas (see the later discussions of measure ment tools in this chapter). BOX 7-1 shows ex amples of elements that affect readability and comprehension.

Literacy Relative to Oral Instruction The inability to comprehend the spoken word or oral instruction above the level of under standing simple words, phrases, and slang words should be considered an important element in the definition or assessment of literacy. Most

BOX 7-1 Examples of Elements That Affect Readability and Comprehension

Material Variables Legibility (e.g., print size, spacing) Organization and flow of content Concept level Length of text Sentence structure Level of vocabulary Relevance to the reader Jargon (medical terminology) Number of polysyllabic words

Reader Variables Health status Perceived threat of illness Effects of illness/stress Physical and mental energy Level of motivation Visual and auditory acuity Educational attainment Background knowledge Ability to decipher language of message

Definition of Terms 265

an acute care setting or at the population health level. Ehealth tools include digital resources de signed to help patients, consumers, and caregiv ers find health information, store and manage their personal health information, make deci sions, and manage their health (CDC, 2009).

The use of ehealth tools and interven tions by healthcare professionals and patients appears to hold promise for increasing trans parency and expanding both parties’ knowledge base. Like health literacy, however, ehealth lit eracy levels are complex and can change based on technological advances. Therefore, undertak ing an assessment of not only health literacy but also ehealth literacy is an important action the nurse can take to determine whether the use of technology will be useful or detrimental to the client’s understanding of health information (Brega et al., 2015; Collins, Currie, Bakken, Vawdrey, & Stone, 2012; Neter & Brainin, 2012).

▸ Scope and Incidence of the Problem

Literacy has been termed the “silent epidemic,” the “silent barrier,” the “silent disability,” and “the dirty little secret” (Conlin & Schumann, 2002; Doak & Doak, 1987; Kefalides, 1999; Wedgeworth, 2007). Based on available statistics over the past 25 years, clearly the United States has significant literacy problems. In fact, this country ranked only among the middle of in dustrialized nations on most measures of adult literacy—yet many of its educators, elected rep resentatives, and social advocates have remained blind to this significant problem (Kogut, 2004).

In 1985, the U.S. Department of Education undertook the first national assessment of adult literacy, known as the Young Adult Literacy Sur vey. Since then, the federal government has con ducted two subsequent largescale assessment surveys (USDHHS, 2003). These two national surveys are described as follows.

The 1992 NALS, considered to be a highly accurate and detailed profile on the condition of

not only to having skills to use the computer but skills to know how to assess and use the in formation found (Landry, 2015). This is called web or information literacy, which is “how well the client can assess the accuracy, reliability, and validity of various web sources” (Merriam & Bierema, 2014, p. 201).

The opportunity to expand clients’ knowl edge base through telecommunications and vir tual resources requires nurse educators to attend to computer literacy levels of their audiences. In the same way that they now recognize the negative effects that illiteracy and low literacy have had on restricting the information base of consumers of health care when printed mate rials are relied upon, nurses must begin to ad vocate for computer literacy in the public they serve (Doak et al., 1996; Moore, Bias, Prentice, Fletcher, & Vaughn, 2009). Computer software programs can be made suitable for use by low literate learners if these individuals have the basic capacity to access and operate computers and the information is simplified for readabil ity and comprehension (Egbert & Nanna, 2009).

The concept of ehealth and informatics has grown globally to encompass use of the Inter net and other virtual resources, such as telehealth and electronic health records, for the delivery and organization of care. Patients also are using smartphone applications, text reminders, blogs or online communities, and health websites to manage their health (Landry, 2015). This inno vative approach requires that patients have ad ditional skills to communicate with healthcare providers and understand their treatment plan. Thus, electronic health literacy must be an addi tional concern to the nurse. Norman and Skinner (2006a) define e-health literacy as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” (para. 6). These authors draw attention to the knowledge and complex skill set that is often taken for granted when people in teract with technology to access and share infor mation. Nurses now must focus their attention on learning and usability issues, whether it be in

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in the U.S. population in 2003, 43% (93 million) fell into the lowest two categories (National Cen ter for Education Statistics, 2006).

The average score results indicated no sig nificant change in prose and document literacy and only a slight increase in quantitative liter acy between 1992 and 2003. However, a higher proportionate percentage of several popula tion groups, such as those who did not grad uate from high school, Hispanics, and those older than 65 years of age, fell into the below basic level of prose literacy (Kutner, Greenberg, Jin, & Paulsen, 2006). The NAAL’s Health Lit eracy Report specifically found that 36% (47 million) adults had basic or below basic health literacy and that older adults (65 years and older) had the lowest health literacy levels (Baer, Kunter, & Sabatini, 2009; National Center for Education Statistics, 2006). For more detailed information on the NAAL survey, visit the Na tional Center for Education Statistics at https:// nces.ed.gov/naal/.

In 2004, the Institute of Medicine, the Agency for Healthcare Research and Quality (AHRQ), and the American Medical Associ ation (AMA) issued their own reports on the status of health literacy in the United States. All three reports revealed that as many as 50% of all American adults lack the basic reading and numerical skills essential to function adequately in the healthcare environment (Aldridge, 2004; IOM, 2004; Weiss et al., 2005).

Most recently, competencies of adults from 33 countries, including the United States, were surveyed through the Program for the Inter national Assessment of Adult Competencies (PIAAC), which is supported by the Organisa tion for Economic Cooperation and Development (OECD). The PIAAC “measures relationships between individuals’ educational background, workplace experiences and skills, occupational attainment, use of information and communi cations technology, and cognitive skills in the areas of literacy, numeracy, and problem solv ing” (National Center for Education Statistics, n.d.a, para. 2). In 2012 and 2014, data were collected from 8,600 U.S. participants in two

Englishlanguage literacy in the United States, revealed surprising statistics. NALS research ers interviewed and collected data from a rep resentative sample of 26,000 individuals, age 16 years and older. Based on the findings from an assessment of literacy skills in three areas (prose, document, and quantitative), literacy abilities were categorized into five levels, with Level 1 being the lowest and Level 5 being the highest.

Some 21% to 23% (approximately 40–44 million) of the 191 million adults in the coun try at that time scored in the lowest level of the three skill areas. They were considered func tionally illiterate. Another 25% to 28%, or ap proximately 50 million adults, scored in the Level 2 category; that is, they were considered to have low literacy skills. Thus, the number of illiterate and low literate adults in the United States conservatively was estimated to be ap proximately 46% to 51% of the population (or 90–94 million in total).

This indicated that roughly half of the U.S. adult population had deficiencies in reading, writing, and math skills (Fisher, 1999; Weiss, 2003). The researchers found that those indi viduals with poor literacy skills (Levels 1 and 2) were disproportionately more often from mi nority populations, from lower socioeconomic groups, and had poorer health status (Andrus & Roth, 2002; Fisher, 1999; Weiss, 2003).

In 2003, building on the NALS of 10 years earlier, the National Assessment of Adult Liter acy (NAAL) became the first study to identify the literacy of America’s adults in the 21st cen tury. New, more sensitive instruments were de signed to enhance measurement of the literacy abilities of the least literate adults. Most import ant, this evaluation included a health literacy component to assess adults’ understanding of healthrelated materials and forms (National Center for Education Statistics, 2006).

The NAAL categorized literacy skills into four levels, and the findings revealed the follow ing percentages and total numbers: below basic, 14% (30 million); basic, 29% (63 million); inter mediate, 44% (95 million); and proficient, 13% (28 million). Of the overall 216 million adults

Scope and Incidence of the Problem 267

Level 2, and Level 3). Those below Level 1 have limited technology skills and can solve problems using only one simple technologyrelated task at a time, whereas those at Level 3 can use multiple technology functions and tools simultaneously while problem solving. In the U.S. sample, only 5% of participants scored at the highest profi ciency of Level 3, which was lower than the in ternational average of 8%, and more participants scored at Level 1 or lower (64%), compared to the international average (55%) (ProLiteracy, 2017; Rampey et al., 2016).

Although this newest measure does not seamlessly translate with those of the past, it demonstrates that the problem of low literacy remains, especially in areas of technology. The PIAAC provides updated international stan dards on which to track and compare literacy progress not only in the United States but world wide. The next round of PIAAC assessments is planned for 2017 (National Center for Educa tion Statistics, n.d.a). See Rampey et al. (2016) for more detailed information on findings of the PIAAC. BOX 7-2 lists websites that provide even more information on health literacy.

waves (National Center for Education Statis tics, n.d.b). Literacy was quantified on a scale of 0–500 and categorized into levels (below Level 1, Level 1, Level 2, Level 3, and Level 4/5). In this assessment, those who scored below Level 1, al though not considered illiterate, could do no more than enter simple information into a form or lo cate simple and specific information in a text doc ument to answer a question. In contrast, those at Level 4/5 could find and synthesize information across multiple highlevel texts. On the average, American participants scored at Level 2, signifi cantly below the average of seven participating countries; only 13% of American adults scored at Levels 4/5. For numeracy, just 10% of Ameri cans participating scored at the highest Levels 4/5 with the average American participant scoring at Level 2 (ProLiteracy, 2017; Rampey et al., 2016).

The PIAAC also assessed problem solv ing that involved technology, defined as “using digital technology, communication tools, and networks to acquire and evaluate information, communicate with others, and perform practi cal tasks” (Rampey et al., 2016, B9). This area is scored on four levels (below Level 1, Level 1,

BOX 7-2 Health Literacy Online Resources

■ AHRQ Health Literacy Universal Precautions Toolkit: https://www.ahrq.gov/sites/default/files /publications/files/healthlittoolkit2_3.pdf

■ Center for Health Care Strategies, Inc. Health Literacy Fact Sheets: http://www.chcs.org/resource /health-literacy-fact-sheets/

■ Centers for Disease Control and Prevention, Health Literacy: https://www.cdc.gov/healthliteracy/ ■ Centers for Disease Control and Prevention, Simply Put: A Guide for Creating Easy-to-Understand

Materials: https://www.cdc.gov/healthliteracy/pdf/simply_put.pdf ■ Harvard School of Public Health, Health Literacy Studies: https://www.hsph.harvard.edu

/healthliteracy/ ■ Health Literacy and Patient Safety: Help Patients Understand. (2007). American Medical Association,

Chicago. Discusses scope of low health literacy issue and integrates patient case studies (23 minutes): https://www.youtube.com/watch?v=cGtTZ_vxjyA

■ Health Literacy Consulting: http://www.healthliteracy.com ■ National Center for Education Statistics: https://nces.ed.gov/naal/ ■ National Center for Families Learning: http://www.familieslearning.org ■ National Center for Education Statistics. What is PIAAC?: https://nces.ed.gov/surveys/piaac ■ Pfizer Health Literacy: http://www.pfizerhealthliteracy.com ■ U.S. Department of Health and Human Services, National Action Plan to Improve Health Literacy:

www.health.gov/communication/hlactionplan/

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society is the result of factors such as the follow ing (Baur, 2011; Gazmararian et al., 1999; Gior gianni, 1998; Hayes, 2000; Hirsch, 2001; Kogut, 2004; Weiss, 2007):

■ An increase in the number of immigrants with English as a second language

■ The aging of the population ■ The increasing amount and complexity of

information ■ The increasing sophistication of technology ■ More people living in poverty ■ Changes in policies and funding for public

education ■ Disparities between minority versus non

minority populations

These factors correlate significantly with the level of formal schooling attained and the level of literacy ability. Although research indi cates that the number of years of schooling is not a good predictor of literacy level, there re mains some correlation between a person’s ed ucational background and the ability to read (O’Bryant et al., 2007). As society becomes in creasingly more technologically challenging, with new products to use and more compli cated functions to perform, the basic language requirements needed for survival continue to expand. Many more people are beginning to fall behind, unable to keep up with an ever more so phisticated world.

In cases of both illiteracy and low literacy, the level of readability is measured in terms of performance, not years of school atten dance. The mean literacy level of the U.S. pop ulation is at or below eighth grade. Medicaid enrollees, on average, read at the fifthgrade level (Andrus & Roth, 2002; Giorgianni, 1998; Winslow, 2001). Many people read at least two to four grade levels below their reported level of formal education. For those in poverty, the gap between grade level completed and actual reading level is even greater (Andrus & Roth, 2002). This deficiency persists because schools tend to promote students for social and age related reasons rather than for academic achieve ment alone (Feldman, 1997), because clients may

Because of the difficulty inherent in defin ing and testing literacy, the lack of inclusion of unidentified illegal immigrants in the United States in the national sample populations stud ied, and the fact that few people with limited reading skills admit to having any difficulty, the scope of the literacy problem is thought to be much greater than the estimates found in for mal studies (Brownson, 1998; Doak et al., 1996; Weiss, 2003).

Limited literacy leads to poor health out comes. In fact, literacy skills are “a stronger predictor of an individual’s health status than income, employment status, education level, and racial or ethnic group” (Weiss, 2007, p. 13). Individuals with limited literacy skills are less knowledgeable about their health problems and have higher hospitalization rates, more emer gency department visits, higher healthcare costs, less healthy behaviors, and poorer health status (Eichler et al., 2009; Weiss, 2007; Weiss et al., 2005). McNaughton et al. (2015) found that acute heart failure patients with low health lit eracy scores were at higher risk for death after hospital discharge.

The rates of illiteracy and low literacy gen erally and the low rates of health literacy partic ularly continue to pose a major threat to many segments of society. This problem is expected to grow worse because of the many trends de scribed next that are operating in the United States and worldwide unless specific measures are taken to curb the tide. To be literate 100 years ago meant that people could read and write their own name. Today, being literate means that one can learn new skills, think critically, solve prob lems, and apply general knowledge to various situations (Weiss, 2003).

▸ Trends Associated with Literacy Problems

The trend toward an increased proportion of Americans having literacy levels that are inad equate for active participation in this advanced

Trends Associated with Literacy Problems 269

Research shows (Cole, 2000; Hayes, 2000; Kogut, 2004; Montalto & Spiegler, 2001; Nath, Sylvester, Yasek, & Gunel, 2001; Rothman et al., 2004; Schillinger et al., 2002; Schultz, 2002; Weiss, 2007; Williams et al., 1998; Winslow, 2001) that the following populations have been identified as having poorer reading and comprehension skills than the average American:

■ Those who are economically disadvantaged ■ Older adults ■ Immigrants (particularly illegal ones) ■ Those with English as a second language ■ Racial minorities ■ High school dropouts ■ Those who are unemployed ■ Prisoners ■ Innercity and rural residents ■ Those with poor health status resulting from

chronic mental and physical problems ■ Those on Medicaid

Of course, not every member of an atrisk population suffers from low literacy. Further, some people do not fall into an “at risk” category yet still lack literacy skills (Baur, 2011; Weiss, 2007).

With respect to demographics, statistics in dicate that 34 million Americans are presently living in poverty and that nearly half (43%) of all adults with low literacy live in poverty (Darling, 2004; Literacy Project Foundation, 2017). Although those who are disadvantaged represent many diverse cultural and ethnic groups, including millions of poor Caucasians, one third of disadvantaged people in this coun try are minorities, and a larger percentage of minorities fall into the disadvantaged category (Giorgianni, 1998; Weiss et al., 2005).

In this 21st century, the major growth in the U.S. population is predicted to come from the ranks of minority groups. By 2050, 53% of the people in the United States are pro jected to belong to a racial or ethnic minority and one in five will be foreign born (Passel & Cohn, 2008). The U.S. Census Bureau (2012) reported that almost 40 million immigrants re side in this country, more than quadruple the number in 1970, with more than half of those

report inaccurate histories of years of school at tended, and because reading skills may be lost over time through lack of practice (Davidhizar & Brownson, 1999; Miller & Bodie, 1994; Weiss, 2003; Williams et al., 2002).

Levels of literacy are often seen as indicators of the wellbeing of individuals, and the literacy problem has larger implications for the overall social and economic status of the country (Kogut, 2004). Low levels of literacy have been associated with marginal productivity, high unemployment, minimum earnings, high costs of health care, and high rates of welfare dependency (Andrus & Roth, 2002; Eichler et al., 2009; Giorgianni, 1998; Weiss, 2007; Winslow, 2001; Ziegler, 1998).

In addition, illiteracy contributes to many of the grave social issues confronting the United States and other countries worldwide, such as homelessness, teen pregnancy, unemployment, poverty, delinquency, crime, and drug abuse (Fleener & Scholl, 1992; Kogut, 2004; World Lit eracy Foundation, 2015). Deficiencies in basic literacy skills become compounded and create devastating cumulative effects on individuals, which produces a social burden that is extremely costly for the American people. Illiteracy and low literacy are not necessarily the reasons for these ills, but the high correlation between lit eracy levels and social problems is a marker for disconnectedness from society in general (Ko gut, 2004; USDHHS, 2003).

▸ Those at Risk Illiteracy has been described “as an invisible handicap that affects all classes, ethnic groups, and ages” (Fleener & Scholl, 1992, p. 740). It is a silent disability. Illiteracy knows no boundaries and exists among persons of every race and eth nic background, socioeconomic class, and age category (Duffy & Snyder, 1999; Parnell, 2014; Weiss, 2003). It is true, however, that illiteracy is rare in the higher socioeconomic classes, for example, and that certain segments of the U.S. population are more likely to be affected than others by lack of literacy skills.

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(Davidhizar & Brownson, 1999; Gazmararian et al., 1999; Williams et al., 2002). Older adults constitute approximately 15% of the total U.S. population now, but the number of those older than 65 will increase to approximately 21% or 74 million Americans by 2030. Individuals older than 85 years of age make up the fastestgrowing age group in the country today and which is pro jected to reach 20 million by 2060 (Federal In teragency Forum on AgingRelated Statistics, 2016). Children born today can expect to live to an average age of at least 80 years (Crandell, Crandell, & Vander Zanden, 2012). Thus, it is likely that a greater overall number older adults will have problems with functional illiteracy.

With respect to educational level, mem bers of the older population will be more edu cated and demand more services as time goes on. In 1960, only 20% of older people were high school graduates; in 2015, 85% were educated at the high school level (USDHHS, 2016). Al though these statistical trends indicate the U.S. population will include a more highly educated group of older adults in the future, the infor mation explosion and rapid technological ad vances may cause them to fall behind relative to future standards of education. Today, the illiter acy problem in older adults is caused by the fact that not only did these individuals have less ed ucation in the past, but their reading skills also have declined over time because of disuse. If a person does not use a skill, he or she loses that skill. Reading ability can deteriorate over time if not exercised regularly (Brownson, 1998).

In addition, cognition and some types of intellectual functioning are affected by aging (Crandell et al., 2012; Kessels, 2003; Santrock, 2017). A significant number of older people have some degree of cognitive changes and sensory impairments, such as vision and hearing loss. On the average, 28% of people age 65 and 38% of those older than 75 years of age have serious hearing impairment; women fare better than men in this regard (Crandell et al., 2012). Along with these normal physiological changes, many older adults suffer from chronic diseases, and large numbers are taking prescribed medications.

individuals living in California, New York, Florida, and Texas. One third of the foreignborn popu lation has arrived since 2000, 62% of immigrant families have children, and 30% of immigrants do not have a high school diploma (Grieco et al., 2012; U.S. Census Bureau, 2012). Of the 1,000 communitybased adult literacy programs sup ported by ProLiteracy, 86% teach English as a second language (ESL; M. Diecuch, personal com munication, January 23, 2017). Nurse educators must recognize how these demographic changes will affect the way in which services need to be rendered, educational materials need to be developed, and information needs to be mar keted (Andrus & Roth, 2002; Borrayo, 2004; Parnell, 2014; Robinson, 2000).

Many minority and economically disadvan taged people, as well as the prison population— which has the highest concentration of adult illiteracy (Duffy & Snyder, 1999)—are not ben eficiaries of mainstream health education activ ities, which often fail to reach them. Overall, they are not active seekers of health information because they tend to have weaker communica tion skills and inadequate foundational knowl edge on which to better understand their needs. Many lack enough fluency to make good use of written health education materials. Moreover, although most PEMs are written in English, flu ency in verbal skills in another language does not guarantee functional literacy in that native language (Horner, Surratt, & Juliusson, 2000). Areas with the highest percentage of minorities and high rates of poverty and immigration also have the highest percentage of functionally il literate people. When these people need med ical care, they tend to require more resources, have longer hospital stays, and have a greater number of readmissions (Levy & Royne, 2009; Weiss, 2007). The challenge now and into the future will be to find improved ways of com municating with these population groups and to develop innovative strategies in the delivery of health care to them.

As for Americans who are older than 65 years of age, two out of five adults (approxi mately 40%) are considered functionally illiterate

Those at Risk 271

Purnell (2013) stresses the importance of assessing other elements of verbal and nonver bal communication, such as emotional tone of speech, gestures, eye contact, touch, voice vol ume, and stance, between persons of different cultures that may affect the interpretation of behavior and the validation of information re ceived or sent. Educators must be aware of these potential barriers to communication when inter acting with clients from other cultures whose lit eracy skills may be limited. Given the increasing diversity of the U.S. population, most currently available written materials are considered inad equate based on the literacy level of minority groups and the fact that the majority of PEMs are available only in English.

Thus individuals with less education, whose number often includes lowincome persons, older adults, racial minorities, and people for whom English is a second language, are likely to have more difficulty with reading and com prehending written materials as well as with un derstanding oral instruction (Winslow, 2001). This profile is not intended to stereotype peo ple who are illiterate but rather to give a broad picture of who most likely lacks literacy skills. When carrying out assessments on their patient populations, it is essential that nurses and other healthcare providers be aware of those suscep tible to having literacy problems.

▸ Myths, Stereotypes, and Assumptions

Rarely do people voluntarily admit that they are illiterate. Illiteracy carries a stigma that creates feelings of shame, inadequacy, fear, and low self esteem (McCune, Lee, & Pohl, 2016; Paasche Orlow & Wolf, 2007b; Weiss, 2007; Williams et al., 2002; Wolf et al., 2007). Most individu als with poor literacy skills have learned that it is dangerous to reveal their illiteracy because of fear that others such as family, strangers, friends, or employers would consider them dumb or in capable of functioning responsibly. In fact, the

These conditions can interfere with the ability to learn or can negatively affect thought pro cesses, which contributes to the high incidence of illiteracy and low health literacy in this pop ulation group (CDC, 2009; Nguyen et al., 2013; Sudore, Yaffe et al., 2006).

Beyond the issue of prevalence, illiteracy presents unique psychosocial problems for the older adult. Because older persons tend to pro cess information more slowly than do young adults, they may become more easily frustrated in a learning situation (Crandell et al., 2012; Kessels, 2003). Furthermore, many older indi viduals have developed ways to compensate for missing skills through their support network. Lifetime patterns of behavior have been set, such that they may now lack the motivation to im prove their literacy skills. Today and in the years to come, those nurses involved with providing health education will be challenged to overcome these obstacles to learning in the older adult.

Cultural diversity, although not considered to be directly related to illiteracy, may also serve as a barrier to effective client education. Ac cording to Davidhizar and Brownson (1999)— and a contention backed up by the NAAL’s 2003 statistics—most adults with illiteracy problems in the United States are Caucasian, nativeborn, Englishspeaking individuals. However, when examining the proportion of the population that has poor literacy skills, minority ethnic groups are at a disproportionately higher risk (Andrus & Roth, 2002).

When healthcare providers communi cate with clients from cultures different from their own, it is important for them to be aware that their clients may not be fluent in English. Furthermore, even if people speak the English language, the meanings of words and their un derstanding of facts may vary significantly based on life experiences, family background, and cul ture of origin, especially if English is the client’s second language (Purnell, 2013). In conversa tion, an individual must be able to understand undertones, voice intonations, and the context (slang, terminology, or customs) in which the message is being delivered.

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Most people with limited literacy abilities are masters at concealment. Typically, they are ashamed of their limitation and attempt to hide the problem in clever ways. Often, they are re sourceful and intelligent about trying to conceal their illiteracy and have developed remarkable memories to help them cope with family and ca reer situations (Doak et al., 1996; Kanonowicz, 1993). Many have discovered ways to function quite well in society without being able to read by memorizing signs and instructions, making intelligent guesses, or finding employment op portunities that are not heavily dependent on reading and writing skills.

An important thing to remember is that many myths about illiteracy exist. It is very easy for healthcare providers to fall into the trap of labeling someone as illiterate or, for that matter, assuming they are literate based on stereotypical images. Some of the most common myths about people who struggle with literacy skills are out lined in TABLE 7-2 (Andrus & Roth, 2002; Doak

majority of people with literacy problems have never told their spouse or children of their dis ability (Quirk, 2000; Williams et al., 2002).

People also tend to underreport their lim ited reading abilities because of embarrassment or lack of insight about the extent of their limita tion. The NALS report revealed that most adults performing at the two lowest levels of literacy skill describe themselves as proficient in being able to read and/or write English (Ad Hoc Committee on Health Literacy, 1999). Because selfreporting is so unreliable and because illiteracy and low literacy are so common, many experts suggest that all patients should be screened to iden tify those who have reading difficulty to deter mine the extent of their impairment (Andrus & Roth, 2002; Safeer & Keenan, 2005; Weiss, 2007; Weiss et al., 2005). Nurses must recognize that many patients would approach such testing reluctantly and be fearful of having their lit eracy report recorded in their health record (PaascheOrlow & Wolf, 2007b; Wolf et al., 2007).

TABLE 7-2 Myths and Truths About Those Who Struggle with Literacy

Myth Truth

They are intellectually slow learners or incapable of learning at all.

Many have average or above-average IQs.

They can be recognized by their appearance.

Appearance alone is an unreliable basis for judgment; some very articulate, well-dressed people have no visible signs of a literacy disability.

The number of years of schooling completed correlates with literacy skills.

Grade-level achievement does not correspond well to reading ability. The number of years of schooling completed overestimates reading levels by four to five grade levels.

Most are foreign born, poor, and of ethnic or racial minority.

They come from very diverse backgrounds and the majority are White, native-born Americans.

Most will freely admit that they do not know how to read or do not understand.

Most try to hide their reading deficiencies and will go to great lengths to avoid discovery, even when directly asked about their possible limitations.

Myths, Stereotypes, and Assumptions 273

patients with illiteracy or low literacy may demonstrate (Andrus & Roth, 2002; Carol, 2007; Davis, Michielutte, Askov, Williams, & Weiss, 1998; Weiss, 2007):

■ Reacting to complex learning situations by withdrawal, complete avoidance, or being repeatedly noncompliant

■ Using the excuse that they were too busy, too tired, too sick, or too sedated with medica tion to maintain their attention span when given a booklet or instruction sheet to read

■ Claiming that they just did not feel like reading, that they gave the information to their spouse to take home, or that they lost, forgot, or broke their glasses

■ Camouflaging their problem by surround ing themselves with books, magazines, and newspapers to give the impression they can read

■ Circumventing their inability by insisting on taking the information home to read or having a family member or friend with them when written information is presented

■ Asking you to read the information for them under the guise that their eyes are bother some, they lack interest, or they do not have the energy to devote to the task of learning

■ Showing nervousness because of feeling stressed by the possibility of getting caught or having to confess to illiteracy

■ Acting confused, talking out of context, holding reading materials upside down, or expressing thoughts that may seem totally irrelevant to the topic of conversation

■ Showing a great deal of frustration and restlessness when attempting to read, of ten mouthing words aloud (vocalization) or silently (subvocalization), substituting words they cannot decipher (decode) with meaningless words, pointing to words or phrases on a page, or exhibiting facial signs of bewilderment or defeat

■ Standing in a location clearly designated for authorized personnel only

■ Listening and watching very attentively to observe and memorize how things work

et al., 1996; Weiss, 2007; Williams et al., 2002; Winslow, 2001).

▸ Assessment: Clues to Look For

Thus, the question remains: How does one rec ognize an illiterate person? Identifying illiteracy is not easy because there is no stereotypical pat tern. This impairment is easily overlooked be cause illiteracy is not visible and affects people of all ages, socioeconomic levels, and national ities (Cole, 2000; Hayes, 2000).

Nurses, because of their role with health care consumers, are in an ideal position to de termine the literacy levels of individuals (Cutilli, 2005; Monsivais & Reynolds, 2003). Because of the prevalence of illiteracy, nurses must never assume that a client is literate. Knowing a per son’s ability to read and comprehend is criti cal in providing teaching–learning encounters that are beneficial, efficient, and cost effective.

Nurses need to watch for informal clues or red flags that indicate reading and writing defi ciencies. A caveat applies, however: Do not rely on the obvious, but look for the unexpected. In so many instances when someone does not fit the stereotypical image, nurses and other health professionals have never even considered the possibility that an illiteracy problem exists.

Overlooking the problem has the potential for grave consequences in treatment outcomes and has resulted in frustration for both patients and caregivers (Cole, 2000; Weiss, 2007). Un fortunately, healthcare providers are often hesi tant to infer that a patient may have low literacy skills because there is an implication of personal inadequacy associated with the failure to have learned to read (Quirk, 2000). If healthcare pro viders become aware of a client’s literacy prob lem, they must convey sensitivity and maintain confidentiality to prevent increased feelings of shame (Quirk, 2000).

During assessment, the nurse educator should take note of the following clues that

274 Chapter 7 Literacy in the Adult Client Population

a patient’s appearance and behavior, and seek out the less than obvious by conducting a thor ough initial assessment of variables to uncover the possibility that a literacy problem exists. An awareness of this possibility and good skills at observation are key to diagnosing illiteracy or low literacy in learners. Early diagnosis enables nurses to intervene appropriately to avoid dis service to those who do not need condemna tion but rather support and encouragement.

▸ Impact of Illiteracy on Motivation and Compliance

In addition to the fact that poor literacy skills affect the ability to read as well as to understand and interpret the meaning of written and ver bal instructions, a person with illiteracy or low literacy struggles with other significant inter related limitations with communication that can negatively influence healthcare teaching (Doak et al., 1998; Kalichman, Ramachandran, & Catz, 1999; Vagvolgyi et al., 2016). The per son’s organization of thought, perception, vo cabulary and language/fluency development, and problemsolving skills are adversely af fected, too (Giorgianni, 1998).

Fleener and Scholl (1992) investigated char acteristics of persons who had identified them selves as literacy disabled. Vagvolgyi et al. (2016) conducted a comprehensive review of the liter ature to define what it means to be functionally illiterate and to uncover answers to questions about deficits in abilities, such as sensory, cog nitive, and neurological, of those identified with one or more causes of illiteracy. These two groups of researchers found that among the function ally illiterate, the most common deficiencies found were in phonics, comprehension, and perception. Difficulties in perception were ev ident in reversing letters and words, miscalling letters, and adding and omitting letters. Also, a major problem was comprehension—that is,

■ Demonstrating difficulty with following instructions about relatively simple activi ties such as breathing exercises or operating the TV, electric bed, call light, and other simple equipment, even when the operating instructions are clearly printed on them

■ Failing to ask any questions about the in formation they received

■ Turning in registration forms or health questionnaires that are incomplete, illegible, or not attempted

■ Revealing a discrepancy between what is understood by listening and what is un derstood by reading

■ Missing appointments or failing to follow up with referrals

■ Not taking medications as prescribed or being noncompliant

In summary, although it has been clearly pointed out that the level of completed formal education is an inaccurate presumption by which to predict reading level, it is certainly one esti mate that nurses should incorporate into their methods of assessment. Also, negative feedback and clues from the client in the form of puz zled looks, inappropriate behaviors, excuses, or irrelevant statements may give the nurse the intuitive feeling that the message being com municated has neither been received nor un derstood. Not only do illiterate people become confused and frustrated in their attempts to deal with the complex system of health care, which is so dependent on written and verbal informa tion, but they also become stressed in their ef forts to cover up their disability.

Nurses, in turn, can feel frustrated when persons who have undiagnosed literacy prob lems seem at face value to be unmotivated and noncompliant in following selfcare instructions. Many times, nurses wonder why patients make caregiving so difficult for themselves as well as for the provider. It is not unusual for nurses to con clude, “He’s too proud to bend,” “She’s in denial,” or “He’s just being stubborn—it’s a control issue.”

Nurses in their role as educators must go beyond their own assumptions, look beyond

Impact of Illiteracy on Motivation and Compliance 275

prefer not knowing the answers to questions and may withdraw altogether to avoid awkward or embarrassing learning situations. Also, they may react to complicated, fastpaced instruc tion with discouragement, feelings of low self esteem, and refusal to participate because their process of interpretation is so slow. Even when questioned about their understanding, persons with low literacy skills will most likely claim that they understood the information even when they did not (Doak et al., 1996).

Another characteristic of illiterate individ uals is that they have difficulty synthesizing in formation in a way that fits into their behavior patterns. If they are unable to comprehend a re quired behavior change or cannot understand why it is needed, they will disregard any health teaching (Vanderhoff, 2005; Weiss, 2007). For example, patients recovering from fractured hips who are taught via demonstration and written instructions how to climb stairs and how to do strengthening exercises may fail to comply with this regimen because of lack of understanding of the information and ways to go about in corporating these changes into their lifestyle (Schultz, 2002).

Persons with poor literacy skills may also think in only concrete, specific, and literal terms. An example of this limitation is the patient with diabetes whose glucose levels were out of control even when he insisted he was taking his insu lin as instructed—injecting the orange and then eating the fruit (Hussey & Guilliland, 1989).

The person with limited literacy also may experience difficulties handling large amounts of information and classifying it into categories. Particularly, older adults who need to take sev eral different medications at various times and in different dosages may either become con fused with the schedule or ignore the instruc tion. If asked to change their daily medication routine, a great deal of retraining may be needed to convince them of the benefits of the new reg imen (Kessels, 2003).

Another major factor in noncompliance is the lack of adequate and specific instruc tions about prescribed treatment regimens.

identification of words without knowing their meaning. Some individuals needed to read aloud to understand, and others read so slowly that they lost the meaning of a paragraph be fore they had finished it. Still other subjects per ceived difficulty in remembering as a factor in their lack of reading skill.

People with poor reading skills have diffi culty analyzing instructions, assimilating and correlating new information, and formulating questions (Giorgianni, 1998). They may be re luctant to ask questions because of concerns that their inquiries will be regarded as incomprehen sible or irrelevant. Frequently they do not even know what to ask, but they fear if they try, oth ers will think of them as ignorant or lacking in intelligence. These individuals have great diffi culty navigating the healthcare delivery system, which relies on written information and printed forms at every juncture. Studies have shown that Health Insurance Portability and Accountability Act (HIPAA) privacy notices, informed consent forms, drug warning labels, and insurance forms all present obstacles for individuals with poor reading skills (Davis et al., 2006; McCormack, Bann, Uhrig, Berkman, & Rudd, 2009; Sudore, Landefeld et al., 2006; Walfish & Ducey, 2007).

Most nurses can recount a situation in which a patient failed to follow advice because he or she did not understand the instructions that were given. Hussey and Guilliland (1989) provide a poignant example, which remains as relevant today as it was then, of a young preg nant girl prescribed antiemetic suppositories to control her nausea. When she had no relief of symptoms, questioning by the nurse revealed that she was swallowing the medication. Obvi ously, not only did she not understand how to take the medicine, but she also likely had never seen a suppository and was not even able to read or understand the word. She did not ask what it was, probably because she did not know what to ask in the first place, and she may have been reluctant to question the treatment out of fear that she would be regarded as ignorant.

If their past experiences with learning have been less than positive, some people may

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as uncooperative and noncompliant. In reality, the underlying problem may be limited cogni tive processing that impedes comprehending and following written and oral communication.

▸ Ethical, Financial, and Legal Concerns

Sources of PEMs include healthcare facilities, commercial vendors, government services, voluntary health agencies, nonprofit charitable organizations, pharmaceutical firms, and med ical equipment supply companies. These ma terials are distributed primarily by nurses and other health professionals and are the major sources of information for clients participating in health programs in many settings.

Written health information materials are in tended to reinforce learning about health pro motion, disease prevention, illness management, diagnostic procedures, drug and treatment mo dalities, rehabilitative course, and selfcare reg imens. Unfortunately, many of these sources fail to account for the educational level, preex isting knowledge base, cultural influences, lan guage barriers, or socioeconomic backgrounds of persons with limited literacy skills.

It is estimated that the total impact of low health literacy on the U.S. economy is as much as $236 billion each year (Center for Health Care Strategies, 2013). A systematic review done by Eichler et al. (2009) determined that a higher expenditure of financial resources is associated with low health literacy on both in stitutional and individual levels. Low health lit eracy can account for 3% to 5% of healthcare costs, and individuals with low health literacy incur additional charges from health service use. The elderly and minorities—specifically those who have English as a second language—are es pecially vulnerable to low health literacy, which ultimately translates into higher healthcare costs for these groups (Levy & Royne, 2009).

Unless patients are competent in reading and comprehending the literature given to them,

Unfortunately, poor literacy skills are seldom assessed by healthcare personnel when, for ex ample, teaching a patient about medications. Literacy problems tend to limit the patient’s ability to understand the array of instructions regarding medication labels, dosage schedul ing, adverse reactions, drug interactions, and complications (Davis et al., 2006; Elliot, 2007; Mauk, 2014; Williams et al., 2002; Wong, 2016). No wonder those who lack the required vocab ulary, organized thinking skills, and ability to formulate questions, and who also receive in adequate instruction, become confused and easily frustrated to the point of taking medica tions incorrectly or refusing to take them at all.

Thus illiteracy, functional illiteracy, and low literacy significantly affect both motivation and compliance levels. What is often mistaken for noncompliance is, instead, the simple inability to comply. Although almost half of the adult population is functionally illiterate, this statis tic is overlooked by many healthcare profes sionals as a major factor in noncompliance with prescribed regimens, followup appointments, and measures to prevent medical complications (Andrus & Roth, 2002; Doak et al., 1996; Mc Cray, 2005; Weiss, 2007; Williams et al., 2002).

A significant number of studies have cor related literacy levels with noncompliance (Brown & Bussell, 2011; Doak et al., 1998; Jin, Sklar, Min Sen Oh, & Chuen Li, 2008; Kalichman et al., 1999; Weiss, 2007). Individuals who have both poor literacy skills and inadequate lan guage skills often have difficulty following in structions and providing accurate and complete health histories, which are vital to the delivery of good health care. The burden of illiteracy leads patients into noncompliance not because they do not want to comply but rather because they are unable to do so (Hayes, 2000; Williams, Counselman, & Caggiano, 1996).

The impact of illiteracy is broader than just the inability to read; it alters the way a person organizes, interprets, analyzes, and summarizes information (Giorgianni, 1998). Caregivers of ten overestimate an individual’s ability to under stand instructions and are quick to label someone

Ethical, Financial, and Legal Concerns 277

and culturally appropriate to the patient and/or significant others. Therefore, PEMs must be writ ten in ways that are culturally relevant and assist clients in comprehending their health needs and problems to undertake selfcare regimens involving elements such as medications, diet, exercise thera pies, and use of medical equipment. Using the pa tient’s preferred language is optimal (Fisher, 1999; Health Literacy Consulting, 2015; Weiss, 2007).

Furthermore, the federally mandated Pa tient’s Bill of Rights has established the rights of patients to receive complete and current infor mation regarding their diagnoses, treatments, and prognoses in terms they can understand (Duffy & Snyder, 1999). It is imperative that the reading levels of PEMs match the patients’ read ing abilities and vice versa. Compounding the need for appropriately written materials is the fact that people forget almost immediately at least half of any instruction they receive orally (Parnell, 2014). Failure to retain information combined with inappropriate reading levels of materials used to reinforce or supplement ver bal teaching methods decreases compliance, increases morbidity, and results in misuse of healthcare facilities (Weiss et al., 2005).

Encouraging selfcare through client edu cation for purposes of health promotion, disease prevention, health maintenance, and rehabilita tion is not a new concept to either consumers or providers of health care. However, the trends in the current healthcare system in the United States have hindered the professional ability of nurses to provide needed information to ensure selfcare that is both safe and effective. Patient education has assumed an even more vital role in assisting clients to independently manage their own healthcare needs given the following factors:

■ Early discharge ■ Decreased reimbursement for direct care ■ Increased emphasis on delivery of care in

the community and home setting ■ Greater demands on nursing personnel in

all settings ■ Increased technological complexity of

treatment

these instructional tools are useless as adjuncts for health education. They are neither a cost effective nor a timeefficient means for teach ing and learning. Materials that are widely dis tributed, but little or not at all understood, pose not only a health hazard for clients but also an ethical, financial, and legal liability for health care providers (Ad Hoc Committee on Health Literacy, 1999; Agarwal, Shah, Stone, Ricks, & Friedlander, 2015; Gazmararian, Curran, Parker, Bernhardt, & DeBuono, 2005; Giorgianni, 1998; Ryhanen, Johansson, Salo, Salantera, & Leino Kilpi, 2008; Schultz, 2002; Vallance, Taylor, & LaVallee, 2008).

Materials that are too difficult to read or comprehend serve little purpose. Health educa tion cannot be considered to have taken place if the written information that has been distrib uted to clients does not enhance their knowl edge and requisite skills necessary for selfcare. Ultimately, indiscriminate or nonselective use of PEMs can result in complete or partial lack of communication between healthcare providers and consumers (Andrus & Roth, 2002; Fisher, 1999; Villaire & Mayer, 2007; Weiss, 2007, 2014; Winslow, 2001).

Initial standards for health education were put forth in 1993 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)—now known as The Joint Commis sion. Many of their current standards address health literacy as a component and require that patients and families receive information neces sary for their care in a language and form that is best for their learning. Healthcare providers also need to ensure that patients and families understand the information provided (Health Literacy Consulting, 2015).

Emphasis on such standards has prompted healthcare agencies and providers to reexam ine their teaching practices, educational mate rials, and systems of documenting evidence of teaching interventions to better match the read ing levels and cultural diversity of the clients be ing served. Current Joint Commission standards further specify that education relevant to a per son’s healthcare needs must be understandable

278 Chapter 7 Literacy in the Adult Client Population

liability when information is written at a level incomprehensible to many patients (Weiss, 2007, 2014). A properly informed consumer is not only a legal concern in health care to day but an ethical one as well.

▸ Readability of Printed Education Materials

Many studies on literacy have attempted to doc ument the disparity between the reading lev els of consumers and the estimated readability demand of printed health information. Given that the health of people depends in part on their ability to understand information con tained in food labeling, overthecounter and prescription medication instructions, en vironmental safety warnings, discharge in structions, health promotion and disease prevention flyers, and the like, the focus of attention on identifying this discrepancy is more than warranted.

A substantial body of evidence in the lit erature indicates that a significant gap exists between patients’ reading and comprehen sion levels and the level of reading difficulty of PEMs (Agarwal et al., 2015; Andrus & Roth, 2002; Eltorai, Ghanian, Adams, Born, & Dan iels, 2014; McClure et al., 2016; Ryan et al., 2014; Vallance et al., 2008; Weiss, 2007; Wilson, 2009; Winslow, 2001). A variety of education materials available from sources such as the government, health agencies, professional associations, health insurance companies, and industries are writ ten beyond the reading ability of many clients.

Healthcare providers are beginning to rec ognize that the reams of written materials many of them rely on to convey health information to consumers are essentially closed to those with illiteracy and low literacy problems. For exam ple, look at the following text on information about colonoscopy:

Your naicisyhp has dednemmocer that you have a ypocsonoloc. A ypocsonoloc is a test for noloc recnac. It sevlovni

■ Assumption by caregivers that printed infor mation is an adequate substitute for direct instruction of patients

These constraints do not allow sufficient opportunities for patients in the home or var ious healthcare settings to receive the neces sary education they need for selfmanagement. Most outpatient care, such as that given in clin ics, physician and other health professional of fices, and sameday surgery centers, requires patients and their families to understand both written and oral instruction (Weiss et al., 2005). Consequently, professional nurses are rely ing more than ever before on PEMs to sup plement their teaching (Horner et al., 2000; Vanderhoff, 2005).

Thus, the burden of becoming adequately educated falls on the shoulders of patients, their families, and significant others. Often un prepared because of shortened hospital stays or limited contact with healthcare providers, con sumers are being asked to assume a greater role in their own recovery and the maximization of their health potential (Parnell, 2014; Weiss, 2003).

It is only recently that research on written health education materials in relation to clients’ literacy skills has examined and attempted to answer even the most basic questions, such as the following:

■ Do consumers read the health education literature provided to them?

■ Are they capable of reading it? ■ Can they comprehend what they read? ■ Are written materials appropriate and suf

ficient for the intended target audience?

In this increasingly litigious and ethically conscious society, growing attention is being paid by health professionals to informed con sent and teaching for selfcare via both verbal and written healthcare instruction (Gazmarar ian et al., 2005). The potential for misinterpre tation of instructions not only can adversely affect treatment but also raises serious con cerns about the ethical and legal implications with respect to professional responsibility and

Readability of Printed Education Materials 279

■ Physicians’ letters to their patients required an average of 16th to 17thgrade reading ability; likewise, health articles in newspa pers ranged from 12th to 14thgrade level (Conlin & Schumann, 2002).

■ The reading grade levels of 15 psychotropic medication handouts for patient education ranged from 12th to 14th grade, well above the 5thgrade level recommended by the National Cancer Institute guidelines (Myers & ShepardWhite, 2004).

■ Sixteen different patient education mate rials publically available on the American Association for Surgery of Trauma website were evaluated for readability. Researchers found the reading level of available materials ranged from grades 9.1 to 12.7, well over the recommended reading grade level for those with low literacy (Eltorai et al., 2014).

■ An evaluation of 13 publicly available patient education materials for sickle cell disease fell between the 8th and 12thgrade reading level, which is above the ability of the target audience (McClure et al., 2016).

As these examples demonstrate, numerous investigators have discovered that PEMs used to disseminate health information are written at grade levels that far exceed the reading ability of the majority of consumers. Results from these studies reveal that most health education litera ture is written above the 8thgrade level, with the average level falling between the 10th and 12th grades. Many PEMs exceed this upper range, even though the average reading level of adults falls at the eighthgrade level. Millions of peo ple in the population read at considerably lower levels and need materials written at the fifth grade level or lower (Brega et al., 2015; Brownson, 1998; Doak et al., 1998; ProLiteracy, 2017).

Furthermore, the health education literature indicates that people typically read at least two grade levels below their highest level of school ing and prefer materials that are written below their literacy abilities. In fact, contrary to pop ular belief, sophisticated readers find simplified

gnitresni a elbixelf gniweiv epocs into your mutcer. You must drink a laiceps diuqil the thgin erofeb the noitanimaxe to naelc out your noloc.

Does this passage make sense, or are you con fused? If the words appear unreadable, that is what written teaching instructions may look like to someone who cannot read (Weiss, 2003).

Many researchers have assessed specific population groups in a variety of healthcare set tings based on the ability of clients to meet the literacy demands of written materials related to their care. These investigators used commonly accepted readability formulas to test consumers’ understanding of printed health infor mation. Their findings revealed the following information:

■ Emergency department instructional mate rials (average 10thgrade readability) are written at a level of difficulty out of the readable range for most patients (Duffy & Snyder, 1999; Ginde, Weiner, Pallin, & Camargo, 2008; Lerner, Jehle, Janicke, & Moscati, 2000; McCarthy et al., 2012; Williams et al., 1996).

■ A significant mismatch exists between the reading ability of older adults and the readability levels of documents essential to their gaining access to healthrelated services offered through local, state, and federal government programs (McGee, 2010; Sudore & Schillinger, 2009; Winslow, 2001).

■ A large discrepancy exists between clients’ average reading comprehension levels and the readability demand of PEMs used in ambulatory care and home care settings (Ache, 2009; Lerner et al., 2000; Schillinger et al., 2002; Walfish & Ducey, 2007).

■ Standard consent forms used in hospitals, private physician offices, and clinics, as well as by institutional review boards (IRBs) to protect potential research subjects, require high school–to collegelevel reading com prehension (Doak et al., 1998; Muir & Lee, 2009; PaascheOrlow, Taylor, & Brancati, 2003; Sudore, Landefeld et al., 2006).

280 Chapter 7 Literacy in the Adult Client Population

and other healthcare practitioners are respon sible for ensuring the appropriate literacy level of the materials given to their clients.

If the literacy level of education materials matches the readers’ literacy skills, consum ers may be better able to understand and com ply with healthcare regimens, thereby reducing the costs of care and improving their quality of life (Ad Hoc Committee on Health Literacy, 1999; Weiss, 2014). Because nurses rely heavily on PEMs to convey necessary information to their clients, the usefulness and efficacy of these materials must be determined in relation to the readers’ abilities to decipher information.

To objectively evaluate the difficulty of writ ten materials, two basic measurement methods exist: formulas and tests. Various formulas mea sure readability of PEMs and are based on as certaining the average length of sentences and words (vocabulary difficulty) to determine the grade level at which they are written. Standard ized tests, which measure actual comprehension and reading skills, involve readers’ responses to instructional materials or the ability to decode and pronounce words to determine their grade level (see Appendix A).

Both methods, although not ideal, are con sidered to have a sufficient relationship to liter acy ability to justify their use. The most widely used readability formulas and standardized tests for comprehension and reading skill rate high on reliability and predictive validity. They also do not require elaborate training to use, al though they do vary in the amount of time re quired to administer them. In addition, the

PEMs acceptable and prefer them when ill be cause of low energy and concentration levels, and even when well because of the demands of their busy schedules and the fact that even highly educated people do not know the vo cabulary of medicine, known as medicalese (Giorgianni, 1998; Meppelink, Smit, Buurman, & van Weert, 2015; Winslow, 2001).

The conclusion to be drawn is that com plex and lengthy PEMs serve no useful teach ing purpose if healthcare consumers are unable to understand them or unwilling to read them. Literacy levels of clients compared with liter acy demands of PEMs, whether in hospital or communitybased settings, are an important factor in the rehabilitation and recidivism of those who are recipients of healthcare services.

The Internet is an excellent resource for nurse educators to locate easytoread PEMs. BOX 7-3 identifies sources of lowliteracy edu cation materials.

▸ Measurement Tools to Test Literacy Levels

Healthcare professionals continually strug gle with the task of effectively communicat ing highly complex and technical information to their consumers, who often lack sufficient background knowledge to understand the so phisticated content of instruction relevant to their care. Whether they author or merely dis tribute printed education information, nurses

BOX 7-3 Sources of Low-Literacy Materials for Clients

■ American College of Physicians Foundation (website includes a variety of free patient education videos and print materials): https://store.acponline.org/ebizatpro/ProductsServices

■ Executive Secretariat: The Plain Language Initiative: http://execsec.od.nih.gov/plainlang /guidelines/index.html

■ National Institute of Health: Clear Communication: https://www.nih.gov/institutes-nih/nih-office -director/office-communications-public-liaison/clear-communication

■ National Patient Safety Foundation: Ask Me 3: http://www.npsf.org/?page=askme3

Measurement Tools to Test Literacy Levels 281

As assessment tools, readability formulas are useful but must be employed with caution because the match between reader and material does not necessarily guarantee comprehension (Aldridge, 2004; Davis et al., 1998). Readabil ity formulas originally were designed as pre dictive averages to rank the difficulty of books used in specific grades of school—not to de termine exactly which factors contribute to the difficulty of a text. Educators should exercise caution when assuming that people can or can not read instructional material simply because a formulabased readability score does or does not match their educational level.

Even though these simple instruments are practical tools for assessment of literacy, their utility is limited because they cannot determine the cause or type of reading and learning prob lems (Davis et al., 1998). Therefore, although readability formulas are easily applied and have proved useful in determining the reading grade level of a text, when used alone they are not an adequate index of readability (Badarudeen & Sabharwal, 2010; Davis et al., 1998; Doak et al., 1996; Doak & Doak, 2010).

Readability formulas are merely one use ful step in determining reading ease relative to a specific document. Many researchers suggest using a multimethod approach to ascertain readability—that is, they suggest applying more than one readability formula to any given piece of written material as well as taking into con sideration the reader and other material vari ables (Doak et al., 1996; Ley & Florio, 1996). Formula scores are simply rough approxima tions of text difficulty. Human judgment is al ways needed in conjunction with formulabased estimates to determine the quality of PEMs.

Readability formulas are mathematical equations derived from multiple regression analyses that measure the readability levels of PEMs by determining the correlation between an author’s style of writing and a reader’s abil ity to identify words as printed symbols within a context (Doak et al., 1996). Most of them pro vide quite accurate gradelevel estimates, give or take one grade level, with 68% confidence on

advent of computerized readability analysis (nearly all wordprocessing programs, such as Microsoft Word, will produce readability sta tistics as a standard feature) has made evaluat ing the reading grade level of written materials much easier and quicker. These methods are most useful to nurse educators for designing and evaluating PEMs.

▸ Formulas to Measure Readability of Printed Education Materials

Readability is not a new concept but rather has been a concern of primary and second ary school educators and educational psychol ogists for years. In the 1940s, there was a great upswing in attempts by educators and reading specialists to develop systematic procedures by which to objectively evaluate reading materi als. Readability is defined as “characteristics of reading materials that make material ‘easy’ or ‘difficult’ to read” (Kahn & Pannbacker, 2000, p. 3). Today, more than 40 formulas are avail able to measure the readability levels of PEMs.

Readability indices have been devised to determine the gradelevel demand of specific written information. Although they can predict a level of reading difficulty of material based on an analysis of sentence structure and word length, they do not account for the inherent individual variables that affect the reader, such as interest in or familiarity with the subject itself or the ac tual content of the materials (Doak et al., 1996).

Even though materials may have similar read ability levels as measured by some formula, not all readers will have equal competence in read ing them. For example, a patient with a long standing chronic illness may already be famil iar with vocabulary related to the disease and, therefore, may be able to read specific gradelevel materials much more easily than a newly diag nosed patient, even though both individuals may have equal literacy skill with other types of material (Doak et al., 1985).

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Fog Index The Fog formula developed by Gunning (1968) is appropriate for use in determining the read ability of materials from grade 4 to college level. It is calculated based on average sentence length and the percentage of multisyllabic words in a 100word passage. The Fog index is considered one of the simpler methods because it is based on a short sample of words (100), it does not require counting syllables of all words, and the rules are easy to follow (Spadero, 1983; Spadero et al., 1980). Appendix A includes details about using the formula.

Fry Readability Graph—Extended The contribution made by the Fry formula derives from the simplicity of its use without sacrificing accuracy, as well as its wide and con tinuous range of testing readability of materials (especially books, pamphlets, and brochures), which spans grade 1 through college (grade 17). This formula is well accepted by literature and reading specialists and is not copyrighted (Doak et al., 1996). A series of simple rules can be applied to plot on a graph two language elements—the number of syllables and the num ber of sentences in three 100word selections (Fry, 1968, 1977; Spadero et al., 1980). If a very long text is being analyzed, such as a book containing 50 or more pages, one should use six 100word samples rather than three such samples (Doak et al., 1996). With some practice, this formula takes only about 10 minutes to determine the readability level of a document. See Appendix A for specific directions on using the formula and Figure A1 for the Fry readability graph.

SMOG Formula The SMOG formula developed by McLaughlin (1969) is recommended not only because it of fers relatively easy computation (simple and fast) but also because it is one of the most valid tests of readability (Wang et al., 2013). The SMOG

average. In many respects, a readability formula is like a reading test, except that it does not test people but rather written material (Fry, 1977).

The first guideline to remember is that read ability formulas should not be the only tool used for assessing PEMs. The second rule is to select readability formulas that have been validated in the reader population for whom the PEM is in tended. Several formulas are geared to specific types of materials or population groups (Wang, Miller, Schmitt, & Wen, 2013).

Ley and Florio (1996) and Meade and Smith (1991) conducted extensive studies of the most commonly used formulas and reported on their reliability and validity when used to measure healthrelated information. Particularly, the Flesch, Fog, and Fry formulas showed strong correlations with healthbased literature (Horner et al., 2000). Further, the Flesch, Fog, and Simplified Mea sure of Gobbledygook (SMOG) formulas have proved successful in evaluating Internetbased educational materials (Antonarakis & Kiliaridis, 2009; LaplanteLèvesque, Brännström, Anders son, & Lunner, 2012). Because so many read ability formulas are available for assessment of reading levels of PEMs, only those that are rel atively simple to work with, are accepted as re liable and valid, and are in widespread use have been chosen for review here.

Flesch–Kincaid Scale The Flesch–Kincaid formula was developed as an objective measurement of readability of ma terials between grade 5 and college level. Its use has been validated repeatedly over more than 50 years for assessing news reports, adult edu cation materials, and government publications. The Flesch formula is based on a count of two basic language elements: average sentence length (in words) of selected samples and average word length (measured as syllables per 100 words of sample). The reading ease (RE) score is calcu lated by combining these two variables (Flesch, 1948; Spadero, 1983; Spadero, Robinson, & Smith, 1980). See Appendix A for formula details and Table A1 to determine reading ease scores.

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software packages can automatically calculate reading levels as well as provide advice on how to simplify text (Aldridge, 2004; Doak et al., 1996). To read about two powerful readability software applications, Readability Calculations and Readability Plus, that are compatible for Windows or Macintosh and are used widely by universities, corporations, hospitals and individ uals to name a few, see http://www.readability formulas.com and see https://readable.io/ to quickly analyze and compare the readability of many types of documents.

Computerized assessment of readability is fast and easy, and it provides a high degree of reliability, especially when several formulas are used. Determining readability by computer programs rather than doing so manually is also more accurate in calculating reading levels be cause it eliminates human error in scoring and because entire articles, pamphlets, or books can be scanned (Duffy & Snyder, 1999; Mailloux, Johnson, Fisher, & Pettibone, 1995). It is advis able to take an average across several pieces of literature, using several different formulas and software programs, when calculating estimates of readability. Unlike other readability software tools, the relatively new Coleman–Liau Readabil ity Formula (also known as the Coleman–Liau Index) is a readability assessment tool that counts the number of characters (letters) instead of sylla bles per word. See http://www.readabilityformulas .com/colemanliaureadabilityformula.php.

▸ Tests to Measure Comprehension of Printed Education Materials

Standardized tests have proved reliable and valid in measuring reader’s comprehension lev els (Doak et al., 1996; Klapwijk, 2013). Usually pretests and posttests used in institutional set tings measure recall of knowledge rather than comprehension. However, the determination of

formula measures readability of PEMs from grade 4 to college level based on the number of polysyllabic words within a set number of sen tences (Doak et al., 1985). It evaluates the read ability grade level of PEMs to within 1.5 grades of accuracy (Myers & ShepardWhite, 2004). Thus, when using the SMOG formula to calcu late the grade level of material, the SMOG re sults are usually about two grades higher than the grade levels calculated by the other meth ods (Spadero, 1983).

The SMOG formula has been used exten sively to judge gradelevel readability of patient education materials. It is one of the most popu lar measurement tools because of its reputation for readinglevel accuracy, its simple directions, and its speed of use, which is a particularly im portant factor if computerized resources for anal ysis of test samples are not available (Meade & Smith, 1991; Wang et al., 2013). See Appendix A, Tables A2 and A3, and Figure A2 for fur ther information on using the SMOG formula.

In summary, Doak et al. (1985) state that it is critically important to determine the read ability of all written materials at the time they are drafted or adopted by using one or more of the many available formulas. These authors contend that you cannot afford to “fly blind” by using health materials that are untested for read ability difficulty. Pretesting PEMs before distri bution enables the nurse to be sure they fit the literacy level of the audience for which they are intended. It is imperative that the formulas used to measure gradelevel readability of PEMs are appropriate for the type of material being tested.

Computerized Readability Software Programs Computerized programs have greatly facilitated the use of readability formulas. Some software programs apply multiple formulas to analyze one text selection. In addition, some packages can identify difficult words in written passages that may not be understood by patients. Doz ens of userfriendly, menudriven commercial

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of a text. The reader is asked to fill in the blanks with the exact word replacements. One point is scored for every missing word guessed correctly by the reader. The final cloze score is the total number of blanks filled in correctly by the reader.

To be successful, the reader must demon strate sensitivity to clues related to grammar, syntax, and semantics. If the reader fills in the blanks with appropriate words, this process is an indication of how well the material has been comprehended—that is, how much knowledge was obtained from the set surrounding the blank spaces and how well the information was used to supply the additional information (Dale & Chall, 1978; Doak et al., 1996). The underlying theory is that the more readable a passage is, the better it will be understood even when words are omitted. The resulting score can be converted to a percentage for ease in interpreting and analyz ing the data (Pichert & Elam, 1985). Appendix A and Figure A3 provide details on constructing, administering, and scoring a Cloze test.

Listening Test Unlike the cloze test, which may be too diffi cult for clients who read below the sixthgrade level—that is, for those persons who likely lack fluency and read with hesitancy—the listening test is a good approach to determining what a low literate person understands and remembers when listening to oral instruction (Doak et al., 1996). Although it may take several hours to develop this test, it takes only 10 to 20 minutes to administer.

The procedure for administering the listening test is to select a passage from instructional mate rials that takes about 3 minutes to read aloud and is written at approximately the fifthgrade level. Formulate 5 to 10 short questions relevant to the content of the passage by selecting key points of the text. Read the passage to the person at a normal rate. Ask the listener the questions orally and record the answers (Doak et al., 1996).

To determine the percentage score, divide the number of questions answered correctly by the total number of questions. The instruc tional material will be appropriate for the client’s

readers’ abilities to understand information is es sential. Health education materials must serve a useful purpose, from the standpoint of assisting patients to assume selfcare as well as for protect ing the health professional from legal liability.

Comprehension implies that the reader has internalized the information found in PEMs (Aldridge, 2004). The two most popular stan dardized methods to measure comprehension of written materials are the cloze test and the listening test. These tests can be used to assess how much someone understands from reading or listening to a passage of text.

Cloze Procedure The cloze test, derived from the term closure based on Gestalt psychology (McKamey, 2006), has been specifically recommended for assess ing understanding of health education literature. Although it takes more time and resources to perform than do readability formulas, the cloze procedure has been validated for its adequacy in ranking reading difficulty of medical literature, which typically has a high concept load. This procedure is not a formula that provides a school gradetype level of readability like the formulas already described but rather is an assessment that takes into consideration the context of a written passage (Doak et al., 1996; Klapwijk, 2013).

The cloze test can be administered to indi vidual clients who demonstrate difficulty com prehending health materials used for instruction. Nevertheless, it is suggested that this test not be administered to every patient in a health setting but rather to a representative sample of consum ers. The cloze test should be used only with those individuals whose reading skills are at sixth grade or higher (approximately Level 1 on the NALS scale); otherwise, it is likely that the test will prove too difficult (Doak et al., 1996).

The cloze test is best used when reviewing the appropriateness of several texts of the same content for a certain audience. The reader may or may not be familiar with the material being tested. This procedure is designed so that every fifth word is systematically deleted from a portion

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Although it is limited to measuring only word recognition and does not test other as pects of reading such as vocabulary and compre hension of text material, this test is nevertheless useful for determining an appropriate level of instruction and for establishing a client’s level of literacy. It is based on the belief that read ing skill is associated with the ability to look at written words and put them into oral language, a necessary first step in comprehension (Doak et al., 1996).

As designed, the WRAT should be used only to test people whose native language is English. It tests on two levels: Level I is designed for test ing children 5 to 12 years of age, and Level II is intended for testing persons older than age 12. The WRAT scores are normed on age but can be converted to grade levels.

The WRAT consists of a graduated list of 42 words. Starting with the easiest and ending with the most difficult, the person taking the test is asked to pronounce the words from the list, starting from the top, where the easier words are located. The individual administering the test listens carefully to the patient’s responses and scores those responses on a master score sheet. Next to those words that are mispronounced, a checkmark should be placed. When five words are mispronounced, indicating that the patient has reached his or her limit, the test is stopped.

To score the test, the number of words missed or not tried is subtracted from the total list of words on the master score sheet to get a raw score. A table of raw scores is then used to find the equivalent grade rating (GR). For more information on this test, see Doak et al. (1996), Davis et al. (1998), and Quirk (2000). Now in its fourth edition, the WRAT4 is the latest version of the original instrument developed in 1946 (Wilkinson & Robertson, 2000).

REALM (Rapid Estimate of Adult Literacy in Medicine) The REALM test has advantages over the WRAT and other word tests because it measures a patient’s

comprehension level if the score is in the range of 75% to 89% (some additional assistance when teaching the material may be necessary for full comprehension). A score of 90% or higher indi cates that the material is easy for the client and can be fully comprehended independently. A score of less than 75% means that the material is too difficult and simpler instructional mate rial will need to be used when teaching the in dividual. Doak et al. (1996) provide an example of a sample passage and questions for a listen ing comprehension test.

▸ Tests to Measure General Reading Skills and Health Literacy Skills of Clients

The four most popular standardized methods to measure reading and health literacy skills are the Wide Range Achievement Test (WRAT), the Rapid Estimate of Adult Literacy in Med icine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS). In addition, the eHealth Lit eracy Scale (eHEALS) assesses client comfort in using the Internet and technology to obtain health information. The Literacy Assessment for Diabetes (LAD) is an instrument specific to patients with diabetes. The Suitability Assess ment of Materials (SAM) assesses how well in structional materials are presented to clients.

WRAT (Wide Range Achievement Test) The WRAT is a word recognition screening test. It is used to assess a learner’s ability to recog nize and pronounce a list of words out of con text as a criterion for measuring reading skills. Other word recognition tests are available, but the WRAT requires the least time to administer (approximately 5 minutes as compared with 30 minutes or more for the other tests).

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correlates very strongly with the original REALM instrument in assessing patient literacy in di verse settings (Arozullah et al., 2007).

TOFHLA (Test of Functional Health Literacy in Adults) The TOFHLA was developed in the mid 1990s for measuring patients’ health literacy skills using actual hospital materials, such as prescription labels, appointment slips, and in formed consent documents. The test consists of two parts: reading comprehension and nu meracy. It has demonstrated reliability and va lidity, requires approximately 20 minutes to administer, and is available in a Spanish version (TOFHLAS) as well as an English version (Parker, Baker, Williams, & Nurss, 1995; Quirk, 2000; Williams et al., 1995). An abbre viated version, known as the STOFHLA, was developed in 1999; it takes only 12 minutes to administer. Not only has this short version been tested for reliability and validity, but it is a more practical measure of functional health literacy to determine who needs assistance with achiev ing learning goals (Baker et al., 1999; Garcia, Espinoza, Lichtenstein, & Hazuda, 2013). The TOFHLA instrument and directions can be accessed at http://www.peppercornbooks.com /catalog/information.php?info_id=5.

Readability formulas and standardized tests for comprehension and reading skills were never designed to serve as writing guides. Pa tient educators may be tempted to write PEMs to fit the formulas and tests, but they should be aware that doing so places emphasis on struc ture, not content, and that comprehensibility of a written message may be greatly compro mised. Pichert and Elam (1985) recommend that readability formulas should be used solely to judge material written without formulas in mind. Formulas are merely methods to check readability, and standardized tests are merely methods to check comprehension and word rec ognition. Neither method guarantees good style in the form of direct, conversational writing.

ability to read medical and healthrelated vocab ulary, it takes less time to administer, the scor ing is simpler, and the test is well received by most clients (Davis et al., 1998; Duffy & Sny der, 1999; Foltz & Sullivan, 1998). This instru ment has been field tested on large populations in public health and primary care settings (Da vis et al., 1993). Although it has established va lidity, REALM offers less precision than other word tests (Hayes, 2000). The raw score is con verted to a range of grade levels rather than an exact grade level, but this result correlates well with the WRAT reading scores.

The procedure for administering the test is to ask patients to read aloud words from three word lists. Sixtysix medical and healthrelated words are arranged in three columns of 22 words each, beginning with short, easy words such as fat, flu, pill, and dose, and ending with more dif ficult words such as anemia, obesity, osteoporo- sis, and impetigo. Clients are asked to begin at the top of the first column and read down, pro nouncing all the words that they can from the three lists. If they come upon a word they can not pronounce, they are told to skip it and pro ceed to the next word. There is no time limit. The examiner keeps score on a separate copy of the list and places a plus sign next to words correctly pronounced and a minus next to those mispronounced or skipped (Davis et al., 1993). The total number of words pronounced cor rectly is the client’s raw score, which is con verted to a grade ranging from third grade and below (score of 0–18) to ninth grade and above (score of 61–66). Those persons whose scores fall at sixth grade or below have literacy skills equivalent to NALS Levels 1 and 2 (Schultz, 2002; Weiss, 2003).

The relatively new REALMR, a revised shorter version (8item) of the original instru ment of 66 items, is designed to rapidly screen patients at risk for low literacy in a clinical set ting. Studies have shown it to be a reliable and valid tool, as well as a practical one, for assess ment of literacy. The delivery time is less than 2 minutes (Bass, Wilson, & Griffith, 2003). The REALMSF, a short form version at seven items,

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but also the technology used to deliver that mes sage. This scale offers a way to assess whether a client would be a good candidate to engage in eHealth materials (Collins et al., 2012). Psy chometric testing has demonstrated reliability of the tool in adolescents, college students, and middle/older age adults (Chung & Nahm, 2015; Nguyen et al., 2016; Norman & Skinner, 2006b). See Exhibit A2 in Appendix A for the scale.

LAD (Literacy Assessment for Diabetes) The LAD was specifically developed in 2001 to measure word recognition in adult patients with diabetes. This reading skills test, compared with WRAT3 (third version) and REALM, was found to have strong reliability and validity (Nath et al., 2001). It consists of three word lists presented in ascending order of difficulty. Many terms are at the 4thgrade reading level, but the remaining words range from 6th through 16thgrade lev els. The LAD can be administered in 3 minutes or less. It was tested on a group of 200 people at a primary care clinic, a senior center, and three prisons. The subjects ranged in age from 20 to 85 years (mean age = 43.5). This standardized test was modeled after REALM but emphasizes common words used when teaching selfcare management of diabetes. The LAD instrument is copyrighted but is available with permission from Charlotte Nath (nathcharlotte@gmail. com) at https://healthliteracy.bu.edu/76/104/122 /mobile/documents/lad.

SAM (Instrument for Suitability Assessment of Materials) In addition to using formulas and tests to mea sure readability, comprehension, and reading skills, Doak et al. (1996), in conjunction with the Johns Hopkins School of Medicine, de signed a tool to rapidly and systematically as sess the suitability of instructional materials for a given population of learners. Ideally, instruc tional tools should be evaluated with a sample of the intended audience, but limited time and

NVS (Newest Vital Sign) The Newest Vital Sign is a tool developed to identify those at risk for low health literacy. It is easy and inexpensive to administer, taking as lit tle as 3 minutes from start to finish ( Johnson & Weiss, 2008; Shah, West, Bremmeyr, & Savoy Moore, 2010; Welch, VanGeest, & Caskey, 2011). Patients are asked to look at an ice cream label and answer questions in relation to the label, which also allows an assessment of numeracy (Collins et al., 2012; Kennard, 2016; Weiss, 2007). Each correct answer gives them one point. Pa tients are placed into one of three categories related to their literacy level: 1–2, likelihood of limited literacy; 3–4, possibility of limited lit eracy; and 5–6, adequate literacy (Johnson & Weiss, 2008). The NVS, which was developed by Weiss and colleagues (2005) with support from the Pfizer Clear Health Communication Initia tive, is available in both English and Spanish versions. It is suggested that the tool be admin istered while the nurse is obtaining vital signs. Early psychometric evaluation shows the NVS is comparable to other available health literacy tests such as REALM and STOFHLA and is rec ommended for use in the primary care environ ment (McCune et al., 2016; Patel et al., 2011). More information on this tool can be found free of charge on the Internet at http://www .pfizer.com/health/literacy. See Appendix A and Exhibit A1A and A1B for more information about administering and scoring the NVS.

eHEALS (eHealth Literacy Scale) The eHealth Literacy Scale, which was designed by Norman and Skinner (2006b), is one of only a few tools available to determine a patient’s ability to find and navigate electronic health information. It consists of eight items that col lectively measure patients’ comfort level and per ceived ability to address their health problems by finding and using electronic health informa tion. Questions center on the client’s use of the Internet in relation to locating health informa tion. Challenges to using electronic health in formation include not just the health message,

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demand, which can be measured by readabil ity formulas, but also on those elements within a text such as technical format, concept density, and accuracy and clarity of the message. It must never be forgotten that knowing the target audi ence in terms of the members’ level of motivation, reading abilities, experiential factors, and cultural background is also of crucial importance in de termining the appropriateness of printed health information as an effective communication tool (Meade & Smith, 1991; Weiss, 2007). Even good readers may fail to respond to important health education literature if they lack the motivation to do so or if the material is not appealing to them.

Despite the welldocumented potential of written materials to increase knowledge, com pliance, and satisfaction with care, PEMs are often too difficult for even motivated clients to read. Clearly, the technical nature of health ed ucation literature lends itself to high readability levels, often requiring collegelevel reading skills to fully comprehend (Winslow, 2001).

Even though printed materials are the most commonly used form of media, as currently writ ten, they remain the least effective means for reaching a large proportion of the adult popu lation who have marginal literacy skills (Mon sivais & Reynolds, 2003; Ryan et al., 2014). Despite the welldocumented potential of writ ten materials to increase knowledge, compliance, and satisfaction with care, PEMs often are too difficult for even motivated patients to read.

Agarwal, Hansberry, Sabourin, Tomei, and Prestigiacomo (2013) studied online patient education materials from 16 specialties. Read ability assessments found all materials to be well over the sixthgrade reading level. Stossel, Segar, Gliatto, Fallar, and Karani (2012) assessed 300 PEMs available to the public on the Inter net and accessible to providers by a popular elec tronic medical record (EMR) vendor and found most of PEMs to be at reading levels much higher than the reading ability of the average American adult reader. What the nurse in the role of edu cator must strive to achieve when designing or selecting healthbased literature is a good and proper fit between the material and the reader.

resources may preclude such an approach. In re sponse to this dilemma, these literacy experts de veloped the Suitability Assessment of Materials instrument. Not only can the SAM tool be used with print material and illustrations, but it also has been applied to videotaped and audiotaped instructions. Although not designed to specif ically measure health literacy or evaluate only healthrelated materials, it can be a very useful tool in determining the effectiveness of instruc tional materials for diverse patient populations in the healthcare arena (Helitzer, Hollis, Cot ner, & Oestreicher, 2009; Lee, Kang, Kim, Woo, & Kim, 2011; Rhee, Von Feldt, Schumacher, & Merkel, 2013; Vallance et al., 2008; Weintraub, Maliski, Fink, Choe, & Litwin, 2004).

The SAM instrument yields a numerical (percentage) score, with materials tested falling into one of three categories: superior (70–100%), adequate (40–69%), or not suitable (0–39%). The application of this tool can identify spe cific deficiencies in instructional materials that reduce their suitability. The SAM instrument includes 22 factors to assess the content, liter acy demand, graphics, layout and typography, learning stimulation and motivation, and cul tural appropriateness of instructional materi als being developed or already in use (Doak & Doak, 2010). The maximum score possible is 44 points (equals 100%). If one or more SAM factors do not apply to the material being tested, the test administrator should subtract two points each for every not applicable factor. For example, if the material tests at 36 but two fac tors did not apply, the maximum possible score would be 40; in this case, the score would be 36/40 = 90% (Doak et al., 1996). See Exhibit A3 in Appendix A for the SAM scoring sheet.

▸ Simplifying the Readability of Printed Education Materials

The suitability of written materials for different audiences depends not only on actual gradelevel

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the behavioral objectives. Limit or cut out altogether extraneous and nicetoknow information such as the history or detailed physiological processes of a disease. Include only survival skills and essential main ideas of who, what, where, and when, with new information related to what the reader already knows. Remember: A person does not have to know how an engine works to drive a car.

3. Select other media to supplement the written information, such as pictures, demonstrations, models, audiotapes (CDs), and videotapes (DVDs). Even poor readers will benefit from written material if it is combined with other forms of delivering a message. Consider the field of advertising, for exam ple. Advertisers get their message across with relatively few words that are often combined with strong, actionpacked visuals.

4. Organize topics into chunks that follow a logical sequence. Priori tize to present the most important information first. If topics are of equal importance, proceed from the more general as a basis on which to build to the more specific. Begin with a statement of purpose. In a list of items, place key facts at the top and bottom because readers best remember information presented first and last in a series.

5. Determine the preferred reading level of the material. If the readers have been tested, preferably write two to four grades below their reading gradelevel score. If the audience has not been tested, the group is likely to display a wide range of reading skills. When in doubt, write instructional materials at the 5thgrade level, which is the lowest common denominator, keeping in mind that the average

Choosing and designing PEMs is a difficult, time consuming, and challenging task that often becomes the responsibility of the nurse (Winslow, 2001).

Obviously the best solution for improving the overall comprehension and reading skills of clients would be to strengthen their basic gen eral education, but this process would require decades to accomplish. What is needed now are ways in which to write or rewrite educa tional materials commensurate with the current comprehension and reading skills of learners. Nathaniel Hawthorne was once reported to have said, “Easy reading is damned hard writing” (Pichert & Elam, 1985, p. 181). He was correct in his perception that clear and concise writing is a task that takes effort and practice.

It is possible, though, to reduce the disparity between the literacy demand of written instruc tional materials and the actual reading level of clients by attending to some basic linguistic, mo tivational, organizational, and content principles (Williams, Muir, & Rosdahl, 2016). Linguistics refers to the type of language and grammatical style used. Motivation principles focus on those elements that stimulate the reader, such as rele vance and appeal of the material. Organizational factors deal with layout and clarity. Content prin- ciples relate to load and concept density of in formation (Bernier, 1993). Wood, Kettinger, and Lessick (2007) describe the language, informa tion, and design (LID) method to create easy toread materials. These elements are examined as they relate to designing or revising instruc tional materials for the marginally literate reader.

Prior to writing or rewriting a text for easier reading, some preliminary planning steps need to be taken to ensure that the final written ma terial will be geared to the target audience (Da vis et al., 1998; Doak et al., 1996; Kessels, 2003):

1. Decide what the client should do or know. In other words, what is the purpose of the instruction? Which outcomes do you hope learners will achieve?

2. Choose information that is relevant and needed by the client to achieve

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The literature contains numerous references related to techniques for writing effective educa tional materials (Aldridge, 2004; Andrus & Roth, 2002; Doak et al., 1996; Doak et al., 1998; Doak & Doak, 2010; Duffy & Snyder, 1999; Horner et al., 2000; Mayer & Rushton, 2002; Monsivais & Reynolds, 2003; Pignone et al., 2005; Weiss, 2007, 2014). Recommendations have been put forth for developing written instructions that can be more easily understood by a wide audience.

The strategies described in this section are specific to simplifying written health informa tion for clients with low literacy skills. The key factor in accommodating lowliterate readers is to write in plain, familiar language using

reading level of the population is approximately 8th grade, that more than 20% read below the 5thgrade level, and that fewer than 50% read above the 10thgrade level.

To cover a wide range of reading skills, it is also possible to develop several sets of instructions—one at a higher grade level, one at a medium grade level, and one at a lower grade level—and allow patients to select the one they prefer (BOX 7-4). Once the reading grade level of a piece of written material is determined, it should be printed on the back of the document in coded form as, for example, RL = 7 (read ing level = seventh grade), for easy reference.

BOX 7-4 Examples of Different Readability Levels

What grade level do you think it is?

Paragraph A It makes good sense that premature births and newborn illnesses are decreased by early pregnancy care. The doctor is actively involved in testing the pregnant woman for pregnancy-induced diabetes and a host of other problems that would not be detected by the patient alone. We know that these problems cause premature births and illnesses in newborns. It certainly makes sense that earlier detection and treatment of these problems by the doctor results in healthier babies.

Paragraph B If you are pregnant or think you may be pregnant, call for an appointment right away. Getting care early in your pregnancy will help you have a healthy pregnancy and a healthy baby. Your PCP (or an OB-GYN doctor you choose from our network) will give you certain tests to make sure everything is going well. If there are any problems, it’s good to find them early. That way, you have the best chance for a healthy baby.

Paragraph C If you are pregnant or think you might be, go to the doctor as soon as you can. If you start your care early, things will go better for you and your baby. Your own doctor or a childbirth doctor from our list will give you a first exam. Tests every month or so will let you know if all is going well. If there is a problem, you’ll know it right away. Then we can do what is needed. Early care is the best way to have a healthy child. Your baby counts on you.

Answer: Approximate grade levels are:

A. 12th grade. B. 8th grade. C. 4th grade.

Please note that the information from this 1998 source is not current and is used for illustrative purposes only. Reproduced from Root, J., & Stableford, S. (1998). Write it easy-to-read: A guide to creating plain English materials. Biddeford, ME: Maine AHEC Health and Literacy Center.

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everyone. The key is to choose words that sound familiar and natural and are easy to read and understand, such as shot rather than injection, doctor rather than physician, and use instead of utilize. Avoid compound words, such as lifesaver, and words with prefixes or suffixes, such as reoccur or emptying, that create multisyllable words.

Also, try to avoid technical words and medical terms (medicalese), and substitute common, nontechnical, lay terms such as stroke instead of cardiovascular accident. Be sure to select substitutions carefully because they may have a different meaning for some people than for others or in one context versus another. For example, if the word medicine is replaced with the word drug, the latter may be interpreted as the illegal variety. Using modest words is not considered talking down to readers; it is considered talking to them at a more comfortable level.

3. Spell out words rather than using abbreviations or acronyms. That is should be used instead of i.e. and for example instead of e.g. Abbreviations for the months of the year (such as Sept.) or the days of the week (such as Wed.) are a real problem for clients with limited vocabulary. Also do not use acronyms, such as CVA or NPO, unless these medical abbreviations are clearly defined beforehand in the text.

4. Organize information into chunks, which improves recall. Also, use numbers sparingly and only when absolutely necessary. Statistics are usually meaningless and are another source of confusion for the lowliterate reader. Limit the number of items in any list to no more than seven. People have a difficult time remembering more than seven consecutive items (Baddeley, 1994).

an easy visual format. The following general guidelines outline some basic linguistic, mo tivational, organizational, and content princi ples to adhere to when writing effective PEMs (see also Appendix A):

1. Write in a conversational style us ing the personal pronoun you and the possessive pronoun your. Use an active voice in the present tense rather than a passive voice in the past or future tense. The message is more personalized, more impera tive, more interesting, and easier to understand if instruction is written as “Take your medicine . . .” instead of “Medicine should be taken . . .” This rule is considered the most important technique to reduce the level of reading difficulty and also to improve comprehension of what is read. Directly addressing the reader through personal words and sentences engages the reader. See a less effective example from an American Cancer Society (1985) pamphlet, followed by a more effective example.

Less Effective People who sunburn easily and have fair skin with red or blond hair are most prone to develop skin cancer. The amount of time spent in the sun affects a person’s risk of skin cancer.

More Effective If you sunburn easily and have fair skin with red or blond hair, you are more likely to get skin cancer. How much time you spend in the sun affects your risk of skin cancer.

2. Use short words and common vo cabulary words with only one or two syllables as much as possible. Rely on sight words, known as highfrequency words, which are recognized by almost

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8. Avoid value judgment words with many interpretations, such as excessive, regularly, and frequently. How much pain or bleeding is excessive? How often is regularly or frequently? Use exact terms to describe what you mean by using, for example, a scale of 1–5 or explaining frequency in terms of min utes, hours, or days. Instead of saying, “drink milk frequently,” you should be more specific by stating, “drink three full glasses of milk every day.”

9. Put the most important information first by prioritizing the need to know. Place essential messages upfront and get rid of extraneous details.

10. Use advance organizers (topic head ings or headers) and subheadings. They clue in the reader to what is going to be presented and help focus the reader’s attention on the message.

11. Limit the use of connectives such as however, consequently, even though, and in spite of that lengthen sentences and make them more complex. Also, avoid and if it connects two different ideas; instead, break the ideas into two sentences.

12. Make the first sentence of a paragraph the topic sentence, and, if possible, make the first word the topic of the sentence. See a less effective example from an American Cancer Society (1985) pamphlet, followed by more effective examples.

Less Effective Even though overexposure to the sun is the leading cause, it isn’t necessary to give up the outdoors in order to reduce your chances of developing skin cancer.

More Effective Enjoying the outdoors is still possible if you take steps to reduce your risk of skin cancer when in the sun.

5. Keep sentences short, preferably not longer than 20 words and fewer if possible, because they are easier to read and understand for clients with shortterm memories or who struggle decoding words of a sentence. Avoid subordinate (or dependent) clauses that make the reading more difficult. The use of commas, colons, or dashes results in long, complex sentences that turn off the reader. Titles also should be short and con vey the purpose and meaning of the material that follows.

6. Clearly define any technical or unfami liar words by using parentheses that include simple terms after difficult words—for example, “bacteria (germ).” A glossary that provides definitions of each difficult term is a helpful tool, but it is highly recommended to spell out terms phonetically immediately following the unfamiliar word within the text—for example, “Alzheimer’s (pronounced Altshimerz).” If a new technical vocabulary word (diabetes) or a new health concept (glycemic control) is introduced, it should be used and repeated frequently (Brega et al., 2015). Standal’s (1981) method suggests identifying words whose meanings should be taught to the reader prior to introducing the in structional material to increase reader comprehension and to avoid having to make major revisions to a printed piece.

7. Use words consistently throughout the text and avoid interchanging words. For example, if discussing diet, continue to use the word diet rather than substituting other terms for it, such as meal plan, menu, food schedule, and dietary prescription, which merely confuse readers and can lead to misunderstanding of instruction.

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progress depends on where and how much your brain is dam aged. Getting better will take time. The care you get will begin while you are in the hospital. How you think and feel about what happened to you will help you handle special problems. The care given by the nurses, doctors, and other health professionals also is very helpful to you. The support you get from your family and friends is important, too.

14. Keep density of words low by not exceeding 30 to 40 characters (let ters) per line. The number of words in each line is influenced by the size of the font.

15. Allow for plenty of white space in margins, and use generous spacing between paragraphs and double spacing within paragraphs to reduce density. Pages that are not crowded seem less overwhelming to the reader with low literacy skills.

16. Keep right margins unjustified be cause the jagged right margins help the reader distinguish one line from another. In this way, the eye does not have to adjust to different spacing between letters and words as it does with justified type.

17. Design layouts that encourage eye movement from left to right, as in normal reading. In simple drawings and diagrams, using arrows or circles that give direction is helpful, but do not add too many elements to a schematic.

18. Select a simple type style (serif, Times New Roman, or Courier) and a large font (14 or 16 point size) in the body of the text for ease of reading and to increase motivation to read. A sans serif font (which does not have the little hooks at the top and bottom of

or You can reduce your chance of skin cancer even when enjoying the outdoors.

13. Reduce concept density by limiting each paragraph to a simple message or action and include only one idea per sentence. In the following example, the original paragraph (American Heart Association, 1983) contains at least six concepts. As rewritten, the revised paragraph has been reduced to four concepts and is written using a personalized approach. Please note that the information from this 1983 source is not current and is used for illustrative purposes only.

Original Paragraph A person who has had a stroke may or may not be able to re turn to his or her former level of functioning, depending on the extent and location of brain damage. Mental attitude, efforts of the rehabilitation team, and the understanding of family and friends also affect the pa tient’s progress. Recovery must be gradual, but it should begin the moment the patient is hospi talized. After the patient is tested to determine the extent of brain damage, rehabilitation such as physical, speech, and occupational therapy should begin. Family and friends should be told how to handle special problems the stroke victim may have, such as irrational behavior or difficulty communicating.

Revised Paragraph Getting back to your normal life after a stroke is an import ant part of your recovery. Each stroke patient is different. Your

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pages with nicetoknow information will turn off even the most eager and capable reader.

23. Select paper on which the typeface is easy to read. Black print on white paper is most easily read and most economical. Dull finishes reduce the glare of light. Avoid highgloss paper, which reflects light into the eyes of the reader and is usually too formal and not in harmony with the purpose and informal tone of your message.

24. Use bold line drawings and simple, realistic pictures and diagrams. Ba sic visuals aid the reader to better understand the text information. Use cartoons judiciously, however, because they can trivialize the message and make it less credible.

Graphic designs that are strictly decorative should never be used because they are distracting and confusing. Also, never superimpose words on a background design because it makes reading the letters of the words very difficult. Only illustrations that enhance understanding of the text and that relate specifically to the message should be included.

Be careful to use pictures that portray the messages intended. For example, avoid using a picture of a pregnant woman smoking or drinking alcohol—this negative message is de pendent on careful reading of the text to correct a faulty impression. The visuals should clearly show only those actions that you want the reader to do and remember. Be sure that visuals do not communicate cultural bias.

Use simple subtitles and cap tions for each picture. Also, be sure drawings are recognizable to the audience. For instance, if you draw a picture of the lungs, be certain they are within the outline of the person’s

letters) or other type of clean style should be used only for titles to give style to the page. Avoid italics, fancy lettering, and ALL CAPITAL letters. Lowliterate readers are not fluent with the alphabet and need to look at each letter to recognize a word. To facilitate their decoding of words in titles, headings, and subheadings, use uppercase and lowercase letters, which provide reading cues given by tall and short letters on the type line. Avoid using a large stylized letter to begin a new paragraph, such as in this example:

This looks attractive, but it is confusing to a poor reader who cannot decode the word minus the first letter.

19. Highlight important ideas or key terms with bold type or underlining, but never use all capital letters or italics.

20. If using color, employ it consistently throughout the text to emphasize key points or to organize topics. Color, if applied appropriately, attracts the reader. Red, yellow, and orange are warm colors, which are more eyecatching and easier to read than cold colors such as violet, blue, and green. Use bold, solid colors and avoid pastel colors that all look gray to older adults with vision problems, such as cataracts.

21. Create a simple cover page with a title (in uppercase and lowercase lettering) that clearly and succinctly states the topic to be addressed. The title should ideally be one to four words in length.

22. Limit the length of a document— the shorter, the better. It should be long enough just to cover the essential, needtoknow information. Too many

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have readers explain the information in their own words (known as the teachback method) or have them demonstrate the desired behavior. If learners can do so correctly, it is a good indication that the information is understood (Caplin & Saunders, 2015). Do not ask questions such as “Do you understand?” because you are likely to get a “yes” or “no” answer, not a substantive response.

26. Put the reading level (RL) on the back of a PEM for future reference—for example, if the PEM is readable at the sixthgrade level, the designation would be RL = 6.

27. Determine readability by applying at least two formulas (the SMOG, Fog, and Fry formulas are suggested). Also, you can measure compre hension by applying the cloze or listening test and check reading and health literacy skills by applying the WRAT, REALM, TOFHLA, or NVS.

It does not take a great deal of effort—just knowhow and common sense—to improve the readability and comprehensibility of instructional materials. (BOX 7-5 provides a summary of tips). The benefits are significant in terms of compli ance and quality of care when marginally literate patients are given PEMs that effectively commu nicate messages they can read and understand.

Always remember to test any new materials before printing and distributing them. Not only will this effort save the cost of printing hand outs that might not be useful, but patients will have the opportunity to participate in the evalu ative process. Readily understandable materials also reduce time and frustration on the part of the nurse educator and avoid the possibility of litigation when better quality and more appro priate healthcare instructions are used. The im portant role of printed media to communicate health information should compel all writers of PEMs to use the techniques recommended in this chapter. As Doak and Doak (1987) so aptly

body to accurately depict the location of the organs. The person with low literacy may not know what he or she is looking at if the lungs are not put in context with the body’s torso. However, pictures do not necessarily make the text easier to read if the readability level remains high.

25. Include a summary section using bullet points or a numbered list to review what has already been presented. A questionandanswer format using the client’s point of view is an effective way to summarize information in single units using a conversational style. The following example is adapted from an American Cancer Society (1985) pamphlet:

Q: Am I likely to get skin cancer? A: If you have spent a lot of time in the sun, you have a greater chance of getting skin cancer than people who have stayed out of the strong sunlight. If you sunburn easily, you are at more risk for skin cancer. If you have fair skin with red or blond hair, you are more likely to get skin cancer than people with dark skin.

Q: How can I tell if I have skin cancer? A: The only way to know for certain is to see your doctor. Your doctor may want to take a sample of skin to test for cancer. If you have a red, scaly patch, a mole that has changed, or an area of the skin that does not heal, see your doctor right away.

Q: How can I prevent skin cancer? A: Stay out of direct sunlight between 11:00 a.m. and 2:00 p.m. When outside in the sun, cover up with clothing, wear a widebrimmed hat, and use sunscreens that block out the sun’s harmful rays.

Ask for feedback after clients have read your instructions. Either

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BOX 7-5 Formatting Checklist for Easy-to-Read Written Materials

General Content ■ Limit content to one or two key objectives. Don’t provide too much information or try to cover

everything at once. ■ Limit content to what patients really need to know. Avoid information overload. ■ Use only words that are well known to individuals without medical training. ■ Make certain content is appropriate for age and culture of the target audience.

Text Construction ■ Write at or below the sixth-grade level. ■ Use one- or two-syllable words. ■ Use short paragraphs. ■ Use active voice. ■ Avoid all but the most simple tables and graphs. Clear explanations (legends) should be placed

adjacent to the table or graph and also in the text.

Fonts and Typestyles ■ Use large font (minimum 12 point) with serifs. (Serif text has the little horizontal lines that you see

in this text at the bottoms of letters like f, x, n, and others. This text, on the other hand, is nonserif.) ■ Don’t use more than two or three font styles on a page. Consistency in appearance is important. ■ Use upper and lowercase text. ALL UPPERCASE TEXT IS HARD TO READ.

Layout ■ Ensure a good amount of empty space on the page. Don’t clutter the page with text or pictures. ■ Use headings and subheadings to separate blocks of text. ■ Bulleted lists are preferable to blocks or text in paragraphs. ■ Illustrations are useful if they depict common, easy-to-recognize objects. Images of people, places,

and things should be age appropriate and culturally appropriate to the target audience. Avoid complex anatomical diagrams.

Used with permission of the American Medical Association from Weiss, B. D. (2007). Health literacy and patient safety: Help patients understand. Manual for clinicians (2nd ed.). Chicago, IL: American Medical Association and American Medical Association Foundation. © Copyright American Medical Association 2007. All rights reserved.

point out, “With so much to be gained, the in vestments of a little time and thoughtful atten tion to the materials provided to patients can pay back dividends too important to ignore” (p. 8).

▸ Teaching Strategies to Promote Health Literacy

Working with clients who are illiterate and marginally literate requires more than just

designing simpletoread instructional litera ture. It also calls for using alternative and in novative teaching strategies to break down the barriers of illiteracy. Using techniques to im prove communication with clients has the po tential to greatly enhance their understanding (Brega et al., 2015; Weiss, 2007).

Further, teaching clients with poor reading skills does not have to be viewed as a problem but rather as a challenge (Dunn, Buckwalter, Wein stein, & Palti, 1985). Existing teaching methods and tools can be adapted to match the logic, language, and experience of the patient who

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are easily overwhelmed. Information about the history of treatment, general principles, statistics, detailed physi ology, and extraneous facts about a topic are not necessary for them to know. Keep teaching sessions short, limiting them to no more than 20 to 30 minutes; 15 to 20 minutes is the ideal time limit.

3. Make points of information as vivid and explicit as possible. Explain information in simple, concrete terms using everyday, livingroom language. Provide personal examples relevant to the client’s background. Visual aids, such as signs and picto graphs, should be large with readable print and contain only one or two messages. For example, a sign read ing “NOTHING BY MOUTH” or, worse yet, “NPO” should be changed to “Do not eat or drink anything” (remember to avoid using all capital letters and abbreviations).

Underlining, highlighting, color coding, arrows, and common interna tional symbols can be used effectively to give directions and draw attention to important information. For exam ple, differentcolored signs, pictorial cues, and other visual stimuli, such as strips on the floor tiles that lead to specific areas of the hospital, are valuable for increasing independence and safety.

4. Teach one step at a time. Teaching in increments and organizing informa tion into segments of information (chunks) help to reduce anxiety and confusion and give enough time for clients to understand each item before proceeding to the next unit of information. Also, these techniques give clients a sense of order and a chance to ask questions after each block of information has been pre sented. Most important, the pacing of

has difficulty with reading and comprehension (Doak et al., 1998). Incidentally, many literate and highly motivated clients also can benefit from some of these same teaching strategies.

Many authors suggest the following tips as useful strategies for the nurse to employ when acting in the role of educator (Brega et al., 2015; Carollo, 2015; Doak et al., 1998; Fidyk, Ventura, & Green, 2014; Hyde & Krautz, 2014; Kemp, Floyd, McCordDuncan, & Lang, 2008; Kessels, 2003; Lerner et al., 2000; Pignone et al., 2005; Rothman et al., 2004; Ryan et al., 2014; Schultz, 2002; Weiss, 2007; Winslow, 2001):

1. Establish a trusting relationship be- fore beginning the teaching–learning process. Start by getting to know the clients to reduce their anxiety. Because many poor readers have a history of being defensive, the nurse educator must attempt to overcome their defense mechanisms by cast ing aside communication barriers such as any preconceived notions, including myths and stereotypes. Also, focus on clients’ strengths. Demonstrate your belief in them as responsible individuals. Be open and honest about what specifically needs to be learned to build their confidence in their ability to per form selfcare activities. Encourage family and friends to help reinforce the clients’ selfconfidence.

2. Use the smallest amount of infor- mation possible to accomplish the predetermined behavioral objectives. Stick to the essentials, paring down the information you teach to what the client must learn. Prioritize behavioral objectives, and select only one or two concepts to pres ent and discuss in any one session. Present the context of the message first before giving any new informa tion. Remember, clients with poor comprehension and reading skills

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to explain something in their own words may take longer and requires patience on the part of the educator, but feedback in this manner can reveal gaps in knowledge or mis conceptions of information. Return demonstration, handson practice, role playing reallife situations, and sharing personal stories in dialogue form are communication modes that provide you with feedback about the patient’s level of functioning.

Trying to elicit feedback by ask ing questions does not always work because people with low literacy skills often do not have the right vocabulary or fluency to explain what they do and do not understand. Remember, do not ask questions that will elicit only a “yes” or “no” response. Learners will likely respond in the affirmative, even when they have no clue as to what the nurse educator is talking about, just so they do not have to admit their ignorance.

Furthermore, learners with low literacy skills are unlikely to ask questions of the educator for fear of embarrassment at not understanding instructions. Use openended statements, such as “Tell me what you understand about . . .,” to obtain feedback from them to verify their comprehen sion. Encouraging clients to repeat instructions in their own words or physically demonstrate an activity is an effective approach to verifying what they really understand.

Chew et al. (2004) developed three questions as a practical and quick method for identifying literacy skills in patients: (1) “How often do you have someone help you read hos pital materials?” (2) “How confident are you filling out medical forms by yourself?” and (3) “How often do

instruction allows for more adequate time between sessions for learners to assimilate information.

5. Use multiple teaching methods and instructional tools requiring fewer literacy skills. Oral instruction con tains cues such as tone, gestures, and expressions that are not found in written materials. However, the spoken word lacks other signals, such as punctuation and capital letters. Consequently, a person with poor reading skills is likely to have some trouble with understanding spoken language as well. The listening test, as previously described, can be used to measure comprehension of oral instruction. Another way to test the difficulty level of information pre sented verbally is to begin by taping a spoken message, converting it into a written form, and then applying a readability formula to it.

Exposing clients to repetition and multiple forms of the same message is highly recommended. Audiotaped instruction, used in combination with other visual re sources such as simple lists, pictures, and videotapes, can help to improve comprehension and reduce learning time. These media forms, as more permanent sources of information, can be sent home with the client for added reinforcement of health messages. Also, interactive com puter programs, which allow clients to proceed at their own pace, can be programmed developmentally to match a user’s literacy skill level.

6. Allow patients the chance to restate information in their own words and to demonstrate any procedures being taught. Use the teachback or “show me” method to verify that information shared with the learner was, in fact, understood. Encouraging learners

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the appropriate combination of time and situation using prompts and reminders to get a person to perform a routine task. For example, placing medications where they best can be seen on a frequent basis or keeping a simple chart to check off each time a pill is taken serves as a reminder to comply with taking medications as prescribed.

9. Use repetition to reinforce information. Repetition, at appropriate intervals, is a key strategy to use with clients who have low literacy. Each major point made along the way should be reviewed. Therefore, time must be set aside to remind learners of what has come before and to prepare them for what is to follow. This is time well spent—repetition, in the form of saying the same thing in different ways, is one of the most powerful tools to help clients un derstand their situations and learn important selfcare measures.

These teaching strategies are especially well suited to the individual needs of people with low literacy skills. As noted earlier, nurses must empower consumers by providing health information that is culturally and linguistically appropriate. Creating an open, trusting, and accepting environment that makes it accept able for the client to say, “I don’t understand,” is the cornerstone of effective communication (Carollo, 2015; Cole, 2000).

It is always a challenge to teach clients who, because of illness or a threat to their wellbeing, may be anxious, frightened, depressed, in denial, or in pain. Teaching pa tients is even more of a special challenge in today’s healthcare environment, when vary ing degrees of literacy compound the ability of a significant portion of the adult popula tion to understand information vital to their health and welfare.

you have problems learning about your medical condition because of difficulty understanding written information?” They found these three questions to be effective screening tests for inadequate health literacy in patients at a Veterans Adminis tration preoperative clinic but not as effective for detecting patients with marginal health literacy.

7. Keep motivation high. It is important to recognize that people with limited literacy may feel like failures when they cannot work through a problem. Reassure them that it is normal to have trouble with new information and that they are doing well. Encour aging them to keep trying and recog nizing any progress they make, even if it occurs only in small increments, is motivating to the slow learner. Rewards—not punishments—are excellent motivators. Sticking to the basics and keeping the information relevant and succinct will maintain a learner’s interest and willingness to learn.

8. Build in coordination of procedures. A way to facilitate learning is to simplify information by using the principles of tailoring and cuing. Tailoring refers to coordinating recommended regimens into the daily schedules of clients rather than forcing them to adjust their life styles to these regimens. Otherwise, clients may feel that changes are being imposed on them. Tailoring allows new tasks to be associated with old behaviors. It personalizes the message so that instruction is individualized to meet the client’s learning needs. For example, coordinating a medication schedule to a patient’s mealtimes does not drastically alter everyday lifestyle and tends to increase motivation and compliance. Cuing focuses on

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interaction activities between healthcare provid ers and clients, and navigation of the healthcare system. Although the literacy and verbal skills of individuals are concerns of critical impor tance, so too are the demands made by PEMs, the need to improve communication skills of health professionals, and the need to make the healthcare system less complex.

Specific reports by the IOM, the AHRQ, and the AMA, all released in 2004, recognized that health literacy is a key priority in transforming the U.S. healthcare system (Aldridge, 2004; Weiss et al., 2005). Specifically, AHRQ examined the relationship between literacy and adverse out comes as well as interventions to improve out comes for people who are low literate (Pignone et al., 2005).

In 2010, the NAP was released to provide guidance to nurses and other healthcare profes sionals regarding improving the current state of low health literacy. The NAP goals direct nurses and other public and private healthcare part ners to implement care strategies that keep the health literacy issue at the forefront (Clancy, 2011). TABLE 7-3 indicates how the NAP goals can be used as a framework to organize many of the strategies discussed. Nurses, regardless of their job title or specialty, will always be in a role whereby they can promote and implement the goals of the NAP in addressing health lit eracy. As Baur (2011) notes, “Nurses see the challenges patients and community members have when they try to make sense of ambigu ous preventive health recommendations, un clear medication instructions, dense hospital discharge instructions, jargonfilled consent forms, health history, insurance forms, and con fusing signage in clinics and hospitals” (p. 64). Nurses must understand the scope and critical need for improving communication and health literacy for every patient.

The interest in the literacy problem has escalated tremendously in the past 5 to 10 years, and recent results from the PIAAC sur vey demonstrate that difficulties with literacy, numeracy, and technology use are still preva lent (Rampey et al., 2016). Despite this, PEMs

▸ State of the Evidence In 1999, the Ad Hoc Committee on Health Lit eracy for the Council on Scientific Affairs of the American Medical Association acknowledged that, although a great deal had been learned to to date about the magnitude and consequences of the problem of illiteracy and low literacy, fur ther research efforts had to focus on four areas:

1. Literacy screening 2. Methods of health education 3. Medical outcomes and economic costs 4. Understanding the causal pathway

of how health literacy influences health status

The committee also called for healthcare policies to address the issue of health literacy for the following reasons:

1. Lowliterate patients cannot be empowered consumers in a market driven healthcare system.

2. Patients who cannot understand healthcare instructions will not receive highquality health care.

3. Healthcare professionals are subject to liability for adverse outcomes in patients who do not understand important health information.

4. Clinical management problems are likely to result in substantial but avoidable costs for the U.S. health care system.

5. Health literacy problems are more prevalent in certain populations (e.g., Medicare beneficiaries, Medicaid recipients, and uninsured individuals).

Indeed, based on the findings of the NALS and NAAL reports, a broad policy agenda on health literacy has been put forth in the 10year goals and objectives of Healthy People 2020 (USDHHS, 2014). The topic area “Health Com munication and Health Information Technology” includes an objective specific to health liter acy improvements and addresses three major health literacy initiatives: prevention measures,

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TABLE 7-3 Strategies to Address the NAP Goals

NAP Goal Strategies

Goal 1: Develop/disseminate health/safety information that is accurate, accessible, and actionable.

Provide a nonthreatening, comfortable, and familiar environment. Speak slowly, introduce yourself, and encourage questions. Encourage family/friends to reinforce self-confidence. Use clear communication by rewriting signs for your clinic; use little medical jargon, different colors, pictorial cues, and other visual stimuli. Explain information in simple terms; use everyday language. Reinforce words by using pictures and drawings; use patient education materials written at fifth-grade level or lower. Rewrite discharge instructions using short sentences, using black ink and 14-point plain font. Read aloud written handouts. Be aware of age-specific and cultural needs. Teach in increments and organize information into chunks. Use photographs, audio, and drawings to communicate the message.

Goal 2: Promote changes in the healthcare system that improve health information, communication, informed decision making, and access to health services.

Encourage nursing/medical schools to incorporate education on effective teaching. Refer patients to adult education and English language programs. Verify patient understanding by adopting the teach-back method. Use open-ended statements. Simplify information by using principles of tailoring and cuing. Use the smallest amount of information possible to accomplish the behavioral objectives. Keep teaching sessions to 15–20 minutes in length.

Goal 3: Incorporate accurate, standards-based, and developmentally appropriate health/science information and curricula in child care/ education through the university level.

Build partnerships with local hospitals, clinics, healthcare providers, librarians, and adult education centers to connect the health literacy skill-building activities of children and adults.

Goal 4: Support and expand local efforts to provide adult education, English-language instruction, and culturally/ linguistically appropriate health information/services in the community.

Become familiar with community information/literacy resources. Volunteer to lecture in the local library to support community health information needs. Engage organizations in making health literacy a priority. Hire more racially/ethnically diverse and bilingual healthcare professionals. Assist reporters and media outlets to release accurate health information.

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with diverse groups of people who have lim ited literacy skills must be explored.

Some innovative ideas are being used to in crease the literacy of children. One such program is R.E.A.D., which stands for “reading education assistance dogs.” This program brings specially trained dogs to public libraries to provide chil dren with a nonjudgmental audience to read to; almost every state has implemented some type of similar program. These dogs are trained to listen to young readers and detect difficulties with reading. They encourage the child to keep going by providing a gentle nudge or lick on the hand as needed. Children typically respond quite positively to this program and early re search finds reading is improved (Hall, Gee, & Mills, 2016; New York Therapy Animals, n.d.). Similar types of innovative ideas are needed to reach the adult population. Specifically, nursing and healthcare research must focus on nurse–cli ent interaction techniques that improve under standing of health information, which would lead to a higher level of motivation and compliance.

It is not yet well understood if health ed ucation materials for clients with low literacy

continue to be significantly above the reading level of the general population (Eltorai et al., 2014; McClure et al., 2016; Sudore, Landefeld et al., 2006; Williams et al., 2016). Also, nu merous research studies have found the conse quences of inadequate literacy and low health literacy are poorer health outcomes, increased hospital readmissions, and higher healthcare costs (Eichler et al., 2009; McNaughton et al., 2015; Stevens, 2015; Weiss, 2007; Weiss et al., 2005; Wong, 2016; Wu et al., 2016). These out comes should serve as an incentive for all types of healthcare institutions and insurance payers to develop education programs to better reach patients with different levels of reading ability.

Further research to develop and test inter ventions that would be effective in addressing problems with literacy is warranted. Carollo (2015) examined older women with low health literacy and found that the patient–clinician re lationship was an important factor in enhancing communication and empowering the patient, two areas that can positively influence health outcomes. Additional research on the optimal methods for communicating and interacting

NAP Goal Strategies

Goal 5: Build partnerships, develop guidance, and change policies.

Join state health literacy initiatives and educate policymakers on the issue.

Goal 6: Increase basic research and the development, implementation, and evaluation of practices/ interventions to improve health literacy.

Develop more rigorous and comprehensive methods to measure individual and population health literacy skills.

Goal 7: Increase the dissemination/use of evidence-based health literacy practices/ interventions.

Engage in research on the topic of health literacy to employ evidence-based strategies when working with clients.

State of the Evidence 303

educational background, motivational levels, reading and comprehension skills, and readabil ity level of the materials used for instruction. The prevalence of functional illiteracy and low literacy is a major problem in the adult popu lation of this country.

Nurses in the role of educators serve as communicators and interpreters of health infor mation. They must always be alert to the poten tially limited capacity of their clients to grasp the meaning of written and oral instruction. Nurse educators need to know how to identify clients with literacy problems, assess their needs, and choose appropriate interventions that create a supportive environment directed toward help ing those with poor reading and comprehen sion skills to better and more safely care for themselves. An awareness of the incidence of illiteracy, the populations who are most at risk, and the effects that literacy levels have on mo tivation and compliance with selfmanagement regimens are key to understanding the barriers to communication between nurses and clients.

The first half of this chapter focused on the magnitude of the illiteracy problem, the myths and stereotypes associated with poor lit eracy skills, the assessment of variables affect ing reading and comprehension of information, and the readability levels of patient education materials. The remainder of the chapter exam ined in detail the measurement tools available to test for readability, comprehension, reading skills, and health literacy; guidelines for writ ing and evaluating education materials; and spe cific teaching strategies to be used to match the logic, language, and experience of clients with literacy problems.

Data suggest that written materials are an important source of health information to rein force and complement other methods and tools of instruction. PEMs are the most costeffective and timeefficient means to communicate health messages, but research suggests that there is a large gap between the average comprehension and reading skills of clients and the readabil ity level of current written instructional aids. Unless this gap is narrowed, printed sources of

do, in fact, improve health outcomes. In addi tion, more evidence is needed on the benefits of nonprint media, such as videos, audiotapes, and computers, in helping clients to overcome bar riers of health illiteracy to improve their quality of life. As use of technology becomes increas ingly common in health care, the assessment of ehealth literacy will become even more import ant based on the results of the PIAAC interna tional survey that shows people struggle with technology use in problem solving (Rampey et al., 2016). Further, much more attention must be paid to the ethical and legal implications of providing education materials to clients with limited literacy skills that are suitable to meet those individuals’ health information needs. Fu ture research must focus on health literacy to support and understand its role in healthcare reform, as well as better inform nurses of the im pact it has on health outcomes (Clancy, 2011). Nurses, in the role of educators, must empiri cally explore teaching and learning approaches to find those techniques that are most effective in working with clients who suffer the burden of illiteracy and low literacy.

One major step in the right direction is for nurses to embrace the attitude of “univer sal precaution” when it comes to literacy. In other words, given the widespread existence of low literacy and the challenges in identifying it, nurses should communicate with every pa tient as if he or she has difficulty understand ing health information (Speros, 2011). This way nurses can promote comprehension of information and minimize the consequences of misunderstanding across all populations. However, they can do this only if they have knowledge about health literacy and inter ventions to navigate low health literacy. This important topic must be addressed in the cur riculum of nursing education (Kennard, 2016; McClearyJones, 2016).

▸ Summary The ability to learn from health instruction varies for clients, depending on such factors as

304 Chapter 7 Literacy in the Adult Client Population

5. Which segments of the U.S. population are more likely to be at risk for having poor reading and comprehension skills?

6. Why are problems with low literacy and functional illiteracy greater in older adults than in younger age groups?

7. What are three common myths about people who are illiterate?

8. What are seven clues that clients who are illiterate may demonstrate?

9. How does illiteracy or low literacy affect a person’s level of motivation and compliance?

10. How does reliance on PEMs to supplement teaching pose an ethical or legal liability for nurse educators?

11. Which measurement tools (formulas and standardized tests) are used specifically to test readability, comprehension, reading, and health literacy skills?

12. What are 10 general guidelines to simplify written educational materials for clients with low literacy skills?

13. What are five teaching strategies that can be used by the nurse educator to make health information more understandable for clients with poor reading and com prehension skills?

information will serve no useful purpose for adults who suffer with illiteracy and low literacy.

Removing the barriers to communication between clients and healthcare providers of fers an ideal opportunity for nurse educators to function as facilitators and work collabora tively with other health professionals to improve the quality of care delivered to consumers. It is their mandated responsibility to teach in under standable terms so that clients can fully benefit from interventions.

Review Questions 1. What are the definitions of the terms

literacy, illiteracy, low literacy, functional illiteracy, and health literacy? How are literacy and health literacy different?

2. Approximately how many Americans are considered illiterate or functionally illiterate? What percentage of the U.S. population does this number represent?

3. Why are the rates of low literacy and illiteracy suspected to be on the rise in the United States?

4. Why is the number of years of schooling a poor indicator of someone’s literacy level?

CASE STUDY As an institution committed to serving the community, Smithfield University Hospital has agreed to provide healthcare services to the homeless men and women living in the Elias Temporary Housing Shelter (ETHS), located 5 miles from the hospital. These services include a special weekly clinic held at the shelter as well as in-hospital services as needed. It is anticipated that all units in the hospital will participate in the program.

ETHS is a 32-bed shelter for men and women who are homeless for a variety of reasons. The residents represent a high-risk segment of the population as many do not participate in preventative health care and a significant number of them present with mental health issues. Most have very limited social and material resources and come to the shelter because they have nowhere else to go. Very few of the residents are employed, and most have a high school diploma or less. Their healthcare needs range from emergency services to acute and preventive physical and mental health services. Several of the men and women have chronic conditions. The residents are a transient population and their contact with healthcare services is limited and infrequent. Health education is an important component of the care they receive from the nursing staff, who strive to teach them to care for themselves.

(continues)

305Review Questions

45(11), 1026–1033. Retrieved from https://www.ncbi .nlm.nih.gov/pubmed/18049342

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1. Which risk factors suggest that this population may have low literacy and inadequate health literacy skills?

2. As the nurse providing education, how would you assess the reading and comprehension levels of the residents? Which clues will you look for?

3. Select a teaching strategy you would use with this population. Explain why this strategy would work when teaching groups with mixed literacy levels.

4. How will you evaluate the learning that has taken place resulting from your instruction?

CASE STUDY (continued)

306 Chapter 7 Literacy in the Adult Client Population

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Gender, Socioeconomic, and Cultural Attributes of the Learner Susan B. Bastable Deborah L. Sopczyk

CHAPTER HIGHLIGHTS

■ Gender Characteristics • Cognitive Abilities • Personality Traits • Sexual Orientation and Gender Identity

■ Socioeconomic Characteristics • Teaching Strategies

■ Cultural Characteristics • Definition of Terms

■ Assessment Models for the Delivery of Culturally Sensitive Care • General Assessment and Teaching Interventions • Use of Interpreters

■ The Four Major Subcultural Ethnic Groups • Hispanic/Latino Culture • Black/African American Culture • Asian/Pacific Islander Culture • American Indian/Alaska Native Culture

■ Preparing Nurses for Diversity Care ■ Stereotyping: Identifying the Meaning, the Risks, and the Solutions ■ State of the Evidence

315

CHAPTER 8

Gender, socioeconomic level, and cultural background are significant influences on a learner’s willingness and ability to respond to and make use of the teaching–learn- ing situation. These three factors also play a role in how people interpret their experiences, react to health and illness, and formulate their expectations of the nurse (Core, 2008). Two of these factors—gender and socioeconomic status (SES)—have been given very little attention to date by nurse educators. In contrast, the third factor—cultural and ethnic diversity—has been the focus of considerable study in recent years

with respect to its effects on learning. Understand- ing diversity, particularly those variations among learners related to gender, socioeconomics, and culture, is of major importance when designing and implementing education programs to meet the needs of an increasingly unique population of learners.

Although this chapter focuses primarily on patients as learners, much of the informa- tion on gender, socioeconomics, and culture can be applied to the teaching and learning of staff nurses and nursing students who come from diverse backgrounds and experiences. This

OBJECTIVES

After completing this chapter, the reader will be able to

1. Identify gender-related characteristics in the learner based on social and hereditary influences on brain functioning, cognitive abilities, and personality traits.

2. Recognize the influence of socioeconomics in determining health status and health behaviors. 3. Define the various terms associated with diversity. 4. Examine cultural assessment from the perspective of different models of care. 5. Distinguish between the beliefs and customs of the four subcultural ethnic groups in the United

States. 6. Suggest teaching strategies specific to the needs of learners belonging to the four subcultural

ethnic groups in the United States. 7. Examine ways in which transcultural nursing can serve as a framework for meeting the learning

needs of various ethnic populations. 8. Identify the meaning of stereotyping, the risks involved, and ways to avoid stereotypical

behavior.

KEY TERMS

gender-related cognitive abilities

gender-related personality behaviors

gender gap gender bias socioeconomic status (SES) poverty cycle

(circle of poverty) acculturation assimilation

cultural awareness cultural competence cultural diversity cultural relativism culture ethnic group ethnocentrism ideology subculture transcultural worldview

primary characteristics of culture

secondary characteristics of culture

spirituality religiosity stereotyping stereotype threat gender-fair language

316 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

chapter explores how individuals respond dif- ferently to healthcare interventions through ex- amination of gender-related variations resulting from heredity or social conditioning that af- fects how the brain functions for learning. In addition, the influence of environment on the learner from a socioeconomic viewpoint is ex- amined. Also, consideration is given to the sig- nificant effects that cultural norms have on the behaviors of learners from the perspective of the predominant four subcultural ethnic groups in the United States. Models for cultural assess- ment and the planning of care are highlighted as well. Finally, this chapter outlines ways to pre- pare nurses for diversity care and to deal with the issue of stereotyping.

▸ Gender Characteristics Most of the information on gender variations with respect to learning is found in the educa- tional psychology and neuroscience literature. The nursing literature, however, contains rela- tively little information about this subject from a teaching–learning perspective. Clearly, the char- acteristics of gender identities do affect learning. Therefore, these findings need to be considered more closely as to how they apply to patient ed- ucation in nursing practice and to teaching of nursing staff and students.

Two well-established facts exist with re- spect to gender. First, individual differences within a group of males or females are usu- ally greater than differences between groups of males versus groups of females. Second, studies that compare the genders seldom can separate genetic differences from environmental influ- ences on behavior (Crandell, Crandell, & Vander Zanden, 2012; Santrock, 2017).

A gap in knowledge remains about what the sexes would be like if humans were not subject to behavioral conditioning. No person can sur- vive outside a social matrix and, therefore, indi- viduals begin to be shaped by their environment right from birth. For example, our U.S. culture exposes girls and boys, respectively, to pink and

blue blankets in the nursery, dolls and trucks in preschool, ballet and basketball in the elemen- tary grades, and cheerleading and football in high school. These social influences continue to affect the sexes throughout the life span.

Of course, men and women are different. But questions remain: How different or the same are they when it comes to learning? To what can the differences and similarities be attributed? Bi- ological and behavioral scientists have, to date, been unable to determine the exact impact that genetics and environment have on the brain. Opinions are rampant, and research findings are still inconclusive.

However, the fact remains that there are dif- ferences as to how males and females act, react, and perform in situations affecting every aspect of life (Cahill, 2014a, 2014b; Thompson, 2010). As Cahill (2014a, 2014b) believes, the issue of sex influences is much too important to be ignored or marginalized. According to a National Acad- emy of Sciences report, “Sex does matter. It mat- ters in ways that we did not expect. Undoubtedly, it also matters in ways that we have not begun to imagine” (Pardue, 2001, p. x).

For example, when it comes to human re- lationships, intuitively women tend to pick up subtle tones of voice and facial expressions, whereas men tend to be less sensitive to these communication cues (Thompson, 2010). In nav- igation, women tend to have difficulty finding their way, whereas men seem to have a better sense of direction (Thompson, 2010). In cog- nition, females tend to excel in languages and verbalization, yet men are likely to demonstrate stronger spatial abilities and related quantitative reasoning skills (Reilly & Neumann, 2013). Sci- entists are beginning to believe that gender dif- ferences have as much to do with the biology of the brain as with the way people are raised (Baron-Cohen, 2005; Gorman, 1992; Wilson & Auger, 2013). The debate, then, is not whether human development is influenced by nature or nurture, but how much influence heredity and environment have on shaping the abilities and personalities of men and women (Eliot, 2009; McLeod, 2007; Sincero, 2012). Kimura (1999)

Gender Characteristics 317

and Larkin (2013), for example, have reported on the many different patterns of behavior and cognition between men and women that are thought to reflect varying hormonal influences on brain development.

Some would argue that these examples are representative of stereotyping. Nevertheless, as generalizations, these statements seem to hold some truth. Neuroscientists have begun to de- tect both structural and functional differences in the brains of males and females. These early findings have led to an upsurge in neurosci- ence research into the mental lives of men and women (Baron-Cohen, 2005; Larkin, 2013). For example, in their study on sex differences in the human brain, Ingalhalikar et al. (2014) found that male brains have less structural in- terconnectedness within and across the two hemispheres than do brains of women. That is, architecturally men and women are wired dif- ferently. Cahill (2014b) contends that sex in- fluences are widespread in brain function and that “males and females appear to be two com- plex mosaics, similar in some respects, mildly to highly different in others” (Cahill, 2014b, p. 577). Thus, gender is a complex puzzle that requires consideration of the interplay of bio- logical, sociological, and cultural factors.

Neurobiologists are just at the dawn of un- derstanding how the human brain works, in- cluding exactly which types of sensory input wire the brain and how that input affects it. Sci- entists suspect that cognitive abilities operate much like sensory ones in that they are stimu- lated by those activities and experiences to which a person is exposed right from birth. Circuits in different regions of the brain are thought to ma- ture at different stages of development. These circuits represent critical windows of opportu- nity at different ages for the learning of math, music, language, and emotion.

Brain development is much more sensitive to life experiences than once believed (Begley, 1996; Hancock, 1996). A baby’s brain is like “a work in progress, trillions of neurons waiting to be wired . . . to be woven into the intricate tapes- try of the mind” (Begley, 1996, pp. 55–56). Some

of the neurons of the brain have been hard- wired by genes, but trillions more have almost limitless potential and are waiting to be con- nected by the influence of environment. The first 3 years of life, scientists have realized, are cru- cial in the development of the mind. The wir- ing of the brain—a process both of nature and of nurture, dubbed the “dual sculptors”—forms the connections that determine the ability to learn and the interest for learning different types of skills (Harrigan, 2007; Nash, 1997).

Thanks to modern technology, imaging ma- chines are revolutionizing the field of neurosci- ence. Functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) are being used to observe human brains in the very acts of thinking, feeling, and remember- ing (Kawamura, Midorikawa, & Kezuka, 2000; Monastersky, 2001; Speck et al., 2000; Yee et al., 2000). Amazing discoveries through brain scan- ning have been made, such as where the emotion of love resides in the brain. Although machines can measure the brain’s blood flow that supports nerve activity, no machines have been devel- oped to date that can read or interpret a per- son’s thoughts. The field of brain scanning still has far to go, but experts consider its potential to be incredible.

The trend in current studies is to focus on how separate parts of the brain interact while performing different tasks rather than focusing on only isolated regions of the brain associated with certain tasks (Monastersky, 2001). Research- ers have already reported that men and women use different clusters of neurons when they read than when their brains are less active. For exam- ple, Kawamura et al. (2000) focused on the cen- ter in the brain of a male patient for reading and writing music, which is located in the cerebrum. They concluded that the left side of the brain is involved in this type of task, just as it is for the ability to read and write language. Also, neuro- imaging studies have found that gender makes a difference in how the brain is connected (Gong, He, & Evans, 2011; Ingalhalikar et al., 2014).

In addition, gender differences in the level of brain activity during working memory—an

318 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

important component for performing many higher functions—have been examined with fMRI. For example, in a study of verbal working memory by Speck et al. (2000), the amount of brain ac- tivity was found to increase with task difficulty. Interestingly, male subjects demonstrated more right-sided hemispheric dominance, whereas fe- males showed more left-sided hemispheric dom- inance. Females, though, demonstrated higher accuracy and slightly slower reaction times in doing the tasks than did males. The results re- vealed significant gender differences in the brain’s organization for working memory.

In general, the brains of men and women seem to operate differently. Studies have re- vealed that women use more of their brains when thinking sad thoughts. When men and women subjects were asked to recall sad memo- ries, the front of the limbic system in the brains of women glowed with activity eight times more than in men. Although men and women have been able to perform equally well in math prob- lems, tests indicate that they seem to use the tem- poral lobes of the brain differently to figure out problems. Also, men and women use different parts of their brains to figure out rhymes. These study results are just a few examples of early yet interesting findings from research that are be- ginning to show that male and female identity is a creation of both nature and nurture. Along with genetics, life experiences and the choices men and women make over the course of a life- time help to mold personal characteristics and determine gender differences in the way people of all genders think, sense, and respond (Beg- ley, Murr, & Rogers, 1995).

In comparing how men and women feel, act, process information, and perform on cognitive and psychological tests, scientists have been able to identify differences in the actual brain chem- istry and structure of humans (TABLE 8-1). Most structural differences that have been uncovered are relatively small, as measured statistically, but quite significant from a functional standpoint (Cahill, 2014a).

This comparison in brain structure varia- tions seems to account better for psychological

gender than simple biological sex differences (Eliot, 2009; Ruigrok et al., 2014). In fact, the gap in differences between adult women and men is larger than between girls and boys. This sug- gests that if differences between the sexes ap- pear early in life, they are likely to be biological in nature, and those gender differences that ap- pear later in adulthood development are likely shaped by the environment resulting from so- cial learning (Eliot, 2009).

Thus, a great deal of overlap exists in terms of how the brains of the sexes work. Otherwise, “women could never read maps and men would always be left-handed. That flexibility within the sexes reveals just how complex a puzzle gen- der actually is, requiring pieces from biology, sociology, and culture” (Gorman, 1992, p. 44).

With respect to brain functioning, a mix- ture of the factors of heredity and environment likely accounts for gender characteristics. Nev- ertheless, even the largest differences in gen- der-related cognitive abilities are not as significant as, for example, the disparity found between male and female height. The following is a comparison of cognitive abilities between females and males in the United States based on developmental and educational psychology findings and biomedical research.

Cognitive Abilities General Intelligence Various studies have yielded inconsistent find- ings on whether males and females differ in gen- eral intelligence. If any gender differences do exist, they seem to be attributed to patterns of ability rather than to IQ (intelligence quotient). When mean intellectual differences have been noted, they have proved minimal (Ardila, Roselli, Matute, & Inozemtseva, 2011; Kimura, 1999). Intelligence is multifaceted, but the unanimous consensus is that men and women do not differ in general intelligence (Reilly, 2012). However, what is well documented is the strong correla- tion between IQ and heredity. That is, if parents are intelligent, their offspring also are likely to

Gender Characteristics 319

TABLE 8-1 Differences in Brain Structure

Brain Structure Men Women

Temporal Lobe

Regions of the cerebral cortex help to control hearing, memory, and a person’s sense of self and time.

In cognitively normal men, a small region of the temporal lobe has approximately 10% fewer neurons than it does in women.

More neurons are located in the temporal region where language, melodies, and speech tones are understood.

Corpus Callosum

The main bridge between the left and right brain contains a bundle of neurons that carry messages between the two brain hemispheres.

This part of the brain in men takes up less volume than in women which suggests less communication between the two brain hemispheres.

The back portion of the callosum in women is bigger than that in men, which may explain why women use both sides of their brains for language.

Amygdala

This is the part of the brain that processes fear, triggers action, and signals danger.

In males, this part of the brain is larger and has testosterone receptors that heighten aggressive responses to compete and fight.

Women’s hormone receptors in this part of the brain lead them to seek safety and connections within a group.

Prefrontal Cortex

Along with the subdivision area known as the straight gyrus, this area of the brain is involved in social cognition and interpersonal awareness.

The straight gyrus in men is smaller, which reduces their social awareness and empathy.

The straight gyrus is 10% larger in women and correlates with their increased social perceptions and sensitive nurturing.

Anterior Commissure

This collection of nerve cells, smaller than the corpus callosum, also connects the brain’s two hemispheres.

The commissure in men is smaller than in women, even though men’s brains are, on average, larger in size than women’s brains.

The commissure in women is larger than it is in men, which may be a reason why their cerebral hemispheres seem to work together on tasks from language to emotional responses.

320 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

Brain Structure Men Women

Hippocampus

This area of the brain is the center for memory and emotion.

Males have more specifically organized but fewer neuron connections and so take longer to process emotional information.

Females have a higher density of and more activity in neural connections that allow them to absorb more sensory and emotional information.

Brain Hemispheres

The left side of the brain controls language, and the right side of the brain is the seat of emotion.

The right hemisphere of men’s brains tends to be dominant.

Women tend to use their brains more holistically, calling on both hemispheres simultaneously.

Brain Size

Total brain size is approximately 3 pounds.

Men’s brains, on average, are larger than women’s.

Women have smaller brains, on average, than men because the anatomic structure of their entire bodies is smaller. However, they have more neurons than men (an overall 11%) crammed into the cerebral cortex.

Data from Begley, S., Murr, A., & Rogers, A. (1995, March 27). Gray matters. Newsweek, 48–54; Eliot, L. (2009, September 8). Girl brain, boy brain? Scientific American. Retrieved from http://www.scientificamerican.com/article/girl-brain-boy-brain/; Jantz, G. L. (2014, February 27). Brain differences between genders: Do you ever wonder why men and women think so differently? Retrieved from https://www.psychologytoday.com/blog/hope -relationships/201402/brain-differences-between-genders; O’Brien, G. (2008). Understanding ourselves: Gender differences in the brain. Retrieved from http://neuronbits.blogspot.com/2015/12/understanding-ourselves-gender.html.

be (Santrock, 2017). On IQ tests during pre- school years, girls score higher; in high school, boys score higher on these tests. These differ- ences may be attributed to higher dropout rates in high school for low-ability boys and gender identity formation in adolescence. Thus, over- all no dramatic differences between the sexes have been found on measures of general in- telligence (Crandell et al., 2012; Snowman & McCown, 2015; Upadhayay & Guragain, 2014).

Nevertheless, a very interesting trend in IQ scores has been noted. IQs (as measured by the

Stanford–Binet intelligence test) are increasing rapidly worldwide. In the United States, chil- dren seem to be getting smarter. As compared with IQs tested in 1932, if people took the same test today, a large percentage would score much higher. Because this increase has occurred over such a relatively short time, heredity cannot be the cause. Instead, increasing levels of educa- tion and the information-age explosion likely explain the trend. This increase in IQ scores is known as the Flynn effect after the researcher who discovered it (Santrock, 2017).

Gender Characteristics 321

small (only about 5% variation) in spatial abil- ity (Gur et al., 2000).

Interestingly, women surpass men in the ability to recognize and later recall the loca- tion of objects in a complex, random pattern (Kimura, 1999). Scientists have reasoned that historically men may have developed strong spatial skills to be successful hunters, whereas women may have needed other types of visual skills to excel as gatherers of nearby sources of food (Gorman, 1992).

Although acknowledging that spatial ability differences are the most persistent finding in the cognitive literature and that the roles of nature (heredity) and nurture (environment) remain hotly debated in the scientific world, Hoffman, Gneezy, and List (2011) argue that the gender gap in the underrepresentation of women in sci- ence, technology, engineering, and math (STEM) fields is a result of the indirect role of nurture. Males typically are given more opportunity for relevant spatial skills training and females are persistently negatively stereotyped as having in- ferior spatial abilities, which leads to their in- creased and decreased performance respectively.

Problem Solving The complex concepts of problem solving, cre- ativity, and analysis, when examined, have led to mixed findings regarding gender differences in these skills. Men tend to try new approaches in problem solving and are more likely to be more focused on important cues and common fea- tures in certain learning tasks. Males also show more curiosity and are significantly less con- servative than women in risk-taking situations. In human relations, however, women perform better at problem solving than do men (Cran- dell et al., 2012).

School Achievement Without exception, girls get better grades on average than boys, particularly at the elemen- tary school level. Scholastic performance of girls is more stable and less fluctuating than that of boys (Crandell et al., 2012; Santrock, 2017;

Verbal Ability Girls learn to talk, form sentences, and use a va- riety of words earlier than boys. In addition, girls speak more clearly, read earlier, and do consis- tently better on tests of spelling and grammar. Originally, researchers believed females per- formed verbally at a higher level than males, but recent research has questioned this early superiority of females. On tests of verbal rea- soning, verbal comprehension, and vocabulary, the findings are not consistent. The conclusion is that no significant gender differences in ver- bal ability exist (American Psychological Asso- ciation [APA], 2014).

Mathematical Ability During the preschool years, there appear to be no gender-related differences in ability to do mathematics. By the end of elementary school, however, boys show signs of excelling in math- ematical reasoning, and the differences in math abilities of boys relative to girls become even greater in high school. Recent studies reveal that any male superiority may be related to the way math is traditionally taught—as a compet- itive individual activity rather than as a coop- erative group learning endeavor. Women have been shown to have a higher level of math anx- iety, using up working memory resources in the brain, leading to underperformance on math tests (APA, 2014; Ganley & Vasilyeva, 2014).

Spatial Ability The ability to recognize a figure when it is ro- tated, to detect a shape embedded in another figure, or to accurately replicate a three-di- mensional object has consistently been found to be better among males than among females. Of all possible gender-related differences in cognitive activity, the spatial ability of males is consistently better than that of females and probably has a genetic origin. Many research findings have shown that men do perform bet- ter on spatial tasks than women. However, the magnitude of this gender difference is still quite

322 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

2005). The role of the sex-specific hormone tes- tosterone has been cited as a possible cause of the more aggressive behavior demonstrated by males (Kimura, 1999). However, anthropolo- gists, psychologists, sociologists, and scientists in other fields continue to disagree about whether aggression is biologically based or environmen- tally influenced. Nevertheless, male and female roles differ widely in most cultures, with males usually being more dominant, assertive, active, hostile, and destructive.

Conformity and Dependence Females have been found generally to be more conforming and more influenced by sugges- tion. The gender biases of some studies have left these findings open to suspicion, however.

Emotional Adjustment The emotional stability of the genders is ap- proximately the same in childhood, but differ- ences do arise in how emotional reactions are displayed. Research has revealed many differ- ences in the way males and females “detect, pro- cess, and express” emotion (Thompson, 2010, p. 1). For example, a study of 55 cultures found that women tend to be more emotional, better perceive verbal and visual emotional cues, and respond with greater sadness than men. On the other hand, men are more likely to be less extro- verted and conscientious, react to stress by show- ing an increase in blood pressure, and experience love and anger less intensely than women. These differences may be a result of cultural expecta- tions, social stereotyping, and heredity. Never- theless, emotional reactions of women have a direct effect on their physical and mental health. Women tend to be at greater risk for depression, anxiety, and mood disorders, and men are at greater risk for hypertension, substance abuse, and antisocial behavior (Larkin, 2013).

Evidence indicates that adolescent girls and adult females have more neurotic symptoms than males. However, this tendency may reflect how so- ciety defines mental health in ways that coincide

Snowman & McCown, 2015). The female advan- tage in school achievement in most course sub- jects is a common finding in educational studies, but the identification of relevant variables con- tributing to this gender difference must be fur- ther explored (Voyer & Voyer, 2014).

In conclusion, research data from meta-anal- yses of hundreds of studies involving millions of participants indicate that perceived or actual differences in cognitive performance among the sexes are most likely caused by social and cul- tural factors not biological factors. That is, cog- nitive abilities are culturally mediated (nurture) rather than gender differences being attributed to innate abilities (nature). If males and females were treated as intellectual equals via gender equity measures in grade schools, colleges and universities, workplaces, and social settings in general, then individuals and society would benefit (APA, 2014; Reilly, 2012). Despite this conclusion, scientists continue to debate about how much, not whether, biology contributes to differences in the cognitive functioning of male and female brains (Nixon, 2012).

Although no compelling evidence proves significant gender-linked differences in the ar- eas of cognitive functioning, except possibly in spatial ability, some findings do reveal gender differences when it comes to personality char- acteristics of males and females in the United States. Evidence reported by Crandell et al. (2012), Santrock (2017), and Snowman and McCown (2015), unless otherwise noted, substantiates the following summary findings.

Personality Traits Most observed gender-related personality behaviors are thought to be largely deter- mined by culture but are, to some extent, a re- sult of mutual interaction between environment and heredity.

Aggression Males of all ages and of most cultures are gener- ally more aggressive than females (Baron-Cohen,

Gender Characteristics 323

Tejada-Vera, 2016). However, more needs to be understood about women’s health, because for years their health issues have been underrep- resented in research studies. Fortunately, this trend has changed within the last 2 to 3 decades, and significant evidence is beginning to surface about the physical and mental health status of females (DeCola, 2012; Dignam, 2000; U.S. De- partment of Health and Human Services [US- DHHS], 2012).

One point that is known is that women are likely to seek health care more often than men do (U.S. Census Bureau, 2012a). It is suspected that one of the reasons women have more con- tact with the healthcare system is that they traditionally have tended to be the primary caretakers of their children, who need pediat- ric services. In addition, during their childbear- ing years, cisgender women seek health services for care surrounding pregnancy and childbirth (Smith, 2006). However, other variables—such as sociodemographics and health status—come into play to account for gender differences in the use of healthcare services (Bertakis, Azari, Helms, Callahan, & Robbins, 2000; Courtenay, 2000; Kaiser Family Foundation, 2015; Regitz- Zagrosek, 2012). Furthermore, Falk et al. (2016) found that females report higher levels of symp- tom distress (pain, fatigue, and nausea) than men likely because women receive less attention and symptom alleviation than men, which in- dicates serious inequality in care.

Perhaps the reason that men tend not to rely as much as women on care from health provid- ers is the gender-role expectation by our soci- ety that men should be stronger. They also tend to be risk takers and to think of themselves as more independent. Although men are less likely to pursue routine health care for purposes of health and safety promotion and disease and accident prevention, they typically face a greater number of health hazards, such as a higher in- cidence of automobile accidents, use of drugs and alcohol, suicide, heart disease, and par- ticipation in dangerous occupations. Further- more, men are less likely to notice symptoms or report them to physicians (Courtenay, 2000).

with male roles. In addition, tests to measure men- tal health usually have been designed by men and, therefore, may be biased against females.

Values and Life Goals In the past, men have tended to show greater in- terest in scientific, mathematical, mechanical, and physically active occupations as well as to express stronger economic and political values. Women have tended to choose literary, social service, and clerical occupations and to express stronger aesthetic, social sense, and religious val- ues. These differences have become smaller over time, however, as women have begun to think differently about themselves, women have more freely pursued career and interest pathways, and society has begun to take a more equal- opportunity viewpoint for people of all genders.

Achievement Orientation Females are more likely to express achievement motivation in social skills and social relations, whereas men are more likely to try to succeed in intellectual or competitive activities. This differ- ence is thought to reflect gender-role expectations that are strongly communicated at very early ages.

The behavioral and biological differences between males and females, known as the gen- der gap, are well documented. Also, well doc- umented is gender bias, “a preconceived notion about the abilities of women and men that prevented individuals from pursuing their own interests and achieving their potentials” (Santrock, 2006, p. 66). How do these differences in gender characteristics of cognitive functioning and personality attributes relate to the health- care needs of patients and the process of engag- ing them in teaching and learning?

With respect to gender differences and ag- ing, as suggested by current life-span mortality rates, white females have a life expectancy of approximately 80 years compared to approxi- mately 73 years for white males. Also, men have higher mortality rates for each of the 10 lead- ing causes of death (Kochanek, Murphy, Xu, &

324 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

of tobacco, alcohol, and drug use among the LGBTQ population as well as a high incidence of depression, anxiety, suicide, and other mental health problems (Livingston et al., 2015; Woodiel & Cowdery, 2014).

2. Structural barriers decrease access to health care for people who are LGBTQ (Mayer et al., 2008). For example, unemployment in the LGBTQ community resulting from job discrimination and lack of insur- ance benefits for same-sex domestic partners have led to a higher than average number of people without health insurance coverage (Gonzales, 2014; Krehely, 2009).

3. Lack of culturally appropriate care for the LGBTQ community results in limited or ineffective use of healthcare services. For example, to avoid negative interactions with healthcare providers, LGBTQ pa- tients—particularly bisexual men and women—are often reluctant to disclose their sexual orientation or gender identity. Without this vital piece of information, nurses and other health professionals are unable to provide comprehensive care. Other members of the LGBTQ community simply avoid seeking health care unless it is of absolute necessity. As a result, they may not take advantage of preventive services or receive early treatment for serious health problems (Durso & Meyer, 2012; McRae, Ochsner, Mauss, Gabrieli, & Gross, 2008).

Teaching Strategies Davidson, Trudeau, van Roosmalen, Stewart, and Kirkland (2006) describe gender as a “mul- tifaceted construct” (p. 731) that includes mod- ifiable attributes that influence health outcomes and health education. These attributes include

Sexual Orientation and Gender Identity The exact number of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals in the United States and around the world is unknown; however, this population is estimated to include more than 8 million people in this country alone (Fenway Institute, 2010). This number is based on U.S. Census data and represents a very conservative estimate of the LGBTQ population. Although the U.S. Census does gather information on same-sex couples, it does not ask questions about sexual orienta- tion or gender identity (Gates, 2013). There- fore, single gays and lesbians are not identified in U.S. Census data, nor are members of the transgender community. Because of hesitancy on the part of many members of the LGBTQ population to disclose their sexual orientation and/or gender identity, underrepresentation is always an issue.

When considering gender and the social and other factors that influence the unique learn- ing styles and educational needs of men and women, it is important to include the LGBTQ community. The LGBTQ population represents a distinct cultural group whose needs are often overlooked by nurses and other health profes- sionals (American Medical Student Association, 2015; Sullivan, Guzman, & Lancellotti, 2017). Although members of the LGBTQ population have many of the same health problems as the general population, disparities do exist, and as a group, their health outcomes are worse than those of the heterosexual community (Centers for Disease Control and Prevention [CDC], 2014; Krehely, 2009).

Three main problems contribute to the health disparities experienced by the LGBTQ population:

1. The social stigma associated with being LGBTQ creates undue stress and contributes to negative health behavior patterns. For example, re- search has identified increased rates

Gender Characteristics 325

displays photos of only traditional families may give the message that nontraditional families are not welcome. Brochures on LGBTQ health issues and unisex bathrooms are all strategies that give a welcoming message to a diverse patient base.

When working with men and women, it is important that the nurse avoid making assump- tions about family structure, sexual orientation, or lifestyle. Many families are structured differ- ently in the 21st century from families in years past. For example, more men are assuming pri- mary responsibility for child care. The nurse should never assume that a patient is hetero- sexual, even if that person is or has been mar- ried to a member of the opposite gender, as almost half of self-identified lesbians have been or are currently married to men (Fenway Insti- tute, 2010). Likewise, the nurse should not as- sume that when a person refers to a spouse that he or she is talking about a member of the op- posite gender. As more and more states are le- galizing same-sex marriage, married members of the LGBTQ community are frequently using the term husband or wife rather than partner.

To complete an accurate assessment of ev- ery individual, the nurse should take the op- portunity to gather accurate information from the patient. Admission or intake forms are of- ten designed for the traditional family. Patients are often not given an opportunity to identify a same-sex domestic partner. Transgender patients are usually forced to select either male or female with no room for elaboration. By adjusting the forms to be more inclusive, the nurse not only creates a welcoming environment but also offers an opportunity for the patient to share import- ant information. Nurses also must be knowl- edgeable about gender-related health disparities and are encouraged to include this information when educating patients. They also are encour- aged to use versatile teaching-style strategies so as not to perpetuate stereotypical approaches to teaching and learning with people of all genders.

In 2011, the Institute of Medicine (IOM) recommended educating healthcare providers about LGBTQ issues, which has resulted in more attention being paid by educational and

personality, social supports, coping skills, val- ues, and health-related behaviors. When plan- ning teaching strategies, nurses must be aware of the extent to which attributes such as these, as well as heredity-related characteristics, affect health-seeking behaviors and influence individ- ual health needs. As stated previously, in some areas males and females display different ori- entations and learning styles (Severiens & Ten Dam, 1994, 1997; Wehrwein, Lujan, & DiCarlo, 2007). The precise differences seem to depend on interests and past experiences in the bio- logical and social roles of men and women in American society.

Women and men are part of different social cultures, too. They use different symbols, belief systems, and ways to express themselves, much in the same manner that different ethnic groups exhibit distinct cultures. In the future, these gen- der differences may become less pronounced as the gender roles become more blended.

Language and symbols are also very important to the LGBTQ community. The most commonly employed symbols of the LGBTQ community are the pink triangle and the rainbow pride flag. These symbols, which are used by this commu- nity as a show of pride and unity, are often dis- played in healthcare settings as a sign of welcome to LGBTQ patients (Woodiel & Cowdery, 2014).

It is also important that nurses become fa- miliar with the labels, terms, and phrases pre- ferred by the LGBTQ community and use them appropriately in conversation and in preparing teaching materials. Language and culture con- tinually change, so the nurse must work toward remaining current. For example, although the word queer was once considered derogatory, in recent years, many within the LGBTQ commu- nity have embraced the term and use it proudly.

When serving in the role of educator, nurses must create an environment that is welcoming to all men and women regardless of gender identity or sexual orientation. Members of the LGBTQ community look for subtle clues to determine whether the nurse will accept them without judgment (Woodiel & Cowdery, 2014). For ex- ample, a women’s or children’s health clinic that

326 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

and family structure (Crandell et al., 2012; Willingham, 2012). Geography also matters be- cause the right mix of efforts to influence habits and to improve public health have the potential to affect longevity depending on where someone lives. In addition, income levels are a major fac- tor influencing a person’s life span. In the United States, the richest people live longer everywhere and the poor have the shortest life spans no mat- ter whether they reside in big or small cites, sub- urban, or rural areas. Between 2001 and 2014, the gap in life spans widened between the rich and the poor. For those with the very highest incomes, men and women live 15 and 10 years longer respectively than the very poorest Americans (Irwin & Bui, 2016). Globally, people with low SES are 46% more likely to die early than are their wealthier counterparts (Brogan, 2017).

Collectively, these many variables influence health beliefs, health practices, and readiness to learn (Darling, 2004; Mackenbach et al., 2003; World Health Organization [WHO], 2017). The determinants of health include the following fac- tors (WHO, 2017):

■ the social and economic environment ■ the physical environment ■ the individual characteristics and behaviors

of people

Although many educators, psychologists, and sociologists have recognized that a cause- and-effect relationship exists among low SES and low cognitive ability, poor quality of phys- ical and mental health, and quality of life, they are hard pressed to suggest realistic solutions for breaking this cycle (APA, 2017; Batty, Deary, & Macintyre, 2006). Likewise, nurses well rec- ognize that patients belonging to lower social classes have higher rates of illness, more severe illnesses, and reduced rates of life expectancy (Mackenbach et al., 2003). People with low SES, as measured by indicators such as income, ed- ucation, and occupation, have increased rates of morbidity and mortality compared to those with higher SES (USDHHS, 2012).

A significant relationship exists between SES and health status. Individuals who have

clinical practice settings to the knowledge, atti- tudes, and skills of health professionals in caring for members of the LGBTQ community (IOM, 2011). However, to date the nursing profession lacks research, theoretical frameworks, and practice guidelines to deliver culturally appro- priate care to meet the diverse healthcare needs of the LGBTQ population (Carabez, Pellegrini, Mankovitz, Eliason, & Dariotis, 2015). Also, Carabez, Eliason, and Martinson (2016) dis- covered a lack of understanding by staff nurses of the needs of transgender patients and chal- lenged nursing education to better prepare the nurse workforce to provide high-quality care to patients with different gender identities.

▸ Socioeconomic Characteristics

Socioeconomic status (SES), in addition to gender characteristics, influences the teaching– learning process. SES is considered the single most important determinant of both physical and mental health in our society (Crimmins & Saito, 2001; Meyer, Castro-Schilo, & Agular- Gaxiola, 2014; Singh-Manoux, Ferrie, Lynch, & Marmot, 2005). Socioeconomic class is an aspect of diversity that must be addressed in the context of education and in the process of teaching and learning.

Social and economic levels of individuals have been found to be significant variables affecting health status, literacy levels, and health behaviors (Crimmins & Saito, 2001; Monden, van Lenthe, & Mackenbach, 2006; Willingham, 2012). Over 46 million Americans (about 15% of the total population) live in poverty (U.S. Census Bureau, 2015). Poverty is defined as an income of $24,250 per year for a family of four (USDHHS, 2015b).

Disadvantaged people—those with low incomes, low educational levels, or social de- privation—come from many different ethnic groups, including millions of poor white people (USDHHS, 2012). SES accounts for the variables of educational level, family income, occupation,

Socioeconomic Characteristics 327

poorer health status, high unemployment, low earnings, and high rates of welfare dependency, all of which are common measures of a soci- ety’s economic well-being (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011; Weiss, 2007).

Whatever the factors are that keep certain groups from achieving at higher levels, these groups are likely to remain on the lower end of the occupational structure. This continu- ous circle of entrapment has been coined the poverty cycle (circle of poverty) and is de- scribed as a phenomenon whereby poor fami- lies become trapped in poverty for generations because of economic, social, and geographical factors that perpetuate new cycles and a seem- ingly endless continuation of being impover- ished (Payne, 2013).

The lower socioeconomic class has been stud- ied by social scientists more than other economic classes. This research focus probably arises be- cause the health views of this group of individ- uals deviate the most from the viewpoints of the health professionals who care for them. People from the lower social stratum have been char- acterized as being indifferent to the symptoms of illness until poor health interferes with their lifestyle and independence. Their view of life is one of a sense of powerlessness, meaninglessness,

higher incomes and are better educated live longer and healthier lives than those who are of low income and poorly educated (Brogan, 2017; Rognerud & Zahl, 2005; Schanzenbach, Nunn, & Bauer, 2016; Zimmerman, Woolf, & Haley, 2015). Thus, the level of socioeconomic well-being is a strong indicator of health out- comes. FIGURE 8-1 illustrates the relationship be- tween SES and health status.

These findings raise serious questions about health differences among people of the United States resulting from unequal access to health care due to SES. These unfortunate health trends are costly to society in general and particularly to the healthcare system. Although harmful health- related behaviors and less access to medical care have been found to contribute to higher mor- bidity and mortality rates, the research is limited on the effect SES has on a disability-free life or active life expectancy (Crimmins & Saito, 2001; Mackenbach et al., 2003).

Crandell et al. (2012) and Santrock (2017) explain that many factors, including poor health care, limited resources, family stress, discrimina- tion, and low-paying jobs, maintain the cycle by which generation after generation is born into poverty. In addition, rates of illiteracy, low liter- acy, and low health literacy have been linked to

Income Less Than Poverty

Level

Income 1 > 2X Poverty Level

Income 2 > 3X Poverty Level

Income 3 > 4X Poverty Level

Income 4X Poverty Level or

Greater

FIGURE 8-1 Percentage of persons with perceived fair to poor health status by income level. Reproduced from U.S. Census Bureau. (2010b). United States 2010 census. Retrieved from https://www.census.gov/2010census/.

328 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

associated with illness that result in overuse of the healthcare system have resulted in increased interest on the part of the public and healthcare providers to control costs (Carpenter, 2011). To- day, more emphasis is being given to keeping people well by efforts aimed at health promo- tion, health maintenance, and disease prevention.

Teaching Strategies The current trends in health care reflecting these socioeconomic concerns are directed toward teaching individuals how to attain and maintain health. The nurse plays a key role in educating the consumer about avoiding health risks, re- ducing illness episodes, establishing healthful environmental conditions, and accessing health- care services. Patient education by nurses for those individuals who are deprived socially and eco- nomically has the potential to yield short-term benefits in meeting these individuals’ immediate healthcare needs. However, more research must be done to determine whether teaching can en- sure the long-term benefits of helping people of low SES develop the skills needed to reach and sustain independence in self-care management (Adams, 2010; Grønning, Rannestad, Skomsvoll, Rygg, & Steinsbekk, 2014; Niedermann, Fran- sen, Knols, & Uebelhart, 2004).

Nurses must be aware of the likely effects of low SES on an individual’s ability to learn because of less than average cognitive functioning, poor academic achievement, low literacy, high suscep- tibility to illness, and inadequate social support systems. Low-income people are at greater risk for these factors, all of which can interfere with learning. Stress hormones caused by poverty, for example, have been shown to “poison the brain for a lifetime” (Krugman, 2008; Lende, 2012). However, what is probably most important is to prevent the effects of poverty in the first place by breaking the vicious generational poverty cycle. Some select approaches, known as two-genera- tional programs, have demonstrated long-term success in achieving better educational outcomes, improved social benchmarks, and greater em- ployment opportunities for children born into

and isolation from middle-class knowledge of health and the need for preventive measures, such as vaccination for their children (Lipman, Offord, & Boyle, 1994; Maholmes & King, 2012; USDHHS, 2012).

The high cost of health care may well be a major factor affecting health practices of peo- ple in the lower socioeconomic classes. Lack of health insurance remains an important factor influencing health status in the United States, particularly among the poor. However, the Af- fordable Care Act, which was signed into law in 2010, is beginning to show an impact on access to health care for all Americans. Whereas the number of Americans without health insurance was over 17% in recent years (O’Hara & Caswell, 2012), the National Health Interview Survey con- ducted in 2014 revealed that this number has dropped to around 13%. Of those adults under 65 years of age, 17.7% were covered by a public health insurance plan and 67.3% with a private plan (Ward, Clarke, Freeman, & Schiller, 2015).

Just as SES can have a negative effect on illness, so, too, can illness have devastating im- plications for a person’s socioeconomic well- being (Elstad & Krokstad, 2003). A catastrophic or chronic illness can lead to unemployment, enforced social isolation, and a strain on so- cial support systems (Lindholm, Burstrom, & Diderichsen, 2001; Mulligan, 2004). Without the socioeconomic means to decrease these threats to their well-being, individuals in pov- erty may be powerless to improve their situa- tion. According to Health Poverty Action (2017) “poverty is both a cause and a consequence of poor health” (p. 1). Poverty often leads to poor health and poor health can trap someone in poverty, which is sometimes referred to as sit- uational poverty (Payne, 2013). As such, people with good health tend to move up in the so- cial hierarchy, whereas those with poor health move downward.

These multiple losses burden the individ- ual, their families, and the healthcare system. Low-income groups are especially affected by changes in federal and state assistance in the form of Medicare and Medicaid. The high costs

Socioeconomic Characteristics 329

To keep pace with a society that is becom- ing increasingly more culturally diverse, nurses need to have sound knowledge of the cultural values and beliefs of specific subcultural ethnic groups as well as incorporate transcultural nurs- ing into practice by recognizing and appreciat- ing differences in individual healthcare customs and preferences (Maier-Lorentz, 2008; Price & Cortis, 2000; Purnell, 2013). Lack of cultural sensitivity by nurses and other healthcare pro- fessionals has the potential to waste millions of dollars through misuse of healthcare services and misdiagnosis of health problems with tragic and dangerous consequences. Furthermore, cultural sensitivity may serve to reduce the racial and eth- nic bias perceived by culturally diverse patients in healthcare settings and minimize the alien- ation of large numbers of people (Benjamins & Whitman, 2014; Nguyen & Mills, 2014).

Underrepresented ethnic groups are begin- ning to demand culturally relevant health care that respects their cultural rights and incorpo- rates their specific beliefs and practices into the care they receive. This expectation is in direct conflict with the unicultural, Western, biomedi- cal paradigm taught in many nursing and other healthcare provider programs across the coun- try (Purnell, 2013).

Definition of Terms Before examining the major subcultural ethnic groups within the United States, it is import- ant to define the terms, as identified by Purnell (2013), that are commonly used in addressing the subject of culture (BOX 8-1).

▸ Assessment Models for the Delivery of Culturally Sensitive Care

Given increases in immigration and the birth rates of minority populations in the United

low-income families. Not only are these children provided with free high-quality, early childhood education from infancy through age 5 but their parents are given assistance in finding better jobs and learning parenting skills to build stronger families (Semuels, 2014).

Nurses should not assume, though, that everyone at the poverty or near-poverty level is equally influenced by these threats to their well-being. To avoid stereotyping, it is essential that every individual and family be assessed to determine their strengths and weaknesses for learning. In this way, teaching strategies unique to specific circumstances can be designed to as- sist socioeconomically deprived individuals in meeting their needs for health care.

Nevertheless, it is well documented that individuals with literacy problems, poor edu- cational backgrounds, and low academic achieve- ment are likely to have low self-esteem, feelings of helplessness and hopelessness, and low ex- pectations. Also, they tend to think in concrete terms, to focus more on satisfying immediate needs, to have a more external locus of control, and to have decreased attention spans. They of- ten have difficulty in solving problems and in analyzing and summarizing large amounts of information. The nurse will most likely have to rely on specific teaching methods and tools identified as appropriate when intervening with patients who have low literacy abilities.

▸ Cultural Characteristics The racial makeup of the United States continues to undergo change. At the beginning of the 21st century, the composition of this nation’s popula- tion was approximately 71.3% white and 28.7% minority. By 2012, minority representation in the country grew to 37%. It is anticipated that the minority population will continue to steadily in- crease in the coming decades. By 2043, it is pro- jected that there will be no majority group in the United States and that by 2060, minority groups will constitute 57% (241.3 million people) of the U.S. population (U.S. Census Bureau, 2012b).

330 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

Reproduced from Purnell, L. D. (2013). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F. A. Davis. Reproduced with permission of F. A. Davis.

BOX 8-1 Purnell’s Definition of Terms

Acculturation: A willingness to adapt or “to modify one’s own culture as a result of contact with another culture” (p. 481).

Assimilation: The willingness of an individual or group “to gradually adopt and incorporate characteristics of the prevailing culture” (p. 481).

Cultural awareness: Recognizing and appreciating “the external signs of diversity” in other ethnic groups, such as their art, music, dress, and physical features (p. 482).

Cultural competence: Possessing the “knowledge, abilities, and skills to deliver care congruent with the patient’s cultural beliefs and practices” (p. 7).

Cultural diversity: A term used to describe the variety of cultures that exist within society. Cultural relativism: “The belief that the behaviors and practices of people should be judged only

from the context of their cultural system” (p. 482). Culture: “The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways,

and all other products of human work and thought characteristic of a population of people that guide their worldview and decision making. These patterns may be explicit or implicit, are primarily learned and transmitted within the family, and are shared by the majority of the cultures” (p. 482).

Ethnic group: Also referred to as a subculture; a population of “people who have experiences different from those of the dominant culture” (p. 483).

Ethnocentrism: “The tendency of human beings to think that [their] own ways of thinking, acting, and believing are the only right, proper, and natural ones and to believe that those who differ greatly are strange, bizarre, or unenlightened” (p. 483).

Ideology: “The thoughts, attitudes, and beliefs that reflect the social needs and desires of an individual or ethnocultural group” (p. 484).

Subculture: A group of people “who have had different experiences from the dominant culture by status, ethnic background, residence, religion, education, or other factors that functionally unify the group and act collectively on each other” (p. 486).

Transcultural: “Making comparisons for similarities and differences between cultures” (p. 8). Worldview: “The way individuals or groups of people look at the universe to form values about their

lives and the world around them” (p. 487).

States as well as the significant increased geo- graphical mobility of people around the globe, the U.S. system of health care and this country’s educational institutions must respond by shift- ing from a dominant, monocultural, ethnocen- tric focus to a more multicultural, transcultural focus (Narayan, 2003). To enhance the delivery of culturally relevant health care and to prepare culturally sensitive professionals, numbers of ma- jor textbooks are available (Andrews & Boyle, 2015; Giger, 2016; Leininger, 2002; Purnell, 2013) and for almost 3 decades the Journal of Transcul- tural Nursing has been publishing theoretical and

research findings for application to practice by staff nurses, nurse educators, and nurse research- ers. These texts and journal articles are con- stant sources of useful information for nurses that assist in raising their awareness of the dis- tinct customs, beliefs, values, and perspectives of many nationalities and races worldwide that constitute the primary ethnic subgroups.

Leininger (1994), a noted proponent of transcultural nursing, posed a question that re- mains relevant today: How can nurses compe- tently respond to and effectively care for people from diverse cultures who act, speak, and behave

Assessment Models for the Delivery of Culturally Sensitive Care 331

3. Workforce issues (e.g., language bar- riers, autonomy, acculturation)

4. Biocultural ecology (e.g., heredity, biological variations, genetics)

5. High-risk behaviors (e.g., smoking, alcoholism, physical activity, safety practices)

6. Nutrition (e.g., common foods, rituals, deficiencies, limitations)

7. Pregnancy (e.g., fertility, practices, views toward childbearing, beliefs about pregnancy, birthing practices)

8. Death rituals (e.g., views of death, bereavement, burial practices)

9. Spirituality (e.g., religious beliefs and practices, meaning of life, use of prayer)

10. Healthcare practices (e.g., traditions, responsibility for health, pain con- trol, sick role, medication use)

11. Healthcare practitioners (e.g., folk practitioners, gender issues, percep- tions of providers)

12. Overview/heritage (e.g., origins, eco- nomic status, education, occupation)

Purnell has also identified 19 assumptions upon which the model is based, of which the fol- lowing are most relevant to this chapter:

■ One culture is not better than another— they are just different.

■ The primary and secondary characteristics of culture determine the degree to which one varies from the dominant culture.

■ Culture has a powerful influence on one’s interpretation of and responses to health care.

■ Every individual has the right to be respected for his or her uniqueness and cultural heritage.

■ Prejudices and biases can be minimized with cultural understanding.

■ Caregivers who intervene in a culturally com- petent manner improve the care of patients and their health outcomes.

■ Cultural differences often require adap- tations to standard professional practices.

in ways different than their own? Studies indi- cate that nurses are often unaware of the com- plex factors influencing patients’ responses to health care.

The Purnell model for cultural competence represents a popular organizing framework for understanding the complex phenomena of cul- ture and ethnicity (Purnell, 2013). This frame- work “provides a comprehensive, systematic, and concise” approach that can assist health profes- sionals to provide “holistic, culturally compe- tent” (p. 15) care when teaching patients in a variety of practice settings.

Purnell (2013) has proposed that many fac- tors influence an individual’s identification with an ethnic group. These factors may be distin- guished as primary and secondary character- istics of culture. Primary characteristics of culture include nationality, race, color, gen- der, age, and religious affiliation. Secondary characteristics of culture include many of a person’s attributes that are addressed in this text, such as SES, physical characteristics, edu- cational status, occupational status, and place of residence (urban versus rural). These two major characteristics affect one’s belief system and view of the world.

The Purnell model, depicted in a circle for- mat, includes the layers of the following concepts:

1. Global society (outermost sphere) 2. Community (second sphere) 3. Family (third sphere) 4. Individual (innermost sphere)

The interior of the circle is cut into 12 equally sized, pie-shaped wedges that repre- sent cultural domains that should be assessed when planning to deliver patient education in any setting:

1. Communication (e.g., dominant lan- guage and nonverbal expressions and cues)

2. Family roles and organization (e.g., head of household, gender roles, de- velopmental tasks, social status, alter- native lifestyles, roles of older adults)

332 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

exist between what the nurse and patient think about health, illness, and treatments and at- tempts to bridge the gap between the scientific perspectives of the nurse and the cultural beliefs (known as popular perspectives) of the patient (Anderson, 1990). The nurse–client negotia- tions model serves as a framework to attend to the culture of the nurse as well as the culture of the patient. In addition to the professional culture, each nurse has his or her own personal beliefs and values, which may operate without the nurse being fully aware of them. These be- liefs and values may influence nurses’ interac- tions with patients and families.

Explanations of the same phenomena may yield different interpretations based on the cul- tural perspective of the layperson or the profes- sional. For example, putting lightweight covers

Other models for conducting a nursing as- sessment have also been proposed (Shen, 2015). Giger and Davidhizar’s (2004) transcultural as- sessment model was first developed in 1988 to teach nursing students how to provide appropri- ate care to culturally diverse patients. This model includes six cultural phenomena (Giger, 2016; Giger & Davidhizar, 2004) that serve as a frame- work to design and deliver culturally sensitive care: (1) communication, (2) personal space, (3) social organization, (4) time, (5) environmental control, and (6) biological variations (FIGURE 8-2).

Another model, the nurse–client negotia- tions model, was developed in the mid-1980s for purposes of cultural assessment and plan- ning for care of culturally diverse people. Al- though it is more than 30 years old, this model remains relevant. It recognizes differences that

CULTURALLY UNIQUE

INDIVIDUAL

1. Communication: Verbal, primary language, nonverbal

3. Social Organizations: Learned behaviors, culture specific, internally oriented values, religious beliefs, kinship decision making

5. Environmental Control: Locus of control, how health system is evaluated

6. Biological Variations: Body structure, genetics, physical attributes, psychological characteristics

2. Personal Space: Actions speak louder than words

4. Time: How time is viewed, concept of time

FIGURE 8-2 Six cultural phenomena. Modified from Giger, J. N., & Davidhizar, R. E. (1995). Transcultural nursing: Assessment and intervention (2nd ed.). St. Louis, MO: Mosby-Year Book.

Assessment Models for the Delivery of Culturally Sensitive Care 333

perspectives or viewpoints. The answers then serve as the basis for negotiation:

■ What do you think caused your problem? ■ Why do you think the problem started

when it did? ■ Which major problems does your illness

cause you? ■ How has being sick affected you? ■ How severe do you think your illness is?

Do you see it as having a short- or long- term course?

■ Which kinds of treatments do you think you should receive?

■ What are the most important results you hope to obtain from your treatments?

■ What do you fear most about your illness?

Nurses who are competent in cultural as- sessment and negotiation likely will be the most successful at designing and implementing cul- turally effective patient education. They also will be able to assist their colleagues in working with patients who may be considered uncoop- erative or noncompliant. Using active listen- ing skills to understand patients’ perspectives and using the universal skills of establishing rapport with them can help nurses to identify potential areas of cultural conflict and select teaching interventions that minimize such con- flict (Campinha-Bacote, 2011). Labeling of pa- tient behaviors, which may stem from cultural beliefs and practices, can negatively influence nurse–patient interactions (Anderson, 1987, 1990; Gutierrez & Rogoff, 2003).

Nurses must remember one very important caveat when conducting cultural assessments: They must be especially careful to avoid ste- reotyping patients based on their ethnic heri- tage. Just because someone belongs to a certain subculture does not necessarily mean that the person adheres to all the beliefs, values, cus- toms, and practices of that ethnic group. Nurses should never assume a patient’s learning needs or preferences for treatment will be like those of others who share the same ethnicity. Knowl- edge of different cultures should serve only as

on a patient may be interpreted by family mem- bers as placing their loved one at risk for getting a chill, whereas the nurse may use this technique to reduce a fever. As another example, a Jeho- vah’s Witness family considers a blood transfu- sion for their child to be contamination of the child’s body, whereas the nurse and other health- care team members believe the transfusion is a life-saving treatment (Anderson, 1987). The im- portant aspect of the nurse–client negotiations model is that it can open lines of communica- tion between the nurse and the patient/family. It helps each party understand how the other interprets or values a problem or practice such that they respect one another’s goals.

Negotiation implies a mutual exchange of information between the nurse and the patient. The nurse should begin this negotiation by learn- ing from the patients about their understanding of their situation, their interpretations of illness and symptoms, the symbolic meanings they at- tach to an event, and their notions about treat- ment. The goal is to actively involve patients in the learning process to help them acquire healthy coping skills and styles of living. Together, nurse and patient then need to work out how the popular and scientific perspectives can be com- bined to achieve goals related to the individual patient’s needs and interests (Anderson, 1990).

General areas to assess when first meeting the patient include the following:

1. The patient’s perceptions of health and illness

2. His or her use of traditional remedies and folk practitioners

3. The patient’s perceptions of nurses, hospitals, and the care delivery system

4. His or her beliefs about the role of family and family relationships

5. His or her perceptions of and need for emotional support (Anderson, 1987; Jezewski, 1993)

According to Anderson (1990) and Narayan (2003), the following questions can be used as a means for understanding the patient’s

334 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

that the values adhered to by professionals are equally important or cherished by the patient and family. Consideration, too, must be given to specific cultural influences that may hinder readiness to learn, such as perceptions of time, financial barriers, and environmental variables. Finally, the patient needs to believe that new be- haviors are not only possible but also beneficial for behavioral change to be maintained over the long term (Kessels, 2003).

Providing culture-specific programs and teaching interventions for children and adults from minority groups is both a practical and ethical need in the U.S. healthcare system. To adequately serve patients in a multiethnic so- ciety, attention must be focused on identifying cross-cultural barriers and delivering culturally effective health education. Studies have clearly shown that health outcomes are improved when education is appropriately given in the context of the individual (Bailey et al., 2009; Hawthorne, Robles, Cannings-John, & Edwards, 2008; Vi- daeff, Kerrigan, & Monga, 2015).

The following specific guidelines for as- sessment should be used regardless of the cul- tural orientation of the patient (Anderson, 1987; Uzundede, 2006):

1. Identify the patient’s primary langu age. Assess his or her ability to understand, read, and speak the language of the nurse.

2. Observe the interactions between the patient and his or her family. Determine who makes the decisions, how decisions are made, who is the primary caregiver, which type of care is given, and which foods and other objects are important.

3. Listen to the patient. Find out what the person wants, how his or her wants are different from what the family wants, and how they differ from what you think is appropriate.

4. Consider the patient’s communica- tion abilities and patterns. Note, for

background cues for gathering additional in- formation about individual variations through assessment.

General Assessment and Teaching Interventions Given that culture affects the way someone per- ceives a health problem and understands its course and possible treatment options, it is es- sential to carry out a thorough assessment prior to establishing a plan of action for short- and long-term behavioral change. Different cultural backgrounds not only create different attitudes and reactions to illness but also can influence how people express themselves, both verbally and nonverbally, which may prove difficult to interpret (Campinha-Bacote, 2003; Hodges & Segal, 2012). For example, asking a patient to explain what he or she believes to be the cause of a problem will help to reveal whether the pa- tient thinks it is because of a spiritual interven- tion, a hex, an imbalance in nature, or some other culturally based belief. The nurse should accept the patient’s explanation (most likely re- flecting the beliefs of the support system as well) in a nonjudgmental manner.

Culture also guides the way an ill person is defined and treated. For example, some cultures believe that once the symptoms disappear, illness is no longer present. This belief can be problem- atic for individuals with an acute illness, such as a streptococcal infection, when a 1- or 2-day course of antibiotic therapy relieves the soreness in the throat. This belief also can pose a prob- lem for the individual with a chronic disease that often has periods of remission or exacerbation.

In addition, readiness to learn must be as- sessed from the standpoint of a person’s culture. Behavior change may be context specific for some patients and their family members; that is, they will adhere to a recommended medical regimen while in the hospital but then fail to follow through with the guidelines once they return home. Also, the nurse must not assume

Assessment Models for the Delivery of Culturally Sensitive Care 335

R—Recommend approaches to treatment

N—Negotiate agreement

Use of Interpreters When the nurse does not speak the same lan- guage as the patient, it is necessary to secure the assistance of an interpreter. Interpreters may be family members or friends, other healthcare staff, or professional interpreters. For many reasons, the use of family or friends as interpreters is not as desirable as using professionally trained indi- viduals for nurse–patient interactions.

Research has shown that ad hoc interpret- ers (e.g., family, friends, nonclinical hospital employees) are much more likely than pro- fessional interpreters to make a clinically sig- nificant error in interpretation (AHC Media, 2012; Flores, Abreu, Barone, Bachur, & Lin, 2012). Family members and friends may not be sufficiently fluent to assume the role of in- terpreter, or they may choose to omit portions of the content they believe to be unneces- sary or unacceptable. Finally, the presence of family members or friends may inhibit com- munication with the nurse and violate the patient’s right to privacy and confidentiality (Hadziabdic & Hjelm, 2013; Juckett, 2014; Kaur, Oakley, & Venn, 2014; Schenker, Lo, Ettinger, & Fernandez, 2008).

Ideally, professionally trained interpreters will be used for assessment, teaching, and other important interactions. Interpreters can con- vey messages verbatim, and they work under an established code of ethics and confidential- ity. When determining whether a healthcare in- terpreter is required, the nurse should consider how critical and complex the teaching situation is, the degree to which the nurse can be under- stood by the patient and family members, the patient’s preferences, and the availability of re- sources (Schenker et al., 2008).

If a bilingual person is not available to fa- cilitate communication, telephone interpreting services, such as Certified Language Interna- tional, provide professional interpreters in more than 200 languages on a 24-hours-a-day,

example, manners of speaking (rate of speech, expressions used) and non- verbal cues that can enhance or hin- der understanding. Also, be aware of your own nonverbal behaviors that may be acceptable or unacceptable to the patient and family.

5. Explore customs or taboos. Observe behaviors and clarify beliefs and prac- tices that may interfere with care or treatment.

6. Become oriented to the individual’s and family’s sense of time and time frames.

7. Determine which communication approaches are appropriate with res- pect to what is the most comfortable way to address the patient and family. Find the symbolic objects and activities that provide comfort and security.

8. Assess the patient’s religious practices and determine how his or her reli- gious beliefs influence perceptions of illness and treatment.

These guidelines will assist in the exchange of information between the nurse and patient. The teacher/learner role is a mutual one in which the nurse is both teacher and learner and the pa- tient is also both learner and teacher. The goal of negotiation is to arrive at ways of working together to solve a problem or to determine a course of action (Anderson, 1987, 1990). The nurse must recognize that each person is an in- dividual and that differences exist within and between ethnic and racial groups.

Another useful framework for patient teach- ing is the LEARN model that emphasizes ways to improve cross-cultural communication be- tween patients and healthcare providers. These guidelines are as follows (Berlin & Fowkes, 1983):

L—Listen with sympathy and understanding to the patient’s perception of the problem

E—Explain your perceptions of the problem

A—Acknowledge and discuss the differences and similarities

336 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

Dominican Republic descents), Asian/Pacific Islander (of Japanese, Chinese, Filipino, Korean, Vietnamese, Hawaiian, Guamanian, Samoan, and Asian Indian descents), and American Indian/ Alaska Native (descendants of hundreds of tribes of Native Americans and of Eskimo descent).

Given the fact that there are many ethnic minority groups in the United States, and hun- dreds worldwide, it is impossible to address the cultural characteristics of each one of them. In- stead, this section reviews the beliefs and health practices of the four major subcultures in this country as identified by the U.S. Census Bureau. Based on the latest 2010 census data available (a full national census is conducted every 10 years), these groups account for approximately one third (34.09%) of the total U.S. population. The Hispanic/Latino and Asian/Pacific Islander groups are the fastest growing ethnic subcul- tures in this country (U.S. Census Bureau, 2011).

One of the most important roles of the nurse is to serve as an advocate for patients. To do so effectively, nurses must be aware of the customs, beliefs, values, and lifestyles of the di- verse populations they serve. Although nurses can learn about the different cultures, ideally nurses who belong to minority groups can best identify with and understand cultural nuances. However, the numbers of registered nurses (RNs) who are from the four ethnic subcultures as compared to the dominant white culture are highly underrepresented in the U.S. workforce (see FIGURE 8-3). If the ethnic profile of RNs is to more closely mirror the ethnic percentages of people in this country, then a concerted effort must be made to attract and retain culturally diverse nursing students to provide culturally appropriate and sensitive health care for better health outcomes (Muronda, 2015).

In addition to information provided here on the four major ethnic subcultures, libraries and the World Wide Web provide an array of resources that describe the beliefs and practices of tribes or minority groups specifically not ad- dressed. No one nurse is expected to be fully aware of all the belief systems and customs of every ethnic and racial minority group.

7-days-a-week basis. These services are certified by The Joint Commission and other accredit- ing bodies, are approved by the U.S. Depart- ment of Health and Human Services, and are HIPAA (Health Insurance Portability and Ac- countability Act) compliant. Also, iPhones and iPads now have translation software apps, known as Vocre and My Language Pro, that will instantly translate voice or text into many dif- ferent languages to connect people in the world. Thus, language is not the major barrier that it once was in the practice setting (http://www .vocre.com; https://itunes.apple.com/US/app /voice-text-translator-speak/id323470584?mt=8).

If not using an interpreter, the nurse can implement the following strategies when teach- ing patients who are partially fluent in English (Juckett, 2014; Stanislav, 2006).

■ Speak slowly and distinctly and allow twice as much time for the teaching session.

■ Use simple sentences, relying on an active rather than a passive voice.

■ Avoid technical terms (e.g., use heart rather than cardiac, or stomach rather than gastric).

■ Also avoid medical jargon (e.g., use blood pressure rather than BP) and idioms (e.g., it’s just red tape you must go through or I heard it straight from the horse’s mouth).

■ Organize instructional material in a logical order.

■ Do not assume that the patient understands what has been said. Ask patients to explain what they heard by using the teach-back approach or request a return demonstration.

▸ The Four Major Subcultural Ethnic Groups

The U.S. Census Bureau (2011) defines the ma- jor subcultural ethnic groups in this country as follows: Hispanic/Latino (of Mexican, Cuban, Puerto Rican, and other Latin descents), Black/ African American (of African, Haitian, and

The Four Major Subcultural Ethnic Groups 337

number of people (approximately 60%) of this subculture, followed by Puerto Ricans, Central and South Americans, and Cuban Americans (Peterson-Iyer, 2008).

Hispanic/Latino Americans are found in every state but are concentrated in just nine states. California and Texas together are home to half of the Hispanic population, but other large concentrations are found in New York, New Jersey, Florida, Illinois, Arizona, New Mex- ico, and Colorado (U.S. Census Bureau, 2010a). Nurses who practice in the Southwestern states are most likely to encounter patients of Mexi- can heritage, those practicing in the Northeast states will most likely be caregivers of patients of Puerto Rican heritage, and nurses in Flor- ida will deliver care to large numbers of Cuban Americans. Although Hispanic Americans have many common characteristics, each subgroup has unique characteristics.

Hispanic/Latino Culture According to the U.S. Census Bureau, the His- panic/Latino group is the largest and the fastest growing subculture in the United States. As of the last full census survey in 2010, there were ap- proximately 50.5 million people (approximately 15%) of Hispanic/Latino origin in this country, an increase of 43% since the start of the 21st cen- tury. Because of immigration and a high birth rate, this group is expected to occupy an even greater proportion of the population in the com- ing decades (Ennis, Ríos-Vargas, & Albert, 2011).

Hispanic or Latino Americans derive from diverse origins. Members of this heterogeneous group of Americans with varied backgrounds in culture and heritage are of Latin American or Spanish origin and use Spanish (or a related dialect) as their dominant language. Those of Mexican heritage account for the largest

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1.5

1.7

0.8

0.3

4.5

5.8

12.2

5.4

15.4

3.6

65.6

83.2 White, non-Hispanic

Hispanic or Latino, any race

Black or African American, non-Hispanic

Asian or Native Hawaiian or Pacific Isl., non-Hispanic

Two or more races, non-Hispanic

American Indian or Alaska Native, non-Hispanic

Percent

RN Population United States Population

FIGURE 8-3 Distribution of registered nurses and the U.S. population by racial/ethnic background in 2008. Reproduced from U.S. Department of Health and Human Services. (2010, September). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC: Health Resources and Services Administration, USDHHS. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdf.

338 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

(Fernandez & Hebert, 2000; Juckett, 2013; Purnell, 2013; Whittemore, 2007).

Approximately 25% of Hispanic families live below the poverty line. Hispanic Ameri- cans, along with African Americans, are approx- imately twice as likely to be below the poverty level than members of other subcultural groups in the United States (CDC, 2011). Their general economic disadvantage leaves little disposable income for paying out-of-pocket expenses for health care. When they do seek a regular source of care, many people in this minority group rely on public health facilities, hospital outpa- tient clinics, and emergency rooms (Kaplan & Inguanzo, 2011; Purnell, 2013; Wright & Newman- Ginger, 2010). Also, they are very accepting of health care being delivered in their homes, where they feel a sense of control, stability, and security (Pacquiao et al., 2000).

The health beliefs of Hispanic people also affect their decisions to seek traditional care. Many studies dating from the 1940s to the cur- rent day on Hispanic health beliefs and practices stress the existence of folklore practices, such as this group’s use of herbs, teas, home remedies, and over-the-counter drugs for treating symp- toms of acute and chronic illnesses. In addi- tion, Hispanic/Latino Americans place a high degree of reliance on health healers, known as curanderos or espiritistas, for health advice and treatment (Fernandez & Hebert, 2000; Purnell, 2013). In addition to being culturally appropri- ate, these health healers are more likely to speak Spanish than traditional healthcare providers, and their services can be obtained at lower cost (Titus, 2014).

Illnesses of Mexican Americans as a His- panic subgroup can be organized into the fol- lowing categories (Juckett, 2013; Purnell, 2013):

1. Diseases of hot and cold, believed to be caused by an imbalanced intake of foods or ingestion of foods at ex- treme opposites in temperature. In addition, cold air is thought to lead to joint pain, and a cold womb results in barrenness in women. Heating or

The people of Hispanic heritage have special healthcare needs that must be addressed. They are disproportionately affected by certain can- cers, alcoholism, drug abuse, obesity, hyperten- sion, diabetes, adolescent pregnancy, tuberculosis, dental disease, and human immunodeficiency virus (HIV)/acquired immune deficiency syn- drome (AIDS). Homicide, AIDS, and perina- tal conditions rank in the top 10 as causes of mortality of Hispanic/Latino Americans. His- panics are less likely to receive preventive care, often lack health insurance, and have less access to health care than whites living in the United States (CDC, 2011; Chen, Bustamante, & Tom, 2015; Fernandez & Hebert, 2000; Hebert & Fernandez, 2000; Hosseini, 2015; Juckett, 2013; Pacquiao, Archeval, & Shelley, 2000; Peterson- Iyer, 2008; Purnell, 2013; USDHHS, 2012).

Fluency in Spanish as a foreign language for nurses is highly recommended when delivering care to this growing, underserved, culturally di- verse ethnic group. Spanish-speaking people represent 62% of all non-English-speaking per- sons in the United States (U.S. Census Bureau, 2010a). Language (less than 25% speak English well), degree of acculturation, and immigration status are the biggest barriers to access of health care by the Hispanic population (Escarce & Ka- pur, 2006). In proportion to their share of the nation’s population, those of Hispanic heritage are underrepresented in the professional nurs- ing workforce. Only 3.6% of all graduates of ba- sic nursing programs are of Hispanic descent (Figure 8-3)—far too few to satisfy the increas- ing need for Hispanic healthcare professionals.

Access to health care by Hispanics is lim- ited both by choice and by unavailability of health services. Only one-fifth of all Puerto Ri- can Americans, one-fourth of Cuban Ameri- cans, and one-third of Mexican Americans see a physician annually. Even when Hispanic peo- ple have access to the healthcare system, they may not receive the care they need. Difficulty in obtaining services, dissatisfaction with the care provided, and inability to afford the rising costs of medical care are major factors that dis- courage them from using the healthcare system

The Four Major Subcultural Ethnic Groups 339

■ Low SES contributes to increased infectious and parasitic diseases.

Alcoholism also represents a serious health problem for many Hispanic Americans. Chronic liver disease and cirrhosis are among the lead- ing causes of death for this population (CDC, 2012). Furthermore, as the Hispanic population becomes more acculturated, certain risk factors for cardiovascular disease and certain cancers are expected to play larger roles in this group (Purnell, 2013).

Today, the literature disagrees about the extent and frequency to which Hispanic peo- ple use home remedies and folk practices. In the southwestern United States, the Hispanic population has been found to use herbs and other home remedies to treat illness episodes at twice the proportion reported in the total U.S. population. Other studies claim that the use of folk practitioners has declined and practi- cally disappeared in some Hispanic subgroups (Purnell, 2013).

Knowing where people get their health in- formation can provide clues to nurses as to how to best teach specific population groups. For example, Mexican Americans, like other Latin American groups, tend to rely on family as the primary source of credible health information. Therefore, when teaching a patient, health in- formation should be shared with significant others within the family unit (Eggenberger, Grassley, & Restrepo, 2006; Purnell, 2013).

Because the family is the center of Hispanic people’s lives, the extended family serves as the single most important source of social support (Peterson-Iyer, 2008). This culture is character- ized by a pattern of respect and obedience to el- ders as well as a pattern of male dominance. The focus of patient education by nurses, therefore, needs to be on the family rather than on the in- dividual. It is likely, for example, that a woman would be reluctant to make decisions about her or her child’s health care without consulting her husband first (Purnell, 2013).

Gender and family member roles are chang- ing, however, as more Hispanic women take jobs

chilling is the traditional cure for parts of the body afflicted by disease.

2. Diseases of dislocation of internal organs, cured by massage or physical manipulation of body parts.

3. Diseases of magical origin, caused by mal ojo, or evil eye, a disorder of infants and children resulting from a woman looking admiringly at someone else’s child without touching the child, resulting in crying, fitful sleep, diarrhea, vomiting, and fever.

4. Diseases of emotional origin, at- tributed to sudden or prolonged terror called susto.

5. Folk-defined diseases, such as latido. 6. Standard scientific diseases.

The overall health status of Hispanic Ameri- cans can be determined by examining key health indicators of infant mortality, life expectancy, and mortality from cardiovascular disease and cancer and measures of functional health. Re- search findings indicate that the health of peo- ple of Hispanic heritage is much closer to that of white Americans than to that of African Americans, even though the Hispanic and black populations share similar socioeconomic con- ditions. Concerning the incidence of diabetes and infectious and parasitic diseases, however, Hispanic people are clearly at a disadvantage in relation to white people. Possible explana- tions for the relative advantages and disadvan- tages in health status of Hispanic Americans involve such factors as the following (Juckett, 2013; Purnell, 2013):

■ Cultural practices favor reproductive success. ■ Early pregnancies and high fertility rates

contribute to low breast cancer incidence but increased cervical cancer rates.

■ Dietary habits are linked to low cancer rates but a high prevalence of obesity and diabetes.

■ Genetic heritage contributes to the suscep- tibility to certain diseases, such as diabetes.

■ Extended family support reduces the need for psychiatric services.

340 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

■ Cultural beliefs were observed. ■ An individual accepted and respected by

the group introduced the nurse. ■ Family members were included. ■ The community was encouraged to take

responsibility for resolving the health pro- blems discussed.

Morbidity, mortality, and risk factor data also provide clues to the areas in which patient edu- cation efforts should be directed. As mentioned earlier, Hispanic people have higher rates of di- abetes, AIDS, obesity, alcohol-related illnesses, and mortality from homicide compared to the general population. These topics should be tar- geted for educational efforts at disease preven- tion and health promotion (CDC, 2012). The following general suggestions are useful when designing and implementing education pro- grams for Hispanic Americans (Fernandez & Hebert, 2000; Hebert & Fernandez, 2000; Juckett, 2013; Pacquiao et al., 2000; Peterson-Iyer, 2008; Purnell, 2013; Schouten & Meeuwesen, 2006):

1. Identify the Hispanic American sub- groups (e.g., Mexican, Cuban, and Puerto Rican) in the community whose needs differ in terms of health beliefs, language, and general health status. Design education programs that can be targeted to meet their distinct ethnic needs.

2. Be alert to individual differences with in subgroups as to age, years of education, income levels, job status, and degree of acculturation.

3. Account for special health needs with respect to incidences of diseases and risk factors to which they are vulnerable—breast cancer in women ( Borrayo, 2004), diabetes, AIDS, obesity, alcohol-related illnesses, homicide, and accidental injuries.

4. Recognize the importance of family in supporting one another, so be sure to direct education efforts to include all interested members and remember

outside the home. Also, children tend to pick up the English language more quickly than their parents and often end up in the powerful posi- tion of acting as interpreters for their adult rel- atives. The heavy reliance on family has been linked to this minority group’s low utilization of healthcare services. In addition, levels of educa- tion correlate highly with access to health care. The less education members within a household have, the poorer the family’s health status and access to health care (Purnell, 2013; USDHHS, 2012). Hispanic Americans are more likely than the general U.S. population to read English be- low the basic health literacy level and to have lower educational attainment than non-His- panic whites (National Center for Education Statistics, 2006).

Teaching Strategies Only approximately 40% of the Hispanic pop- ulation has completed 4 years of high school or more, and only 10% have completed college, as compared with approximately 80% and 20%, re- spectively, of the non-Hispanic population (Fry, 2010). Both the educational level and the pri- mary language of Hispanic patients need to be taken into consideration when selecting instruc- tional materials (National Center for Education Statistics, 2006). Sophisticated teaching meth- ods, such as self-instruction and simulation, and instructional tools, such as computer resources and high-literacy print materials, likely would be inappropriate for those who have minimal levels of education.

The age of the population also can affect health and patient education efforts. According to the U.S. Census Bureau (2009), the Hispanic population is young as a total group (34% of this group is younger than 18 years of age). Thus, the school system is an important setting for educat- ing members of the Hispanic community. For Hispanic students, education programs in the school system on alcohol and drug abuse and on cardiovascular disease risk reduction have proved successful when the following criteria were met by the nurse in the role of patient educator:

The Four Major Subcultural Ethnic Groups 341

may be misleading or misinterpreted by the nurse. Ask patients to repeat in their own words what they have been told using the teach-back method to determine their level of understanding (Weiss, 2007).

14. If interpreters are used, be sure they speak the dialect of the learner and that they interpret instructions rather than just translate them verbatim, so that the real meaning gets conveyed. Also, be sure to talk to the patient, not to the interpreter. If an interpreter is not available, use a telephone interpreting service.

15. Provide written and audiovisual ma- terials in Spanish that reflect lingui- stic appropriateness and cultural sensitivity (Borrayo, 2004).

As discussed previously, nurses must account for the cultural beliefs and health and education needs of Hispanic Americans. By ex- tending themselves to Hispanics in a culturally sensitive manner, nurses have the opportunity to effectively and efficiently address the needs of this rapidly growing segment of the U.S. pop- ulation (Borrayo, 2004).

Black/African American Culture According to the most recent census survey, members of the black/African American cul- ture make up the second largest ethnic group in the United States. Currently, black Amer- icans constitute 14% of the nation’s popula- tion. Most of this ethnic population resides in the South (54%), and approximately 19% live in the Midwest, 18% in the Northeast, and 9% in the West. The greatest concentration resides in large metropolitan areas (Rastogi, Johnson, Hoeffel, & Drewery, 2010).

The cultural origins and heritage of black Americans are quite diverse. Their roots are mainly from Africa and the Caribbean Islands. They speak a variety of languages, including French, Spanish, African dialects, and various forms of English. Depending on the age cohort

that decision making typically rests with the male and elder authority figures in homes where tradition is strong.

5. Provide adequate space for teaching to accommodate family members who typically accompany patients seeking health care.

6. Be aware of the importance of the Roman Catholic religion in their lives when dealing with such issues as contraception, abortion, and fam- ily planning.

7. Demonstrate cultural sensitivity to health beliefs by respecting and tak- ing time to learn about their ethnic values and beliefs.

8. Consider other care practices, such as home remedies that they might be using before entering or while within the healthcare system.

9. Be aware of the modesty felt by some women and girls, who may be par- ticularly uncomfortable in talking about sexual issues in mixed company.

10. Display warmth, friendliness, and tactfulness when developing relation- ships because they expect nurses and other health providers to be informal and interested in their lives.

11. Determine whether Spanish is the language by which the patient best communicates, but remember that even though speaking Spanish may be preferred, the patient and family members are not always literate in their native language.

12. Speak slowly and distinctly, avoiding the use of technical words and slang if the patient has limited proficiency in the English language.

13. Do not assume that a nod of the head or a smile indicates understanding of what has been said. Members of this heritage respect authority and, therefore, it is not uncommon for them to display nonverbal cues that

342 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

Because of racial and social injustice, African Americans are the least healthy ethnic group in the United States (Noonan et al., 2016) and they have the most health concerns because of genetics, access to care, environmental influ- ences, and cultural factors (Mandal, Scott, Islam, & Mandal, 2013).

Poverty and low educational attainment have had major consequences for the black American community in terms of social equal- ity and health and medical issues. Although black families place a high value on education, which they see as a way to raise their standard of living by being able to secure better jobs and a higher social status, there continues to be a greater-than-average high school dropout rate among blacks, and many individuals remain poorly educated with accompanying literacy problems (Purnell, 2013). Despite the fact that fewer African Americans have a college degree than white Americans, one promising trend is that recently the number of black workers in the labor force earning a college degree (25%) is growing more quickly than ever before (U.S. Department of Labor, 2012). Nevertheless, low educational levels and socioeconomic depriva- tion that have persisted and continue to persist in the black community are strongly correlated with higher incidence of disease, poor nutrition, lower survival rates, and a decreased quality of life in general (Noonan et al., 2016; Purnell, 2013; Rognerud & Zahl, 2005).

Also, increased exposure to hazardous working conditions in low-paying, manual la- bor jobs has resulted in a greater incidence of occupation-related diseases and illnesses among this population. In addition, the majority of blacks reside in inner-city areas where expo- sure to violence and pollution puts them at greater risk for disease, disability, and death. The average life span of black Americans is shorter than that of white Americans because of the high death rates of blacks from can- cer, cardiovascular disease, cirrhosis, diabe- tes, accidents, homicides, and infant mortality (Anderson et al., 2000; Dignam, 2000; Forrester, 2000; Holt, Kyles, Wiehagen, & Casey, 2003;

to which they belong, African Americans may prefer to identify themselves differently as a ra- cial group. For example, members of the young- est generation often refer to themselves by the term African American, whereas middle-aged and older members of this ethnic group usually prefer the term black or black American. Each designation is politically correct according to the U.S. Census Bureau’s identification of this ethnic group as black/African American. How- ever, because the diversity of cultural heritage varies within the many black subgroups, nurses and other providers need to be aware of ethnic differences in cultural beliefs, customs, and tra- ditions between these groups (Purnell, 2013).

Unfortunately, African Americans have suffered a long history of inequality in social, economic, and educational opportunity. The history of slavery of black/African Americans has shaped their experiences throughout the centuries to present day in our country. Over the many years, the issues of skin color have led to dehumanization, segregation, a struggle for civil rights, and racism (Watts, 2003). As for education, they were victims of school seg- regation and inferior facilities until a 1954 U.S. Supreme Court decision, Brown v. Board of Ed- ucation of Topeka, outlawed the separation of blacks and whites in the public school system. However, this educational deprivation has had long-term consequences, such as unequal access to higher paying and higher status job oppor- tunities, which has led to low wages and a dis- proportionate number (approximately 23%) of African Americans living at or below the pov- erty level (Rastogi et al., 2010).

Because of these realities, healthcare dispar- ities persist in the 21st century for the descen- dants of slaves as an ethnic minority (Noonan, Velasco-Mondragon, & Wagner, 2016; Watts, 2003). Also, the legacy of slavery has affected the mental health of blacks whose repressed but justifiable feelings of anger and outrage at the social injustices endured by their people for generations continue to have an impact on the psyche, leading to a high incidence of violent, de- pressive, and suicidal behaviors (Carten, 2015).

The Four Major Subcultural Ethnic Groups 343

that it is not unusual for grandmothers to want to stay at the hospital bedside when their grand- children are ill. This extended family network provides emotional, physical, and financial sup- port to members during times of illness and other crises (Forrester, 2000; Purnell, 2013).

Single parenting within the African American culture is an accepted position without stigma at- tached to it. In 2011, approximately 67% of black or African American children were being raised in a single-parent family, as compared to 25% of white children and 42% of Hispanic or Latino children (National Kids Count Program, 2011). Becoming a mother at a young age, although not highly desirable or condoned by black women, is met with a fairly high level of tolerance in this cultural group (Purnell, 2013). In fact, black women do not perceive negative sanctions within their culture if they do not meet the ideal norm of getting an education or job prior to marriage and children. Relatives are supportive of one an- other if help is needed with childrearing.

Spirituality and religiosity are very much a prominent cultural component of this ethnic group’s community. These aspects are a central and defining feature of African American life, serv- ing as a source of hope, renewal, liberation, and unity (Carten, 2015). Spirituality is defined as a belief in a higher power, a sacred force that exists in all things. Religiosity is defined as an individ- ual’s level of adherence to beliefs and ritualistic practices associated with religious institutions (Holt, Clark, & Kreuter, 2003; Mattis, 2000; Mattis & Jagers, 2001; Puchalski & Romer, 2000).

Both spirituality and religion often play a role in the development and maintenance of social relationships throughout the human life span. Blacks, more so than whites, t urn to reli- gion to cope with health challenges. Additionally, as trusted resources in the community, African Americans are turning more and more to their churches for support in times of illness, as a buf- fer against oppression, as well as for health ed- ucation and other health promotion activities (Carten, 2015; Collins, 2015; Hayes, 2015).

Religious practices also have been found to influence health beliefs and positively influence

Keyserling et al., 2000; Mandal et al., 2013; Monden et al., 2006; Noonan et al., 2016; Rognerud & Zahl, 2005; Samuel-Hodge et al., 2006). Also, blacks are at higher risk for drug and alcohol abuse, drug addiction, teenaged pregnancy, and sexually transmitted diseases (Purnell, 2013).

Purnell (2013) reported findings indicating that African Americans are pessimistic about human relationships and that their belief sys- tem emphasizes three major themes:

1. The world is a hostile and dangerous place to live.

2. The individual is vulnerable to attack from external forces.

3. The individual is considered helpless, with few internal resources with which to combat adversity.

Because many African Americans tend to be suspicious of Western ethnocentric medi- cal providers, they often seek the assistance of nurses and physicians only when they deem it absolutely needed (Purnell, 2013). Figure 8-3 shows that not enough RNs from this ethnic group are represented in the nursing workforce in proportion to the number of blacks in the U.S. population. Blacks’ mistrust of traditional U.S. health care is believed to stem from cen- turies of discrimination and unethical research practices, such as the infamous Tuskegee syphi- lis study (Eiser & Ellis, 2007; Wilson, 2011). In- stead, folk practitioners are held in high esteem by this population and are sought after for the culturally sensitive care they provide.

Common to the black culture is the concept of extended family, consisting of several house- holds, with the older adults often taking the leadership role within the family constellation. Respect for elders and ancestors is greatly val- ued. Older adults are held in high regard because living a long life indicates that the individual had more opportunities to acquire greater ex- perience and knowledge. Decision making re- garding healthcare issues is, therefore, often left to the elders. Family ties are especially strong between grandchildren and grandparents, such

344 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

of blacks when nurses carry out patient educa- tion in various healthcare settings.

When teaching black Americans preventive and promotion measures as well as when caring for them during illnesses, the nurse must explore the patients’ value systems and cultural beliefs. Generally, any folk practices or traditional be- liefs should be respected, allowed (if they are not harmful), and incorporated into the rec- ommended treatment or healthcare interven- tions used by Western medicine. The following list offers more specific points for nurses to con- sider to be sure they render culturally appropri- ate care for black Americans (Forrester, 2000; Purnell, 2013). Members of this minority pop- ulation group tend to:

■ Express feelings openly to family and friends, but they are much more private about family matters when in the company of strangers.

■ Prefer being greeted in a formal manner by using their surnames when outside their circle of family and friends, which demonstrates respect and pride for their family heritage.

■ Feel comfortable with less personal space and use humor, joking, and teasing to reduce stress and tension.

■ Be oriented more to the present than the past or future and, thus, are likely to be relaxed about specific time frames. As a result, appointments will usually be kept, but they may be late, which requires health providers to be flexible with scheduling.

■ Live in a traditional family structure that is matriarchal with a high percentage of households run by a female single parent. Women play a dominant role in decision making, and grandmothers are often involved in providing economic support and child care for their grandchildren, so nurses must recognize the importance of sharing health information directly with them.

Diabetes and hypertension continue to be the most serious health problems for African Americans, with higher morbidity and mor- tality rates from these diseases than in other Americans (Mandal et al., 2013; Noonan et al.,

health status and outcomes in the African Ameri- can community (Newlin, Knafl, & Melkus, 2002). These strong religious values and beliefs by indi- viduals may extend to their feelings about illness and health. Many black Americans find inner strength from their trust in God. Some believe that whatever happens is God’s will. This belief has led to the perception that black Americans have a fatalistic view of life (Purnell, 2013) and are governed by a relatively strong external lo- cus of control (Holt, Clark, & Kreuter, 2003).

A traditional folk practice, known as voo- doo, consists of beliefs about good or evil spirits inhabiting the world. One belief is that a reli- gious leader or voodoo doctor has the power to appease or release hostile spirits. Illness, or dis- harmony, is thought to be caused by evil spirits because a person failed to follow religious rules or the dictates of ancestors. Curative measures involve finding the cause of an illness—a hex or a spell placed on a person by another or the breaking of a taboo—and then finding some- one with magical healing powers or witchcraft to rid the afflicted individual of the evil spirit(s). Some black American families also continue to practice home remedies such as using mustard plasters, taking herbal medicines and teas, and wearing amulets to cure or ward off a variety of illnesses and afflictions (Purnell, 2013).

Teaching Strategies In a review of articles published within the past decade, Weekes (2012), Mandal et al. (2013), Mantwill, Monestel-Umana, and Schulz (2015), and Sayah, Majumdar, Egede, and Johnson (2015) explored the impact of health literacy on health outcomes among African Americans. The findings were somewhat mixed but most found that health literacy influenced African Americans’ understanding of diseases, their feelings of self-efficacy, their perceived suscep- tibility to illness, and their adherence to med- ical protocols and medication regimens. More research needs to be conducted but this litera- ture review highlights the importance of con- sidering the role of health literacy on the health

The Four Major Subcultural Ethnic Groups 345

(Noonan et al., 2016). Efforts to recruit more blacks into the nursing profession would most assuredly help to reduce some of the barriers to caring for this population of Americans.

Asian/Pacific Islander Culture People from Asian countries and the Pacific Is- lands constitute the third major ethnic subcul- tural group in the United States. Asian Americans who have come here originated from approxi- mately 52 countries in the Far East, Southeast Asia, and the subcontinent of India. Although Japanese and Chinese immigrants settled in the United States in the early 1900s, many South- east Asians came as refugees to the United States after World War II, the Korean War, the fall of South Vietnam, and the chaos in the govern- ments of Laos and Cambodia. To a large extent, they have settled on the West Coast, particularly in the San Francisco Bay area of California and in Washington state (U.S. Census Bureau, 2017; Villanueva & Lipat, 2000; Young, McCormick, & Vitaliano, 2002). Also, the states of New York, New Jersey, and Texas have experienced a large influx of Asian peoples, particularly from China, the Philippines, and Japan. As of 2015, 21 million Asian/Pacific Islanders (5.8% of the total U.S. population) live in the country (U.S. Census Bureau, 2017).

Although Asian/Pacific Islander people have been classified as a single ethnic group, Asian Americans are not homogenous. They repre- sent diverse minority populations with over 800 languages and dialects and their beliefs and practices are not the same because a wide va- riety of cultural and religious backgrounds are represented (Asian American Health Initiative, 2005; Kim & Keefe, 2010). Some similarities ex- ist among members of this group, but there are also many differences (Purnell, 2013). By un- derstanding the basic beliefs of the Asian/Pacific Islander people, nurses can be better prepared to understand and accept their cultural differ- ences and varied behavior patterns. Figure 8-3 indicates that the supply of registered nurses of Asian/Pacific Islander descent had grown to

2016; Samuel-Hodge et al., 2006). Also, as stated previously, blacks are at higher risk for being victims of violence, accidents, disabilities, and cancer (Forrester, 2000; Purnell, 2013). Obe- sity is another major problem among black Americans. Food to them is a symbol of health and wealth, their family interactions and so- cial events center around dietary preferences (soul food) based on culture and necessity, and a higher-than-ideal body weight is viewed pos- itively by members of this ethnic group. Soul food, a type of cuisine that consists predomi- nantly of fatty, salty, and sugary foods, also has contributed to the high incidence of cardiovas- cular diseases (Belle, 2009).

Nurses must concentrate on disease preven- tion measures; institute early screening for high blood pressure, cancer, and diabetes, as well as screening for signs and symptoms of other dis- eases common in this population; and provide culturally appropriate health education to im- prove the overall health status of black Amer- icans (Bailey, Erwin, & Belin, 2000; Minority Nurse Staff, 2013; Plescia, Herrick, & Chavis, 2008; Powe, Daniels, Finnie, & Thompson, 2005). Their strong family ties encourage black individ- uals to be treated by the family before seeking care from nurses and other health professionals. This cultural practice may be a factor contribut- ing to the delay or failure of blacks to seek treat- ment for diseases at the early stages of illness.

Economic factors make it less likely for black Americans to have ready access to health- care services. Identified barriers to black Amer- icans seeking the health care they need include lack of culturally relevant care, perceptions of racial discrimination, and a general distrust of both healthcare professionals and the healthcare system. Establishing a trusting relationship, therefore, is an essential first step to be taken by nurses if blacks are to receive and accept the health services they require and deserve. Recog- nizing their unique responses to health and illness based on their spiritual and religious foundations, their strong family ties, and other traditional be- liefs is essential if therapeutic interventions devel- oped by the healthcare team are to be successful

346 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

that guide the social behavior of people who ad- here to Confucianism are described as follows.

Patterns of Authority. The following five relationships run from inferior (No. 1) to supe- rior (No. 5) to form a pattern of obligation and authority in the family as well as in social and political realms:

1. Son (child) to father 2. Wife to husband 3. Younger brother to older brother 4. Friend to friend 5. Subject to ruler

These patterns of authority and obligation influence decision making and social interac- tions. For example, a friend is to regard a friend as a younger or older brother. Women’s subser- vience to men is reflected in a woman’s behav- ior to always seek the advice of her husband when making decisions. This authority needs to be respected by nursing staff when, for in- stance, a woman refuses to choose a contra- ceptive method until she asks for her husband’s advice and permission.

Man in Harmony with the Universe. In the Confucian system, people are considered to exist between heaven and earth, and life has to be in harmony with the universe. An example of this principle is when Asians respond pas- sively to new information, accepting it rather than actively seeking to clarify it. Therefore, it is important for the nurse to ask the patient for an explanation of the information taught to determine if it was understood.

Ancestor Worship. Concern for the moral order of relationships is reflected in a deep reverence for tradition and rituals. Great emphasis is placed on funerals, the procedures for mourning, and the group sharing of a meal with the dead.

Taoism The Tao philosophy has its roots in the belief of two opposing magical forces in nature, the

5.8% in 2008 (from 3.1% in 2004) and is close in proportion (although not necessarily in geo- graphic distribution) to the population of this ethnic group in the United States.

The major philosophical orientation of the Asian/Pacific Islander people is a blend of four philosophies—Buddhism, Confucianism, Tao- ism, and phi. Four common values are strongly reflected in these philosophies (Purnell, 2013):

1. Male authority and dominance 2. Saving face (behavior resulting from

a sense of pride) 3. Strong family ties 4. Respect for parents, elders, teachers,

and other authority figures

The following is a brief review of the be- liefs and healthcare practices of the Asian/Pa- cific Islander people (Pang, 2007; Purnell, 2013).

Buddhism The fundamental belief underlying Buddhism is that all existence is suffering. The continua- tion of life, and therefore suffering, arises from desires and passions. According to the Buddhist philosophy, humans are not limited to a single existence terminating in death; instead, everyone is reincarnated. Cambodians, who are particu- larly strongly influenced by the Buddhist phi- losophy, strive to accumulate religious merits or good deeds to ensure a better life to come. Shar- ing, donating, being generous, and being kind are all ways to accumulate merits. They adhere to a deep belief in karma, whereby things done in this existence will help or hinder them to reach nirvana, a place free of pain and suffering.

Confucianism Moral values and beliefs are heavily influenced by Confucian philosophy, which focuses on the moral aspects of one’s personality. Two predom- inant moral qualities are humaneness (the atti- tude that is shown toward others) and a sense of moral duty and obligation (attitudes that per- sons display toward themselves). The principles

The Four Major Subcultural Ethnic Groups 347

Thus, the Asian/Pacific Islander culture values harmony in life and a balance of nature. Shame is something to be avoided, families are the center of life, elders are respected, and an- cestors are worshiped and remembered. Chil- dren are highly valued because they carry on the family name and are expected to care for aging parents. The woman’s role is one of subservi- ence throughout her entire life—she will fol- low the advice of parents while unmarried, the husband’s advice while married, and the chil- dren’s advice when widowed. For people of this ethnic group, marked cultural differences con- front them when they live in the United States with respect to ways of life, ways of thinking, values orientation, social structure, and family interactions (Chao, 1994; Young et al., 2002). Children may adapt quickly to this environ- ment, but the older generations tend to have difficulty acculturating (Asian American Health Initiative, 2005).

In addition to these philosophical beliefs and practices, just like any other ethnic subculture, the differences in health disparities and health concerns depend on genetics, environmental factors, access to care, and cultural factors. (Na- tional Institutes of Health, 2016). Kim and Keefe (2010) address the myth that Asian Americans are the most adjusted of all ethnic groups based on studies that for years have categorized them “as a single, undifferentiated group rather than as distinct ethnic groups” (p. 286). Therefore, with- in-group disparities have gone unreported until recently. The major barriers to health care are lan- guage, cultural beliefs, health literacy, health in- surance, and immigrant status. The health issues that affect Asian Americans vary; for example, Chinese Americans are at higher risk for hyper- tension (Chen & Hu, 2014), Filipino Americans have higher rates of diabetes (Fuller-Thomson, Roy, Chan, & Kobayashi, 2017), Vietnamese harbor a stigma of viral hepatitis B (HBV) and liver disease (Dam et al., 2016), Korean women have the lowest rate of cervical cancer screen- ing (Fang et al., 2017), Hmong Americans have a much lower rate of colorectal cancer screening

negative (yin) and the positive (yang), which af- fect the course of all material and spiritual life. The basic concepts of Chinese philosophy— namely, the beliefs in tao (the way of nature) and yin and yang (the principle of balance)—stress that human achievement in harmony with na- ture should be accomplished through nonaction.

Common also is the idea that good health depends on the balance between hot and cold. Equilibrium of hot and cold elements, it is thought, produces good health. Thus drugs, natural ele- ments, and foods are classified as either hot or cold. It is believed that sickness can be caused by eating too much hot or cold food. Hot foods include meats, sweets, and spices; cold foods in- clude rice and vegetables.

Illness is believed to result from an imbal- ance in the forces of nature. Ill health is believed to be a curse from heaven, with mental illness being the worst possible curse, because the in- dividual was irresponsible in not obtaining the right amount of rest, food, and work. The Chi- nese people believe in strong family ties, re- spect for elders, and the authority of men as the head of the household. Consequently, sons are highly valued.

Phi Phi worship is a belief in the spirits of dead rel- atives or the spirits of animals and nature. Phi ranges from bad to good. If a place has a strong phi, the individual must make an offering before doing anything in that place, such as building a house or tilling the land. If someone violates a rule of order, an atmosphere of bad phi can result in illness or death. Redemption can be sought from a phi priest as a hope of getting relief from suffering. Offerings are made and special rites are performed to rid the person of a bad phi.

Followers of this philosophy respect elders and avoid conflict by doing things in a pleas- ant manner. Those who adhere to the phi phi- losophy demonstrate hospitality and generosity. They show respect to others by the way a person is addressed, and they tend to prize hard work and ambition.

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Western medicine is thought to be “shots that cure,” and Asian patients expect to get some form of medicine (injections or pills) whenever they seek medical help in the United States. If no medication is prescribed, the person may feel that care is inadequate unless an explana- tion is given.

Common to many Southeast Asians is the idea that illnesses, just like foods, are classi- fied as hot and cold. This belief coincides with the yin and yang philosophy of the principle of balance. If a disease is considered hot in ori- gin, then giving cold foods is believed to be the proper treatment.

Conflict and fear are the most likely res- ponses to laboratory tests and having blood drawn. Many members of this ethnic group be- lieve that removing blood makes the body weak and that blood is not replenished. Fear of sur- gery may result from the conviction that souls inhabit the body and may be released. Another major fear is the loss of privacy leading to ex- treme embarrassment and humiliation.

Teaching Strategies Among Asian/Pacific Islanders, respect is au- tomatically given to most healthcare providers who are thought of as knowledgeable. Asians are sensitive and formal, so using a nonthreat- ening approach is necessary before caring for them. They must be given permission to ask a question but are not offended by questions from others. Language barriers are usually the first and biggest obstacles to overcome in working with people of Asian/Pacific Islander descent.

One specific characteristic to be noted of the Japanese subculture is a childlike depen- dency known as amae. This dependent be- havior continues through adulthood but is especially evident when people are ill. Aware- ness of this common behavior pattern will allow nurses to approach patients of Japanese heritage in a culturally relevant and tolerant manner (Hisama, 2000).

Asian/Pacific Islanders’ approach to learn- ing involves repetition and rote memorization

(Tong et al., 2017), Asian Americans in general are at higher risk for depression and lower self- esteem (Carrera & Wei, 2017; Choi, Israel, & Maeda, 2017), and Asian American college women have a higher incidence of eating disor- ders (Cheng, Tran, Miyake, & Kim, 2017).

The treatment and care principles that con- stitute the Western biomedical model are very different from those of Eastern medicine prac- tices. Although Western medicine is based on the belief that external forces cause disease, such as bacteria and viruses, that the functional ability of the body slowly degenerates, and that disease is either physical or mental, Eastern medicine is based on the belief that the body functions as a whole and each part (organ) has a mental and physical role in disease and impairment. These differences can have a profound impact on care delivery. Traditional Asian healing prac- tices include herbal remedies, acupuncture, and other alternative medicine approaches, such as coin rubbing and cupping (Carteret, 2011).

Thus, the medical practices of Asian/Pacific Islanders, like their other unique cultural practices, differ significantly from Western ways (Carteret, 2011; National Institutes of Health, 2016). The health-seeking behaviors of immigrants tend to be crisis oriented, following the pattern in their homelands where medical care was not readily available. They are likely to seek health care only when seriously ill. Reinforcement is needed to encourage them to come for follow-up visits af- ter an initial encounter with the healthcare sys- tem. Sometimes they are viewed by practitioners as noncompliant when they do not do exactly what is expected of them, when they withdraw from follow-up treatments, or when they do not keep scheduled appointments.

Asian people make great use of herbal rem- edies to treat various ills, such as fevers, diarrhea, and coughs. Dermabrasion—a practice often misunderstood by U.S. healthcare providers— is a home remedy implemented to cure a wide variety of problems such as headaches, cold symptoms, fever, and chills. In their traditional healthcare system, Asian individuals rely on folk medicines from healers, sorcerers, and monks.

The Four Major Subcultural Ethnic Groups 349

reside primarily in the northwestern, central, and southwestern regions of the United States (Norris et al., 2011). The term Native American is used throughout this section of the chapter to include both the American Indian and Na- tive Alaska people.

Approximately half of the members of this ethnic group are eligible for health services provided by the federal government. The In- dian Health Service of the U.S. Public Health Service maintains responsibility for providing health care to them (Sequist, Cullen, & Acton, 2011; Sofer, 2017; USDHHS, 2015a). Figure 8-3 clearly indicates that proportionately there are fewer RNs of Native American heritage to pro- vide culturally appropriate care for the people belonging to this population group.

The current challenge to nurses is to in- tegrate Western medicine with traditional non-Western tribal folk medicine to provide cross-cultural health education to Native Amer- icans in reservation-based communities across the nation. To do so, nurses must understand contemporary cultural patterns that set this ethnic group apart from non-Native Ameri- cans, including their theories of what causes various diseases and the associated treatments (Cantore, 2001; Lowe & Struthers, 2001). It is also essential for nurses to become focused on a more ethnomedical orientation. This means understanding the nature and consequences of illness problems and therapeutic interventions from the ethnic group’s perspective, rather than adhering to the biomedical orientation of defin- ing diseases and treatment options from only a Western perspective.

The Native American concept of health and illness incorporates the relationship of humans with their universe. Differences in beliefs, however, may be found among the various Native American tribes in the United States. The following are major characteristics associated with this ethnic group as addressed by Purnell (2013), Lowe and Struthers (2001), Harding (1998), Scharnberg (2007), Joho and Ormsby (2000), Portman and Garrett (2006), and Cantore (2001).

of information. The learning style of Asians is essentially passive—no personal opinions, no confrontations, no challenges, and no outward disagreements. Nurses should be aware that in the Asians’ wish to save face for themselves and others, they avoid being disruptive and will agree to what is said.

Decision making, however, is a family af- fair. Family members, especially the male au- thority figure, must be included in identifying the best solution for a situation. Asians are eas- ily shamed, so patients must be reassured and told what is considered acceptable behavior by Western moral and legal standards. Nods of the head do not necessarily mean agreement or un- derstanding. Questions need to be asked in sev- eral ways to confirm that they understand any instructional messages given.

When working with members of this Asian/ Pacific Islander culture, nurses must remember that education is most effective when it is a two- way process. Patients and their families need to be aware of the beliefs and practices of Amer- ican culture, and, in turn, the nurse needs to recognize the challenges created by the cultural beliefs and practices of this ethnic group. This mutual understanding will strengthen the ther- apeutic relationship between the nurse and the patient to create an emotional environment that is appropriate for learning to take place (Park, Chesla, Rehm, & Chun, 2011).

American Indian/Alaska Native Culture The U.S. Census Bureau (2010a) has identified more than 5.2 million people (almost 1.7% of the U.S. population) who are members of the Amer- ican Indian/Alaska Native ethnic group (Norris, Vines, & Hoeffel, 2011). More than 500 distinct tribes of American Indians and Alaska Natives exist, including Eskimo and Aleut tribes (Lowe & Struthers, 2001). The largest of these tribes is the Cherokee. Other tribes of significant size are the Navaho, Sioux, Chippewa, Choctaw, Pueblo, and the Latin American Indian. These tribes

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(shaman) into the system of care given to pa- tients. The central and formal aspects of Native American medicine are ceremonial, embracing the notion of a supernatural power. Although the ceremonies vary from tribe to tribe, the ideas of causation and cure are common to all Native Americans. The rituals performed are based on the signs and symptoms of an illness. In some instances, family members also conduct these rituals. Cornmeal, from the sacred food of corn, is an item that is frequently used in a variety of curative ceremonies. Herbal remedies have for generations served native healers as their phar- macopoeia. The nurse must demonstrate legit- imate respect for such ritualistic symbols and ceremonial activities.

To be without a family of many relatives is to be considered very poor in the Native Amer- ican world. The family and tribe are of utmost importance, which is a belief that children learn from infancy. It is not unusual for many fam- ily members—sometimes large groups of 10 to 15 people—to arrive at the hospital and camp out on the hospital grounds to be with their sick relative. Talking is unnecessary, but sim- ply being there is highly important for every- one concerned.

Grandmothers are of particularly great importance to a sick child, and they frequently must give permission for a child to be hospital- ized and treated. The Native American kinship system allows for a child to have several sets of grandparents, aunts, uncles, cousins, brothers, and sisters. Sometimes numbers of women sub- stitute as a mother figure for a child, which may cause role confusion for the healthcare provider.

Children are given a great deal of freedom and independence to learn from their decisions and live with the consequences of their actions. They tend not to be viewed as very competitive or assertive because to call attention to oneself is interpreted by Native Americans as showy and inappropriate. They may appear spoiled, but in fact they are taught self-care and respect for oth- ers at a very early age. Children are doted on by family members, and, in turn, they have high regard for their elders. In fact, the older adults

1. A spiritual attachment to the land and harmony with nature

2. An intimacy of religion and medicine 3. Emphasis on strong ties to an exten-

ded family network, including im- mediate family, other relatives, and the entire tribe

4. The view that children are an asset, not a liability

5. A belief that supernatural powers exist in both animate and inanimate objects

6. A desire to remain distinct and avoid acculturation, thereby retaining one’s own culture and language

7. A lack of materialism, lack of time consciousness, and a desire to share with others

These common characteristics can easily be overlooked by the nurse when care is being pro- vided to patients of this ethnic group. To some extent, Anglo-American culture and Western healthcare practices have been integrated into the Native American way of life. However, these seven characteristics still predominate today to set this subculture apart as a unique entity.

Native Americans see a close connection be- tween religion and health. When a family mem- ber becomes ill, witchcraft is still perceived by some tribes as the real cause of illness. In tradi- tional societies, witchcraft functions to supply answers to perplexing or disturbing questions. It also explains personal insecurities, intragroup tensions, fears, and anxieties.

Some Native American tribes still prac- tice witchcraft but tend to deny it as a reality because of the negative stereotype and stigma attached to it by outsiders. Nevertheless, the in- timacy between religion and medicine persists and is exhibited in the form of “sing” prayers and ceremonial cure practices. However, few nurses would think of providing space and pri- vacy for several relatives to be able to conduct a ceremony for a hospitalized family member.

Also, some Native American tribal be- liefs require incorporating the medicine man

The Four Major Subcultural Ethnic Groups 351

passive people, devoted to tribe and family, and willing to share possessions and self with others. They are very vulnerable when it comes to their pride and dignity, and they can be eas- ily offended by insensitive caregivers.

In terms of human relationships, Native Americans believe that to look someone in the eye is considered disrespectful. Some tribes feel that looking at the eyes of another person re- veals and may even steal someone’s soul. Even though a friendly handshake and eye contact are acceptable and even expected in the white American culture, it must be acknowledged that these gestures do not have the same meaning for the Native American. Nurses may consider lack of eye contact to mean that these patients are not interested in learning, or inattentive, when in fact all along they were taking in the message of instruction being given.

The type and incidence of health problems faced by Native Americans have undergone sig- nificant change over the years. In the first half of the 20th century, acute and infectious diseases were prevalent and were the principal cause of death. Today, because of increased life expec- tancy, Native Americans are succumbing to many lifestyle diseases and chronic conditions (Na- tional Institutes of Health, 2017). Chief among the causes of morbidity and mortality are heart disease, cancer, diabetes, and drug and alcohol abuse. The rates of obesity, heart disease, suicide, and diabetes for the Native American popula- tion are among the highest of all ethnic groups. These issues and others are amenable to edu- cational intervention and need to be addressed by nurses (Blue Bird Jernigan et al., 2017; Cwik et al., 2016; Gittelsohn & Rowan, 2011; Goodwin, Burhansstipanov, Dignan, Jones, & Kaur, 2017; Jemigan, Duran, Ahn, & Winkleby, 2010; Komro et al., 2017; Muller et al., 2017; O’Connell et al., 2010; Sequist et al., 2011; Sofer, 2017; Varcoe et al., 2017; Veazie et al., 2014).

Teaching Strategies The Indian Health Service is a government- operated health system established in 1955 to

in Native American communities are highly re- spected and looked to for advice and counsel.

Another characteristic of Native Americans is that they generally are not very future oriented; they take one day at a time and do not feel they have control over their own destiny. Time is con- sidered to exist on a continuum with no begin- ning and no end. Native Americans tend not to live by clocks and schedules. In fact, many of their homes do not have clocks, and family members eat meals and do other activities when they please.

Members of this ethnic group tend to be casual in their approach to life. This lack of time consciousness and pressure is a crucial factor when a prescribed regimen calls for the patient to follow a medication, exercise, or di- etary schedule. Inattention to time, in addition, can interfere with Native Americans keeping scheduled appointments, although lack of funds rather than time seems to be the main cause of missed appointments.

Another aspect of time is reflected in Native Americans’ belief that death is a part of the life cycle. Their grief processes are culturally very dif- ferent. Funerals are accompanied by large feasts and the sharing of gifts with relatives of the de- ceased. The outward signs of grieving may dif- fer from tribe to tribe; some tribes believe that death and passage to the afterlife should be cel- ebrated, whereas others believe that tears ease the passage to the afterlife, so mourning is ex- pected. Life after death is viewed as an oppor- tunity to join the world of long-ago ancestors. Native Americans’ view of death is closely re- lated to their opinion about the appropriate disposal of amputated limbs. Because diabetes is so prevalent in the Native American popula- tion (O’Connell, Yi, Wilson, Manson, & Acton, 2010), it is important to know that they usu- ally want to reclaim an amputated body part for proper burial.

Sharing is another core value of Native Americans. The concept of “being” is funda- mental, and there is little stress on achievement or material wealth. Individuals are valued much more highly than material goods. Overall, Native Americans are a proud, sensitive, cooperative,

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on transcultural care and cultural competence in practice (Betancourt, Corbett, & Bondaryk, 2014; Burchum, 2011; Cai, 2016; Raman, 2015; Smith, 2013). Multiculturalism as a relatively new concept promotes awareness and accep- tance of diversity and attention to the healthcare needs of unique populations (Truong, Paradies, & Priest, 2014; Vidaeff et al., 2015). The delivery of appropriate health care now and in future years depends on use of a culturally informed approach that goes beyond simple language translation and an understanding of the characteristics of different cultures. As primary caregivers, nurses must learn how to relate to people—including patients and their family members, fellow health- care practitioners, and nursing students—who come from a variety of cultural backgrounds (Jeffreys, 2016).

As part of former President Bill Clinton’s national leadership to eliminate cultural dispar- ities in health by the year 2010, the U.S. govern- ment introduced a series of initiatives put forth in the Healthy People 2010 document. One goal of this 10-year plan was to eliminate racial and ethnic disparities in health (USDHHS, 2000). This initiative has been praised as being “the first explicit commitment by the government to achieve equity in health outcomes” (Jones, 2000, p. 1214). The nursing profession em- braced this goal to eliminate discrepancies in health outcomes among minority populations (Carol, 2001). Since then, a follow-up Healthy People 2020 document has been released (US- DHHS, 2012). The profession continues to con- tribute to the expectation of eliminating these disparities by focusing on change in both aca- demic and practice settings as well as through clinical research (Shen, 2015; Singer, Dressler, George, & The NIH Expert Panel, 2015).

One important step to ensure culturally competent nursing care in this new century is to increase minority representation in nursing. The profession needs to recruit and retain more minority students and faculty to expand the di- versity of RNs within its ranks (Carthron, 2007). Unfortunately, people from minority groups comprise only 16.8% of the nursing workforce

meet federal treaty obligations to provide hos- pitals and outpatient clinics for the delivery of healthcare services to 2 million of the country’s 5.2 million Native Americans belonging to 565 tribes. With the increased focus on using health information technology and telemedicine to de- liver prevention and medical management pro- grams, important achievements have recently been made in improving diabetes control and increas- ing life expectancy. Nevertheless, health dispari- ties persist in this ethnic population as compared to the overall U.S. population (Sequist et al., 2011; Sofer, 2017). The Health Education program of the Indian Health Service is committed to pos- itively influencing wellness behaviors and good lifestyle choices through health promotion and disease prevention efforts (USDHHS, 2015a).

Although all Native Americans share some of the core beliefs and practices of their cul- ture, each tribe is unique in its customs and lan- guage. Finding the ways and means to integrate Western medicine with the traditional Native American folk medicine in caring for the varied needs of this population group presents a chal- lenge to the nurse. It also presents a learning op- portunity for the learner who is receiving these health education services. Nurses need to focus on giving information about these diseases and risk factors, emphasize the teaching of skills re- lated to changes in diet and exercise, and help clients to build positive coping mechanisms to deal with emotional problems.

▸ Preparing Nurses for Diversity Care

The United States is no longer the homogeneous melting pot society it once was. Today, numer- ous, varied, and distinct cultures are present in the United States because of an increasing trend toward global migration of people and a change in philosophy about respecting cultural diversity. In addition, nurses are caring for people from many cultures because of the globalization of nursing practice and the professional emphasis

Preparing Nurses for Diversity Care 353

should be acutely aware of the need to attend to these differences in a sensitive, open, and fair manner.

Nurse educators and other health profes- sionals must relate to each person as an indi- vidual. It is important to develop an awareness that although a person can be considered a member—or may identify with members—of a certain ethnic group, the individual has his or her own abilities, experiences, preferences, and practices. Learning needs, learning styles, and readiness to learn are all factors that influ- ence lifestyle behaviors that go beyond the cul- ture in which someone was raised.

Nonetheless, everyone has been socialized in subtle and not-so-subtle ways according to his or her own diversity attributes, socioeconomic and political backgrounds, and other life expo- sures. It is important to acknowledge the prej- udices, biases, and the tendency to stereotype that can come into play when dealing with oth- ers like or unlike ourselves. A conscious attempt must be made to recognize these possible atti- tudes and the effect they may have on others in our care (Burgess, van Ryan, Dovido, & Saha, 2007). To address the dangers of stereotyping on more than just a superficial level, this sec- tion examines examples of what constitutes un- acceptable forms of stereotyping, which pitfalls can arise in dealing with diversity, and what can be done to avoid behaviors that stereotype our- selves and others.

Stereotyping is defined by Purnell (2013) as “an oversimplified conception, opinion, or be- lief about some aspect of an individual or group of people” (p. 486). Exaggerated generalizations are commonly made about the characteristics, behaviors, and motives associated with any per- son or group of people. Actually, stereotyping can be positive or negative, depending on how, where, when, why, and about whom it is ap- plied (Satel, 2002).

For example, stereotyping can be a useful and acceptable process to organize or classify people if based on facts and logical reasoning that helps them to identify and understand in- formation—for example, “he’s Jewish,” “she’s

(Figure 8-3), whereas more than 34% of the to- tal U.S. population belongs to a variety of cul- tural subgroups (U.S. Census Bureau, 2011). Another initiative to break down cultural bar- riers to health care calls for strengthening mul- ticultural perspectives in the curricula of health education programs, including nursing educa- tion (Kratzke & Bertolo, 2013; Mikkonen, Elo, Kuivila, Tuomikoski, & Kaariainen, 2016; Perez & Luquis, 2014).

Nurses must be able to create an environ- ment in which people are encouraged to express themselves and freely describe their needs. An emerging paradigm, cultural distress, describes patient reactions to care when nurses do not attend to a person’s cultural needs (Dewilde & Burton, 2016). As Dreher (1996) so aptly stated many years ago, “Transcending cultural differ- ences is more than an appreciation of cultural diversity. It is transcending one’s own invest- ment in the social and economic system as one knows it and lives it” (p. 4). Nurses must con- centrate on the cultural strategies, such as cul- tural humility (Isaacson, 2014), that are needed to help individuals and groups negotiate the healthcare system.

▸ Stereotyping: Identifying the Meaning, the Risks, and the Solutions

In addressing the diversity issues of gender, socioeconomics, and culture, nurses must ac- knowledge the risks of stereotyping inherent in discussing these three attributes of the learner. Throughout this chapter, it has been clearly doc- umented that differences exist in learning based on gender, socioeconomics, and culture, which in turn often require alternative approaches to teaching. It is important to realize that differ- ences are not based on judgments as to what is good or bad, or right or wrong; rather, nurses

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Stereotype threat is a term to describe a negative impression associated with an individ- ual’s status that triggers physiological and psy- chological behaviors in patients as well as in providers that may be a contributor to health- care disparities (Abdou & Fingerhut, 2014; Bur- gess, Warren, Phelan, Dovidio, & van Ryn, 2010; Ofri, 2011). As Curtin (2017) so aptly stated in her discussion about bridging the “we vs. they” gap, “consideration for others shouldn’t be a ter- ribly difficult proposition. It takes no more en- ergy to be thoughtful than to be thoughtless, to be accepting rather than condemning, to be kind rather than intolerant” (p. 48).

For example, research into gender stereo- typing in the past 25 years has documented that elementary and secondary school teach- ers interact more actively with boys compared to girls by asking boys more questions, giving them more feedback (praise and positive en- couragement), and providing them with more specific and valuable comments and guidance. In these subtle ways, stereotypical expectations are reinforced (Snowman & McCown, 2015). Attitudes toward gender-role competencies are considered a type of stereotyping. Gender bias has produced inequality in education, employ- ment, and other social spheres.

Nurses must concentrate on treating people of all genders equally when providing access to health education, delivering health and illness care, and designing health education materials that contain bias-free language. For example, they must avoid gender-specific terms, such as using he or she, unless critical to the con- tent, and choose words that minimize ambigu- ity in gender identity, such as using the plural pronoun they. If possible, nurses should avoid beginning or ending words with man or men, such as man-made, mankind, or chairmen. Do not specify marital status unless necessary by using Ms. instead of Mrs. The purpose for us- ing gender-fair language is to reduce gen- der stereotyping and social discrimination (Sczesny, Formanowicz, & Moser, 2016). Sug- gestions for how to avoid sexist language can be found in the Guidelines for Gender-Fair

Italian,” or “they’re Democrats.” Conversely, ste- reotyping can be negative if it is used to place people in an artificial or unfair position that oversimplifies their situation and is not based on facts. Negative stereotyping leads to disre- specting, dehumanizing, and defaming an in- dividual or group, which serves as a barrier to equality and fairness toward others. Of most importance, negative stereotyping can result in poorer health outcomes for the patients (Uni- versity of Southern California, 2015). Also, ste- reotyping members of health professions can lead to negative or false perceptions that hin- der the delivery of collaborative patient-centered care by healthcare teams (Ateah et al., 2011; Cook & Stoecker, 2014).

Stereotyping deserves a bad name when it is associated with bias or clichés. A huge emotional component exists to stereotyping. The language that is used, the attitudes that are projected, the conclusions that are drawn, and the con- text in which stereotyping is used all determine whether it has a positive or negative quality.

Unfortunately, classification by association is often bias. Stereotyping in this sense is used to label someone. For example, Americans tend to think of themselves as the freedom fighters and liberty lovers of the world; in the same breath, they may describe members of other groups or nationalities as violators of human rights or ter- rorists. This threat of stereotyping is even greater today based on the terrorist attacks occurring in the United States and worldwide, especially in the past 2 decades. Simple appearance, such as a beard, attire, or form of speech, can be the basis of broad and deep prejudices.

People particularly tend to use an excuse to classify individuals when they do not like or respect others whose backgrounds, attitudes, abilities, values, or beliefs are different from or opposed to their own or are misunderstood or misinterpreted. Stereotyping, either conscious or subconscious, results in intolerance toward oth- ers and engenders the belief that our way is the only way or the right way. In health care, label- ing, stereotyping, and stigmatizing responses by nurses and other providers marginalize patients.

Stereotyping: Identifying the Meaning, the Risks, and the Solutions 355

■ Does someone’s appearance influence (raise or lower) my expectations of that person’s abilities or affect the quality of care I deliver?

■ Do I assess the educational and experien- tial backgrounds, personal attributes, and economic resources of patients to ensure appropriate health teaching?

■ Am I knowledgeable enough of the cultural traditions of various groups to provide sen- sitive care in our multicultural, pluralistic society?

It is all too easy to stereotype someone not out of malice but rather out of ignorance. Nurses have a responsibility to keep informed of the most current beliefs and facts about various gender attributes, socioeconomic influences, and cul- tural traditions that could influence their teach- ing and learning either positively or negatively. Every day, research in nursing, social science, psychology, and medicine is yielding informa- tion that will assist in planning and revising ap- propriate education interventions to meet the needs of diverse patient populations.

▸ State of the Evidence It is essential that nurses base their practice on evidence from empirical studies and expert opin- ion so that they can deliver the highest quality, most scientifically sound care to clients. Such evidence also is important as a basis for the ed- ucational preparation of staff nurses and future members of the nursing profession to give them the most up-to-date knowledge and skills needed to function competently and confidently in to- day’s healthcare environment.

With respect to gender attributes of the learner, it is evident that efforts to understand how the human brain works and the differences among the sexes in how they think, feel, and re- spond are still in their infancy. Neuroscience is just beginning to unravel the mysteries and discover the differences and similarities in the way male and female brains are wired. In the last 10 to 15 years, there has been an upsurge

Use of Language by the National Council of Teachers of English (2002) and Purdue Online Writing Lab’s (2010) Stereotypes and Biased Language document.

With respect to age, socioeconomics, culture and race, religion, or disabilities, stereotyping most definitely exists. Throughout this chapter, many cautions have been issued against stereo- typing of individuals and groups. For example, just because someone belongs to a specific eth- nic group does not necessarily mean that the individual adheres to all the beliefs and prac- tices of that culture.

A thorough and accurate assessment of the learner is the key to determining the specific abilities, preferences, and needs of every in- dividual. The nurse should choose words that are accurate, clear, and free from bias when- ever speaking or writing about an individual or a group of individuals. Nurses should refer to someone’s ethnicity, race, religion, age, and SES only when it is essential to the content be- ing addressed. For instance, it is more politi- cally and socially correct to use the term older adult than the term elderly or aged. Do not la- bel a member of a special population as a dis- abled person but rather use people-first language when referring to him or her as a person with a disability. Also, it is more appropriate and more acceptable to refer to a person with dia- betes rather than a diabetic or to a person with AIDS rather than an AIDS victim.

To avoid stereotyping, nurses should ask themselves the following questions:

■ Do I use neutral language when teaching patients and families?

■ Do I confront bias when evidenced by other healthcare professionals?

■ Do I request information equally from patients regardless of gender, SES, age, or culture?

■ Are my instructional materials free of ste- reotypical terminology and expressions?

■ Am I an effective role model of equality for my colleagues?

■ Do I treat all patients with fairness, respect, and dignity?

356 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

increase in the number of new studies being con- ducted in this area. For example, the increasingly more multicultural nature of U.S. society requires that nurses understand the impact of ethnic be- liefs on the epidemiology of various diseases, on the effectiveness of health promotion efforts, on illness prevention measures, and on health maintenance and rehabilitation interventions.

Moreover, research is just in its initial stages in developing instruments that might give insight into the cultural effects of clients’ perspectives on health and responses to illness. More explo- ration is needed in creating as well as adopting reliable and valid instruments to measure health beliefs, attitudes, customs, and patterns of be- havior in males and females of different ethnic backgrounds. Clearly, health providers lack sub- stantial evidence on how the context of culture affects health and illness.

▸ Summary This chapter explored the influence of gender characteristics, SES, and cultural beliefs on both the ability and the willingness of patients to learn about health and health care. The in-depth ex- amination of these three factors explains certain behaviors observed or potentially encountered in a teaching–learning situation. It also serves to assist the nurse in using strategies that sensi- tively address and respect the individual charac- teristics and specific needs of the learner.

The most important message to remember from this chapter is the care nurses must take not to stereotype or generalize common character- istics of a group to all members associated with that group. For example, if the nurse does not know much about an ethnic subculture, he or she should ask patients about their beliefs rather than just assuming they abide by the tenets of a certain cultural group. In that way, nurses can avoid offending learners.

In their role as teachers, nurses must be cau- tious to treat each learner as an individual. They must determine the extent to which patients as- cribe to, exhibit beliefs in, or adhere to ways of

of interest and fascination with the discoveries in the field of neurobiology. New brain imaging instruments are beginning to reveal which indi- vidual portions of the brain are responsible for cognition, emotions, and tasks, but even more important are revelations about how the differ- ent parts of the brain operate or interact in con- cert with one another.

Brain research is an exciting, largely un- charted field, and some of the research find- ings presented to date have been conflicting or inconclusive. Therefore, the challenge is to in- corporate what is currently known to refine our approaches to teaching and learning but not to be too quick in jumping to assumptions or gen- eralizations in the application of preliminary re- search findings before the evidence is conclusive.

Recent years also have witnessed a grow- ing acceptance and subsequent interest in the LGBTQ population. The body of knowledge on the characteristics, healthcare needs, and effec- tiveness of various strategies and interventions that can be used when working with this cul- tural group has increased significantly over the past 5 to 10 years. As more clients have begun openly sharing their sexual orientation and gen- der identity with their healthcare providers, it is critical that the nurse be prepared to deliver cul- turally competent care to this group of people.

Further research into the impact of socio- economics on health outcomes also needs to be conducted. For example, scant information is cur- rently available about IQ and socioeconomics in relation to health status and health inequalities. Research also has shown that although cognitive abilities are related to health, the associations be- tween socioeconomic environment, social posi- tion, educational attainment, and employment status on the health inequalities in morbidity and mortality are still not altogether clear. Much more research needs to be done to understand the im- pact of socioeconomic position in relation to the ability, preference, and motivation for learning.

Nursing research priorities regarding the influence of cultural diversity on the health of individuals and groups must be identified and defined. Knowledge gaps remain despite the

357Summary

3. In which ways does SES negatively affect a person’s health, and, conversely, how does illness affect an individual’s socio- economic well-being?

4. How does the SES of individuals influence the teaching–learning process?

5. What is meant by the term poverty cycle? 6. What is the definition of each of the fol-

lowing terms: assimilation, acculturation, culture, ethnic group, transcultural, and ethnocentrism?

7. What are the 12 cultural domains identified in Purnell’s model of cultural competence that should be accounted for when con- ducting a nursing assessment?

8. What are the four major ethnic subcultural groups in the United States?

9. What are the prominent characteristics of each of the four major ethnic subcul- tural groups?

10. Which teaching strategies are most ap- propriate to meet the needs of individ- uals from each of the four major ethnic subcultural groups?

11. What can the nurse do to avoid cultural stereotyping?

doing things that might affect their learning. As Griffith (1982) so aptly commented many years ago, humans live in a double environment—an outer layer of social and cultural experiences and an inner layer of innate strengths and weak- nesses—which influences how they perceive and respond to their world.

Nurses, as professionals, should constantly strive to improve the delivery of care to all peo- ple regardless of their gender identity, socioeco- nomic level, or cultural origin. Nurses need to be aware of how these three factors affect the teaching–learning process before they can com- petently, confidently, and sensitively deliver care to satisfy the education needs of patients and their family members who come from di- verse backgrounds.

Review Questions 1. What are the gender-related characteri-

stics in cognitive functioning and per- sonality behavior that affect learning?

2. How does the environment versus here- dity influence gender-specific approaches to learning?

CASE STUDY “They told us this might happen, but we were hoping this day would never come,” said Kim Hoang as she and her siblings crowded into the tiny conference room—shaken to hear the news that their grandmother, Anh Hoang, a 74-year-old Vietnamese woman, was in end-stage renal failure. “My grandmother is old world. We don’t know how she will cope with all of this,” Kim added. The nurse and physician explained the treatment plan. Dialysis is required three times each week, and the schedule is rigid. Mrs. Hoang’s diet restrictions also are significant. New medications will be added, and Mrs. Hoang needs to learn to care for her dialysis site. She will feel better once dialysis starts, but she might be fatigued and will probably require periodic blood transfusions. Kim asked to be present when her grandmother’s teaching takes place. “My grandmother’s English is not very good, and I can help explain things to her. She doesn’t feel comfortable around strangers,” Kim said.

1. How would you respond to Kim’s request to serve as the interpreter for her grandmother? 2. Which areas are most important to consider when completing Mrs. Hoang’s cultural

assessment? 3. If during assessment you discover conflicts between Mrs. Hoang’s cultural beliefs and the

treatment protocols, how will you handle them?

358 Chapter 8 Gender, Socioeconomic, and Cultural Attributes of the Learner

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367References

Educating Learners with Disabilities and Chronic Illnesses Deborah L. Sopczyk

CHAPTER HIGHLIGHTS

■ Scope of the Problem ■ Models and Definitions

• Definition of the Term Disability ■ The Language of Disabilities ■ The Roles and Responsibilities of Nurse Educators ■ Types of Disabilities ■ Sensory Disabilities

• Hearing Impairments • Visual Impairments

■ Learning Disabilities • Dyslexia • Auditory Processing Disorder • Dyscalculia

■ Developmental Disabilities • Attention-Deficit/Hyperactivity Disorder • Intellectual Disabilities • Asperger Syndrome/Asperger Profile/Autism Spectrum Disorder

■ Mental Illness

(continues)

369

CHAPTER 9

■ Physical Disabilities • Traumatic Brain Injury • Memory Disorders

■ Communication Disorders • Aphasia • Dysarthria

■ Chronic Illness ■ The Family’s Role in Chronic Illness or Disability ■ Assistive Technologies ■ State of the Evidence

CHAPTER HIGHLIGHTS (continued)

OBJECTIVES

After completing this chapter, the reader will be able to

1. Recognize the scope of the disability problem from a worldwide, national, and individual perspective.

2. Compare various definitions of the term disability. 3. Distinguish between the four models that influence the way disabilities are addressed in society. 4. Describe the language that should be used when writing about, talking to, or talking about

people with disabilities. 5. Summarize the roles and responsibilities of the nurse as educator in teaching learners with disabilities. 6. Differentiate between the two major types of disabilities, the six categories of disabilities, and

the multiple subcategories of each of these disabilities. 7. Describe the various teaching strategies (methods and materials) that can be used when

working with learners who have sensory, learning, developmental, mental, physical, and/or communication disabilities.

8. Discuss the effects of a chronic illness or disability on patients and their families. 9. Give examples of assistive technologies and their applications to enhance the lives of people

with disabilities.

KEY TERMS

disability people-first language identity-first language habilitation rehabilitation sensory disabilities hearing impairment visual impairment learning disability

dyslexia auditory processing disorder

(APD) dyscalculia developmental disability attention-deficit/hyperactivity

disorder (ADHD) intellectual disability Asperger syndrome

global aphasia expressive aphasia receptive aphasia anomic aphasia augmentative and alternative

communication (AAC) dysarthria assistive technologies

370 Chapter 9 Educating Learners with Disabilities and Chronic Illnesses

Teaching others about health and wellness or disease and its treatments is a critical and challenging role for the nurse caring for any population of individuals in any setting. However, the teaching–learning process is es- pecially demanding when working with people whose abilities to learn are challenged by sen- sory, cognitive, mental health, physical, and other types of disabilities that affect their capacities to see, hear, speak, move, understand, remember, or process information. In light of these chal- lenges, education remains a critical component of care as nurses assist patients with disabilities and their significant others to maintain already established patterns of living or to develop new ones to accommodate changes in health status or functional ability.

This chapter focuses on those persons whose sensory, cognitive, mental health, or physical con- ditions require nurses to adapt their approach in teaching others to enable learning. Although the information presented here focuses specifi- cally on patient populations, the same principles of teaching and learning can be extrapolated to apply to other categories of learners. For exam- ple, the nurse educator, in the role of inservice educator, faculty member, or staff development coordinator, may use these strategies when teach- ing hospital personnel or nursing students who have a physical or learning disability.

This chapter provides an overview of a wide range of sensory, cognitive, mental, and physical disabilities and other issues that affect the ways in which people learn. Included are the most common disabilities encountered by nurses, such as learning disabilities, mental illness, and communication disorders. Although not a dis- ability, chronic illness is included because it is a situational issue that often causes disabilities and that requires a change in the way the nurse approaches health education. This chapter also provides a summary of assessment, teaching, and evaluation strategies that nurse educators can use in designing and implementing teach- ing plans for individuals with unique learning needs and their families.

▸ Scope of the Problem “Disability is part of the human condition. Al- most everyone will be temporarily or permanently impaired at some point in their life, and those who survive to old age will experience increas- ing difficulties in functioning” (World Health Organization [WHO], 2015b, p. 3). Therefore, it is not surprising that more than 1 billion peo- ple throughout the world (about 15% of the pop- ulation) live with a condition that is classified as a disability. This number is expected to in- crease as populations age and the incidence of debilitating conditions such as diabetes, obesity, and cancer continues to grow (WHO, 2016b).

Given these worldwide statistics, it is not sur- prising that a significant number of Americans live with a wide range of disabilities that affect them in a variety of ways. In the United States, nearly 60 million Americans (1 in 5) are esti- mated to have a disability, with almost half of these persons reporting a disability that is con- sidered to be severe (U.S. Census Bureau, 2012). Almost 1 in 12 Americans aged 18–64 report having a disability severe enough to limit their ability to work (Cornell University, 2012).

If the incidence of disabilities seems high, it is important to remember that not all disabil- ities are readily apparent to the casual observer. For example, not all people with disabilities use a wheelchair, wear a hearing aid, or walk with the assistance of a white cane.

Individuals with disabilities are more likely than people without disabilities to have more ill- nesses and greater health needs, are less likely to receive preventive health and other types of so- cial services, and are more likely to suffer from poverty (Brucker & Houtenville, 2015; Reichard, Stolzle, & Fox, 2011). However, it is important to avoid making assumptions about this population. People with disabilities are diverse in the type and extent of health disparities they have, and the ac- cess to services that are available varies from per- son to person (Horner-Johnson, Dobbertin, Lee, Andresen, & the Expert Panel on Disability and Health Disparities, 2014; Wisdom et al., 2010).

Scope of the Problem 371

Some disabilities are associated with addi- tional chronic health problems. For example, Down syndrome—a common cause of intel- lectual disability—is associated with various chronic physical conditions, including heart disease, epilepsy, and leukemia. In the case of Down syndrome, the associated intellectual dis- ability complicates the chronic health conditions; that is, individuals with Down syndrome are less likely to access health services because of fear, lack of understanding on the part of caregiv- ers, and environmental barriers (Vander Ploeg Booth, 2011).

Other factors contributing to health dispar- ities among people with disabilities include fear, lack of understanding and physical barriers. Cost is another major issue. People with disabilities face many challenges related to employment re- sulting in financial constraints (Brucker, Mitra, Chaltoo, & Mauro, 2015). Therefore, even with health insurance, people with disabilities may have insufficient resources for copays, transportation costs, and other expenses related to accessing health care (Lee, Hasnain-Wynia, & Lau, 2012).

It has been said that people with disabili- ties represent the largest minority group in the United States, a group that is composed of indi- viduals of all ages, of all racial and ethnic back- grounds, and from all walks of life (DoSomething. org, 2017). Health care for this group of people is often complex and costly. More than 25% of healthcare expenditures in the United States are associated with disability care, borne largely by Medicaid and the public sector (Anderson, Armour, Finkelstein, & Wiener, 2010). As edu- cators, nurses can play a significant role in pro- moting health and wellness, ensuring proper self-care, and improving overall quality of life.

▸ Models and Definitions Kaplan (2010) describes four models or per- ceptions of disabilities that influence the way in which disabilities are addressed in society:

■ The moral model ■ The medical model

■ The rehabilitation model ■ The disabilities (social) model

The moral model, which views disabili- ties as sin, is an old model that unfortunately persists in some cultures. When a disability is viewed as sinful, individuals and their families not only experience guilt and shame but may also be denied the care they require. The United Nations has established a set of Standard Rules on the Equalization of Opportunities for Per- sons with Disabilities specifying that individuals with disabilities have a fundamental right of ac- cess to care, rehabilitation, and support services (United Nations, 1993; WHO, 2015b). WHO as- sists countries to comply with this United Na- tions ruling.

The medical and rehabilitation models are similar in that both view disabilities as prob- lems requiring intervention, with the goal being cure, “normalcy,” or reduction of the perceived deficiency (Kaplan, 2010; Shyman, 2016). The health or rehabilitation professional is central to both models. Many positive results have come out of efforts to develop medical and surgical treatment, prostheses and other equipment, and strategies to improve the quality of life of people with disabilities. However, the underlying be- lief associated with these two models—namely, that people with disabilities must be “cured” or “fixed”—has been criticized by disability ad- vocates. The difference between the two mod- els is that the medical model views disability as a defect or sickness, whereas the rehabilitation model sees disability as a deficiency. The medi- cal model particularly is blamed for promoting expensive procedures in attempts to treat con- ditions that often cannot be cured. The rehabil- itation model, on the other hand, is less invasive and can fix or alleviate a disability through less expensive approaches such as physical therapy, counseling, and training services (Kaplan, 2010).

The disabilities model, sometimes referred to as the social model, is the framework that has had the most influence on current thinking. The disabilities model embraces disability as a nor- mal part of life and views social discrimination,

372 Chapter 9 Educating Learners with Disabilities and Chronic Illnesses

rather than the disability itself, as the problem (Kaplan, 2010). According to this model, people with disabilities are often excluded from social, political, relational, cultural, and economic as- pects of mainstream life and it is this exclusion that is most problematic. Whereas the medical and rehabilitation models focus on the prob- lem or condition of the individual, the disabil- ities or social model views disability as a social construct and focuses on barriers in society that limit opportunities (Matthews, 2009).

Definition of the Term Disability The term disability has been defined in dif- ferent ways, with many of these definitions re- flecting one or more of the models described by Kaplan (2010). Most definitions are broad and serve to categorize a wide variety of im- pairments stemming from injury, genetics, con- genital anomalies, or disease. Some definitions go beyond the underlying physical or mental health issue to include different responses by societies to the individual who has a disability. For example, WHO (2016a) defines disability as “a complex phenomenon, reflecting an in- teraction between features of a person’s body and features of the society in which he or she lives” (para. 2). The connection that this defini- tion makes between an individual’s ability and the expectations of society reflects the spirit of the disabilities model and gives recognition to the environmental and social barriers faced by people with disabilities. WHO uses the Interna- tional Classification of Functioning, Disability and Health, known more commonly as ICF, as a framework for measuring health and disability at the individual and population levels. Adopted in 2001, the ICF provides a means of classifying the consequences of disease and trauma and rec- ognizes three dimensions of disabilities: body function/impairment, activity/restrictions, and participation/restrictions (Centers for Disease Control and Prevention [CDC], 2012b). The ICF identifies disability as a universal human experience and places emphasis on the impact of a disability rather than on its cause.

In the United States, the Social Security Administration (SSA, 2016) defines disabil- ity in terms of an individual’s ability to work. This definition and its associated criteria are designed to be used to determine eligibility for Social Security payments for individu- als with severe disabilities. The criteria used by the SSA require that individuals be classi- fied as disabled only if they have a long-term or fatal condition that makes it impossible for them to continue in their current role or adapt to other work for an extended period of time. The SSA does not pay benefits for partial or short-term disability.

On July 26, 1990, President George H. W. Bush signed into law the Americans with Dis- abilities Act (ADA). The definition of disability under the ADA is “a physical or mental impair- ment which substantially limits one or more of the major life activities of the individual” (U.S. Department of Justice, 2009, p. 1). A major life activity includes functions such as caring for one- self, standing, lifting, reaching, seeing, hearing, speaking, breathing, learning, and walking. This significant legislation has extended civil rights protection to millions of Americans with dis- abilities. The first part of the law, which became effective in January 1992, mandated accessibil- ity to public accommodations. The second part of the law went into effect in July 1992 and re- quired employers to make reasonable accom- modations in hiring people with disabilities (Merrow & Corbett, 1994; Pelka, 2012).

Although the ADA’s definition of disabil- ity, with its emphasis on physical and mental impairments, may give the impression that it is steeped in the medical or rehabilitation model, the protections it provides are consistent with the disabilities model. The ADA legislation makes it illegal to discriminate based on a dis- ability in the areas of employment, public ser- vice, public accommodations, transportation, and telecommunications. On a practical level, it means that an individual cannot be denied employment or promotion because of miscon- ceptions or biases regarding that individual’s disability (Pelka, 2012).

Models and Definitions 373

In each of these statements, the emphasis is on the disability rather than the person. Using people-first language, these statements would be reworded as follows:

■ Justin is a 5-year-old boy who is diagnosed with asthma. Justin continues to have symp- toms despite treatment.

■ Marcy is a woman with a developmental disability. Marcy wants to learn how to care for herself and she learns best when given careful direction.

In recent years, the use of people-first lan- guage has become somewhat controversial. Some groups within the disabilities movement argue that a disability is an integral part of who a person is and should be affirmed rather than listed as a secondary characteristic (Dunn & Andrews, 2015). These individuals prefer the use of “identity-first language,” which places the disability-related word first when describing a person with a disability. For example, when us- ing identity-first language, a person would be referred to as autistic rather than a person with autism. Advocates of identity-first language be- lieve that a disability is an all pervasive “edifying and meaningful component of a person’s iden- tity that defines the way in which an individual experiences and understands the world around him” (Brown, 2011, para. 11). Therefore, these advocates believe that identity-first language celebrates rather than apologizes for the disabil- ity and serves to unite people with a disability.

No definitive rules exist for governing the use of language about disabilities. However, language is powerful so it is important that nurses pro- ceed carefully when writing about, talking about, or talking to people with disabilities. The words and labels nurses use to describe people influ- ence the way individuals think about themselves and the way individuals are perceived by society. The following guidelines should be considered:

■ When working with or writing about groups with a specific disability, try to determine preference. The literature, advocacy groups, and websites are good sources of information about group preference.

ADA legislation provides the foundation on which all facets of society will be free of dis- crimination, including the healthcare system. Therefore, health professionals can expect to en- counter people with disabilities in every setting in which they practice, such as schools, clinics, hospitals, nursing homes, workplaces, and pri- vate homes. Persons with a disability will ex- pect nurses and other healthcare professionals to provide appropriate instruction adapted to their special needs.

▸ The Language of Disabilities

Since the 1960s, the disability rights move- ment has worked to improve the quality of life of people with disabilities through political ac- tion. Through this effort, tremendous gains have been realized, including improved access to public areas, education, and employment. The disability rights movement also advocates for appropriate use of language with respect to people with disabilities.

In the late 1970s, disabilities advocates be- gan to encourage the use of “people-first or per- son-first language” (Family to Family Network, 2016: Haller, Dorries, & Rahn, 2006). The term people-first language refers to the practice of putting “the person first before the disability” in writing and speech and “describing what a person has, not what a person is.” People-first language is based on the premise that language is powerful and that referring to an individual in terms of his or her diagnosis or disability devalues the individ- ual (Snow, 2012, p. 3). Resulting from this effort, the federal government uses people-first language in its legislation and many professional journals require authors to use it in their manuscripts.

Consider the following statements:

■ Justin, a 5-year-old asthmatic, has not res- ponded well to treatment.

■ Developmentally disabled people, like Marcy, do best when provided with careful direction.

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self-care agents. Here, the focus is on wellness and strengths—not limitations—of the individ- ual. The role of the nurse educator in working with people who have a disability is varied and situation dependent.

The nurse may encounter patients who are newly disabled because of injury or illness or who have an illness that affects an existing dis- ability. The nurse may also work with patients whose health or illness needs are related to their disability only insofar as the disability influ- ences the way in which they learn or respond to treatment. For example, the nurse may teach self-care skills to a client with a new spinal cord injury, teach modification of self-care skills fol- lowing orthopedic surgery to a client with an old spinal cord injury, or adapt a teaching plan for a client who is blind and newly diagnosed with diabetes. It is the role of the nurse to teach these individuals the necessary skills required to maintain or restore health and maintain in- dependence (habilitation) and to relearn or restore skills lost through illness or injury (re- habilitation). When people with disabilities are encountered in health and illness settings, nurses are responsible for adapting their teach- ing strategies to help them learn about health, illness, treatment, and care.

When teaching patients who have a disabil- ity, the nurse must assess the degree to which families can and should be involved. Families of individuals who have a new disability are be- coming increasingly involved in the individual’s care and rehabilitation efforts. However, when working with someone who has an existing dis- ability, the appropriateness of involving family must be assessed carefully. The nurse must never assume that because a person has a disability, he or she is incapable of self-care.

Because of the complex needs of this popu- lation group, healthcare teaching often requires an interdisciplinary team effort. In developing a teaching plan, the nurse must assess the need to involve other health professionals such as physi- cians, social workers, physical therapists, psychol- ogists, and occupational and speech therapists. As with other clients, the nurse educator has the

■ Do not confuse disability with disease. Can- cer is a disease. Children with leukemia are more appropriately referred to as children with leukemia than leukemics. Autism is a lifelong condition that defines the way people affected view the world. Many people with autism prefer the term “autistic” as they believe it defines who they are and the way they view the world.

■ Unless a preference is accepted by an entire group, avoid using one format exclusively (Dunn & Andrews, 2015).

■ Do not make assumptions.

Snow (2012) offers these additional sug- gestions for using disability-sensitive language:

■ Use the phrase congenital disability rather than the term birth defect. The term birth defect implies that a person is defective.

■ Avoid using the terms handicapped, wheelchair bound, invalid, mentally retarded, special needs, and other labels that have negative connotations.

■ Speak of the needs of people with disabilities rather than their problems. For example, an individual does not have a hearing prob- lem but rather needs a hearing aid.

■ Avoid phrases such as suffers from or victim of. Phrases like these evoke unnecessary and unwanted pity.

■ When comparing people with disabilities to people without disabilities, avoid using phrases such as normal or able bodied. Phrases such as these place the individual with a disability in a negative light.

▸ The Roles and Responsibilities of Nurse Educators

The role of the nurse in teaching persons who have a disability continues to evolve as, more than ever, patients and their families expect and are expected to assume greater responsibility as

The Roles and Responsibilities of Nurse Educators 375

questions that help them to determine their needs and solve their problems?

2. Are there barriers to learning such as low literacy skills, vision impair- ments, hearing deficits, or impaired mobility?

3. If sensory or motor issues exist, is the patient willing and able to use supportive devices?

4. Which learning style best suits the patient in processing information and applying it to self-care activities?

5. Are the goals of the client and the goals of the family similar?

6. Is the patient’s environment conducive to learning?

7. Do the learners value learning new information and skills as a way to achieve functional improvement?

The nurse should serve as a mentor to pa- tients and their family members in coordinating and facilitating the multidisciplinary services re- quired to assist persons with disabilities in achiev- ing an optimal level of functioning. This role is especially important when working with a patient who has a new disability. When family members or significant others are involved in care and serve as the individual’s support system in the com- munity, they must be invited right from the very beginning to take an active part in learning in- formation as it applies to assisting with self-care activities and treatments for their loved ones. Appendix B provides a list of organizations that serve as resources for this population of learners.

▸ Types of Disabilities Disabilities can be classified into two major cat- egories: mental and physical. Physical disabili- ties typically are those that involve orthopedic, neuromuscular, cardiovascular, or pulmonary problems but may also include sensory condi- tions such as blindness or deafness. A disability is not an illness or disease but rather the conse- quence of illness, injury, congenital anomaly, or

responsibility to work in concert with individu- als with disabilities and their family members to assess learning needs, design appropriate educa- tional interventions, and promote an environ- ment that will enhance learning. The teaching plan must reflect an understanding of the per- son’s disability and incorporate interventions and technologies that will assist the patient in overcoming barriers to learning.

Application of the teaching–learning pro- cess is intended to promote adaptive behaviors in people that support their full participation in activities designed to promote health and, in the case of illness, optimal recovery. Emphasis on the various components of the learning pro- cess may differ depending on the disability, but it often requires changes in all three domains— cognitive, affective, and psychomotor.

Prior to teaching, assessment is always the first step in determining the needs of clients with respect to the nature of their problems or needs, the short- and long-term consequences or effects of their disability, the effectiveness of the coping mechanisms they employ, and the type and extent of sensorimotor, cogni- tive, perceptual, and communication deficits they experience. When dealing with persons experiencing a new disability, the nurse must determine the extent of their knowledge with respect to the disability, the amount and types of new information needed to effect changes in behavior, and their readiness to learn. As- sessment should be based on feedback from the patient as well as observation, testing when ap- propriate, and input from the healthcare team. In some cases, it may be wise to interview fam- ily members and significant others to obtain additional information.

In assessing readiness to learn, Diehl (1989) outlines the following questions to be asked, which continue to be relevant today, when the nurse is determining whether the timing of the teaching–learning process is appropriate:

1. Do the individual and family members demonstrate an interest in learning by requesting information or asking

376 Chapter 9 Educating Learners with Disabilities and Chronic Illnesses

total or partial auditory loss. It is estimated that approximately 30–48 million Americans have hearing loss in one or both ears (Lin, Niparko, & Ferrucci, 2011). Of every 1,000 children born in the United States, approximately two or three are diagnosed as deaf or hard of hearing (National Institute on Deafness and Other Communication Disorders [NIDCD], 2014). Nine out of every 10 children who are born deaf are born to par- ents who can hear (NIDCD, 2014).

The incidence of hearing loss increases with age. Approximately 18% of all American adults aged 45–64 years have a hearing impairment. This share increases to 47% by age 75, with men being more likely to develop a hearing impair- ment than women (NIDCD, 2014). Adult-onset hearing loss is often associated with exposure to loud sounds or noises (CDC, 2017c).

People with impaired hearing—both the deaf and the hard of hearing—have a complete loss or a reduction in their sensitivity to sounds. Hearing loss is generally described according to three attributes: type of hearing loss, degree of hearing loss, and configuration of the hearing loss (American Speech-Language-Hearing As- sociation [ASHA], 2017b). The three basic types of hearing loss are as follows:

1. Conductive hearing loss: A type of hearing loss that is usually correctable and causes reduction in the ability to hear faint noises. Conductive hearing loss occurs when the ear loses its ability to conduct sound—for exam- ple, when the ear is plugged with ear wax, a foreign body, a tumor, or fluid.

2. Sensorineural hearing loss: A type of hearing loss that is permanent and caused by damage to the cochlea or nerve pathways that transmit sound. Sensorineural hearing loss is some- times referred to as nerve deafness. It not only results in a reduction in sound level but also leads to difficulty in hearing certain sounds. Although they do not “cure” the hearing impair- ment, cochlear implants and hearing

genetics. Therefore, a physical problem such as a brain injury may result in a physical disability such as impaired ability to ambulate. Physical problems also may result in a mental disability. For example, the mental disability of dementia that is associated with Alzheimer’s disease is a result of physical changes in the brain. Mental disabilities include psychological, behavioral, emotional, or cognitive impairments.

Six categories of physical and mental dis- abilities have been chosen for discussion in this chapter because they represent common conditions that the nurse is likely to encounter in practice: (1) sensory disabilities, (2) learn- ing disabilities, (3) developmental disabilities, (4) mental illness, (5) physical disabilities, and (6) communication disorders. The multiple spe- cific disabilities (subcategories) that fall under each of these major categories are described as follows, along with the teaching strategies that should be used to meet the needs of learners.

▸ Sensory Disabilities Sensory disabilities include the spectrum of disorders that affect a person’s ability to use one or more of the five senses—auditory, visual, tac- tile, olfactory, and gustatory. The most common of these involve the ability to hear or see. Sen- sory disabilities can be complex, with multidi- mensional consequences that the nurse must address when in the role of educator. Nurses should be prepared to attend to the physical and emotional issues that may be related to the sensory loss. For example, vision impairment in older adults is associated with subsequent de- pression (Qian, Glaser, Esterberg, & Acharya, 2012). Children with impaired hearing have been found to have an injury rate twice that of children without hearing impairments (Mann, Zhou, McKee, & McDermott, 2007).

Hearing Impairments Hearing impairment is a common disability that affects people of all ages who have either a

Sensory Disabilities 377

to speak or have limited verbal abilities and vo- cabularies (Lederberg, Schick, & Spenser, 2012). This is especially true for adults who are prelin- gually deaf—that is, they have been deaf since birth or early childhood. They and speakers of other languages share many of the same prob- lems in learning English.

Problems with clients understanding health- and illness-related vocabulary also may be ex- acerbated with people who are deaf. Numerous research studies have found that although health education is critical for the Deaf, they often are faced with significant barriers in accessing and understanding health information (Pollard & Barnett, 2009; Smith, Massey-Stokes, & Lieberth, 2012). For example, a study about high levels of cardiovascular risk among Deaf adolescents found they encounter significant barriers in communicating about health information with parents and health education teachers (Smith, Kushalnagar, & Hauser, 2015). The study also found that even those with strong reading skills had difficulty understanding medical terminol- ogy commonly found on websites and in health information brochures.

Clearly, individuals who are deaf will have different skills and needs depending on the type of deafness and the amount of time they have been without a sense of hearing. Those who have been deaf since birth will not have had the benefit of language acquisition. As a result, they may not possess understandable speech and may have limited reading and vocabulary skills. Most likely, their primary modes of communication will be sign language and lipreading.

In recent years, research has inspired new hope for children with severe hearing loss to develop language skills. In 1984, the Food and Drug Administration (FDA) approved mar- keting of the first cochlear implant, a device that restores partial hearing by sending signals directly to the auditory nerve fibers, bypassing damaged hair cells in the inner ear (American Academy of Otolaryngology-Head and Neck Surgery, 2015). Cochlear implants are used with adults and children when hearing aids are in- effective in restoring hearing in the presence of

aids can improve hearing in persons with this type of disability.

3. Mixed hearing loss: A type of hearing loss that is a combination of conduc- tive and sensorineural losses.

People with hearing loss may have a prob- lem with one or both ears. The degree of hear- ing loss experienced by people with a hearing impairment is classified on a scale ranging from slight to profound. Although health profession- als may use the scale to differentiate people who are classified as being deaf or hard of hearing, clients themselves do not always agree with this classification. According to the National Associ- ation of the Deaf, how people label themselves is very personal and depends on many variables, in- cluding how closely the individual identifies with the Deaf community. Therefore, the nurse must determine if the patient with profound hearing loss prefers to be referred to as deaf or hard of hearing (National Association of the Deaf, 2010).

The use of people-first language is some- what controversial in the Deaf community. A recognized Deaf culture exists with a shared identity, language, and other cultural compo- nents (Clason, 2014; Johnson & McIntosh, 2009; McLaughlin, Brown, & Young, 2004). Because of this shared culture of which they are proud, many Deaf people want to be recognized as deaf because it reflects who they are as people. Re- garding the spelling of the term deaf, it is sug- gested that the word deaf with a lowercase d be used when referring to the physical condition of not being able to hear, and the word Deaf with an uppercase D be used when referring to peo- ple affiliated with the Deaf community or Deaf culture (Berke, 2017; Strong, 1996).

Communication is a primary concern for health professionals working with people who are deaf or hard of hearing. Regardless of the de- gree of hearing loss, any person with a hearing impairment faces communication barriers that interfere with efforts at patient teaching (Stock, 2002). Hearing loss poses a very real communi- cation problem because some individuals who are deaf or hearing impaired also may be unable

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first things nurses need to do is ask patients to identify their communication preferences. Sign language, written information, lipreading, and visual aids are some of the common choices. Although one of the simplest ways to transfer information is through visible communication signals such as hand gestures and facial expres- sions, this method will not be adequate for any lengthy teaching sessions.

The following modes of communication are suggested as ways to decrease the barriers of communication and facilitate teaching and learning for clients with hearing impairments in any setting.

Sign Language Many people who are deaf consider American Sign Language (ASL) to be their primary lan- guage and preferred mode of communication. In many families with children who are deaf, ASL is used in the home and is the first language chil- dren learn. For other children who are raised in an environment where Deaf culture predomi- nates, ASL is the medium of social communi- cation among peers, which reinforces English as a second language. Children who primarily use ASL have difficulty achieving fluency in En- glish and may struggle with written English as well (Disabilities, Opportunities, Internetwork- ing, and Technology [DO-IT], 2017). Some evi- dence, though, suggests that a high level of ASL proficiency is related to higher English literacy skills (Vicars, 2003).

ASL differs from simple finger spelling, which is a method of using different hand po- sitions to represent letters of the alphabet. In contrast, ASL is a complex language made up of signs as well as finger spelling combined with facial expressions and body position. Eye gaze and head and body shift also are incorporated into the language (NIDCD, 2017). In recent years, much debate has taken place within the Deaf community regarding the development of a written form of ASL and it remains somewhat controversial, particularly among the Deaf com- munity (Grushkin, 2017).

severe hearing loss (Food and Drug Adminis- tration, 2016). Research has shown that cochlear implants have a positive effect on language de- velopment when inserted in very young chil- dren (Ertmer, Young, & Nathani, 2007; Nicholas & Geers, 2007).

If deafness has occurred after language has been acquired, Deaf people may speak quite un- derstandably and have facility with reading and writing and some lipreading abilities. If deaf- ness has occurred in later life, often caused by the process of aging, affected individuals will probably have poor lipreading ability, but their reading and writing skills should be within av- erage range, depending on their educational and experiential background. If aging is the cause of hearing loss, visual impairments also may be a compounding factor. Because vision and hearing impairments are two common sen- sory losses in the older adult, these deficits pose major communication problems when teach- ing older clients.

People with hearing impairments, like other individuals, require health care and health ed- ucation information at various periods during their lives. Because of the diversity within this population, assessment is a critical first step in patient education to determine the extent of the hearing loss and the use of hearing aids, cochlear implants, or other types of assistive equipment. Also, individuals with hearing loss often experi- ence social isolation and feelings of inadequacy (Fusick, 2008). These feelings may contribute to a lack of confidence when faced with health chal- lenges. Nurses should assess the patient’s prior knowledge of the issue being addressed, recog- nizing that people who have hearing impair- ments may not have been exposed to the same kinds of health information as people who can hear (Pollard, Dean, O’Hearn, & Haynes, 2009).

Finally, it is important to remember that Deaf individuals will always rely on their other senses for information input, especially their sense of sight. For patient education to be ef- fective, then, communication must be visible. Because there are several different ways to com- municate with a person who is deaf, one of the

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should ask questions of the patient, request ver- bal teach-back or demonstrations, allow the pa- tient to ask questions, and use other appropriate assessment strategies (Scheier, 2009). Providing supplemental text, diagrams, and other forms of media will help to increase understanding (Palmer et al., 2017).

Lipreading Lipreading is the process of interpreting speech by observing movements of the face, mouth, and tongue (Feld & Sommers, 2009). One common misconception among hearing persons is that all people who are deaf can read lips. This is a potentially dangerous assumption for the nurse to make. Not all people who are deaf read lips, and even among those who do, lipreading may not be appropriate for health education or other forms of patient communication. Among Deaf persons in general, word comprehension while lipreading is only about 30–45%. Therefore, even the most skilled lipreaders also use facial cues, body language, and context to get the full mes- sage. However, the technique of lipreading taxes the brain in several different ways, so a lipreader can become exhausted over an extended period of time (Callis, 2016). Consequently, only a skilled lipreader will obtain any real benefit from this form of communication (Rouger et al., 2007).

When working with a client who is lipread- ing, nurses should:

■ Speak normally. It is not necessary to exag- gerate lip movements, because this action will distort the movements of the lips and interfere with interpretation of the words.

■ Make sure clients are wearing their eye- glasses. Lipreading requires good vision.

■ Provide sufficient lighting on their faces and remove all barriers from around the face, such as gum, pencils, hands, and surgical masks. Beards, mustaches, and protruding teeth also present a challenge to the lipreader.

■ Supplement teaching using other forms of communication as it is not possible for cli- ents to lipread every word.

The nurse who does not know ASL is ad- vised to obtain the services of a professional in- terpreter. Sometimes a family member or friend of the patient skilled in signing is willing and available to act as an interpreter during teach- ing sessions. However, just as it is preferable to use a professional interpreter when dealing with an individual who speaks a different lan- guage, so it also is preferable to use a profes- sional interpreter for a person who uses sign language (Scheier, 2009). Family members and friends may have difficulty translating medical words and phrases and may be hesitant to con- vey information that may be upsetting to the patient. Prior to enlisting the assistance of an interpreter, whether family member or profes- sional, the nurse should always be certain to obtain the patient’s permission to do so. Infor- mation communicated regarding health issues may be considered personal and private. If the information to be taught is sensitive or confi- dential, it is advised that family or friends should not be enlisted as interpreters. Hiring a certified language interpreter is often the best strategy.

Federal law (Section 504 of the Rehabil- itation Act of 1973, PL 93-112) requires that health facilities receiving federal funds secure the services of a professional interpreter upon request of a patient. If the patient cannot pro- vide the names of interpreters, the nurse should contact the state Registry of Interpreters of the Deaf (RID). This registry can provide an up-to- date list of qualified sign language interpreters.

During a teaching session, the nurse should stand or sit next to the interpreter. He or she should talk at a normal pace and look at and talk directly to the Deaf person when speaking. The interpreter will convey information to the patient as well as share patient responses with the nurse. It is important to remember that ASL does not provide a word-for-word translation of the spoken or written word and that misunder- standings can occur. Patient education involves the exchange of what is often very detailed and important information. To determine whether the information given is understood, the nurse

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useful media as a supplement to increase un- derstanding of written materials.

Verbalization by the Client Sometimes clients who are deaf will choose to communicate through speaking, especially if they have established a rapport and a trusting relationship with the nurse. The tone and inflec- tion of the voice of a client who is deaf may be different from normal speech, so nurses must listen carefully, remembering that time may be needed to become accustomed to the patient’s voice sounds (pitch) and speech rhythms. A quiet, private place should be selected for teaching so that the patient’s words can be heard. If the pa- tient’s words are difficult to understand, it may help to write down what is heard, which may help those listening to get the gist of the message.

Sound Augmentation For those patients who have a hearing loss but are not completely deaf, hearing aids are often a useful device. A patient who has already been fitted for a hearing aid should be encouraged to use it, and it should be readily accessible, fit- ted properly, turned on, and with the batteries in working order. If the client does not have a hearing aid, with permission of the patient and family, the nurse should make a referral to an auditory specialist, who can determine whether such a device is appropriate for the patient.

Only one out of five people who could ben- efit from a hearing aid in actuality wear one (NIDCD, 2014). Cost contributes to this prob- lem. Although Medicare policies vary from state to state, as a rule Medicare does not pay for rou- tine hearing examinations or hearing aids. Un- der some circumstances, Medicare will pay for diagnostic hearing tests when hearing loss is suspected to result from illness or treatment (Medicare, 2012). Therefore, it is important to seek permission of the client before initiating the referral for a hearing examination or hearing aid.

Another means by which sounds can be augmented is by cupping one’s hands around

■ Conduct teaching sessions in a quiet envi- ronment. It is easier to lipread when distrac- tions are kept to a minimum (Lipreading .org, 2017)

■ Consider using an interpreter if English is the client’s second language. Clients can lipread more accurately when the speaker is using the client’s primary language (Lip- reading.org, 2017).

Written Materials Written information is probably the most reli- able way to communicate, especially when un- derstanding is critical. In fact, nurse educators should always write down the important infor- mation as a supplement to the spoken word even when the Deaf person is versed in lipreading or an interpreter is involved. Written communica- tion is always the safest approach, even though it is time consuming.

Printed client education materials must al- ways match the reading level of the audience. When preparing written materials for learners who are deaf, it is prudent to keep the message simple. Although recent studies suggest that stu- dents who are deaf are making strides in their reading performance, the data on this point are inconclusive and many people with deafness still struggle with the written word (Easterbrook & Beal-Alvarez, 2012).

When providing handwritten or typewrit- ten instructions or using commercially prepared printed education materials, remember to keep in mind that a person with limited reading abil- ity often interprets words literally. Therefore, in- structions should be clear, with minimal use of words or phrases that could be misinterpreted or confusing. For example, instead of writing, “When running a fever, take two aspirin,” write “For a fever of 100.5°F or higher, take two as- pirin.” The second message is clearer in that it avoids misinterpretation of the word “running” and provides clarification of the word “fever.” In addition, visual aids such as simple pictures, drawings, diagrams, and models are also very

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In summary, the following guidelines can be applied when using any of the already men- tioned modes of communication (McConnell, 2002; Navarro & Lacour, 1980).

Nurse educators should:

■ Be natural, not rigid or stiff, and do not attempt to overarticulate speech.

■ Use short, simple sentences. ■ Speak at a moderate pace, pausing occa-

sionally to allow for questions. ■ Be sure to get the Deaf person’s attention by

a light touch on the arm before beginning to talk.

■ Face the patient and stand no more than 6 feet away when trying to communicate.

■ Ask the patient’s permission to eliminate environmental noise by lowering the tele- vision, closing the door, and so forth.

■ Make sure the patient’s hearing aid is turned on, the batteries are working, and his or her glasses are clean and in place.

Nurse educators must avoid:

■ Talking and walking at the same time. ■ Moving their head excessively. ■ Speaking while in another room or turning

away from the person with hearing loss while communicating.

■ Standing directly in front of a bright light, which may cast a shadow across their face or glare directly into the patient’s eyes.

■ Joking and using slang or vocabulary the pa- tient might misinterpret or not understand.

■ Placing an intravenous line in the hand the patient will need for sign language.

No matter which methods and materials of communication for teaching are chosen, it is important to confirm that health messages have been received and correctly understood. It is essential to validate patient comprehension in a nonthreatening manner, such as using the teach-back approach. However, in attempts to avoid embarrassing or offending one another, patients as well as healthcare providers will often acknowledge with a smile or a nod in response to what either party is trying to communicate when,

the client’s ear or using a stethoscope in reverse. That is, the patient puts the stethoscope in his or her ears, and the nurse talks into the bell of the instrument (Babcock & Miller, 1994).

If the patient can hear better out of one ear than the other, speakers should always stand or sit nearer to the good ear, use slow speech, and provide adequate time for the pa- tient to process the message and to respond. Shouting, which distorts sounds, should be avoided. That is because it is not necessarily an increase in decibels that makes a difference but rather the tone, rhythm, articulation, and pace of the words.

Telecommunications Technology can be used effectively to teach a per- son who is deaf. The Deaf also can be taught to use technology to enhance life skills. Some ex- amples of telecommunication devices that ac- complish both goals include television decoders for closed captioned programs, captioned tele- phones that transcribe everything a person says into writing on a screen, and alerting devices that warn of a crying baby, ringing doorbell, or ringing phone.

Captioned films for patient education are available free of charge through Modern Talking Pictures and Services. Text telephones (TTY or Teletype), sometimes referred to as TDD (tele- communication devices for the deaf ), are type- writer-like devices that allow for text messages between two parties. These devices use a relay station to translate messages if only one party has the TTY device.

Under federal law, these technology-based devices are considered reasonable accommo- dations for persons with deafness and hearing impairments. However, nurses should note that translation of the spoken word on health-related videos created for the hearing population, with- out the tone of voice, voice level, and other strate- gies speakers use to emphasize a point, may alter the message that is conveyed to patients who are deaf (Pollard et al., 2009; Wallhagen, Pettengill, & Whiteside, 2006).

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important to note that mild to moderate vision loss is commonplace. The most prevalent condi- tions that result in some degree of visual impair- ment are myopia (nearsightedness), hyperopia (farsightedness), astigmatism (distorted vision at all distances), and presbyopia (loss of ability to focus up close for reading), the latter of which occurs in middle-aged adults (CDC, 2015c). These refractive errors usually can be corrected with eyeglasses or contact lenses. Correction of common visual impairments has implications for safety and quality of life by reducing falls, fractures, depression, and car accidents (Welp, Woodbury, McCoy, & Teutsch, 2016).

A visual impairment is defined as some form and degree of visual difficulty and includes a wide spectrum of deficits, ranging from par- tial vision loss to total blindness; it may also include visual field limitations, such as tunnel vision, alternating areas of total blindness and vision, and color blindness. In the United States, a person is determined to be legally blind if vi- sion is 20/200 or less in the better eye with cor- rection or if visual field limits in both eyes are within 20 degrees in diameter. Approximately 90% of people who are legally blind have some degree of vision. Typically, a person who is le- gally blind is unable to read the largest letter on the eye chart with corrective lenses (American Foundation for the Blind, 2017b). In compar- ison, total blindness is defined as an inability to perceive any light or movement (American Foundation for the Blind, 2017a).

Fortunately, many devices are available to help legally blind persons maximize their re- maining vision. People who are without sight most likely have had services and are famil- iar with those adaptations that work best for them. However, depending on patients’ situa- tions and the circumstances under which the nurse is teaching, the nurse educator may want to further investigate their background to en- sure that the most appropriate format and tools for communicating with visually impaired pa- tients are being used. Patients who seem to be legally blind but who have not been evaluated by a low-vision specialist should be provided

in fact, the message is not well understood. To be sure that the health education requirements of patients who are deaf and hearing impaired are being met, the nurse educator must find ef- fective strategies to communicate the intended message clearly and precisely while at the same time demonstrating acceptance of individuals by making accommodations to suit their needs (Harrison, 1990). People who have lived with a hearing impairment for a while usually can in- dicate which modes of communication work best for them.

Visual Impairments Approximately 285 million people worldwide are visually impaired. Of this total, 39 mil- lion are blind, and 246 million have low vision (WHO, 2015a). Findings from the 2015 National Health Interview Survey (NHIS) indicate that the number of adults in the United States with some degree of vision impairment has grown to 23.7 million people or about 10% of the adult population. Over one-half million children in the United States are classified as legally blind (American Foundation for the Blind, 2017b). These survey data further indicate that vision loss is more common among women, older adults, and people who are poor or near poor.

Blindness and visual impairment are caused by many factors (FIGURE 9-1). Disease is the major cause of loss of vision in adults, with cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy accounting for the greatest number of disease-related impairments (Braille Institute, 2016; Lighthouse International, 2015; National Institutes of Health, 2017). Although vitamin A deficiency is the leading cause of blindness in children worldwide, amblyopia and strabismus, optic nerve neuropathy, prematu- rity, low birth weight, and congenital conditions such as congenital cataracts are the most com- mon factors leading to blindness in children in the United States (International Agency for the Prevention of Blindness, 2017).

Although severe vision loss provides the greatest challenge to the nurse as educator, it is

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person who is blind may be very different from one who has low vision. Additionally, multiple disabilities must be considered, particularly when working with older adults.

■ Make sure to speak directly to patients rather than to their sighted companions.

■ Contact a low-vision specialist who can pre- scribe optical devices such as a magnifying lens (with or without a light), a telescope, a closed-circuit TV, or a pair of sun shields, any of which will help nurses to adapt their teaching materials to meet the needs of their patients.

■ Rely on patients’ other senses of hearing, taste, touch, and smell when conveying messages as a means to help them assimi- late information from their environment. Because their listening skills are usually particularly acute, it is not necessary to shout. When teaching, the nurse should speak in a normal tone of voice.

■ Always approach patients by announcing your presence, identifying yourself and others, and explaining clearly why you are there and what you are doing because peo- ple who are blind cannot take advantage of nonverbal cues such as hand gestures, facial expressions, and other body language. Instead, use their talents of memory and recall to maximize learning.

■ If a handshake is appropriate, take the client’s hand first. It is also important for the nurse to indicate when a conversation is over and when he or she is leaving the room.

■ When teaching psychomotor skills, describe as clearly as possible the steps of a procedure, explain any noises associated with treatments or the use of equipment, and allow patients to touch, handle, and manipulate equipment so that they can perform return demonstrations.

■ Use the tactile learning technique when teaching them the characteristics and the placement of objects. For example, allow pa- tients to identify their medications by feeling the shape, size, and texture of tablets and capsules. To locate their various medicines, glue pills to the tops of bottle caps or put

with contact information for these sources: the local blind association and the local commission for the blind and visually handicapped. Patients may require assistance in negotiating the com- plex system and in obtaining services.

Healthcare encounters present challenges for both the patient with low vision or blindness and for the professionals who care for them. In a series of focus groups with people with blind- ness or low vision, O’Day, Killeen, and Iezonni (2004) identified four barriers encountered in healthcare settings:

■ Lack of respect ■ Communication problems ■ Physical barriers ■ Information barriers

Lack of respect was the basis for many of the negative healthcare encounters described by the participants. For example, participants felt that healthcare providers often made assump- tions that patients would be unable to partici- pate in their own care and recovery. Subsequent studies supported this finding. In a study of bar- riers to low-vision rehabilitation, Southhall and Wittich (2012) found that people with visual impairments were often reluctant to disclose their vision loss for fear of triggering prejudice and discrimination.

Directing comments to a sighted companion rather than to the patient was another common complaint. In terms of education, participants ex- pressed concern that many health providers are not prepared to care for people with visual im- pairments. Without Braille versions of informa- tion sheets, audiotaped instructions, and other assistive strategies, patients with visual impair- ments left teaching sessions feeling anxious and, most important, without the information required.

The following are some tips nurses might find helpful when teaching patients with visual impairments (Babcock & Miller, 1994; Boyd, Gleit, Graham, & Whitman, 1998; Luckowski & Luckowski, 2015; Manduchi & Coughlan, 2012; McConnell, 1996; University of Washington, 2012):

■ As a first step, assess patients to avoid making assumptions about their needs because a

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normal view), high contrast (which can invert typical black-on-white to other color options) and screen-resolution adjustments (which make information on the computer screen easier to see). Advanced assistive technology comes equipped with text-to- speech converters; synthetic speech; screen readers; and Braille keyboards, displays, and printers.

■ Access appropriate resources for informa- tion, such as the Braille library, the National Braille Press, or local blind associations for printed education materials.

■ When teaching ambulation, always use the sighted guide technique by allowing the patient to grasp your forearm while walking about one half-step ahead of the blind person or seek the referral of a mo- bility specialist available through the local associations for the blind.

■ Hold teaching sessions in quiet, private spaces, whenever possible, to minimize dis- tractions and to allow adequate time to deliver instruction in an unhurried manner.

Diabetes education consumes a great deal of a nurse educator’s teaching time and pres- ents unique challenges. Because of the high in- cidence of this disease in the U.S. population, diabetic retinopathy is a major cause of blind- ness. Patients who have lost their sight because of this disease probably have already mastered some of the necessary skills to care for them- selves but will need continued assistance. Also, it is possible for persons with visual impair- ments to be diagnosed at a later time in their life with diabetes. In either case, these patients will need to learn how to use appropriate adap- tive equipment.

Fortunately, there has been continuous im- provement in the equipment used for self-moni- toring of blood glucose levels and for self-injection of insulin. Easy-to-use monitors with large dis- play screens or voice instructions are now avail- able as are new nonvisual adaptive devices for measuring insulin, insulin pens that contain pre- filled dosages, and built-in magnifiers that have

them in different-sized or different-shaped containers; keep items in the same place at all times so they can independently locate their belongings; and arrange things in front of them in a regular clockwise fashion to facilitate learning when performing a task that must be accomplished in an orderly, step-by-step manner.

■ Enlarge the font size of letters in printed and handwritten materials as a typical important first step in using these types of instructional tools.

■ Use bold colors to provide contrast, which is a key factor in helping a person with limited sight distinguish objects. Assess whether black ink on white paper or white ink on black paper is better; if using a dark placemat with white dishes or serving black coffee in a white cup helps them to see items more clearly; and if placing pills, equipment, or other materials on a contrasting background helps them locate objects they need.

■ Use proper lighting, which is of utmost impor- tance in assisting patients to read or locate objects. Regardless of the print size, the color of the type, or the paper used, if the light is not sufficient, patients will have a great deal of difficulty distinguishing words or manipulating objects.

■ Provide large-print watches and clocks with either black or white backgrounds that are available through a local chapter for the visually handicapped.

■ Make use of audiotapes and cassette record- ers as instructional tools to convey patient education, some of which are available as talking books and can be obtained through the National Library Service or through the state library for the blind and visually handicapped. Also, oral instructions can be audiotaped to be listened to as necessary at another time and place and can be played over again as many times as needed to reinforce learning.

■ Make use of standard computer features such as screen magnifiers (which can change the text to be 2 to 16 times larger than the

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accepted working definition for purposes of as- sessment, diagnosis, and categorization of an array of learning disabilities, states that a learn- ing disability is a “disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imper- fect ability to listen, think, speak, read, write, spell or do mathematical calculations” (NCLD, 2017, para. 4). Learning disabilities is an um- brella term that is used to describe an array of conditions including dyslexia, dyscalculia, and auditory processing disorder.

Experts agree on some common charac- teristics of learning disabilities (Child Develop- ment Institute, 2012; LDOnline, 2017; National Joint Committee on Learning Disabilities, 2011), such as they:

■ involve learning problems and uneven patterns of development in children and adults.

■ can be identified in childhood and yet con- tinue to persist into adulthood. For example, difficulty with language development in a preschool child may signal long-term learn- ing challenges in the school-aged child that may go unresolved through the adult years.

■ are neurobiologically based and are caused by factors other than environmental disad- vantage, mental retardation, and emotional disturbance.

■ are the result of a different wiring of the hu- man brain that influences the way in which information is received, processed, and communicated.

The causes of learning disabilities are var- ied and often unclear. Genetics plays a role in approximately 50% of cases. Also, it is suspected that numerous factors that affect the brain, es- pecially during gestation, delivery, and the early years of life, can result in a learning disability. For example, the use of alcohol during preg- nancy, difficulties during delivery, and expo- sure to toxins such as lead paint can all result in learning disabilities (Learning Disabilities As- sociation of America, 2015).

made insulin administration much easier for patients who have difficulty reading a syringe (Cohen & Ayello, 2005).

▸ Learning Disabilities Learning disabilities have emerged as a major issue in the United States (CDC, 2015a). Al- though often associated with school-aged chil- dren, these neurologically based disorders begin in childhood and persist through adulthood (Taymans et al., 2009). Learning disorders are complex conditions that are frequently hidden and vary from individual to individual. As a re- sult, they are often misunderstood and under- estimated (Child Development Institute, 2012; Learning Disabilities Association of America, 2013; LDOnline, 2017; National Joint Com- mittee on Learning Disabilities, 2011; Santrock, 2017; Snowman & McCown, 2015).

A definitive definition of the term learning disability has been the subject of a great deal of controversy over the years as educators and psy- chologists alike have debated the issues (Crandell, Crandell, & Vander Zanden, 2012; Santrock, 2017; Snowman & McCown, 2015; Ysseldyke & Algozzine, 1983). Resulting from this debate, many definitions of learning disabilities can be found in the literature, most of which can be categorized as either medically or educationally based (National Center for Learning Disabilities [NCLD], 2017). The medical model definitions are based on the Diagnostic and Statistical Man- ual (DSM) of Mental Disorders and focus on the deficit present with each type of learning disabil- ity. For example, the DSM-5 describes learning disabilities as a diagnosis requiring “persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling” (NCLD, 2014, p. 2).

Educationally based definitions of learning disabilities are derived from the federal educa- tion law, Individuals with Disabilities Education Act (IDEA), and emphasize the neurological processing disorder that underlies the condi- tion. The IDEA definition, which stands as the

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other children (Yettick & Lloyd, 2015). Approx- imately 27% of high school students with learn- ing disabilities drop out of school, and only 14% of high school students with learning disabili- ties go on to postsecondary education programs (U.S. Department of Education, 2006).

Among the adult population with learn- ing disabilities, 46% are out of the workforce and approximately 92% have annual incomes of less than $50,000 within 8 years of leaving high school, with many living at the poverty level (Cortiella & Horowitz, 2014). Estimates of the number of inmates and parolees with learning disabilities are as high as 65% (Learning Disabil- ities Association of America, 2015). Although evidence-based research on adults with learn- ing disabilities is limited, data suggest that al- though some adults with learning disabilities do poorly—and in fact, some report that the disability and associated challenges get worse over time— many adults with learning disabilities overcome the associated challenges and lead happy, suc- cessful lives (Gerber, 2012). Given this fact, it is important that the nurse not make assumptions about the presence or absence of a learning dis- ability based on an individual’s employment or financial status. Despite the statistics that reveal the lifelong challenges of individuals with learn- ing disabilities, many individuals with learning disabilities have been found to have at least av- erage, if not superior (gifted), intelligence. In fact, learning disabilities are often labeled “the invisible handicap” because they do not neces- sarily result in low achievement. Some very fa- mous and successful people in world history are thought to have had some type of learning disability—ranging from artists (Leonardo da Vinci) to political leaders (Woodrow Wilson, Winston Churchill, and Nelson Rockefeller) to military figures (George Patton) to scientists (Albert Einstein and Thomas Edison) (Crandell et al., 2012).

Even though a large discrepancy may be noted between the intellectual abilities of a person with a learning disability and his or her performance levels, no cause-and-effect rela- tionship exists. Persons who exhibit this dis- crepancy are not necessarily learning disabled

The statistics on learning disabilities are sobering. Nearly 6% of the children in the U.S. public school system have been identified as having a learning disability (National Center for Education Statistics, 2016). The rate of learn- ing disabilities in adults is probably similar to that in children. However, adults who were in school prior to the passage of federal special ed- ucation legislation may never have been diag- nosed, which therefore results in lower numbers of identified individuals. Self-reporting among the adult population reveals a rate of learning disabilities that ranges from .07% to 2.7% with younger adults more likely to report a learning disability than older adults (NCLD, 2014). Over- all, approximately 4.6 million or 1.7% of Ameri- cans live with a learning disability (NCLD, 2014).

About three to four times as many boys as girls are identified as having a learning disabil- ity, but this gender difference is thought to re- sult from referral bias—more boys are sent for identification and treatment because of their behavior (Crandell et al., 2012; Santrock, 2017). Children with learning disabilities represent the largest segment of those in special education classes, accounting for nearly 40% of the group (Aron & Loprest, 2012).

Lifelong challenges extend far beyond the classroom for children and adults with learning disabilities and their families. A survey of parents found that higher levels of parental distress as well as higher levels of child anxiety and depres- sion exist when a child has a learning disability (Bonifacci, Storti, Tobia, & Suardi, 2016). Only one third of parents surveyed reported positive feelings about their children’s abilities to learn and their own abilities to cope (NCLD, 2014).

Children with learning disabilities, like other children, are often victims of bullying. Approx- imately, 46% of parents of children with learn- ing disabilities report that their child has been bullied (NCLD, 2014), a figure that is consistent with the rest of the child population (Bullying- statistics.org, 2017; Klomek et al., 2016; Rose, Espelage, Monda-Amaya, Schogren, & Aragon, 2015). Graduation rates for children with dis- abilities vary from state to state, but overall they earn a high school diploma at a lower rate than

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can apply equally as well to an older person who has not been diagnosed as learning dis- abled until later in adulthood. It is important to remember that an individual with a learning disability can experience one type of learning disability or a combination of various types of such disabilities.

(Crandell et al., 2012; Santrock, 2017). TABLE 9-1 lists common misconceptions and correspond- ing realities about learning disabilities.

Although these problems and their asso- ciated characteristics are frequently identified when referring to children with disabilities, many of these characteristics and problems

Misconception Individuals with learning disabilities have a low IQ.

Reality Individuals with learning disabilities have the capacity to learn but their brains are wired in a way that causes them to struggle with tasks associated with school and everyday life (Kane, 2012).

Misconception Vaccinations can cause learning disabilities.

Reality No evidence exists to suggest that vaccinations are related to the development of learning disabilities in children (NCLD, 2014).

Misconception Too much television, too much time playing computer games, poor parenting, and general laziness can result in learning disabilities.

Reality The cause of learning disabilities is often unclear. Common causes include genetics, birth injury, and childhood exposure to toxins such as lead.

Misconception Children outgrow their learning disabilities. Medication can cure a learning disability.

Reality Learning disabilities last a lifetime. However, many adults learn to compensate for their learning differences and lead successful lives. Medications can assist with learning, but will not cure the underlying problem.

Misconception Learning disabilities are related to vision problems that can be treated with corrective lenses (NCLD, 2014).

Reality Learning disabilities are related to the way the brain processes visual stimuli, not problems with the lenses of the eye.

Misconception Learning disabilities are easily diagnosed (Kane, 2012).

Reality Learning disabilities are complex problems that require careful and sometimes painstaking evaluation by educators and healthcare professionals.

TABLE 9-1 Misconceptions and Realities About Learning Disabilities

Data from Dunne, S. (2016, October 12). Common myths and facts about learning disabilities. Retrieved from http://www.springer-ld.org/ld-resources/blog /cbarnhart/10/12/2016/common-myths-and-facts-about-learning-disabilities; Kane, J. (2012, March 16). Five misconceptions about learning disabilities. PBS News Hour. Retrieved from http://www.pbs.org/newshour/rundown/five-misconceptions-about-learning-disabilities/; Morin, A. (2014). At a glance: Common myths about learning and attention issues. Retrieved from https://www.understood.org/en/learning-attention-issues/getting-started/what-you-need-to-know /common-myths-about-learning-attention-issues.

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subtypes of dyslexia exist, each characterized by a different neurologic deficit (Handler, 2016; Heim et al., 2008; Menghini et al., 2010; Wajuhian & Naidoo, 2012). These subtypes are made up of a combination of problems including the inabil- ity to break down words into individual sounds, difficulty distinguishing letters visually, and an inability to associate sounds with letters (Heim et al., 2008; Hultquist, 2006; Public Broadcast- ing Service [PBS], 2010). Furthermore, people with dyslexia have been shown to have a deficit in “working” or “short-term memory,” making it difficult for them to process complex sentences (Crandell et al., 2012; Wiseheart, Altmann, Park, & Lombardino, 2008). These deficits contribute to an overwhelming classroom experience for children or adults with dyslexia as they attempt to listen and write at the same time while being distracted by surrounding noise as they try to understand the content being presented (Olds, 2016). Levine (2002) has created a website, Misunderstood Minds, that includes exercises that simulate the reading difficulties of some- one with dyslexia (http://www.pbs.org/wgbh /misunderstoodminds).

Although people with dyslexia can learn to read, the challenges they face can result in self-esteem issues that often begin early in life (Olds, 2016). Young children often experience problems at school because of their disability (Ingesson, 2007), and older adults who were never diagnosed or who did not receive read- ing intervention are at greatest risk. The nurse must be sensitive to these issues when engaged in teaching.

People with visual perception problems such as dyslexia face many other challenges. For example, they may experience a figure–ground problem such that the person is unable to attend to a specific object within a group of objects, such as finding a cup of juice on a food tray. Furthermore, judging distances or positions in space or dealing with spatial relationships may prove difficult, resulting in the person bump- ing into things, being confused about left and right or up and down, or being unable to throw a ball or do a puzzle.

The most common learning disorders are discussed in the following subsections.

Dyslexia Dyslexia is “a neuro-developmental learning disorder that is characterized by slow and in- accurate word recognition” despite conven- tional instruction, adequate intelligence, and intact sensory abilities (Peterson & Pennington, 2012, p. 1997). Dyslexia accounts for the larg- est percentage of people with learning disabil- ities, affecting approximately 10% to 15% of the U.S. population (Crandell et al., 2012; Dys- lexia Research Institute, 2017). Often associ- ated with reading difficulty, dyslexia is actually a language disorder that results in a wide array of symptoms, including difficulty sounding out words (decoding), word recognition, and/or reading comprehension (Handler, 2016). Indi- viduals with dyslexia often have other learning disabilities, including attention-deficit/hyperac- tivity disorder, language impairment disorder, and speech sound disorder (Dyslexia Research Institute, 2017; Peterson & Pennington, 2012).

Dyslexia has been the subject of consid- erable research and although many questions remain, some significant discoveries related to this condition have been made in recent years. Current research findings suggest that dyslexia is moderately heritable; the cause is multifac- torial with genetic and environmental risk fac- tors (Handler, 2016; Peterson & Pennington, 2012). Although the diagnosis of dyslexia is associated with several genes, factors such as parental education have been found to have the potential to modify genetic risk (Penning- ton, McGrath, Rosenberg, Barnard, & Smith, 2009). In addition, dyslexia is associated with early hearing loss, and it is suggested that this hearing loss results in a failure of the brain to make the necessary connections between sounds and letters.

It is a common misconception that people with dyslexia simply see letters in reverse or- der or upside down. In reality, dyslexia is much more complex. Recent research indicates several

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Finally, when teaching motor skills, it is important for nurses to remember that people with dyslexia may have impaired left–right dis- crimination and may become confused during instruction and coaching if the nurse makes ref- erence to a “left hand” or “right foot.” To help overcome this problem, nurses can tape an X on the appropriate hand or refer to the “arm with the watch.”

Auditory Processing Disorder An auditory processing disorder (APD), also known as a central auditory processing disorder (CAPD), is an umbrella term used to describe a condition that causes listening dif- ficulties despite normal or near normal hear- ing acuity (Bellis, 2017; de Wit et al., 2016). CAPD is the result of an inability of the cen- tral nervous system to efficiently process or interpret sound impulses (Kids Health, 2017). Under usual conditions, sound vibrations are converted to electrical impulses in the ear and then transmitted by the auditory nerves to the brain, where they are interpreted. APDs oc- cur when the brain fails to process or inter- pret these sound impulses effectively. This type of disability affects approximately 5% of chil- dren (Kids Health, 2017). Because the central nervous system is complex, it is important to note that there are many reasons why an indi- vidual may not attend to, understand, and/or remember what he or she hears. CAPD should not be confused with other conditions such as attention-deficit/hyperactivity disorder that includes similar symptoms but is caused by a different underlying deficit (Bellis, 2017). Al- though the cause of CAPD is usually unknown, this condition can be developmental or acquired and is associated with ear infections and head trauma in both adults and children (Musiek, Barran, & Shinn, 2004).

Educators as well as speech, language, and other professionals who work with individ- uals with APD have been engaged in debate over various aspects of the condition for many years (Richard, 2011). For example, there is no

Nurses face numbers of issues when teach- ing patients with dyslexia and other types of per- ceptual deficits. Assessment is a critical first step. A discussion with the patient is advisable to de- termine the extent of the individual’s abilities and disabilities and how he or she learns best. For example, many people with visual percep- tual deficits tend to be auditory learners. Those who learn best by hearing need to have visual stimulation kept to a minimum.

Visual materials such as pamphlets and books are ineffective unless the content is explained orally or the information is read aloud. If visual items are used, nurses should give only one item at a time, with a sufficient period in between times to allow for the pa- tient to focus on and master the information. It may also be helpful to add pictures to written material wherever possible to help convey in- formation. CDs and audiotapes (with or with- out earphones) and verbal instruction may be beneficial as well.

Some patients with dyslexia have difficulty with the spoken word and may struggle to ex- press themselves or understand what is being said to them (International Dyslexia Associa- tion, 2017). For these clients, it is important to proceed in an unhurried manner, presenting small amounts of information over time with frequent assessment of learning. If a patient has difficulty with spoken as well as written words, a combined approach using both oral instruc- tion and visual information may be effective. Nurses can assess recall and retention of infor- mation by oral questioning, allowing learners to express orally what they understand and remem- ber about the content that has been presented.

Assistive technology is now available for use in the classroom or work environment that can enhance teaching–learning situations for people with dyslexia. For example, smart pens can record information while they take notes, which allows them to listen again to what they were taught. Also, reading pens allow them to scan information that can be enlarged or displayed with syllabic breakdown of words (Dyslexia Help, 2017).

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materials, pictures, charts, films, books, puzzles, printed handouts, and the computer are the best ways to communicate information. Using hand signs for key words when giving verbal instruc- tions and allowing the learner to have hands-on experiences and opportunities for observation are helpful techniques. Individuals with audi- tory processing problems often rely on tactile learning as well. They enjoy doing things with their hands, want to touch everything, prefer writing and drawing, engage in physical explo- ration, and enjoy physical movement through sports activities.

Individuals with APD may rely on vision to help them learn. The visual learner may intently watch the instructor’s face for the formation of words, expressions, eye movements, and hand gestures. Awareness of these details may have de- veloped as a compensatory strategy to aid com- prehension. If the learner does not understand something being taught, he or she may exhibit frustration by becoming irritable and inattentive. Patients and their family members may desire an audiotape of instruction so that they can replay it as needed to reinforce or clarify information given.

Dyscalculia Dyscalculia is a severe learning disability that impairs those parts of the brain involved in mathematical processing, which results in an inability to understand the abstract concepts as- sociated with numbers (Rapin, 2016). Individ- uals with dyscalculia have a deficit that makes academic achievement difficult and, more im- portant, interferes with activities of daily living. Dyscalculia is not a learning problem but rather represents an inability to understand numerical sets. Therefore, the problem for individuals with dyscalculia is not related to difficulty learning mathematical functions but rather to an inabil- ity to comprehend the relationship between a numerical symbol and the objects it represents (British Dyslexia Association, 2015; Spinney, 2009). Dyscalculia cannot be explained by a sen- sory deficit or by lack of educational opportu- nities (DeVisscher & Noel, 2012).

universally accepted definition of APD (Campbell, 2011). Much of the controversy stems from a lack of understanding of the underlying mecha- nism involved. According to C. A. Miller (2011),

We learn our native language by listening to speech. If the sounds of speech are not delivered to the language system accurately and quickly, then surely language ability will be compromised. However, despite decades of research, a complete theoretical account of how auditory perceptual deficits lead to im- paired language has proven elusive. In the absence of such an account, auditory processing has become a buzzword that has almost as many meanings as there are people who use it. (p. 309)

APD is characterized by the inability to distinguish subtle differences in sounds—for example, blue and blow or ball and bell. There also may be a problem with the auditory fig- ure–ground relationship, such that the sound of someone speaking cannot be identified clearly when others are speaking in the same room. Auditory lags may occur, whereby sound input cannot be processed at a normal rate. Parts of conversations may be missed unless one speaks at a speed that allows the individual enough time to process the information.

During instruction, it is important to limit the noise level and eliminate background dis- tractions. Using as few words as possible and repeating them when necessary (using the same words to avoid confusion) are useful strategies. Nurses should work with the patient to deter- mine the volume and rate of speech that are best understood. For example, some patients find that speech that is a little slower and a lit- tle louder works well (Musiek et al., 2004). Di- rect eye contact helps keep the learner focused on the task at hand.

Visual teaching methods such as gaming (e.g., puppetry), demonstration–return demon- stration, role model, and role play, as well as pro- viding visual instructional tools such as written

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as possible and conducted in an unhurried man- ner. Nurses may find it helpful to begin with the concrete when teaching and then move to the abstract slowly and carefully. Pictures and dia- grams may help the patient grasp more abstract concepts. Assessment is vital to determine that the patient has learned the content or skills pre- sented and reinforcement of learning is critical.

▸ Developmental Disabilities

The term child development refers to the physi- cal, cognitive, and social-emotional growth that takes place throughout the period of childhood. It is sequential and measured according to a set of milestones or expected outcomes that have been established, which takes into account the variability that is present within the general pop- ulation (CDC, 2017b). These milestones measure the child’s ability to demonstrate age-expected skills in areas such as language, cognition, gross and fine motor control, and social and emo- tional behavior.

Children who do not meet developmental milestones are considered to have a developmen- tal delay. Approximately 13% of preschool chil- dren demonstrate developmental delays severe enough to make them eligible for early interven- tion services (Rosenberg, Zhang, & Robinson, 2008). Many of these children are simply devel- oping at a slower than normal rate and, with in- tervention, will eventually achieve developmental milestones (Harstad, 2017). Others have more significant problems.

A developmental delay is a temporary or short-term challenge whereas a developmental disability represents a lifelong condition re- sulting from a change in the pattern or nature of a child’s development. In the United States, about one in six or 15% of children have one or more developmental disabilities (CDC, 2016a). “Children with developmental disabilities are not traveling at a slower pace; they are travel- ing a different route altogether” (Quinn, 2000,

Dyscalculia can be either developmental (i.e., acquired at birth) or the result of injury to the brain. The developmental form of this con- dition is present in 5% to 6% of school-aged children and persists for some individuals into adulthood (Wilson, 2012). Developmental dy- scalculia is suspected when a child fails to per- form in mathematics at a level consistent with his or her chronological age and level of intelli- gence despite adequate instruction (Dyscalcu- lia.org, 2017). Acquired dyscalculia can occur at any time. Individuals with dyscalculia often have other learning or developmental disabili- ties such as dyslexia or attention-deficit/hyper- activity disorder (ADHD) (Rapin, 2016).

It is important for nurses to recognize that the impact of dyscalculia on a patient extends beyond his or her ability to calculate an insulin dose or count the correct number of pills. Such individuals may also have the following issues (Dyscalculia.org, 2017):

■ Difficulty grasping the abstract concept of time. As a result, these clients may be unable to read a clock, follow a schedule, or under- stand the sequence of past and future events.

■ Inability to differentiate between right and left.

■ Problems with learning specific activities that require sequential processing—that is, any activity in which steps must be followed.

■ Problems with reading numbers, such as on a prescription bottle.

■ Confusion when schedules/routines change.

The approach to working with a patient with dyscalculia varies depending on the age of the individual and his or her experience with this disorder. A teenager or adult who has lived with dyscalculia for many years may have de- veloped strategies for addressing issues such as time, schedules, and numbers. It is important that assessment be done prior to teaching to de- termine the extent of the disability and the cop- ing strategies that have been successful for the patient. As with any person who has a learning disability, teaching should be done in an envi- ronment that is as free from distraction as much

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specific classifications of developmental dis- abilities such as autism, emotional disturbance, hearing and visual impairment, traumatic brain injuries, learning disabilities, and mental retar- dation (Crandell et al., 2012; Snowman & Mc- Cown, 2015).

When working with a child with a devel- opmental disability, it is essential that the nurse recognize the important role of parents, who are the real experts in caring for their child be- cause they know the child best. It is a wise nurse who invites these parents to participate and as- sist the staff during their child’s hospitalization and then works with them in the home. Like- wise, when caring for an adult with a develop- mental disability, caregivers are often the people who know the patient better than anyone else. However, the nurse needs to be sensitive to the arduous schedule involved in caring at home for a child or adult with a severe developmen- tal disability and recognize that during times of illness, parents and family members are often stressed and fatigued.

Managing the treatment of persons with developmental disabilities accounts for an in- creasing portion of healthcare practice today. Because developmental disabilities usually are diagnosed during infancy and are likely to last a lifetime, nurses must acquire sensi- tivity to family issues and learn to be flexible in their approaches to meet the intellectual, emotional, and medical concerns of patients with special needs (Webb, Tittle, & VanCott, 2000). Several of the common developmental disabilities are described in detail in the fol- lowing subsections.

Attention-Deficit/Hyperactivity Disorder Attention-deficit/hyperactivity disorder (ADHD) is a disability of both children and adults that is characterized by difficulty focusing on everyday tasks, as demonstrated by inappropri- ate behavior such as lack of attention and being impulsive. Although many individuals display

p. 22). Although children with developmental disorders may find alternative paths to meeting developmental milestones, many are left with deficits that persist into adulthood. Examples of developmental disorders include ADHD and Down syndrome.

Another group of developmental disorders is classified as pervasive developmental disor- ders, which involve impairment in the develop- ment of socialization and communication skills (Office for People with Developmental Disabili- ties, 2017). Because socialization and communi- cation are keys to an individual’s connectedness to the world, impairments in these areas tend to permeate all areas of development (Quinn, 2000). Examples of pervasive developmental disorders include autism and Rett syndrome.

Public policy has been enacted to protect the 3 to 4 million people in the United States with developmental disabilities. The Develop- mental Disabilities Assistance and Bill of Rights Act of 2000 defines developmental disabilities in broad terms as those chronic mental or phys- ical conditions present before 22 years of age that are likely to continue indefinitely and re- sult in substantial limitations in at least three of the following major life activities: self-care, re- ceptive and expressive language learning, mo- bility, self-direction, capacity for independent living, and economic self-sufficiency (U.S. De- partment of Health and Human Services [US- DHHS], 2000). This legislation establishes state councils on developmental disabilities; univer- sity centers for excellence in disability education, research, and service; and national initiatives to collect data and provide needed assistance to in- dividuals and families.

The Individuals with Disabilities Education Act, originally passed in 1975 as the Education for All Handicapped Children Act, addresses the educational needs of children with devel- opmental disabilities. Amended several times since its inception, IDEA ensures that children with disabilities receive a free and appropriate public education as well as early intervention services starting with infancy. In the latest up- date of IDEA in 2004, regulations include more

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brain injury (TBI), and maternal smoking (Na- tional Institute of Mental Health [NIMH], 2016).

ADHD is a common and growing problem. Approximately 5% of children and adolescents and 4–5% of adults in the United States and 2.5% of adults worldwide are diagnosed with this disorder (CDC, 2017a; Faraone et al., 2015; WebMD, 2017). The number of children ever diagnosed with ADHD has been increasing at a rate of approximately 4% per year (CDC, 2017a). Although boys outnumber girls by at least three to one in terms of the incidence of this disorder, recent research suggests that gender bias might have a role in overdiagnosing boys (Bruchmuller, Marrof, & Schneider, 2012; Snowman & McCown, 2015). Some children outgrow symptoms of ADHD, but many do not. For example, a study by Miller, Ho, and Hinshaw (2012) found that impaired executive functions (ability to plan and organize, response inhibition, sustained at- tention, set shifting, working memory, and rea- soning) in girls with ADHD were still present in young adulthood.

ADHD in the adult population is estimated to be both underdiagnosed and undertreated and often exists with comorbid mental health and substance abuse disorders (Antshel et al., 2011; Chen, 2016). Individuals with ADHD are often stigmatized, because ADHD is viewed by some as a behavioral disorder over which the individ- ual should be able to assert control. The poor academic and work performance often associ- ated with ADHD further exacerbates the prob- lem (Sherman, 2012). For these reasons, adults with ADHD may be unaware that they have the condition or be reticent to disclose this diagno- sis (CDC, 2015a; Sherman, 2012).

ADHD affects individuals at all levels of intellect and is often compounded with other learning disabilities. The classic symptoms of inattention, hyperactivity, and impulsivity pres- ent numerous challenges for adults and children; as a result, people with ADHD often struggle in school and at work. Social issues are also pres- ent and can be significant. Individuals, partic- ularly children and young adults with ADHD, often feel that they are different than their peers

some symptoms of ADHD from time to time, an actual diagnosis of this problem is dependent on the individual displaying symptoms most of the time and across settings, such as at home, in school, on the playground, and at the work- place. Furthermore, a child must display six or more symptoms for at least 6 months, and an adult must display five or more symptoms be- fore a diagnosis is confirmed (Block, Macdon- ald, & Piotrowski, 2015; CDC, 2015a).

The many controversies surrounding the diagnosis and treatment of ADHD have made this developmental disability a household word. However, despite the debate about diag- nosis, treatment, and unnecessary labeling of children, ADHD is recognized as a legitimate medical condition by the American Medical Association, the American Psychiatric Asso- ciation, and multiple other major professional and health organizations. The stigma that re- sults from the many misconceptions that ex- ist about ADHD and its treatment can affect both the children and adults who live with this condition as well as their families (Lebowitz, Rosenthal, & Ahn, 2016; Sarver, Rapport, Kofler, Raiker, & Friedman, 2015).

ADHD is a developmental condition of in- attention and distractibility, with or without hy- peractivity, that manifests in three forms (Soreff, 2017; Understood.org, 2017):

■ Inattentive—a type of ADHD that is char- acterized by inability to attend to tasks, forgetfulness, and distraction

■ Hyperactive/impulsive—a type of ADHD that results in restlessness, impulsivity, and a lack of control

■ Combined/other—a combination of the first two types

Although all three types are referred to as ADHD, it is important to note that hyperactiv- ity is not present in all cases.

Heredity plays a role in ADHD, making in- dividuals susceptible to certain environmental factors that are associated with the condition. These environmental risk factors include, but are not limited to, low birth weight, traumatic

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Got Transition Model, for successfully stream- lining adolescents to adult health care. This model has six core components that include the establishment of transition policies, track- ing and monitoring progress, determining tran- sition readiness, transition planning, transfer of care, and follow-up after transfer is complete (Inman, Scott, & Aleshire, 2017). The need for education for the youth and family is critical throughout the process.

Children and adults with ADHD have a wide range of needs that can be addressed through education. One area of importance re- lates to the misuse and/or diversion of stimulant medication often used to treat ADHD. This is a common problem, particularly among ado- lescents who may misuse the drug themselves, sell it, and/or give it to friends. Research has demonstrated that healthcare providers often neglect or fail to adequately address this im- portant area for teaching (Colaneri, Keim, & Adesman, 2017).

Nurses should consider the following strat- egies when working with adults and children with ADHD:

■ Provide encouragement during teaching because they are likely to have experienced failure in school and work settings and may lack confidence in their abilities to manage their health care.

■ Focus on the positives rather than on the deficits. Research indicates that they have many of the same cognitive strengths as those without ADHD (Climie & Mastoras, 2015).

■ Consider the learning style of individuals. For visual learners, use colorful handouts and slides; for kinesthetic learners, incor- porate movement and activity; and for auditory learners, have them read out loud and consider the use of a recorder so that teaching sessions can be replayed. Because patients with ADHD may have difficulty maintaining appropriate attention levels, these strategies likely will attract and hold their attention. Break content to be taught into small, focused sessions whenever possible.

and may experience stigma that is self-imposed (McKeague, Hennessy, O’Driscoll, & Heary, 2015). Poor social skills exacerbate the prob- lem and research has shown that children with ADHD have difficulty with friendships and peer interactions and are often bullied and victim- ized (Kok, Groen, Fuermaier, & Tucha, 2016). Adults with ADHD are more likely to report be- ing lonely than people without ADHD (Stickley, Koyanagi, Takahashi, Ruchkin, & Kamio, 2017). Often, medication therapy in combination with psychological interventions is the treatment of choice for both children and adults with ADHD.

Careful assessment is critical before working with anyone with ADHD. Nurses should have an open discussion with the patient, and with the parents if the patient is a child, to determine how he or she learns best. If the patient is un- able to identify strategies that have worked well in school or work, the nurse must assess the pa- tient’s response to various techniques and make accommodations as necessary. The nurse can then develop an individualized education plan (IEP) to promote learning through use of pa- tient teaching strategies that compensate for or minimize the effect of the disability (Crandell et al., 2012; Greenberg, 1991; Hockenberry & Wilson, 2011). It is also important to remem- ber, especially when working with adults or chil- dren who have symptoms of ADHD, that the patient may be undiagnosed or may choose to withhold this diagnosis.

Because ADHD is a condition that may persist into adulthood, a transition plan must be in place as the adolescent moves from pedi- atric to adult health care. Increasing autonomy in self-care and healthcare decision making is an important goal for adolescents with ADHD as they transfer into adult healthcare settings. However, adolescents and their families are of- ten fearful to leave their pediatric practitioner; and in fact, some individuals experience nega- tive outcomes as they move to adult care prac- titioners who are unfamiliar with their needs. The American Academy of Family Physicians and American College of Physicians have estab- lished guidelines, which are referred to as the

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promotion. In some areas, nurses may find that bias, misunderstanding, and lack of knowledge have resulted in the educational needs of these individuals being ignored. For example, although individuals with intellectual disabilities have the same needs for love, companionship, and sex- ual gratification as other people, sex education is often overlooked, sometimes with negative consequences (Bernert & Ogletree, 2015; Gurol, Polat, & Oram, 2014; Schaafsima, Kok, Stoffelen, VanDoorn, & Curfs, 2014).

When planning a teaching intervention with an individual who has an intellectual disability, the nurse must keep in mind the patient’s de- velopmental stage, not his or her chronological age. It is important to remember that intellectual abilities can vary significantly from individual to individual so assessment is critical. If the pa- tient does not communicate verbally, the nurse should note whether certain nonverbal cues, such as gestures, signing, or other symbols, are used for communication purposes. Most peo- ple with intellectual disabilities are incapable of abstract thinking. Although the majority can comprehend simple explanations, concrete ex- amples must be given. For example, instead of saying, “Lunch will be here in a few minutes,” the nurse could show a clock and point to the time. Both adults and children with intellectual disabilities benefit from short, clear explanations and demonstrations prior to treatments to avoid misunderstandings and unnecessary anxiety.

When communicating with patients, nurses must always remember that facial expression and voice tone are more important than words spoken. They should talk with family members or other caregivers to learn about unique ways in which the patient communicates, including words they may use for body parts or any non- verbal cues for a “yes” or “no” response. Nurses should lavish any positive behavior with great praise. They should keep the information sim- ple, concrete, and repetitive, and they should be consistent, but firm, setting appropriate lim- its. Avoid dominating any teaching session, but rather let patients actively participate and gain a sense of accomplishment. Nurse educators must

If they have multiple care-related tasks to accomplish on their own, teach them to break their care into smaller tasks.

■ Structure the environment to eliminate un- necessary distraction.

■ Consider using stress reduction techniques prior to teaching to enhance learning in patients who may be anxious.

Intellectual Disabilities Intellectual disabilities are among the most common developmental disabilities, affecting approximately 6.5 million people in the United States alone (Center for Parent Information and Resources [CPIR], 2015). An intellectual disability is a condition that originates before the age of 18 and results in impaired reasoning, learning, problem solving, and adaptive behav- ior (American Association on Intellectual and Developmental Disabilities, 2012). A score of less than 75 on an IQ test is one of the major indicators of intellectual disability; use of such an instrument for diagnosis is typically supple- mented with tests to assess limitations in con- ceptual, practical, and social skills (CPIR, 2015).

Intellectual disabilities have multiple causes. First, intellectual disability is a major character- istic of several syndromes such as Down syn- drome, fragile X syndrome, and fetal alcohol syndrome. Second, any factor that affects the developing neurologic system of the fetus can result in intellectual disability—for example, drugs, disease, and trauma. Third, birth trauma, low birth weight, disease, and other factors that negatively affect the newborn or young child can cause intellectual disability (WebMD, 2016). Fi- nally, intellectual disability can occur as a result of social factors such as lack of education and lack of stimulation from adults not being respon- sive to infants and young children (Jha, 2012)

Nurses are likely to encounter a child or adult with an intellectual disability in a vari- ety of settings and circumstances. Their teach- ing needs will range from simple explanations of medical procedures to more complex assess- ment and instruction in areas such as health

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has changed, it is likely that the term “Asperger syndrome” will continue to be used for some time. Also, advocates within the autism com- munity suggest that referring to this disability as a “syndrome” implies that it is a pathology. As such, it fails to acknowledge the many pos- itive abilities, talents, and potentials of people with Asperger syndrome. As a result, there is a movement to change the title to Asperger pro- file, which is viewed as a more positive and ac- curate term (Asperger/Autism Network, 2017).

Children with Asperger syndrome, in ad- dition to having impaired language, commu- nication, and social interaction skills, exhibit distinguishing characteristics such as repeti- tive rituals, clumsiness, and obsessive interest in a single topic (National Institute of Neuro- logical Disorders and Stroke, 2017). Although they have good cognitive skills, with average or above average vocabularies, these children may have difficulty modulating the pitch of their voice and speak in a flat, monotone man- ner (Medical News Today, 2015). Asperger syn- drome cannot be cured, but with treatment, many children with this condition can learn to grow into functioning adults. However, adults with Asperger syndrome may continue to dis- play subtle symptoms of the disorder, particu- larly in relation to social interactions (Asperger/ Autism Network, 2017; Hughes, 2016).

Teaching individuals with Asperger syn- drome presents many challenges, particularly with children. Although the symptoms are typ- ically less severe in adults, teaching involves social interaction between two people, so the adult with Asperger may struggle when com- municating with the nurse. When teaching an adult or child with Asperger, it is important to remember that intellectual disability is typically not present. Therefore, the following teach- ing strategies should be used by the nurse to help individuals with this syndrome focus and communicate:

■ Provide multiple cues and a lot of repe- tition. Children have significantly more difficulty following verbal instructions

assign simple tasks with simple directions and show what is to be done, rather than relying on verbal commands. They should give only one direction at a time. A reward system often works very well as, for example, giving children stickers with familiar childhood characters to place on their bed or pajamas that will remind the child of a job well done. For adults, rewards that are important to that individual will work as well.

Asperger Syndrome/Asperger Profile/Autism Spectrum Disorder Asperger syndrome is a pervasive developmen- tal disability that falls at the high end of the au- tism spectrum and is characterized by impaired communication, impaired social interaction, and repetitive or restrictive patterns of thought and behavior (National Institute of Neurologi- cal Disorders and Stroke, 2017). The statistics surrounding Asperger syndrome are uncertain as many individuals, particularly adults, remain undiagnosed. It is estimated that 1 in 250 to 1 in 5,000 children are affected, which is approx- imately 1% of the population worldwide (As- perger/Autism Network, 2017; U.S. National Library of Medicine, 2017). Asperger syndrome is a brain dysfunction that is caused by a com- bination of genetics and environmental factors (U.S. National Library of Medicine, 2017). The exact genetic abnormality has yet to be identified.

In recent years, the title and classification of Asperger syndrome has been the subject of some controversy and change. The American Psychiatric Association voted in December 2012 to eliminate Asperger syndrome as a dis- tinct diagnosis in the fifth edition of Diagnos- tic and Statistical Manual of Mental Disorders (DSM-5). Instead, in DSM-5, the condition falls under the umbrella term “autism spectrum dis- order” (Autism Research Institute, 2013). This decision was somewhat controversial, particu- larly among the Asperger syndrome community. Therefore, although the actual diagnostic label

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▸ Mental Illness In the United States, mental disorders are clas- sified according to the categories outlined in Diagnostic and Statistical Manual of Mental Dis- orders (DSM-5). Mental disorders affect an es- timated 20% of Americans ages 18 and older; that is, nearly one in five adults has a diagnos- able mental disorder in any given year, which translates to a total of 45.9 million people. Se- rious mental health illnesses such as schizo- phrenia affect one in 17 Americans (National Alliance on Mental Illness, 2017). Mental dis- orders are the leading cause of disability in the United States and Canada for people aged 15– 44, and only a fraction of those affected receive treatment (NIMH, 2012). These statistics re- veal the relative prevalence of mental illness in our society and indicate that nurses will often care for patients with a psychiatric problem as a primary or secondary diagnosis.

Until about 1886, mentally ill persons were restrained in iron manacles. With the advent of pharmacotherapy in the 1950s, the life of a per- son with a mental illness began to change. The discovery of the various neuroleptic and antide- pressant drugs was a major contribution to the improved quality of life for the mentally ill. Pre- viously dependent clients were now able to live outside of an institution. For the last 35 years, the care of the mentally ill has been moving into community health centers, and clients have spent less time confined to a mental health fa- cility and more time in the community, at work, and at home (Unite for Sight, n.d.). The quality of treatments and, therefore, the quality of life for those with mental illness can only improve. It is incumbent upon nurses to examine their own feelings about mental illness so they can en- gage in a viable teaching–learning relationship.

Although educating people with mental disorders requires many of the same basic prin- ciples of patient teaching, some specific teach- ing strategies should be considered. As with any other nursing intervention, the first step is to begin with a comprehensive assessment. In this

than do children who do not have Asperger (Saalasti et al., 2008). For adults the stress of having to engage in an interaction with the nurse may make it difficult for them to attend to the information being presented (Hughes, 2016).

■ Avoid using facial expressions, body lan- guages, changes in the tone or volume of speech. People with Asperger tend to miss or misinterpret nonverbal cues (Asperger/ Autism Network, 2017; Falkmer, Bjallmark, Larsson, & Falkmer, 2012).

■ Be direct, avoid vague or ambiguous expres- sions, and stick to relevant topics. Individuals with Asperger syndrome tend to interpret communication in a very literal way and they also have difficulty understanding subtlety in communication. Therefore, when teaching the client, the nurse should be direct, avoid vague or ambiguous expressions, and stick to relevant topics (Hughes, 2016).

■ Teach skills in context. Individuals with As- perger often have difficulty generalizing what they have been taught to other situa- tions. For example, if working on specific motor skills, have them practice climbing the steps on the bus or using equipment in the playground (Hayhurst, 2008).

■ Ask directive questions rather than open- ended questions requiring a lengthy response. Children with Asperger have limitations in narrative competence; thus, when asked to tell a story, their tale tends to be shorter and less coherent than other children’s stories (Rumpf & Becker, 2012). As with other developmental disabilities,

when the patient with Asperger syndrome is a child, parents are often a valuable resource for suggestions on how to relate to their child. Most children will have a treatment plan in place, and parents are taught how to help their chil- dren overcome their challenges in communi- cating, interacting with others, and learning. It is important that the nurse talk about the child’s plan with the family to implement strategies that have proved effective.

Mental Illness 399

other participate in patient education sessions (Haber et al., 1997).

Three essential strategies have proved es- pecially successful when teaching people with mental illness (Haber et al., 1997):

1. Teach by using small and brief words, repeat information—use mnemonics, write down important information by placing it on index cards, and use simple drawings or symbols.

2. Keep sessions short and frequent. For instance, instead of a half-hour session, break the learning period into two 15-minute sessions or three 10-minute sessions.

3. Involve all possible resources, includ- ing the patient and his or her family, by actively engaging them in helping to determine the patient’s preferred learning styles as well as the best way to reinforce content.

As with any teaching program, it is import- ant to set goals and determine outcomes with the patient. The specific behavioral objectives depend on individual learning needs, overall learning outcomes, and abilities. To the extent possible, patients should be empowered to take control over their health and health care.

Despite the great strides made in the treat- ment of acute mental illness, the mentally ill per- son still faces the problem of being stigmatized. Assumptions sometimes are made that people who are mentally ill are incapable of and not interested in learning to care for themselves. In fact, their needs for learning are great, but they are often not given the same opportunities to engage in educational programs as those per- sons with physical disabilities.

Motivating the patient with a chronic men- tal illness can be challenging. A certificate of recognition may be given to each patient when he or she completes a program, which can be a powerful motivator. To have a positive effect on the quality of life of the chronically mentally ill, educators must provide information to achieve the goals of independence and self-management.

case, it is wise to determine whether the patient has any cognitive impairment or inappropri- ate behavior as well as to assess their level of anxiety. Assessment also should attempt to de- termine if the individual has limited literacy. Research has shown that people with mental illness are more likely to have lower literacy skills than the general population, which af- fects their ability to access health-related in- formation and creates challenges for patient education (Lincoln, Arford, Doran, Guyer, & Hopper, 2015).

The emotional threat that a person with a psychiatric disorder perceives may result in in- creased anxiety levels and subsequently trig- ger a chain of physiological reactions that then decrease his or her readiness to learn (Haber, Krainovich-Miller, McMahon, & Price-Hoskins, 1997). High anxiety can make learning nearly impossible (Kessels, 2003; Stephenson, 2006). Despite the nurse’s best efforts, patients with a mental disorder may not be able to identify their need to learn and may not be sufficiently ready to learn. The nurse, however, may not be able to wait for readiness to happen. Therein lies the challenge.

Although persons with mental disorders can learn given the right circumstances and strategies, it is important to remember that of- ten people with mental illness experience dif- ficulty in processing information and verbally communicating information. In addition, they may experience decreased concentration and become easily distracted, which can limit their ability to stay on task. These symptoms of their disease can be compounded by the medications used to treat mental illness, which can cause drowsiness, difficulty concentrating, blurred vision, or agitation.

It is very important that care, including ed- ucation, of the patient with mental illness build upon the individual’s strengths and skills (Jack- son, 2009). The nurse must establish a partner- ship with the patient, and when appropriate, with his or her family or caregiver. Also, because the patient’s behavior can be unpredictable, it is very important that the family or significant

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to 4-year-olds and 15- to 19-year-olds. The CDC (2016b) estimates that at least 5.3 million Americans currently have a long-term or life- long need for help to perform activities of daily living resulting from a TBI.

The cognitive deficits that occur depend on the severity and location of the injury but may include poor attention span, slowness in think- ing, confusion, difficulty with short-term and long-term memory, distractibility, sleep disor- ders, mental fatigue, and difficulty with orga- nization, problem solving, reading, and writing (ASHA, 2016). Also, TBI is associated with an array of neurological and psychiatric abnormal- ities that affect behavior such as posttraumatic stress disorder, impulsivity, socially inappro- priate behavior, and poor judgment (McGee, Alekseeva, Chemyshev, & Minagar, 2016). As might be expected, communication skills will more than likely be an issue. Cognitive deficits may persist for an extended time.

The treatment of people with severe brain injury is most often divided into three stages:

1. Acute care (in an intensive care unit) 2. Acute rehabilitation (in an inpatient

brain-injury rehabilitation unit) 3. Long-term rehabilitation after dis-

charge (at home or in a long-term care facility)

When considering the teaching needs of pa- tients with a TBI at each of these stages, it is im- portant to remember that the family, not just the individual who was injured, must be addressed. The effects of TBI can be devastating and can af- fect everyone (Rashid et al., 2014; Warren et al., 2016). Careful assessment of the individual and the family must be done and teaching must fo- cus not only on the ongoing care of the patient but also on the resources available to assist the individual and family.

At every stage of treatment, many hurdles need to be conquered. Once the injured person’s life is assured and the physical condition improves, the client is discharged from the acute care unit. Although the client may look healthy upon dis- charge, he or she may still require rehabilitation.

▸ Physical Disabilities Traumatic Brain Injury A fall, car accident, gunshot wound, and a blow to the head are just a few potential causes of trau- matic brain injury (TBI). Falls are the leading cause of TBI, particularly for children from birth to the age of 4 and adults older than the age of 75. Approximately 2.5 million people sustain a TBI each year in the United States. Of these cases, approximately 75% involve concussions or other mild forms of head injury (CDC, 2016b). The potential long-term effects of TBI are signifi- cant and can seriously affect the quality of life of those affected. Nationally, billions of dollars are spent each year on hospital, rehabilitation, long-term, and palliative care for victims of this injury (Kline & Bondi, 2016).

Although anyone can sustain a TBI, in recent years awareness has increased about the risks for TBI associated with military ser- vice and sports. Because of the development of protective devices for combat, soldiers are now surviving explosions that at one time were considered deadly. However, rarely do soldiers come out of these events unscathed and many suffer from major or minor repeated head in- juries over one or more deployments (McKee & Robinson, 2014; PBS, 2011). Likewise, foot- ball players, skiers, cheerleaders, and others in- volved in high school, college, professional, and recreational sports are at greater risk than the general population for TBI. Considerable efforts are underway to prevent and respond to these sports-related injuries including new rules and regulations regarding play and improved pro- tective devices (Brainline.org, 2014).

TBI includes two specific types: closed head injury, which refers to nonpenetrating in- jury, and open head injury, which refers to pen- etrating injury resulting in brain tissue exposure and disruption of normal protective barriers. Males are 1.5 times more likely than females to sustain a TBI as are individuals with ADHD (Schachar, Park, & Dennis, 2015). The two age groups at highest risk for the injury are infants

Physical Disabilities 401

Patients recovering from TBI face many challenges. Just as the family needs to adjust to the changes in their injured family mem- ber, patients themselves must cope with loss of identity. The significant physical and cog- nitive changes caused by the brain injury of- ten alter how the individual interacts with the world (Fraas & Calvert, 2009). They face not only recovery from physical injury but often an uncertain future.

Learning needs for this population center on the issues of patient safety and family cop- ing. Safety issues are related to cognitive and be- havioral capabilities. Families are faced with a life-changing event and will require ongoing sup- port and encouragement to take care of them- selves. Recovery may require several years, and most often the person is left with some form of impairment.

According to the CDC (2016b), 40% of all persons hospitalized with a TBI have at least one unmet need for services 1 year after the injury. The most frequently noted needs relate to man- aging stress and emotional upsets, controlling one’s temper, improving one’s job skills, and re- gaining memory and problem-solving ability. Marshall et al. (2015) describe a set of revised guidelines for the management of mild TBI and the symptoms that persist after injury. TABLE 9-2 lists guidelines for teaching persons with a TBI.

For this reason, families need to be kept up to date on their loved one’s prognosis and prog- ress from the very beginning. Throughout the rehabilitation process, family teaching must be consistent and thoughtful, because most of the residual impairments are not visible except for the sensorimotor deficits.

The communication, cognitive-perceptual, and behavioral changes associated with TBI may be dramatic. However, one of the most difficult problems for the family is often the recognition that their relative will probably never be the same person again. In fact, personality changes pres- ent a significant burden for the family. Studies have shown that the level of family stress is di- rectly related to the extent of the individual’s personality changes and the relative’s own per- ception of the symptoms arising from the head injury (Grinspun, 1987; McGee et al., 2016).

Although most of the literature deals with the importance of family inclusion during the rehabilitation period, clearly persons with brain injury will always need the involvement of their family. Again, the benefits of participation in family groups are immeasurable. Considerable strength is gained from group participation, and learning is accomplished through a friendly, in- formal approach. Most important, people with brain injury need unconditional acceptance from their friends and family.

Do Don’t

■ Use simple rather than complex statements. ■ Use gestures to enhance what you are saying. ■ Give step-by-step directions. ■ Allow time for responses. ■ Recognize and praise all efforts to communicate. ■ Use listening devices. ■ Keep written instructions simple, with as small an

amount of information as possible.

■ Stop talking or give up trying to communicate.

■ Speak too fast. ■ Talk down to the person. ■ Talk to others as if the patient is not

there.

TABLE 9-2 Guidelines for Effective Teaching of the Brain-Injured Patient

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teaching more difficult (Machiels, Metzelthin, Hamers, & Zwakhalen, 2017).

The following strategies may be helpful when working with patients who have memory loss for whatever reason and to whatever extent.

■ To relearn the memory process, emphasize memory techniques that focus on the need for attention, the benefit of repeating infor- mation, and the importance of practicing recall to grasp the information being taught (Thomas, 2009).

■ If the patient has intact communication skills, encourage him or her to take notes during teaching sessions or the session can be audiotaped to provide the patient and his or her family with reinforcement of information.

■ If a patient has minor memory problems, assist him or her to create a system of re- minders, such as use of a personal digital assistant (PDA), calendar, or sticky notes.

■ Use vivid pictures or have patients draw pictures to help them visualize concepts (Wadsley, 2010).

■ Teach patients to “chunk information.” For example, rather than remembering the seven numbers in a phone number, they can think about a phone number in double digits—for example, 7-45-86-42 (Wadsley, 2010). The same principle can be applied to any procedure that has multiple steps.

■ Structure teaching sessions to allow for brief, frequent repetitive sessions that provide constant reinforcement of learning.

■ Involve the family or caregiver in the teaching session whenever possible to support the patient and reinforce information.

▸ Communication Disorders

Communication disorders can affect an indi- vidual’s ability to both send and receive mes- sages. A cerebrovascular accident is the most

Memory Disorders Memory is a complex process that allows peo- ple to retrieve information that has been en- coded and stored in the brain (Cherry, 2017). Typically, most people can retrieve information quite quickly and without much effort from ei- ther their short-term or long-term memories. Short-term memory refers to information that is remembered if one is attending to it—for ex- ample, being able to complete the steps of a procedure in a return demonstration immedi- ately following a presentation. Individuals with short-term memory deficits may be unable to recall what they learned an hour before, but they may be able to recall the information at a later point in time. Long-term memory consists of information that has been repeated and stored and becomes available whenever the individual thinks about it, such as being able to remem- ber a telephone number over a long period of time. Brain injury, a wide range of diseases, and medical disorders can all result in mild to se- vere memory disorder.

Brain injury often results in a memory dis- order referred to as amnesia. Individuals with anterograde amnesia have memory until the brain injury but are unable to form memories in the present. Individuals with retrograde amne- sia have memory loss prior to the brain injury. Most people with brain injury have a combina- tion of both types of amnesia (Mastin, 2010). In some cases, amnesia can be permanent; however, despite what is depicted in movies and televi- sion, people with amnesia typically remember who they are (Mayo Clinic, 2017).

Alzheimer’s disease, multiple sclerosis, Par- kinson’s disease, brain tumors, and depression are just a few of the conditions that can result in some degree of memory disorder. In some conditions, such as Alzheimer’s disease, mem- ory loss increases as the disease progresses. In other conditions, memory impairment is more of a nuisance than a life-altering disability. Many clients with memory disorders, for example, those with Alzheimer’s disease, also experience a decline in communication skills, which makes

Communication Disorders 403

brain, which is where the primary function of language resides in most people.

Expressive aphasia affects the dominant cerebral hemisphere and results in patients hav- ing difficulty conveying their thoughts, speak- ing haltingly, and using sentences consisting of a few disjointed words, but they understand what is being said to them. Specifically, expres- sive aphasia occurs when an injury damages the inferior frontal gyrus, just anterior to the facial and lingual areas of the motor cortex, known as Broca’s area. Because Broca’s area is so near the left motor area, the stroke often leaves a person with right-sided paralysis as well.

Receptive aphasia is a result of damage to Wernicke’s area of the temporal lobe and affects auditory and reading comprehension. Although the hearing in patients is not impaired, they are nevertheless unable to understand the signifi- cance of the spoken or written word.

Individuals with anomic aphasia un- derstand what is being said to them and can speak in full sentences, but they have difficulty finding the right noun or verb to convey their thoughts. Circumlocution, or speaking around an issue, switching thoughts when they can- not remember a word, or taking new pathways to describe the word they can’t remember is common. The specific anatomical abnormal- ity that results in anomic aphasia, however, is unclear.

The inability to communicate normally is a devastating consequence of a brain injury and requires the full support of the healthcare team. Aphasia has the potential to be a highly frustrating experience for both the patient and his or her caregivers. Speech therapy should be one of the earliest interventions, and the nurse will need to incorporate those strategies iden- tified as effective by the speech therapist into the teaching–learning plan. Every effort must be made to establish communication at some level. Without communication, nurses are ham- pered in their ability to conduct an assessment, establish a relationship with the patient, and en- gage in meaningful interaction (Thompson & McKeever, 2014). Regardless of how severe the

common cause of impaired communication and is the leading cause of long-term disability in the United States. A stroke occurs about every 40 seconds and death from a stroke happens on average every 4 minutes. Approximately 800,000 Americans have a stroke each year. African Americans and Native Americans are at great- est risk for stroke. More than 7 million Ameri- cans are living with its long-term effects, about one third have mild impairments, another third are moderately impaired, and the remainder are severely impaired (American Heart Association & American Stroke Association, 2017; Mozaf- farian et al., 2016).

Aphasia One of the most common residual deficits of a stroke is aphasia, which “is an impairment of language, affecting the production or com- prehension of speech and the ability to read or write” (National Aphasia Association, 2017, p. 1). Aphasia results from damage to the language center of the brain and is not the result or cause of an impairment in intelligence. Although seen commonly in adults who have suffered a stroke, aphasia can also result from a brain tumor, in- fection, head injury, or dementia.

An estimated 1 million people in the United States today suffer from aphasia. The type and severity of the language dysfunction depend on the precise location and the extent of the damaged brain tissue (National Aphasia Asso- ciation, 2017). Many forms of aphasia are possi- ble, and newly diagnosed patients usually work with a speech therapist. Some of the more com- mon types of aphasia include global aphasia, ex- pressive aphasia, receptive aphasia, and anomic aphasia (National Aphasia Association). Deter- mining the type of aphasia involved will assist the nurse in developing an appropriate teach- ing plan for the patient.

Global aphasia is the most severe form of aphasia and produces deficits in both the ability to speak and understand language as well as to read and write. Global aphasia is typically the result of extensive damage to the left side of the

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Therefore, neither the nurse nor members of the family should talk down to the patient. Ample praise and positive reinforcement for attempts to speak or efforts to understand are also important. It is unnecessary and demor- alizing to correct every misunderstanding or error in word selection and pronunciation— the goal is communication rather than per- fection. Finally, it is important that the nurse, as well the family, avoid the tendency to pro- tect the patient by shielding him or her from group conversations, especially those conver- sations that are important to the patient (Na- tional Aphasia Association, 2017).

The term augmentative and alternative communication (AAC) describes the strategies and technologies that can be used to aid commu- nication with a patient who has aphasia follow- ing a brain injury, such as a stroke (Wallace & Bradshaw, 2011). Additional strategies and tech- nologies that can be used by the nurse include the following (Jensen et al., 2015; McKelvey, Hux, Dietz, & Beukelman, 2010; Wallace & Bradshaw, 2011):

■ Be sure you have the patient’s attention, and that he or she is comfortable and is ready to attempt to engage in interaction before you begin communication.

■ Establish a consistent system for everyone to use that allows patients to respond to yes/no questions. It is critical that all staff use the same system. If one person asks the patient to shake his or her head up and down for “yes” and side to side for “no” and yet another suggests squeezing the nurse’s hand for “yes,” the patient will become frustrated and confused. During teaching sessions, the nurse should use this system not only to get information from the person but also to verify that he or she is grasping the material being presented in a teaching session.

■ Teach the patient to point to certain objects to quickly express common needs. For ex- ample, the nurse might explain that “when you point to your water pitcher, I will know that you want a drink of water.”

communication deficit is, with effort, it is almost always possible to assist patients who have had a stroke to communicate in some manner and to some extent.

Family plays a key role in working with pa- tients who have aphasia. Knowledge of the person is key to establishing a therapeutic relationship between the patient and the nurse. Family can help to fill in the gap and assist the nurse in un- derstanding who the patient is, where they have been, and where they had hoped to go in their lives. Also, family can provide insight into the patient’s likes and dislikes, habits, and ways of being (Thompson & McKeever, 2014).

First and foremost, when working with a patient who has expressive aphasia, it is import- ant to remember that communication will take time. Patients who struggle to find the right word may need extra minutes to express themselves, so communication cannot be hurried. As these patients struggle to speak, nurses must resist the temptation to finish sentences or fill in the gaps for them without asking permission to do so. Patients with receptive aphasia may suddenly find that their native language sounds foreign. These individuals may need extra time to pro- cess and understand what is being said. They may find it especially difficult to follow very fast speech, like that heard on the radio or television news, and can easily misinterpret the subtleties of language (e.g., taking the literal meaning of sarcasm or a figure of speech such as “He kicked the bucket”). With any type of aphasia, the nurse should focus on what the patient can do rather than on the speech deficits (National Aphasia Association, 2017; Sander, 2014).

Environmental control is critical for all teaching sessions with patients who have apha- sia. The nurse must make sure that he or she has the individual’s full attention before attempt- ing to communicate and that a quiet, disrup- tion-free area is created. Because patients are often frustrated or embarrassed by their disabil- ity, a private area also is preferred. Moreover, the nurse must always remember that the pa- tient’s difficulty with communication is not re- flective of an inability to think or understand.

Communication Disorders 405

say, “Point to the pill you will take for pain” or “Show me whether you are supposed to take this medicine with food or with water.”

■ Support patients’ speech therapy programs by having them recall word images and by first naming commonly used objects (e.g., spoons, knives, forks) followed by those objects in the immediate environment (e.g., bed, table). Another strategy is to have the person repeat the words spoken by the nurse. It is wise to begin with simple terms and work progressively toward more com- plex phrases.

The act of communicating may be exhaust- ing for the patient with expressive aphasia, so it is important to keep teaching sessions short and focused. Most people become tired when sessions are longer than 20 minutes. Often their speech will become slurred at this point, and they will experience mental fatigue. Whenever pos- sible and if the patient agrees, it may be helpful to have a family member or significant other present during teaching sessions so that they can reinforce learning as needed.

As nurses attempt to work with and engage patients with aphasia in a teaching–learning in- tervention, they must be aware of their own atti- tudes. The effort to communicate with someone without using their usual speech and language can be a frustrating experience. Nurses should be sure to take time out and reflect on the re- wards of assisting the patient and family in over- coming this barrier.

Dysarthria Many people with degenerative disorders, such as Parkinson’s disease, multiple sclerosis, and myas- thenia gravis, also have dysarthria. Dysarthria is a neuro-motor disorder that is caused by damage to the nerves or muscles associated with eating and speaking, including the mouth, tongue, lar- ynx, or vocal cords. Individuals with dysarthria have problems that range from mild to severe

■ Use simple sentence structure, speak slowly, and emphasize important words. Repeat significant points using different words or phrases. Ask only one question at a time. Break questions down into parts so that simple answers are acceptable.

■ Avoid jumping from topic to topic. Keep like topics together, and announce when you are changing topics—for example, “We just finished talking about when to take your medicine; now I will talk about how to take your pills.”

■ Teach the patient to use exaggerated facial expressions, hand movements, or tone of voice to improve speech comprehension. For example, a patient who grimaces when attempting to ask for pain medication is more easily understood. It is important that the patient, the family, and the nurse be open to using different ways to enhance communication. The nurse also can model messages using exaggerated facial expres- sions to assist the patient who has difficulty with comprehension.

■ Make use of available communication boards that provide a platform for pictures, letters, or other symbols to be displayed so a pa- tient can point or gesture to convey a mes- sage. Communication boards range in style and level of technological enhancement, but all provide a simplified way of assist- ing patients to communicate. Some are digitized so that, for example, a question mark on the board might be programmed to elicit a voice that says, “I don’t under- stand; please repeat.” If a communication board with pictures or letters is not avail- able, the nurse can create one with person- ally relevant, context-related photographs specific to the learning that needs to take place. For example, when teaching the pa- tient about medications, the nurse might il- lustrate the medicines ordered, the purpose of each agent, and how it should be taken. When assessing the patient’s understand- ing of the information, the nurse could then

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▸ Chronic Illness Chronic illness is the leading cause of death in the United States, accounting for approximately 70% of all deaths in the country each year. It is a major cause of blindness, amputations, stroke, and other cognitive, sensory, and physical im- pairments and accounts for 86% of the nation’s healthcare costs (CDC, 2012a, 2015b). Although defined by the U.S. Center for Health Statis- tics as a condition lasting 3 months or longer, chronic illness often lasts a lifetime and can re- sult in persistent health problems and/or per- manent disabilities (National Health Council, 2014). Unlike acute illnesses, which usually have a clearly defined beginning and end, chronic ill- ness is characterized by uncertainty, recurrence or persistence of symptoms, long-term risk, and/ or lasting deficits. It is important to note, how- ever, an important distinction: Although chronic illness can cause disabilities and some chronic illnesses are disabling, chronic illness in and of itself is not a disability.

The face of chronic illness is ever chang- ing. Advances in treatment have turned diseases once considered death sentences, for example, cancer and HIV/AIDS, into chronic conditions. Increased awareness and greater understanding have resulted in changing perceptions and con- ditions like drug addiction and alcoholism, once viewed as human weaknesses, are now under- stood to be devastating chronic health condi- tions (National Institute on Drug Abuse, 2017).

Every aspect of an individual’s life can be touched by chronic illness—physical, psycho- logical, social, economic, and spiritual. Because successful management of a chronic illness is often a lifelong process, the development of good learning skills is a matter of survival. It is impossible within the confines of this chap- ter to cover specific teaching strategies for each chronic illness; instead, some general teaching and learning principles are suggested in the fol- lowing pages.

The learning process for individuals with a chronic illness is fraught with hills and valleys.

with their speech being unintelligible, audible, natural, and efficient (Mackenzie, 2011; Sander, 2014). The type (flaccid, spastic, ataxic, hypo- kinetic, and mixed) and severity of dysarthria depend on which area of the nervous system is affected (ASHA, 2017a).

The intervention of a speech-language pa- thologist may help improve the function of var- ious muscles used for speech in patients with dysarthria. In some cases, for example, Parkin- son’s disease medication may help to improve speech. Some mechanical devices have been developed as well, such as a prosthetic palate, which is used to control hypernasality.

Sign language may be used if the person’s arm and hand muscles are not significantly af- fected. The nurse should work with the speech- language pathologist to determine whether any of the other nonverbal aids would be appropri- ate, such as communication boards or a porta- ble electronic voice synthesizer. With the advent of adaptive technologies, the possibilities are al- most limitless.

To improve communication with people with dysarthria, the nurse should implement the following strategies (ASHA, 2017a; Yorkston et al., 2001):

■ Control the communication environment by reducing distractions.

■ Pay attention to the patient and watch him or her while speaking.

■ Be honest and let the patient know when understanding him or her is difficult.

■ Encourage the patient to speak more slowly if he or she is hard to understand.

■ Convey the part of the message that is not understandable so that the patient does not have to repeat the entire message.

■ Ask questions that require a “yes” or “no” answer or have the patient write out his or her message when the patient cannot be understood.

■ Conduct teaching sessions when the patient is rested because fatigue causes speech to become more difficult to understand.

Chronic Illness 407

6. Keeping interactions normal with others as well as maintaining one’s lifestyle as consistent as possible

7. Funding (finding the necessary money to pay for treatments or to survive despite partial or complete loss of employment)

8. Confronting psychological, marital, and family problems that often arise in dealing with long-term illness

Patients who are chronically ill often man- age complex therapeutic regimens. Braden’s self- help model (learned response to chronic illness experience) is a nursing theory that provides a framework with which to describe factors that enhance learning and moderate responses in chronic illness (Lubkin & Larsen, 2016). This model proposes a teaching approach that the nurse can use to encourage independence in pa- tients versus them feeling helpless or respond- ing passively to interventions.

▸ The Family’s Role in Chronic Illness or Disability

Families are usually the care providers and the support system for the person with a dis- ability, and they need to be included in all the teaching–learning interactions. Their reactions and perceptions of the impact of chronic illness or disability, rather than the illness or disability itself, influence all aspects of adjustment. Family participation does have a profound influence on the success of a patient’s rehabilitation program (Lubkin & Larsen, 2016; Turner et al., 2007).

When assessing the patient and family, it is important to note what the family consid- ers high-priority learning needs. Most often, such needs will be related to the caregiver’s per- ceived lifestyle change. A caregiver might ask, “Can I continue working outside the home?” or “Will I be able to maintain my relationships with friends?” It is important that the nurse

Most chronic conditions have several phases that affect the educational needs of both the ill per- son and his or her family. In turn, no single ap- proach will fit each teaching–learning situation.

It is important to be aware of the timing, acu- ity, and severity of the disease progression. The family’s reaction and perception of the chronic illness are also important influences on the teaching–learning process (E. T. Miller, 2011). Families need information and education to deal with the limitations and changes in their loved one’s lifestyle.

People who are chronically ill often expe- rience a conflict between their feelings of de- pendence and their need to be independent (Nilsson, Lindberg, Skar, & Soderberg, 2016). Sometimes the energy and focus required to maintain independence are overwhelming, both physically and emotionally. Often, living with a chronic illness includes a loss and/or change in roles. When people suffer from role loss (e.g., a father who is no longer able to keep his job), their self-esteem may be affected as well. If lin- gering issues persist surrounding the individ- ual’s role loss and self-esteem, they need to be addressed, because they are obstacles to read- iness to learn.

Controlling chronic illness is a major time- consuming activity. Strauss and others (1984) identified eight key problem areas experienced by chronically ill patients and their families that are still relevant today:

1. Prevention of medical crises and the management of problems once they occur

2. Control of symptoms 3. Carrying out prescribed regimens

and dealing with problems associated with adhering to continuous self-care management

4. Prevention of, or living with, social isolation that decreases contact with others

5. Adjustment to changes over the course of the disease through periods of ex- acerbation or remission

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chronically ill or disabled can adapt, adjust, and live healthy, happy, full lives.

▸ Assistive Technologies The growth of modern technology has pervaded all areas of our lives, making them better in many ways. Without a doubt, the personal computer is the technology that has had the greatest im- pact. Until recently, however, computers were inaccessible to individuals with a disability. Yet, when assistive technology has been made avail- able to them, individuals with disabilities have experienced dramatic changes in their lives. Computers with the appropriate adaptations have liberated people from social isolation and feelings of helplessness and have instilled in them feelings of self-worth and independence.

Since the enactment of the ADA in 1990, the diversity of the patient population cared for by nurses has grown to include more individu- als with disabilities in every practice setting. As nurses’ understanding of assistive technology is enhanced, their ability to advocate, recom- mend, and assist persons to attain the appro- priate equipment and training will likewise be bolstered (Lindberg, Nilsson, Zotterman, Soderberg, & Skar, 2013; Reed & Bowser, 1999; Stanhope & Lancaster, 2014). Assistive tech- nologies are defined as technological tools (computers and communication devices) avail- able to persons with disabilities that provide ac- cess to education, employment, recreation, and communication opportunities that allow such individuals to live as independently as possi- ble (Alliance for Technology Access [ATA], n.d.). Examples of assistive technology include voice-activated computer programs, special- ized keyboards, communication devices, arm and wrist supports, amplified telephone hand- sets, screen magnifiers, and environmental con- trols (ATA, n.d.).

Assistive technology is playing an ever- increasing role in our work and daily living ac- tivities. Today the possibilities for devices are endless. For instance, issues of the Journal of

assist the patient and family to identify prob- lems and develop mutually agreed-upon goals. Adaptation is key. Communication between and among family members is crucial. If a family has open communication, the nurse is in a good position to help the family mobilize their re- sources to obtain needed educational and emo- tional support.

The education process also needs to take into consideration the family’s strategies for coping with their relative’s illness or disability. Without a doubt, the overwhelming nature of chronic illness affects the quality of life not only for the person who is ill but also for all the fam- ily members (Lubkin & Larsen, 2016). In their role as caregivers, family members have their own anxieties and fears.

A chronic illness or disability can either de- stroy or strengthen family unity. Siblings and children of the person with a disability may be at different stages of acceptance. Denial may be present during the initial diagnosis of an ill- ness or disability. Later, as the patient and his or her family realize that the situation is likely to be permanent and has many consequences, the nurse may witness them pass through peri- ods of anger, guilt, depression, fear, and hostility. As these feelings gradually become less intense, teaching lessons will need to be readjusted to fit the new circumstances. Flexibility is vital to achieving successful outcomes. Be sure to treat each family member as unique, and recognize that some family members may never fully ad- just to the altered circumstances. TABLE 9-3 lists some of the most common sources of tension in patient and family education.

Nurses need to value their teaching role when they work with the family of a person with a chronic illness or disability. Unlike fam- ilies dealing with an acutely ill member, fami- lies with a member who is permanently ill or disabled will have intermittent contact with the healthcare system throughout their lives. Therefore, whenever teaching sessions are re- quired, the availability of families should be a primary consideration. Given adequate support and resources, families with a member who is

Assistive Technologies 409

TABLE 9-3 Relieving External Tensions in Patient and Family Education

Problem Response

Family Dynamics

Patient or family member feeling overwhelmed

Goal setting: Help family refocus on tasks at hand. Review goals that have been attained to boost morale.

Anxiety and fear of performing complex procedures

Establish an atmosphere of acceptance. Don’t be in a hurry. Offer opportunities for discussion and questions and answers. Reassure patient and family that they have made the right treatment choice.

Emotions associated with chronic or terminal conditions

Provide opportunities to express feelings. Offer referrals to community resources.

Caregiver burnout and illness Simplify patient management where possible (e.g., scheduling drug doses to reduce nighttime treatment). Remain accessible. Remember: When caregiver needs are not being met, resentments increase. Provide information on respite care.

Patient fatigue, especially with chronic illness

Help the patient identify individual ability for as much active participation in the family life as possible.

Young patients are frequently overwhelmed by complex emotions about their illness and therapy

Encourage both children and adolescents to use artwork to express their feelings. Suggest support groups. Offer support to parents and siblings who must alter their family lifestyle.

Geriatric Considerations

An increase in the number of drugs taken daily (on average four or more per day) leads to increased potential for adverse reactions

Use only one pharmacy so that one source keeps track of medications. Continually evaluate all drugs taken for need, safety, compatibility, potential adverse reactions, and expiration dates.

Decreased visual acuity Use teaching materials with large, bold type. Encourage the use of corrective lenses or a magnifying glass.

Modified with permission from LaRocca, J. C. (1994). Mosby’s home health nursing pocket consultant. St. Louis, MO: Mosby–Year Book.

Visual Impairment and Blindness, published by the American Foundation for the Blind (http:// www. afb.org), advertise products geared toward individuals with disabilities, such as devices that

read aloud from the computer screen in either human or synthetic speech and a glow-in-the- dark print Braille rubber wristband for children who are visually impaired. As can be imagined,

410 Chapter 9 Educating Learners with Disabilities and Chronic Illnesses

match the person with the right technology. In- dividuals with physical, sensory, and/or cogni- tive impairments affecting their ability to use a computer may benefit from a host of adaptive devices (Family Center on Technology and Dis- ability, 2012).

Assistive technology is here to stay. Although it will probably be forever changing, the process for ensuring individualized computer solutions will remain much the same, and the benefits are enormous. It is exciting to reflect on the posi- tive, possibly life-changing effects that the per- sonal computer and other telecommunication devices can have on the lives of individuals with a disability. Such products have the potential to change what it means to be disabled.

The role of the nurse as educator includes a patient advocacy component. Acting on the patient’s and family’s behalf, the nurse can work with the multidisciplinary team, including the assistive technology specialist, to enable special populations to participate in all of life’s experi- ences. Thanks to what assistive technologies will be able to do, more people with disabilities will enjoy greater independence and fulfillment.

▸ State of the Evidence The current debate on health care and health- care reform has created a growing awareness of the rising costs of health care. The problems associated with chronic illness and disability in the United States continue to grow, as does concern about the mounting cost of managing the long-term health problems associated with these conditions. In the past, the national spot- light has been focused on obesity, tobacco and alcohol use, and other risk factors for chronic illness and disability. As healthcare research and government funding for programs designed to cut costs by preventing these costly health con- ditions are beginning to emerge, so, too, has the demand for personal accountability in areas such as weight management, where the individual plays a role in the incidence and management of the condition.

such adaptations are very helpful to anyone who has vision, learning, or cognitive disabilities.

Most people use a combination of systems or devices depending on their needs. The good news is that mainstream technology is moving in the direction of universal design, which means that it will be available to almost anyone. Tech- nology has the potential to improve the lives of people with disabilities by giving them the tools to become more independent, more productive, and better able to participate in a wide range of life experiences.

People with communication problems, es- pecially those who are unable to speak or whose speech is difficult to understand, can use aug- mentative and alternative communication de- vices, such as the computer, to add a whole new dimension or quality to their lives. Technology has already made much of the previously im- possible possible, and even greater advances can be expected in the future. It is incumbent upon the nurse to know how to help individuals with disabilities locate and access whatever assistive technology is needed to convey health informa- tion. This technology might include software programs with closed captioning built in for the hearing impaired or on-screen keyboards that can be accessed with a mouse, trackball, or an illuminated pointer device for someone with fine or gross motor deficits.

Every computer-based solution is the re- sult of a carefully planned, individually deter- mined process. Individuals with a disability are the experts on what works best for them. How- ever, some guidelines should be considered when selecting the best adaptive computer. The best computer solution for individuals with disabili- ties will allow for independent and effective use. Other criteria include affordability, portability, flexibility, and simplicity of learning. If these criteria are met, then the adaptive computer is probably in compliance with the ADA’s reason- able accommodations.

As the menu of assistive technologies has expanded, their use has become more widely considered and recommended. It remains a challenging and sometimes complex process to

State of the Evidence 411

when applying the principles of teaching and learning to meet the needs of these special pop- ulations of individuals, their families, and their significant others.

The shock of any disability, whether it oc- curs at the beginning of life or toward the end, has a tremendous impact on individuals and their families. At the onset of the condition and throughout the transition and recovery process, the patient and family face the prospect of hav- ing to learn new information or relearn previous skills, as successful habilitation or rehabilitation means acquiring knowledge and applying it to their situation. Inner strength and courage are attributes needed to face each new day, as the ef- fort to live a normal life never ends. The physical, social, emotional, and vocational implications of living with a disability or the permanence of a chronic illness necessitate the nurse as educator to be well prepared to meet all members of these special populations right where they are in their struggle to live a life of quality and independence.

Review Questions 1. How widespread is the disability issue in

the United States and worldwide? 2. What is meant by the term disability? 3. What is the disabilities model, and how

does it differ from the moral model, the medical model, and the rehabilitation model?

4. What is the difference between people-first and identity-first language that requires nurses to incorporate these concepts into their writing and speaking?

5. Which questions should the nurse ask when assessing readiness to learn in a person with a disability or chronic illness?

6. Which teaching strategies can the nurse use when communicating with patients who have hearing impairments, visual impairments, or learning disabilities?

7. What are the characteristic behaviors of persons with ADHD that factor into choosing educational interventions for effective teaching and learning with this population?

Responsibility for the cost of care is another much-debated topic. Should responsibility for cost of care be with the federal or state govern- ment? Should individuals be mandated to have health insurance coverage? What is the respon- sibility of third-party payers in covering the cost of disabilities and chronic care?

For all the reasons cited previously, the need for health education is at an all-time high. Health education remains a viable solution for teaching people to reduce risk factors and man- age their health, thereby preventing chronic ill- ness and disability. Nurses need to continue to incorporate health education into their practice and conduct research on effective ways to influ- ence behavior change.

The national spotlight on reduction of risk factors for chronic illness and disability is reflected in the U.S. Surgeon General’s report on health promotion and disease prevention, Healthy People 2020 (USDHHS, 2010). This document supports national endeavors to cre- ate a healthier nation by serving as the basis for prevention efforts, including the identifi- cation of national objectives and the provision of evidence-based resources and tools that can be used by communities to implement public health programs. Healthy People 2020 addresses health topics broadly and can be used by nurses to plan teaching programs in a wide range of settings. For example, in relation to nutrition and weight status, Healthy People 2020 identi- fies objectives and strategies for people across the life span and in environments including schools, healthcare settings, the home, and the workplace (USDHHS, 2010).

▸ Summary This chapter covered some of the most common disabilities experienced by millions of Americans resulting from disease, injury, heredity, aging, and congenital defects. These conditions affect physical, cognitive, or sensory capacities and re- quire behavioral change in one or more of these domains of learning. The nurse educator must be creative, innovative, flexible, and persistent

412 Chapter 9 Educating Learners with Disabilities and Chronic Illnesses

10. What are the key problem areas experienced by patients who are chronically ill and by their family members or significant others?

11. How can assistive technology devices improve the quality of life for a person with a disability?

8. How is the term developmental disability defined in relation to a developmental delay?

9. What approaches can the nurse use to teach children with mental or physical impairments?

CASE STUDY It is early morning on the pediatric unit, and the staff are conducting morning rounds. They are discussing 10-year-old Matthew Yoakum, who was transferred to the unit yesterday evening from the ICU. Matt had a below-the-elbow amputation of his right arm following an accident on his family farm. The following conversation takes place.

Jose Garcia, MSW: “Matt and his family are having a very hard time. Apparently, Matt was helping his father when he started fooling around, slipped, and fell into the hay elevator. His lower arm was so badly mangled that the surgeon couldn’t save it.”

Kristen Stryker, PT: “I’ve met with the family. They are feeling very guilty. Matt has ADHD and has had a lot of behavior problems at school. His dad told me that he should have been watching Matt more carefully because he knows that his son has a hard time concentrating on what he is doing.”

Usha Gupta, RN: “We have seen some behavior problems here as well. Last night one of the staff went into his room to ask him to lower his radio and he refused. When she turned the radio off, Matt began spitting and swearing at her.”

Carly Thomas, OTR: “I think he and his family are very frightened. This has all happened so quickly and the consequences of his injury are significant.”

Usha Gupta, RN: “We need to develop a teaching plan. Maybe if they have a better sense of what is going to happen, they will begin to feel more in control.”

Develop a teaching plan for the Yoakum family by responding to the following questions.

1. What information should be collected as part of the assessment of this family? 2. Which factors in this situation might interfere with the patient’s and family members’ readiness

to learn? 3. Which teaching strategies would you use to facilitate learning?

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421

PART THREE

Techniques and Strategies for Teaching and Learning CHAPTER 10 Behavioral Objectives and Teaching Plans

CHAPTER 11 Teaching Methods and Settings

CHAPTER 12 Instructional Materials

CHAPTER 13 Technology in Education

CHAPTER 14 Evaluation in Healthcare Education

Behavioral Objectives and Teaching Plans Susan B. Bastable Loretta G. Quigley

423

CHAPTER 10

CHAPTER HIGHLIGHTS

■ Types of Objectives ■ Characteristics of Goals and Objectives ■ The Importance of Using Behavioral Objectives ■ Writing Behavioral Objectives and Goals

• Performance Words with Many or Few Interpretations ■ Common Mistakes When Writing Objectives ■ Taxonomy of Objectives According to Learning Domains

• The Cognitive Domain • The Affective Domain • The Psychomotor Domain

■ Development of Teaching Plans ■ Use of Learning Contracts

• Components of the Learning Contract ■ The Concept of Learning Curve ■ State of the Evidence

OBJECTIVES

After completing this chapter, the reader will be able to

1. Differentiate between the terms goals and objectives. 2. Assess opposing viewpoints of using behavioral objectives for teaching and learning. 3. Write behavioral objectives accurately and concisely using the four components of condition,

performance, criterion, and who will do the performing. 4. Discuss the common errors made in writing objectives. 5. Distinguish among the three domains of learning: cognitive, affective, and psychomotor. 6. Explain the teaching methods appropriate for instruction in each domain. 7. Develop teaching plans that reflect internal consistency between elements. 8. Recognize the role of the nurse educator in developing objectives for the planning,

implementation, and evaluation of teaching and learning. 9. Describe the importance of learning contracts as an alternative approach to structuring a

learning experience. 10. Determine the potential application of the learning curve concept to the development of

psychomotor skills.

KEY TERMS

taxonomy educational objectives instructional objectives behavioral objectives

(learning objectives) goal objective subobjective

cognitive domain massed practice distributed practice affective domain psychomotor

domain situated cognition transfer of learning

selective attention mental imaging (mental

practice) intrinsic feedback augmented feedback teaching plan learning contract learning curve

Previous chapters have addressed the unique characteristics and attributes of the learner with respect to learning needs, readiness to learn, and learning styles. Clearly, assess- ment of the learner is an essential first step in the teaching–learning process. Assessment de- termines what the learner needs to know, when and under which conditions the learner is most receptive to learning, and how the learner learns best or prefers to learn.

Before a decision can be made about se- lecting the content to be taught or choosing the teaching methods and instructional materials to be used to change learner behavior, the educator must first decide what the learner is expected to

accomplish. Individual needs are determined by identifying gaps in the learner’s knowledge, atti- tudes, or skills. Identification of needs is a pre- requisite to formulating behavioral objectives that serve as a “road map” (Nothwehr, Dennis, & Wu, 2007, p. 794) to guide subsequent plan- ning, implementation, and evaluation of teach- ing and learning.

In the 20th century, noted educators and education psychologists developed approaches to writing and classifying behavioral objectives that offer teachers assistance in organizing in- structional content for learners functioning at various levels of ability. Mager (1997) has been the primary educator credited with developing

424 Chapter 10 Behavioral Objectives and Teaching Plans

a system for writing behavioral objectives that serves to help teachers make appropriate instruc- tional decisions as well as to assist learners in un- derstanding what they need and are expected to know. The underlying principle has been that if one does not know where he or she is going, how will the person know when he or she has arrived?

In addition, the taxonomic system devised by Bloom, Englehart, Furst, Hill, and Krathwohl (1956) for categorizing objectives of learning ac- cording to a hierarchy of behaviors has been the cornerstone of teaching for over half a century. This concept of taxonomy—that is, the order- ing of these behaviors based on their type and complexity—pertains to the level of knowledge to be learned, the kind of behaviors most rele- vant and attainable for an individual learner or group of learners, and the sequencing of knowl- edge and experiences for learning from simple to the most complex.

Based on the original work of Bloom and his colleagues (1956), Anderson et al. (2001) proposed a revision to this initial taxonomy for learning, teaching, and assessing behaviors. The most prominent differences include changing the names in the six categories from noun to verb forms and rearranging the last two categories. A comparison of the original taxonomy with

the revised one is shown in FIGURE 10-1. The revisions to Bloom’s taxonomy have the poten- tial to make explicit teacher assessment, student assessment, as well as teacher and student self- assessments as patterns of use emerge.

Skill in preparing and classifying behav- ioral objectives is a necessary function of the educator’s role, whether teaching patients and their families in healthcare settings, teaching staff nurses in inservice and continuing educa- tion programs, or teaching nursing students in academic institutions. The importance of un- derstanding the systems of writing and catego- rizing behavioral objectives to specify learner outcomes is imperative if data yielded from ed- ucational efforts are to be consistent and mea- surable. Also, the knowledge and use of these techniques are becoming essential because of the need to quantify and justify the costs of teach- ing others in an environment characterized by ever-increasing cost-containment pressures.

This chapter examines the importance of behavioral objectives for effective teaching; de- scribes how to write clear and precise behavioral objectives; provides an overview of the taxon- omy levels of cognitive, affective, and psycho- motor domains; and outlines the development of teaching plans and learning contracts. The

425Behavioral Objectives and Teaching Plans

FIGURE 10-1 Revisions to Bloom’s taxonomy. Reproduced from Wilson, L.O. (2001). Anderson and Krathwohl–Bloom’s taxonomy revised. Retrieved from http://thesecondprinciple.com/teaching-essentials/beyond-bloom-cognitive-taxonomy-revised/. 2001, Leslie Owen Wilson, Ed. D.

Evaluation Create

1956

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

Create

Evaluate

Analyze

Apply

Understand

Remember

2001

Noun to Verb Form

concept of the learning curve as it applies to mastering psychomotor skills is also discussed. Each of these elements provides a framework for successful teaching.

▸ Types of Objectives It is important to clarify the meaning of the terms educational objectives, instructional ob- jectives, and behavioral or learning objectives. Although often used synonymously, these terms can be distinguished from one another. Edu- cational objectives are used to identify the intended outcomes of the education process, whether referring to an aspect of a program or a total program of study, that guide the design of curriculum units. Instructional objectives describe the teaching activities, specific con- tent areas, and resources used to facilitate ef- fective instruction (Morrison, Ross, Kemp, & Kalman, 2010). Behavioral objectives, also referred to as learning objectives, make use of the modifier behavioral or learning to de- note that this type of objective is action ori- ented rather than content oriented, learner centered rather than teacher centered, and short-term outcome focused rather than pro- cess focused. Behavioral objectives describe precisely what the learner will be able to do following a learning situation.

▸ Characteristics of Goals and Objectives

The terms goal and objective are often used in- terchangeably as if they are one and the same. However, a real difference exists between the two terms. This distinction must be clearly un- derstood because it is common to find con- fusion on the meaning of these terms among nurses and nurse educators alike (Krau, 2011; Wittmann-Price & Fasolka, 2010). Two factors differentiate goals from objectives: their rela- tionship to time and their level of specificity (Haggard, 1989).

A goal is the final outcome to be achieved at the end of the teaching and learning process. Goals, also commonly referred to as learning outcomes, are global and broad in nature and are long-term targets for both the learner and the teacher. Goals are the desired outcomes of learning that realistically can be achieved usu- ally in a few days, weeks, or months. They are considered multidimensional in that a number of objectives are subsumed under or incorpo- rated into an overall goal.

An objective, in contrast to a goal, is a spe- cific, single, concrete, one-dimensional behavior. Objectives are short term and should be achieved at the end of one teaching session, or shortly af- ter several teaching sessions. A behavioral ob- jective is the intended result of instruction, not the process or means of instruction itself. Be- havioral objectives describe precisely what the learner will be able to do following the instruc- tion. Objectives are statements of specific, short- term behaviors. They lead step by step to the more general, overall long-term goal. According to Mager (1997), an objective describes a per- formance that learners should be able to exhibit before they are considered competent.

Subobjectives also may be written and re- flect aspects of a main objective. They, too, are specific statements of short-term behaviors that lead to the achievement of the primary objec- tive. Objectives and subobjectives specify what the learner will be able to do after being exposed to one or more learning experiences.

It is necessary to have both goals and objec- tives to accomplish something. Goals without objectives cannot be achieved and objectives with- out goals will never result in anything meaning- ful and worthwhile. Although the two concepts are distinct and separate, they are closely related and integral to one another (Kumar, 2011).

Objectives must be achieved before the goal can be reached. They must be observable and measurable for the educator to be able to determine whether they have been met by the learner. Objectives can be thought of as advance organizers—that is, statements that inform the learner of what is expected from a cognitive,

426 Chapter 10 Behavioral Objectives and Teaching Plans

affective, or psychomotor perspective prior to meeting the goal, which is the desired end re- sult or intended outcome (Surbhi, 2015). Ob- jectives are derived from a goal and must be consistent with and related to that goal. As an analogy, a goal can be thought of as an entire pie, the objectives as individual portions of the pie that make up the goal, and the subobjectives as bite-sized pieces of a single portion of the pie.

Together, objectives and goals form a map that provides directions (objectives) as to how to arrive at a specific destination (goal). For ex- ample, a goal might be that a patient with heart failure will learn to manage his or her disease. To accomplish this goal, which both the nurse and the patient have agreed on, specific objec- tives must be outlined to address changes in behavior. These changes would be related to diet, medications, exercise, and fluid monitor- ing (Buck, McAndrew, Dionne-Odom, Wion, & Riegel, 2015). The objectives to accomplish the goal become the blueprint for attaining the de- sired outcome of learning.

The successful achievement of predeter- mined objectives is, in part, the result of ap- propriate instruction. Certainly, many other factors, such as learner motivation and ability to perform, are also key factors to the success- ful demonstration of specific behaviors before the learner can be declared to have overall com- petence in the desired behavior.

If the teaching–learning process is to be successful, the setting of goals and objectives must be a mutual decision on the part of both the teacher and the learner. Both parties must participate in the decision-making process and buy into the immediate objectives and ultimate goals. Involving the learner right from the start in creating goals and objectives is crucial. Oth- erwise, time and effort on the part of the edu- cator and the learner may be wasted, because the learner may choose to reject the content if it is deemed—at least from his or her perspective— to be unimportant, irrelevant, impractical, un- attainable, or something already known.

Goal and objective setting for any educational experience should be as much a responsibility of

the learner as it is of the teacher. Blending what the learner wants to learn with what the teacher has determined that the learner needs to know into a common set of objectives and goals pro- vides for an educational experience that is mu- tually accountable, respectful, developmental, and fulfilling (Reilly & Oermann, 1990).

Objectives and goals must be clearly writ- ten, realistic, and learner centered. If the ob- jectives and goals do not specifically identify precisely what the learner is expected to do in the short and long term, then the learning pro- cess will lack clear guideposts to follow or an obvious outcome to strive for. Likewise, if goals and objectives are unrealistic in that they are too difficult to achieve, the learner can become dis- couraged, which dampens motivation and inter- feres with the ability to comply. For instance, a goal that a patient will maintain a salt-free diet is likely to be impossible to accomplish or to adhere to over an extended time. Establishing a goal of maintaining a low-salt diet, with the objectives of learning to avoid preparing and eating high-sodium foods, is a much more re- alistic and achievable expectation of the learner.

Also, goals and objectives must be directed to what the learner is expected to be able to do, not what the teacher is expected to teach. Ed- ucators must be sure not only that their teach- ing remains objectives oriented but also that the objectives are learner centered. This approach keeps educators targeted on results, not on the act of teaching. Educators must remember, as Anderson et al. (2001) emphasize, not all learn- ers will take away the same thing from the same instruction, unless objectives are focused and precisely expressive.

▸ The Importance of Using Behavioral Objectives

The following key points justify the need for writing behavioral objectives (Ferguson, 1998;

The Importance of Using Behavioral Objectives 427

prepare instructional materials or content un- til they know the knowledge and skills students are expected to learn. Thus, after a nurse edu- cator has identified the needs of an individual learner or group of learners, it is important that the educator clearly state the behavioral objec- tives to be achieved as well as intended results of instruction (goal) even before proceeding with any other step of the educational process.

The following questions, summarized by Haggard (1989) that are still relevant today, will arise if objectives are not consistently written:

■ How will anyone else know which objectives have been set?

■ How will the educator evaluate and docu- ment success or failure?

■ How will learners keep track of their progress?

Developing behavioral objectives not only helps educators explore their own knowledge, values, and beliefs about teaching and learning but also encourages them to examine the ex- periences, values, motivations, and knowledge of the learner. The writing of objectives is not merely a mechanical task but rather a synthe- sizing process. Establishing objectives and goals is considered by many educators to be the ini- tial, most important consideration in the teach- ing and learning experience (Haggard, 1989; Mager, 1997).

▸ Writing Behavioral Objectives and Goals

Well-written behavioral objectives give learn- ers very clear statements about what is expected of them. They also assist teachers in being able to measure learner progress toward achieving the objectives. Over the years, Robert Mager’s (1997) approach to writing behavioral objectives has become widely accepted among educators. His message to them is that for objectives to be meaningful, they must precisely, clearly, and very specifically communicate the teacher’s in- structional intent (Arends, 2015).

Krau, 2011; Morrison et al., 2010; Phillips & Phillips, 2010). The careful construction of well- written objectives:

■ Helps to keep educators’ thinking on target and learner centered.

■ Communicates to learners and healthcare team members what is planned for teaching and learning.

■ Helps learners understand what is expected of them so they can keep track of their progress.

■ Forces the educator to select and organize educational materials so they do not get lost in the content and forget the learner’s role in the process.

■ Encourages educators to evaluate their own motives for teaching.

■ Tailors teaching to the learner’s unique needs. ■ Creates guideposts for teacher evaluation

and documentation of success or failure. ■ Focuses attention on what the learner will

come away with once the teaching–learning process is completed, not on what is taught.

■ Orients teacher and learner to the end results of the educational process.

■ Makes it easier for the learner to visualize performing the required skills.

Robert Mager (1997) points out three other major advantages in writing clear objectives:

1. They provide the solid foundation for the selection or design of instructional content, methods, and materials.

2. They provide learners with ways to organize their efforts to reach their goals.

3. They help determine whether an objective has, in fact, been met.

As Mager (1997) asks, “If you don’t know where you’re going, how will you know which road to take to get there?” (p. 14). For exam- ple, mechanics do not select repair tools un- til they know what has to be fixed, surgeons do not choose instruments until they know which operation is to be performed, and builders do not buy construction materials before drafting a blueprint. Likewise, teachers should never

428 Chapter 10 Behavioral Objectives and Teaching Plans

should the learner be able to do it? (3) How well must the learner be able to do it? A fourth com- ponent must also be included that describes the “who” to guarantee that the behavioral objec- tive is indeed learner centered.

Thus, behavioral objectives are statements that communicate who will do what under which conditions and how well, how much, or when (Cummings, 1994). An easy way to remember the four elements that should be in a behavioral objective is to follow the ABCD rule proposed by Smaldino, Lowther, and Russell (2012):

A—audience (who)

B—behavior (what)

C—condition (under which circumstance)

D—degree (how well, to what extent, within what time frame)

For example, the following behavioral objective includes these four elements: “After a 20-minute teaching session on relaxation techniques (C- condition), Mrs. Smith (A-audience) will be able to identify (B-behavior) three distinct tech- niques for lowering her stress level (D-degree).”

TABLE 10-1 outlines the four-part method of objective writing. TABLE 10-2 gives examples of well-written and poorly written objectives.

According to Mager (1997), the format for writing concise and useful behavioral ob- jectives includes the following three important characteristics:

1. Performance: Describes what the learner is expected to be able to do to demonstrate the kinds of behaviors the teacher will accept as evidence that objectives have been achieved. Activities performed by the learner may be observable and quite visible, such as being able to write or list something, whereas other activities may not be as visible, such as being able to identify or recall something

2. Condition: Describes the situations under which the behavior will be observed or the performance will be expected to occur.

3. Criterion: Describes how well, with what accuracy, or within what time frame the learner must be able to perform the behavior so as to be considered competent.

These three characteristics translate into the following key questions: (1) What should the learner be able to do? (2) Under which conditions

Writing Behavioral Objectives and Goals 429

TABLE 10-1 The Four-Part Method of Objective Writing

Condition (Circumstance or Testing Situation)

Audience (Identify Who Learner Is)

Behavior (Learner Performance)

Degree (Criterion Reflecting Quality or Quantity of Mastery)

Without using a calculator the student will solve five out of six math problems

Using a model the staff nurse will demonstrate the correct procedure for changing sterile dressings

Following group discussion

the patient will list at least two reasons for losing weight

After watching a video the caregiver will select high-protein foods for the patient with 100% accuracy

If a word is used to describe something a learner can be, then it is not a doing word but rather a being word. Examples of being words, known also as abstractions, include to under- stand, to know, to enjoy, and to appreciate (Mager, 1997). Understanding, knowing, enjoying, and appreciating are considered abstract states of be- ing that cannot be directly measured but merely inferred from performances. Therefore, verbs that signify an internal state of thinking, feel- ing, or believing should be avoided because they are difficult to measure or observe.

It is impossible to identify all behavioral terms that might potentially be used in objec- tive writing. The important thing to remember in selecting verbs to describe performance is that they must be specific, observable or measurable, and action oriented. As stated by Anderson et al. (2001), if the teacher can describe the behavior to be attained, it will be easily recognized when learning has occurred. TABLE 10-3 gives examples

Performance Words with Many or Few Interpretations When writing behavioral objectives using the for- mat suggested by Mager (1997), the recommen- dation is to use precise action words or verbs as labels that are open to few interpretations when describing learner performance.

An objective is considered most useful when it clearly states what a learner must demonstrate for mastery in a knowledge, attitude, or skill area. A performance verb describes what the learner is expected to do. A performance may be visible or audible. For example, the learner is able to list, to write, to state, or to walk. These performances are directly observable. A perfor- mance also may be invisible. For example, the learner is able to identify, to solve, to recall, or to recognize. Any performance, whether it is visible/ audible or invisible, described by a “doing” word is measurable.

430 Chapter 10 Behavioral Objectives and Teaching Plans

TABLE 10-2 Samples of Written Objectives

Well-Written Objectives Poorly Written Objectives

■ Following instruction on hypertension, the patient will be able to state three out of four causes of high blood pressure.

■ On completing the reading materials provided about the care of a newborn, the mother will be able to express any concerns she has caring for her baby after discharge.

■ After a 20-minute teaching session, the patient will verbalize at least two feelings or concerns associated with wearing a colostomy bag.

■ After reading handouts, the patient will be able to state three examples of foods that are sources high in protein.

■ The patient will be able to prepare a menu using low-salt foods. [Condition and criterion missing]

■ Given a list of exercises to relieve low back pain, the patient will understand how to control low-back pain. [Performance not stated in measurable terms, criterion missing]

■ The nurse will demonstrate crutch walking postoperatively to the patient. [Teacher centered]

■ During discharge teaching, the patient will be more comfortable with insulin injections. [Performance not stated in measurable terms, condition missing, criterion missing]

■ The patient will verbalize and demonstrate the proper steps to performing self-catheterization. [Contains two expected behaviors, criterion missing, time frame missing]

■ After a 20-minute teaching session, the patient will appreciate knowing the steps required to complete a finger stick. [Performance not stated in measurable terms, criterion missing]

and seasoned educators alike. The most fre- quent errors made in writing objectives are as follows:

■ Describing what the teacher does rather than what the learner is expected to do

■ Including more than one expected behavior in a single objective (avoid using and to connect two verbs—e.g., the learner will select and prepare)

■ Forgetting to identify all four components of condition, performance, criterion, and who the learner is

■ Using terms for performance that are open to many interpretations, are not action ori- ented, and are difficult to measure

in two columns of terms: one column listing verbs that are not recommended for use because they are too broad, ambiguous, and imprecise to evaluate, and the other column listing verbs that are specific and relatively easy to measure (Gronlund, 1985; Gronlund & Brookhart, 2008).

▸ Common Mistakes When Writing Objectives

In creating behavioral objectives, many com- mon mistakes can be easily made by novice

Common Mistakes When Writing Objectives 431

TABLE 10-3 Examples of Verbs with Many or Few Interpretations

Terms with Many Interpretations (Not Recommended)

Terms with Few Interpretations (Recommended)

to know to apply to explain

to understand to choose to identify

to appreciate to classify to list

to realize to compare to order

to be familiar with to construct to predict

to enjoy to contrast to recall

to value to define to recognize

to be interested in to describe to select

to feel to demonstrate to state

to think to differentiate to verbalize

to learn to distinguish to write

Data from Gronlund, N. E. (1985). Stating objectives for classroom instruction (3rd ed.). New York, NY: Macmillan; Gronlund, N. E. (2004). Writing instructional objectives for teaching and assessment (7th ed.). Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

ordering levels of behavior according to their type and complexity (Reilly & Oermann, 1990). Bloom et al. (1956) and Krathwohl, Bloom, and Masia (1964) developed a very useful taxonomy, known as the taxonomy of educational objec- tives, as a tool for classifying behavioral objec- tives. This taxonomy is divided into three broad categories or domains: cognitive (thinking do- main), affective (feeling domain), and psycho- motor (doing or skills domain).

Although these three domains of cogni- tive, affective, and psychomotor learning are described as existing as separate entities, they are interdependent and can be experienced si- multaneously. Humans do not possess thoughts, feelings, and actions in isolation from one an- other and typically do not compartmentalize learning. For example, the affective domain in- fluences the cognitive domain, and vice versa; the processes of thinking (cognitive) and feel- ing (affective) influence psychomotor perfor- mance, and vice versa (Menix, 1996).

In addition to each objective being classi- fied by a domain, each domain is ordered in a taxonomic form of hierarchy. Behavioral objec- tives are classified into low, medium, and high levels, with simple behaviors listed first (at the lower end), followed by behaviors of moderate

■ Writing objectives that are unattainable and unrealistic given the ability level of the learner

■ Writing objectives that do not relate to the stated goal

■ Cluttering objectives by including unnec- essary information

■ Being too general so as not to specify clearly the expected behavior to be achieved

If you use the SMART rule, it is easy to cre- ate effective objectives for different audiences in diverse settings. This objective-setting process is shown in TABLE 10-4.

▸ Taxonomy of Objectives According to Learning Domains

A taxonomy is a way to categorize things accord- ing to how they are related to one another. For example, in science, biologists use taxonomies to classify plants and animals based on their nat- ural characteristics. In the late 1940s, psychol- ogists and educators became concerned about the need to develop a system for defining and

432 Chapter 10 Behavioral Objectives and Teaching Plans

TABLE 10-4 Writing SMART Objectives

Specific Be specific about what is to be achieved (i.e., use strong action verbs, be concrete).

Measurable Quantify or qualify objectives by including numeric, cost, or percentage amounts or the degree/level of mastery expected.

Achievable Write attainable objectives.

Realistic Resources (i.e., personnel, facilities, equipment) must be available and accessible to achieve objectives.

Timely State when the objectives will be achieved (i.e., within a week, a month, by the day of patient discharge, before a new staff member completes orientation?).

Data from Glenn M. Parker Associates, Inc. (2000). Team workout. Amherst, MA: HRD Products.

The Cognitive Domain The cognitive domain is known as the “think- ing” domain. Learning in this domain involves acquiring information and addressing the de- velopment of the learner’s intellectual abilities, mental capacities, understanding, and think- ing processes (Eggen & Kauchak, 2012). Objec- tives in this domain are divided into six levels (Bloom et al., 1956), each specifying cognitive

difficulty, with the more complex behaviors listed last (at the higher end). This concept of hierarchy realizes that learners must success- fully achieve behaviors at lower levels of the do- mains before they are able to adequately learn behaviors at higher levels of the domains. Thus, to use an analogy of climbing a ladder, you can- not get to the top unless you go up one step at a time. See FIGURE 10-2 for a diagram of the level of complexity of the behaviors in each domain.

Taxonomy of Objectives According to Learning Domains 433

COGNITIVE DOMAIN

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

AFFECTIVE DOMAIN

Characterization

Organization

Valuing

Responding

Receiving

FIGURE 10-2 Domain hierarchies. Data from Gronlund, N. E., & Brookhart, S. M. (2008). Gronlund’s writing instructional objectives (8th ed.). Upper Saddle River, NJ: Pearson Merrill Prentice Hall; Krathwohl, D. R., Bloom, B. J., & Masia, B. B. (1964). Taxonomy of educational objectives: The classification of educational goals. Handbook II: The affective domain. New York, NY: David McKay; Simpson, E. J. (1972). The classification of educational objectives in the psychomotor domain. In M. T. Rainer (Ed.), Contributions of behavioral science to instructional technology: The psychomotor domain (3rd ed.). Englewood Cliffs, NJ: Gryphon Press, Prentice Hall.

behavior). Example: After watching a 10-minute video on nutrition following gastric bypass surgery, the patient will be able to give at least three examples of food choices that will be included in his diet.

Application level: Ability of the learner to use ideas, principles, abstractions, or theories in specific situations, such as figuring, writing, reading, or handling equipment (knowl- edge and comprehension are prerequisite behaviors). Example: On completion of a cardiac rehabilitation program, the patient will modify three exercise regimes that can fit into his or her lifestyle at home.

Analysis level: Ability of the learner to recognize and structure information by breaking it down into its separate parts and specifying the relationship between the parts (knowledge, comprehension, and application are prerequisite behaviors). Example: After reading handouts provided by the nurse educator, the family member will calculate the correct number of total

processes ranging from the simple (knowledge) to the more complex (evaluation), as seen in Figure 10-2.

Levels of Behavioral Objectives and Examples in the Cognitive Domain

Knowledge level: Ability of the learner to memorize, recall, define, recognize, or identify specific information, such as facts, rules, principles, conditions, and terms, presented during instruction. Example: After a 20-minute teaching session, the patient will be able to state with accuracy the definition of chronic obstructive pulmonary disease (COPD).

Comprehension level: Ability of the learner to demonstrate an understanding of what is being communicated by recognizing it in a translated form, such as grasping an idea by defining it or summarizing it in his or her own words (knowledge is a prerequisite

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FIGURE 10-2 Domain hierarchies. (continued)

PSYCHOMOTOR DOMAIN

Origination

Adaptation

Complex overt response

Mechanism

Guided response

Set

Perception

for prenatal care has been shown to improve perinatal outcomes (Rotundo, 2012). Cogni- tive domain learning is the traditional focus of most teaching. In education of patients, as well as nursing staff and students, emphasis remains on the sharing of facts, theories, and concepts. Perhaps this emphasis has evolved because ed- ucators typically feel more confident and more skilled in being the giver of information than in being the facilitator and coordinator of learn- ing. Lecture and one-to-one instruction are the most frequently used methods of teaching in the cognitive domain.

With respect to cognitive learning, how much time for practice is necessary to influ- ence the short-term and long-term retention of information? Cognitive scientists have been exploring the allocation of practice time to the learning of new material. Generally, research findings indicate that learning distributed over several sessions leads to better memory than in- formation learned in a single session.

This phenomenon has been described by Willingham (2002) as the “spacing effect.” That is, learning information all at once on one day, an approach known as massed practice, is much less effective for remembering facts than learning information over successive periods of time, an approach known as distributed prac- tice. Massed practice, commonly identified as “cramming,” might allow the recall of informa- tion for a short time, but evidence strongly sup- ports that distributed practice is very important in forging memories that last for years.

The effect of spreading out learning over time is very clear. The average person exposed to distributed practice remembers 67% better than people who receive massed training. That is, spacing the time allocated for learning sig- nificantly increases memory. The longer the de- lays between practice sessions, the greater and more permanent is the learning. In fact, if learn- ing is distributed over time, not only does this spacing effect hold, but it becomes even more robust (Willingham, 2002).

This evidence, when applied to the educa- tion of patients, staff nurses, or student nurses,

grams of protein included on average per day in the family diet.

Synthesis level: Ability of the learner to put together parts into a unified whole by creating a unique product that is written, oral, or in picture form (knowledge, com- prehension, application, and analysis are prerequisite behaviors). Example: Given a sample list of foods, the patient will devise a menu to include foods from the four food groups (dairy, meat, vegetables and fruits, and grains) in the recommended amounts for daily intake.

Evaluation level: Ability of the learner to judge the value of something by applying appropriate criteria (knowledge, compre- hension, application, analysis, and synthesis are prerequisite behaviors). Example: After three teaching sessions, the learner will assess his readiness to function independently in the home setting.

TABLE 10-5 lists verbs commonly used in writing cognitive-level behavioral objectives.

Teaching in the Cognitive Domain Several teaching methods and tools exist for the purpose of developing cognitive abili- ties. The methods most often used to stimu- late learning in the cognitive domain include lecture, group discussion, one-to-one instruc- tion, and self-instruction activities, such as computer-assisted instruction. Verbal, written, and visual tools are all particularly successful in enhancing the teaching methods to help learners master cognitive content. For example, research has shown computer-assisted instruction to be effective in teaching clients about HIV preven- tion (Evans, Edmunson-Drane, & Harris, 2000; Ford, Mazzone, & Taylor, 2005).

However, cognitive skills can be gained by exposure to all types of educational experiences, including the instructional methods used pri- marily for affective and psychomotor learning. For example, the concept of group discussion

Taxonomy of Objectives According to Learning Domains 435

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TABLE 10-5 Commonly Used Verbs According to Domain Classification

Cognitive Domain

Knowledge: choose, circle, cite, count, define, identify, label, list, match, name, outline, read, recall, repeat, report, select, state, tell, write Comprehension: associate, describe, discuss, distinguish, estimate, explain, express, generalize, give example, locate, recognize, review, summarize Application: apply, demonstrate, examine, illustrate, implement, interpret, modify, order, relate, report, restate, revise, solve, translate, use Analysis: analyze, arrange, calculate, classify, compare, conclude, contrast, determine, differentiate, discriminate, detect, distinguish, question Synthesis: assemble, arrange, categorize, combine, compile, correlate, create, design, devise, detect, generalize, generate, formulate, integrate, manage, organize, plan, prepare, propose, reorganize, revise, specify, summarize Evaluation: appraise, assess, conclude, critique, criticize, debate, defend, estimate, evaluate, grade, judge, justify, measure, rank, rate, recommend, review, score, select, test

Affective Domain Receiving: accept, admit, ask, attend, focus, listen, observe, pay attention Responding: agree, answer, conform, discuss, express, participate, recall, relate, report, state willingness, try, verbalize Valuing: assert, assist, attempt, choose, complete, disagree, follow, help, initiate, join, propose, volunteer Organizing: adhere, alter, arrange, combine, defend, explain, express, generalize, integrate, resolve Characterizing: assert, commit, discriminate, display, influence, propose, qualify, solve, verify

Psychomotor Domain

Perception: attend, choose, describe, detect, differentiate, distinguish, identify, isolate, perceive, relate, select, separate Set: attempt, begin, develop, display, position, prepare, proceed, reach, respond, show, start, try Guided response, mechanism, and complex overt response: align, arrange, assemble, attach, build, change, choose, clean, compile, complete, construct, demonstrate, discriminate, dismantle, dissect, examine, find, grasp, hold, insert, lift, locate, maintain, manipulate, measure, mix, open, operate, organize, perform, pour, practice, reassemble, remove, repair, replace, separate, shake, suction, turn, transfer, walk, wash, wipe Adaptation: adapt, alter, change, convert, correct, rearrange, reorganize, replace, revise, shift, substitute, switch Origination: arrange, combine, compose, construct, create, design, exchange, reformulate

each specifying the associated level of affective responses as seen in Figure 10-2.

Levels of Behavioral Objectives and Examples in the Affective Domain

Receiving level: Ability of the learner to show awareness of an idea or fact or a conscious- ness of a situation or event in the environ- ment. This level represents a willingness to selectively attend to or focus on data or to receive a stimulus. Example: During a group discussion session, the patient will admit to any fears he may have about needing to undergo a repeat angioplasty.

Responding level: Ability of the learner to respond to an experience, at first obediently and later willingly and with satisfaction. This level indicates a movement beyond denial and toward voluntary acceptance, which can lead to feelings of pleasure or enjoyment resulting from some new experience (re- ceiving is a prerequisite behavior). Example: At the end of one-to-one instruction, the child will verbalize feelings of confidence in managing her asthma using the peak-flow tracking chart.

Valuing level: Ability of the learner to regard or accept the worth of a theory, idea, or event, demonstrating sufficient commit- ment or preference to an experience that is perceived as having value. At this level, there is a definite willingness and desire to act to further that value (receiving and responding are prerequisite behaviors). Example: After attending a grief support group meeting, the patient will complete a journal entry reflecting her feelings about the experience.

Organization level: Ability of the learner to organize, classify, and prioritize values by integrating a new value into a general set of values; to determine interrelationships of values; and to establish some values as

strongly suggests the need to allocate time for the acquisition of knowledge. Such scientific findings explain, for example, why teaching a patient on the day of discharge from the hospi- tal is ineffective or why students who cram for a test do not retain the information as well as their counterparts who distributed their learn- ing over an extended length of time (Willing- ham, 2002).

The Affective Domain The affective domain is known as the “feel- ing” domain. Learning in this domain involves an increasing internalization or commitment to feelings expressed as emotions, interests, beliefs, attitudes, values, and appreciations. Whereas the cognitive domain is ordered in terms of com- plexity of behaviors, the affective domain is di- vided into categories that specify the degree of a person’s depth of emotional responses to tasks. The affective domain includes emotional and social development goals. As stated by Eggen and Kauchak (2012), educators use the affec- tive domain to help learners realize their own attitudes and values.

Although nurses recognize the need for individuals to learn in the affective domain, constructs such as a person’s attitudes, beliefs, and values cannot be directly observed but can only be inferred from words and actions (Maier-Lorentz, 1999). Nurse educators tend to be less confident and more challenged in writ- ing behavioral objectives for the affective do- main. This is because it is difficult to develop easily measurable objectives and evaluate learn- ing outcomes based on inferences of someone’s observed behavior (Goulet & Owen-Smith, 2005; Morrison et al., 2010).

Reilly and Oermann (1990) differentiate among the terms beliefs, attitudes, and values. Beliefs are what an individual perceives as re- ality; attitudes represent feelings about an ob- ject, person, or event; and values are operational standards that guide actions and ways of living. Objectives in the affective domain are divided into five categories (Krathwohl et al., 1964),

Taxonomy of Objectives According to Learning Domains 437

variety of methods specifically geared to affec- tive domain learning.

Focusing on behaviors in the affective do- main is critically important but is often un- derestimated. Unfortunately, priority is rarely given to teaching in the affective domain. The nurse’s focus more often emphasizes cognitive and psychomotor learning, with little time be- ing set aside for exploration and clarification of the learner’s feelings, emotions, and attitudes (Miller, 2014; Morrison et al., 2010; Zimmer- man & Phillips, 2000).

Nurses must address the needs of the whole person by recognizing that learning is subjective and value driven (Schoenly, 1994). For nurses practicing in any setting, affective learning is es- pecially important because they constantly face ethical issues and value conflicts (Tong, 2007). The pluralistic nature of U.S. society requires nurses to respect racial and ethnic diversity in the population groups they serve (Marks, 2009). Additionally, advancing technology also places nurses in advocacy positions when patients, fam- ilies, and other healthcare professionals struggle with treatment decisions. In turn, patients and family members face the prospects of making moral and ethical choices as well as learning to internalize the value of adhering to prescribed treatment regimens and incorporating health promotion and disease prevention practices into their daily lives.

The teaching and learning setting is key in helping learners achieve affective behav- ioral outcomes. An open, trusting, empathetic, and accepting attitude by nurses sets the foun- dations for engaging patients and their fami- lies in learning. Staff nurses’ beliefs, attitudes, and values significantly influence their affec- tive behavior and therefore the quality of nurs- ing care they deliver, as they integrate cultural competency into their nursing practice. A nurse who is teaching students must have a personal value system that coincides with the values of the profession. Three American Nurses Asso- ciation documents—Code of Ethics for Nurses with Interpretive Statements (2015), Nursing’s Social Policy Statement (2010a), and Standards

dominant and pervasive (receiving, respond- ing, and valuing are prerequisite behaviors). Example: After a 45-minute group discussion session, the patient will be able to explain the reasons for her anxiety and fears about her self-care management responsibilities.

Characterization level: Ability of the learner to display adherence to a total philosophy or worldview, showing firm commitment to the values by generalizing certain ex- periences into a value system (receiving, responding, valuing, and organization are prerequisite behaviors). Example: Following a series of teaching sessions, the learner will display consistent interest in maintaining good hand-washing technique to control the spread of infection to patients, family members, and friends.

Table 10-5 lists verbs commonly used in writing affective-level behavioral objectives.

Teaching in the Affective Domain Several teaching methods are powerful and reli- able in helping the learner acquire affective behav- iors. Role model, role play, simulation, gaming, questioning, case studies, and group discussion sessions are examples of methods of instruc- tion that can be used to prepare nursing staff and students as well as patients and their fami- lies to develop values and explore attitudes, in- terests, and feelings.

The affective domain encompasses three levels (Menix, 1996) that govern attitudes and feelings:

■ The intrapersonal level includes personal per- ceptions of one’s own self, such as self-concept, self-awareness, and self-acceptance.

■ The interpersonal level includes the perspec- tive of self in relation to other individuals.

■ The extrapersonal level involves the perception of others as established groups.

All three levels are important in affective skill development and can be taught through a

438 Chapter 10 Behavioral Objectives and Teaching Plans

seems to be the most widely recognized as rele- vant to patient, staff, and student teaching. Ob- jectives in this domain, according to Simpson (1972), are divided into seven levels, from sim- ple to complex, as seen in Figure 10-2.

Levels of Behavioral Objectives and Examples in the Psychomotor Domain

Perception level: Ability of the learner to show sensory awareness of objects or cues associated with some task to be performed. This level involves reading directions or observing a process with attention to steps or techniques in developing a skill. Exam- ple: After a 10-minute teaching session on aspiration precautions, the family caregiver will describe the best position to place the patient in during mealtimes to prevent choking. Set level: Ability of the learner to exhibit readiness to take a certain kind of action as evidenced by expressions of willingness, sen- sory attending, or body language favorable to performing a motor act (perception is a prerequisite behavior). Example: Following a demonstration of how to do proper wound care, the patient will express a willingness to practice changing the dressing on his leg using the correct procedural steps. Guided response level: Ability of the learner to exert effort via overt actions under the guidance of an instructor to imitate an observed behavior with conscious aware- ness of effort. Imitating may be performed hesitantly but with compliance to directions and coaching (perception and set are pre- requisite behaviors). Example: After watching a 15-minute video on the procedure for self-examination of the breast, the patient will perform the exam on a model with 100% accuracy. Mechanism level: Ability of the learner to repeatedly perform steps of a desired skill with a certain degree of confidence,

of Clinical Nursing Practice (2010b),—provide nurse educators with ethical and values guide- lines for professional practice.

Although most teaching and learning of students and staff emphasize the cognitive do- main, the affective domain can facilitate their professional identity and values formation (Taylor, 2014), enhance their critical thinking and clinical judgment about ethical and moral issues, and increase their cultural competence in the delivery of fair and equal treatment in caring for people from many different backgrounds.

The Psychomotor Domain The psychomotor domain is known as the “skills” domain. Learning in this domain in- volves acquiring fine and gross motor abilities such as walking, handwriting, manipulating equipment, or performing a procedure. Psy- chomotor skill learning, according to Reilly and Oermann (1990), “is a complex process de- manding far more knowledge than suggested by the simple mechanistic behavioral approach” (p. 81). According to Eggen and Kauchak (2012), “while intellectual abilities enter into each of the psychomotor tasks, the primary focus is on the development of manipulative skills rather than on the growth of intellectual capability” (p. 17).

To develop psychomotor skills, integra- tion of both cognitive and affective learning is required. The affective component recognizes the value of the skill being learned. The cogni- tive component relates to knowing the princi- ples, relationships, and processes involved in the skill. Although all three domains are involved in demonstrating a psychomotor competency, the psychomotor domain can be examined sepa- rately and requires different teaching approaches and evaluation strategies (Reilly & Oermann, 1990). Psychomotor skills are easy to identify and measure because they include primarily movement-oriented activities that are relatively easy to observe.

Psychomotor learning can be classified in a variety of ways (Dave, 1970; Harrow, 1972; Moore, 1970; Simpson, 1972). Simpson’s system

Taxonomy of Objectives According to Learning Domains 439

skill in recognizing respiratory distress in their child with asthma.

Table 10-5 lists verbs commonly used in writing psychomotor-level behavioral objectives.

Another taxonomic system for psychomo- tor learning proposed by Dave (1970) is based on behaviors that include muscular action and neuromuscular coordination. Dave’s system recognizes that levels of skill attainment can be achieved and refined over a period of months depending on the frequency with which the learner uses certain skills in practice. Objec- tives in this domain, according to Dave, are di- vided into five levels, as shown in TABLE 10-6.

These taxonomic criteria for the development of psychomotor skill competency suggest that ac- curacy should be stressed rather than the speed at which a skill is acquired (Reilly & Oermann, 1990). Dave’s levels will apply when considering aspects of the learning curve, discussed later in this chapter. Nevertheless, the levels of psycho- motor behavior, no matter which taxonomic sys- tem is used, require the general and orderly steps of observing, imitating, practicing, and adapting.

Teaching of Psychomotor Skills Different teaching methods, such as demon- stration, return demonstration, simulation, and self-instruction, are useful for the develop- ment of motor skills. Also, instructional mate- rials, such as videos (DVDs), audiotapes (CDs), models, diagrams, and posters, are effective ap- proaches for teaching and learning in the psy- chomotor domain (Oermann, 2016; Ross, 2012; Salyers, 2007).

When teaching psychomotor skills, it is im- portant for the educator to remember to keep skill instruction separate from a discussion of principles underlying the skill (cognitive com- ponent) or a discussion of how the learner feels about carrying out the skill (affective compo- nent). Psychomotor skill development is very egocentric and usually requires a great deal of concentration as the learner works toward mas- tery of a skill (Oermann, 1990).

indicating mastery to the extent that some or all aspects of the process become habitual. The steps are blended into a meaningful whole and are performed smoothly with little conscious effort (perception, set, and guided response are prerequisite behaviors). Example: After a 20-minute teaching session, the patient will demonstrate the proper use of crutches while repeatedly applying the correct three-point gait technique.

Complex overt response level: Ability of the learner to automatically perform a complex motor act with independence and a high degree of skill, without hesitation and with minimum expenditure of time and energy; per- formance of an entire sequence of a complex behavior without the need to attend to details (perception, set, guided response, and mech- anism are prerequisite behaviors). Example: After three 20-minute teaching sessions, the patient will demonstrate the correct use of crutches while accurately performing differ- ent tasks, such as going up stairs, getting in and out of the car, and using the toilet.

Adaptation level: Ability of the learner to modify or adapt a motor process to suit the individual or various situations, indicating mastery of highly developed movements that can be suited to a variety of condi- tions (perception, set, guided response, mechanism, and complex overt response are prerequisite behaviors). Example: After reading handouts on healthy food choices, the patient will replace unhealthy food items she normally chooses to eat at home with healthy alternatives.

Origination level: Ability of the learner to create new motor acts, such as novel ways of manipulating objects or materials, as a result of an understanding of a skill and a developed ability to perform skills (perception, set, guided response, mechanism, complex overt response, and adaptation are prereq- uisite behaviors). Example: After simulation training, the parents will respond correctly to a series of scenarios that demonstrate

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and ultimately it may result in failure to achieve either of the behaviors successfully. It is essential for the teacher to keep in mind that questions re- lated to the cognitive or affective domain should be posed only before or after the learner prac- tices a new psychomotor skill (Oermann, 1990).

In psychomotor skill development, the abil- ity to perform a skill is not equivalent to hav- ing learned or mastered a skill. Performance is a transitory action, whereas learning is a more permanent behavior that follows from repeated practice and experience (Oermann, 1990). The actual mastery of a skill requires practice to allow the individual to repeat the performance time and again with accuracy, coordination, confidence, and out of habit. Practice does make perfect, so repetition leads to perfection and reinforcement of the behavior. However, once a task-oriented skill has been practiced, the teacher can introduce situated cognition. Within this constructivist perspective, learners are challenged to think crit- ically about what they know and can do in the

It is easy to interfere with psychomotor learning if the teacher asks a knowledge (cog- nitive) question while the learner is trying to focus on the performance (psychomotor re- sponse) of a skill. For example, while a nursing student is learning to suction a patient, it is not unusual for the teacher to ask, “Can you give me a rationale for why suctioning is important?” or “How often should suctioning be done for this particular patient?” As another example, while the patient is learning to self-administer par- enteral medication, the teacher may simultane- ously ask the patient to respond cognitively to the question, “What are the actions or side ef- fects of this medication?” or “How do you feel about injecting yourself?” These questions de- mand cognitive and affective responses during psychomotor performance.

What the educator is doing in this situation is asking the learner to demonstrate at least two different behaviors at the same time. This ap- proach can result in frustration and confusion,

Taxonomy of Objectives According to Learning Domains 441

TABLE 10-6 Dave’s Levels of Psychomotor Learning

Imitation At this level, observed actions are followed. The learner’s movements are gross, coordination lacks smoothness, and errors occur. Time and speed required to perform are based on learner needs.

Manipulation At this level, written instructions are followed. The learner’s coordinated movements are variable, and accuracy is measured based on the skill of using written procedures as a guide. Time and speed required to perform vary.

Precision At this level, a logical sequence of actions is carried out. The learner’s movements are coordinated at a higher level, and errors are minimal and relatively minor. Time and speed required to perform remain variable.

Articulation At this level, a logical sequence of actions is carried out. The learner’s movements are coordinated at a high level, and errors are limited. Time and speed required to perform are within reasonable expectations.

Naturalization At this level, the sequence of actions is automatic. The learner’s movements are coordinated at a consistently high level, and errors are almost nonexistent. Time and speed required to perform are within realistic limits, and performance reflects professional competence.

Environmental stimuli: Depending on the type and level of stimuli as well as the learning style (degree of tolerance for certain stimuli), distractions in the immediate surroundings may interfere with the ability to acquire a skill.

Anxiety level: The ability to concentrate can be dramatically affected by how anxious someone feels. Nervousness about performing in front of another person is a particularly important factor in psychomotor skill development. High anxiety levels interfere with coordination, steadiness, fine muscle movements, and concentration levels when performing complex psychomotor skills. It is important to reassure learners that they are not necessarily being tested during psy- chomotor skill performance. Reassurance and support reduce anxiety levels related to the fear of not meeting expectations of themselves or of the teacher.

Developmental stage: Physical, cognitive, and psychosocial stages of development all in- fluence an individual’s ability to master a movement-oriented task. Certainly, a young child’s fine and gross motor skills as well as cognitive abilities are at a different level from those of an adult. The older adult, too, likely exhibits slower cognitive processing and increased response time (needing more time to perform an activity) compared to younger clients.

Practice session length: During the beginning stages of learning a motor skill, short and carefully planned practice sessions and fre- quent rest periods are valuable techniques to help increase the rate and success of learning. These techniques are thought to be effective because they help prevent physical fatigue and restore the learner’s attention to the task at hand.

Aldridge (2017) conducted a qualitative literature review to explore nursing students’ perceptions of psychomotor skills learning. He identified six themes as important to learning new skills: (1) peer support and peer learning

context of the specific situation in which they are functioning. Teaching learners to actively construct knowledge helps them make sense of their experiences and develop their skills of in- quiry (Keating, 2014; Woolfolk, 2017).

Riding a bicycle is a perfect example of the difference between being able to perform a skill and having mastered that skill. When one first attempts to ride a bicycle, movements tend to be very jerky, and a great deal of concentration is required. Falling off the bicycle is not unex- pected in the learning process. Once the skill is learned, however, bicycle riding becomes a smooth, automatic operation that requires min- imal concentration.

Some behaviors that are learned do not require much reinforcement, even over a long period of disuse. Yet, other behaviors, once mas- tered, need to be rehearsed or relearned to per- form them at the level of skill once achieved. The amount of practice required to acquire any new skill varies with the individual, depending on many factors. Oermann (1990), Bell (1991), and Mwale and Kalawa (2016) have addressed some of the more important variables:

Readiness to learn: The motivation to learn affects the degree of effort exhibited by the learner in working toward mastery of a skill.

Past experience: If the learner is familiar with equipment or techniques similar to those needed to learn a new skill, then mastery of the new skill may be achieved at a faster rate. The effects of learning one skill on the subsequent performance of another related skill are collectively known as transfer of learning (Gomez & Gomez, 1984; Moursund, 2016). For example, if a family member already has experience with aseptic technique in changing a dressing, then learning to suction a tracheostomy tube using sterile technique should not require as much time to master.

Health status: An illness state or other physical or emotional impairments in the learner may affect the time it takes to acquire or successfully master a skill.

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intrinsic feedback. This is feedback generated from within the learners, giving them a sense of or a feel for how they have performed. They may sense that they either did quite well or that they felt awkward and need more practice. The teacher also has the opportunity to provide augmented feedback. In this case, the teacher shares infor- mation or an opinion with the learners or con- veys a message through body language about how well they performed (Oermann, 1990). The immediacy of the feedback, along with intrin- sic and augmented feedback, makes it a unique feature of psychomotor learning. In addition, performance checklists can serve as guides for teaching and learning and are another effective tool for evaluating the level of skill performance.

An important point to remember is that making mistakes is an expected part in the pro- cess of teaching or learning a psychomotor skill. If the teacher makes an error when demonstrat- ing a skill or the learner makes an error during return demonstration, this occasion is the per- fect teaching opportunity to offer anticipatory guidance: “Oops, I made a mistake. Now what do I do?” Unlike in cognitive skill develop- ment where errorless learning is the objective, in psychomotor skill development a mistake made represents an opportunity to demonstrate how to correct an error and to learn from the not-so-perfect initial attempts at performance. The old saying “You learn by your mistakes” is most applicable to psychomotor skill mastery.

The spacing of practice time improves the likelihood that learners will remember new facts, as described by Willingham (2002) ear- lier in this chapter. The spacing effect seems to apply to the learning of simple as well as com- plex motor skills. Willingham (2004) also ad- dressed the necessity for practice to be repeated beyond the point of perfection if skill learning is to be long lasting, automatic, and achieved with a high level of competence.

In summary, learning is a very complex phenomenon. It can occur in all three domains simultaneously, can happen formally or infor- mally, and can occur in a variety of settings. Evaluation of learning is equally challenging,

are important; (2) practicing on real people is essential to mastery; (3) faculty members matter during the learning experience; (4) conditions of the environment are essential; (5) know- ing that patients need good nursing skills; and (6) anxiety is ever present because of fear of harming patients. These findings are useful in helping faculty to understand students’ ex- periences in the teaching and learning of psy- chomotor skills.

Performing motor skills is not done in a vac- uum; that is, the learner is inevitably immersed in an environmental context full of stimuli. Learn- ers must select those environmental influences that will assist them in achieving the behavior (relevant stimuli) and ignore those factors that interfere with a specific performance (irrelevant stimuli). This process of recognizing and select- ing appropriate and inappropriate stimuli is called selective attention (Gomez & Gomez, 1984).

Motor skills should be practiced first in a laboratory setting to provide a safe and non- threatening environment for the novice learner. Gomez and Gomez (1987) also suggest arranging for practice sessions to take place in the clinical or home setting to expose the learner to actual environmental conditions—a technique known as open skills performance learned under chang- ing and unstable environments.

Mental imaging, also referred to as men- tal practice has surfaced as a helpful alterna- tive for teaching motor skills, particularly for patients who have mobility deficits or fatigue (Page, Levine, & Khourey, 2009; Page, Levine, Sisto, & Johnston, 2001). Research indicates that learning psychomotor skills can be enhanced through use of such imagery. Mental practice, which involves imagining or visualizing a skill without body movement prior to performing the skill, can enhance motor skill acquisition (Page et al., 2009).

Another hallmark of psychomotor learn- ing is the type and timing of the feedback given to learners. Psychomotor skill development al- lows for spontaneous feedback so that learners have an immediate idea of how well they per- formed. During skill practice, learners receive

Taxonomy of Objectives According to Learning Domains 443

2. To communicate in writing exactly what is being taught, how it is being taught and evaluated, and the time allotted to meet each of the behav- ioral objectives. This is essential for the involvement of the patient and each member of the healthcare team.

3. To legally document that an individ- ual plan for each learner is in place and is being properly implemented.

Many healthcare agencies require evi- dence of teaching plans to meet internal pol- icies, validate evidence-based practices, and adhere to guidelines for accreditation. Agencies may look to standardize documented teaching plans through the electronic medical record as a means to measure improved outcomes (Zynx Health, 2015). Teaching plans can be presented in many different formats to meet institutional requirements or the preference of the user. How- ever, all eight components must be included for the teaching plan to be considered comprehen- sive and complete.

A teaching plan should incorporate the fol- lowing eight basic elements (Ryan & Marinelli, 1990):

1. Purpose (the why of the educational session)

2. Statement of the overall goal 3. List of objectives 4. An outline of the content to be covered

in the teaching session 5. Instructional method(s) used for

teaching the related content 6. Time allotted for the teaching of each

objective 7. Instructional resources (materials/

tools and equipment) needed 8. Method(s) used to evaluate learning

A sample teaching plan template is shown in FIGURE 10-3. This format is highly recommended because the columns allow the educator, as well as anyone else who is using it, to see all parts of the teaching plan at one time. Also, this format pro- vides the best structure for determining whether all the elements of a plan fit together cohesively.

especially in the affective domain because af- fective behaviors are not as obvious and clearly observable as the skills acquired in the cogni- tive and psychomotor domains.

Clearly the cognitive, affective, and psycho- motor domains represent separate behaviors, yet these domains are interrelated. For example, the performance of a psychomotor skill requires cog- nitive knowledge or understanding of informa- tion. Knowledge might be about the scientific principles underlying a practice or the rationale explaining why a skill is important to carry out. Also, an affective component to performing the skill must be acknowledged. Understanding the feelings and attitudes of learners is essential if the psychomotor behavior is to become inte- grated into their overall experience. Mastering behavioral objectives in all domains is neces- sary for the learner to ultimately attain the goal of competence and independence in self-care.

▸ Development of Teaching Plans

After mutually agreed-upon goals and objec- tives 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 ob- jectives serve as a basis for developing a teach- ing plan.

A teaching plan is a blueprint to achieve the goal and the objectives that have been de- veloped. Along with listing the goal and ob- jectives, this plan should indicate the purpose, content, methods, tools, timing, and evaluation of instruction. The teaching plan should clearly and concisely identify the order of these vari- ous parts of the education process.

Teaching plans are created for three ma- jor reasons:

1. To direct the teacher to look at the relationship between each of the steps of the teaching process to make sure that there is a logical approach to teaching.

444 Chapter 10 Behavioral Objectives and Teaching Plans

related to one another. Adherence to the con- cept of internal consistency requires that the do- main of learning for each objective be reflected across each of the elements of the teaching plan, from the purpose all the way through to the end

When constructing a teaching plan, the ed- ucator must be certain that, above all else, in- ternal consistency exists within the plan (Ryan & Marinelli, 1990). A teaching plan is said to be internally consistent when all eight parts are

Development of Teaching Plans 445

FIGURE 10-3 Sample teaching plan.

PURPOSE:

GOAL:

Objectives and Subobjectives

Time Allotted (in min.)

Content Outline Method of Instruction Resources

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process of evaluation. All parts of the teaching plan need to relate to each other, with the over- all intention of meeting the goal. Internal con- sistency is the major criterion for judging the integrity of a teaching plan. For example, if the nurse has decided to teach a skill with an ob- jective in the psychomotor domain, then the purpose, goal, objectives, content, methods of instruction, instructional materials, amount of time allocated for teaching, and evaluation methods should reflect that specific psychomo- tor domain. Nurses need to know how to orga- nize and present information in an internally consistent teaching plan.

The following is an example of consistency among the first three elements of a teaching plan:

Purpose: To provide mothers of male new- borns with the information necessary to perform postcircumcision care.

Goal: The mother will independently man- age postcircumcision care for her baby boy.

Objective: Following a 20-minute teaching session, the mother will be able to demon- strate the procedure for postcircumcision care with each diaper change (psychomotor).

In this example, the purpose, goal, and objec- tive reflect the psychomotor domain. The other elements of content, methods of instruction, in- structional resources, time allotment, and eval- uation methods also must be appropriate to the psychomotor domain as well to ensure internal consistency of the plan. See TABLE 10-7 for a com- plete teaching plan on postcircumcision care.

Several factors must be considered when developing a teaching plan and organizing each of the eight components. Even before the teaching plan is developed, a decision needs to be made about what domains should be in- cluded. If the purpose and goal are written to accomplish a skill that may include more than one domain, then the teaching plan should re- flect one or more objectives for every domain included. In addition, the content, methods of teaching, time allocation, resources, and meth- ods of evaluation should flow across the plan in

parallel with each objective and be appropriate for accomplishing the domain of learning re- lated to each objective.

Also, the teacher needs to be conscious and realistic about developing certain elements of a teaching plan. For example, selecting self- instruction in an online format as a method of teaching may not be appropriate for some learn- ers who do not know how to use or who cannot afford to have computers, smartphones, certain types of software, and access to the Internet. Al- though the nurse may find one-on-one teach- ing the most effective with patients, the expense may be prohibitive. Selecting group discussion may be more cost effective and more appropriate in meeting the goals and objectives of a teach- ing plan that is the same for more than one pa- tient with a similar diagnosis.

The content outline for each objective de- pends on the complexity of that objective and how it relates to the goal. The detail of the con- tent to be taught, that is, the amount and depth of information required, depends on the assess- ment of the learner’s needs, readiness to learn, and learning style.

The method(s) of teaching chosen also should be appropriate for the information be- ing taught, the learners, and the setting. If, for example, the purpose is to teach a patient to self-administer medication from an asthma inhaler (psychomotor domain), then the pri- mary methods of teaching should be demon- stration and return demonstration. However, if the purpose is to provide knowledge of what is a low-fat diet to a group of individuals with high cholesterol (cognitive domain), then lecture, programmed instruction, or group instruction would be more appropriate teaching methods.

The amount of time for teaching of each objective also must be specified. A teaching ses- sion should be no more than 15 to 20 minutes in length and certainly no more than 30 min- utes. Additional teaching sessions may be re- quired for the learner to achieve each objective and eventually reach the learning goal.

The resources to be used should match the content and support the teaching method(s). For

446 Chapter 10 Behavioral Objectives and Teaching Plans

Development of Teaching Plans 447

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implemented with any individual learner or group of learners. Learning contracts are “based on the principle of the learners being active partners in the teaching-learning system, rather than pas- sive recipients of whatever it is that the teacher thinks is good for them. It is about their own- ership of the process” (Atherton, 2003, p. 1).

A learning contract is defined as a writ- ten (formal) or verbal (informal) agreement be- tween the teacher and the learner that specifies teaching and learning activities that are to occur within a certain time frame. A learning contract is a mutually negotiated agreement, usually in the form of a written document, drawn up to- gether by the teacher and the learner, that out- lines what the learner will learn, what resources will be needed, how learning will be achieved and within what time period, and which crite- ria will be used for measuring the success of the experience (Jones-Boggs, 2008; Keyzer, 1986; Knowles, Holton, & Swanson, 1998; Mathe- son, 2003).

Inherent in the learning contract is the ex- istence of some type of reward for upholding the contract (Wallace & Mundie, 1987). For patients and families, this reward may be rec- ognition of their success in mastering a task that helps them move closer to independence in self-care and a high quality of life. Learning contracts are considered an effective teaching strategy for empowering the learner because they emphasize self-direction, mutual negotiation, engagement, and mutual evaluation of estab- lished competency levels (Chan & Chien, 2000; Chien, Chan, & Morrissey, 2002; Jones-Boggs, 2008). Many terms have been used to describe this approach, such as independent learning, self-directed learning, and learner-centered or project-oriented learning (Chan & Chien, 2000; Lowry, 1997; Waddell & Stephens, 2000).

Learning contracts stress shared account- ability for learning between the teacher and the learner. The method of contract learning actively involves the learner at all stages of the teaching– learning process, from assessment of learning needs and identification of learning resources to the planning, implementation, and evaluation of

example, when teaching breast self-examination an anatomic model of the breast plus written and audiovisual materials would be useful instruc- tional tools. Using a variety of resources is ideal to keep the learner’s attention, address various learning styles, and reinforce information. Incor- porating many different types of resources is espe- cially helpful to the learner with low literacy skills.

Finally, the method(s) of evaluation should match the domains of each objective and validate whether the goal has been met. Evaluation meth- ods must measure the desired learning outcomes to determine if and to what extent the learner achieved the goal. For example, a learner recently diagnosed with coronary artery disease may have a behavioral objective to be able to state, list, or cir- cle the three most important symptoms of a heart attack. In this teaching situation, the evaluation method to test that knowledge could be a written posttest or the oral question-and-answer approach.

In summary, nurses need to be able to de- velop teaching plans as part of their profes- sional practice. Developing teaching plans is a challenging skill that should not be underesti- mated. Just as with any nursing care plan, all el- ements of a teaching plan need to relate to each other to be truly effective. Table 10-7 is an exam- ple of a teaching plan that meets all the rules of construction and has internal consistency. The goal is reflective of the purpose, the objectives are derived from the goal, the content is appro- priate to meet the objectives, and the teaching methodology and evaluation methods as well as the resources and timing relate to the content.

If any aspect in a teaching plan is not re- lated to the overall goal, then these components must be revised. Keep in mind that the econom- ics of the teaching plan are a realistic consider- ation in today’s cost-driven healthcare system.

▸ Use of Learning Contracts

The concept of learning contracts is an increas- ingly popular approach to teaching and can be

448 Chapter 10 Behavioral Objectives and Teaching Plans

activities will be facilitated, such as instructional strategies and resources.

3. Evaluation: Specifies the criteria used to evaluate achievement of objec- tives, such as skills checklists, care standards or protocols, and agency policies and procedures of care that identify the levels of competency expected of the learner.

4. Time frame: Specifies the length of time needed for successful comple- tion of the objectives. The target date should reflect a reasonable period in which to achieve expected outcomes depending on the learner’s abilities and circumstances. The completion date is the actual time it took the learner to achieve each objective.

In addition to these four components, it is im- portant to include the terms of the contract. Role definitions delineate the teacher–learner relation- ship by clarifying the expectations and assumptions about the roles each party will play. The educa- tor is responsible for coordinating and facilitat- ing all phases of the contract process. In the case of nursing staff and student nurse learning, the educator plays a major role in the selection and preparation of preceptors and acts as a resource person for both the learner and the preceptor. FIGURE 10-4 presents a sample learning contract.

▸ The Concept of Learning Curve

Learning curve is a common phrase used to describe how long it takes a learner to learn any- thing new. This phrase, however, often is used incorrectly when referring to learners who have acquired new knowledge (cognitive domain) or have developed new attitudes, beliefs, or values (affective domain). Research, to date, supports the correct use of the term learning curve, also some- times referred to as the experience curve theory, only in relation to psychomotor domain learning.

learning activities (Jones-Boggs, 2008; Knowles et al., 1998). For example, learning contracts have been used as a low-cost tool to increase students’ academic performance both in the classroom and clinical setting and to encour- age independence and self-direction (Bailey & Tuohy, 2009; Frank & Scharff, 2013; Gregory, Guse, Dick, Davis, & Russell, 2009).

Translating the concept of learning con- tracts to the healthcare environment, they are a unique way of presenting information to the learner. They are the essence of an equal and cooperative partnership, which challenges the traditional teacher–client relationship through a redistribution of power and control. Allowing learners to negotiate a contract for learning shifts the control and emphasis of the learning experi- ence from a traditionally teacher-centered focus to a learner-centered focus. Learning contracts can be especially useful in facilitating the dis- charge of patients to their home from the hospital or rehabilitation settings. In situations involv- ing the care of a complex patient by multidis- ciplinary team members, a contract provides a patient-centered, cohesive communication tool between the patient, family caretakers, and the healthcare team (Cady & Yoshioka, 1991; Ye- tzer, Goetsch, & St. Paul, 2011).

Components of the Learning Contract A complete learning contract includes four ma- jor components (Knowles, 1990; Knowles et al., 1998; Wallace & Mundie, 1987):

1. Content: Specifies the precise be- havioral objectives to be achieved. Objectives must clearly state the desired outcomes of learning activities. Negotiation between the educator and the learner determines the content, level, and sequencing of objectives according to learner needs, abilities, and readiness.

2. Performance expectations: Specify the conditions under which learning

The Concept of Learning Curve 449

recently. The medical profession began to de- scribe the application of this concept to the learn- ing of surgical and other invasive techniques in the first decade of the 21st century (Gawande, 2002; Waldman, Yourstone, & Smith, 2003). Since then physicians have realized the usefulness of the learning curve concept in determining how long it takes them to become competent in per- forming procedures using new technologies, such as simulators, laparoscopes, endoscopes, and ro- botic instruments (Eversbusch & Grantcharov, 2004; Flamme, Stukenborg-Colsman, & Wirth, 2006; Hernandez et al., 2004; Hopper, Jamison, & Lewis, 2007; Kruglikova, Grantcharov, Drewes, & Funch-Jensen, 2010; Manuel-Palazuelos et al., 2016; Murzi et al., 2016; Qiao et al., 2014; Resnic et al., 2012; Savoldi et al., 2009). For the nurs- ing profession, only relatively few sources reveal the concept’s application to practice (Burritt & Steckel, 2009; Cheung et al., 2014; Gair, 2012).

Lee Cronbach (1963) was an educational psychologist whose classic work provides the

The concept of the learning curve is similar to the stages of motor learning described in Chapter 3.

McCray and Blakemore (1985) note that the learning curve “is basically nothing more than a graphic depiction of changes in performance or output during a specified time period” (p. 5). A learning curve shows the relationship between practice and performance of a skill. It provides a concrete measure of the rate at which some- one learns a task. In many situations, evidence of learning (improvement) follows a very pro- ductive and predictable pattern. Understanding the key concepts surrounding the learning curve is essential for any teacher who is approaching the teaching and learning process when it in- volves skill development.

Although the learning curve concept has been used in business and industry to measure employee productivity since the early 1900s, a thorough search of the medical and nursing literature reveals little documentation that this concept was applied to skill practice until very

450 Chapter 10 Behavioral Objectives and Teaching Plans

FIGURE 10-4 Sample learning contract.

Name of Learner:

Name of Educator:

Name of Preceptor (if applicable):

Date of Contract Negotiated:

Terms of Contract:

Objectives Activities Evaluation Target Date

Completion Date

Signatures: (Learner) (Educator) (Preceptor)

Lists cognitive, affective, and psychomotor behaviors mutually agreed on and intended to be achieved

Lists teaching–learning strategies and resources to be used to achieve the objectives

Lists the criteria to be used to measure learning demonstrated

Lists a realistic time frame for achievement of expected outcome(s)

Specifies the dates that each objective is accomplished

task. Motivation may account for in- creased gains when the learner has interest in the task, receives approval from others, or experiences a sense of pride in discovering the ability to perform.

3. Decreasing gains: During this stage the rate of improvement slows and additional practice does not produce such steep gains. Learning occurs in smaller increments as the learner incorporates changes by using cues to smooth out performance.

4. Plateau: During this stage no substantial gains are made. This leveling-off period is characterized by a minimal rate of progress in performance. Instead, the learner is making other adjustments in mastering the skill. The belief that there is a period of no progress is considered false because gains in skills can occur even though overall performance scores remain stable.

5. Renewed gains: The rate of perfor- mance rises again during this stage

foundation to understanding the concept of the learning curve. Cronbach defines the learning curve, specifically related to psychomotor skill development, as “a record of an individual’s im- provement made by measuring his ability at dif- ferent stages of practice and plotting his scores” (p. 297).

According to Cronbach (1963), the learn- ing curve is divided into six stages (FIGURE 10-5):

1. Negligible progress: Initially very little improvement is detected during this stage. This prereadiness period is when the learner is not ready to perform the entire task, but relevant learning is taking place. This period can be relatively long in young children who are developing physical and cognitive abilities, such as focused attention and gross and fine motor skills, and in older adults who may have difficulty in perceiving key discriminations.

2. Increasing gains: Rapid gains in learn- ing occur during this stage as the learner grasps the essentials of the

The Concept of Learning Curve 451

FIGURE 10-5 A schematic learning curve. Modified from Cronbach, L. J. (1977). Educational psychology (3rd ed.). New York, NY: Harcourt Brace Jovanovich. © 1977 Global Rights & Permissions, a part of Cengage Learning, Inc. Reproduced by permission. http://www.cengage.com/permissions

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the reliability of the performance. Any novice can occasionally perform a skill correctly (be- ginner’s luck), but what counts is consistency in the progress that is key to actually learning the skill. As Atherton (2013) states, it is incorrect to use the cliché “steep learning curve” to imply that something is difficult to learn. In fact, the opposite is true. As a learner practices a diffi- cult skill, in almost all cases the line rises slowly, not quickly, over time. In other words, a steep, short learning curve indicates that the learner mastered a skill rapidly and easily.

More nursing research needs to be con- ducted on applying the learning curve concept to the teaching and learning of psychomotor skills. Such studies would help educators to im- prove their understanding of various dimensions of the teaching and learning process related to mastering skills. In relation to patient, staff, and student teaching, research might answer such questions as the following:

■ Can a learning curve be shortened given the characteristics of the learner, the situation, or the task at hand?

and the plateau period has ended. These gains usually are from growth in physical development, renewed interest in the task, a response to challenge, or the drive for perfection.

6. Approach to limit: During this stage progress becomes negligible. The ability to perform a task has reached its potential, and no matter how much more the learner practices a skill, he or she is not able to improve. However, this is a hypothetical stage because individuals never truly stop learning.

Individual learning curves are irregular (FIGURE 10-6) and often do not follow a smooth theoretical curve, as seen in Figure 10-5. Such factors as attention, interest, energy, ability, sit- uational circumstances, and favorable or unfa- vorable conditions for learning provide the ups and downs that are expected in performance (Barker, 1994; Cronbach, 1963; Gage & Ber- liner, 1998; Woolfolk, 2017). It is important to note that the learning curve can be skewed by

452 Chapter 10 Behavioral Objectives and Teaching Plans

FIGURE 10-6 Learning curve during one year of typing practice. Data from Cronbach, L. J. (1963). Educational psychology (2nd ed.). New York, NY: Harcourt, Brace & World.

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Plateau Renewed Gains

Approach to Limit

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the lack of progress he is making. This happens as the pace of learning varies over time. Also, the patient may experience a time at the beginning or in the middle of the curve when he or she seems not to be learning at all. Educators can re- alistically support the learner if they understand that the pace and pattern of skill development are based on the concept of the learning curve.

▸ State of the Evidence Nurse educators not only require knowledge and experience to teach various audiences of learners effectively but also need the clinical evidence to prove their teaching methods and interventions are effective. Evidence should be based on up-to- date research to help guide the nurse in the delivery of evidence-based care. The nurse should identify the types of information needed in specific situa- tions and be competent in accessing the appropriate databases to obtain the information and research necessary to carry out all aspects of the educator role. “This leads to an increased awareness for the need for appropriate information to provide best care, solve an identified clinical problem, or facil- itate a change in practice” (Pierce, 2005, p. 236).

Plenty of evidence has established the value and utility of behavioral objectives for teaching and learning. Also, numerous research studies in the psychology literature have substantiated the framework, known as the taxonomic hierarchy, for categorizing behaviors (cognitive, affective, and psychomotor) according to type (domain) and complexity (level of difficulty). Further- more, a body of knowledge is available on how to develop internally consistent teaching plans using these behavioral objectives to legally doc- ument and properly implement individual plans of care for patient education. Such plans are of- ten mandated by accrediting bodies of health- care agencies and organizations.

Although the use of learning contracts is a relatively new concept, educational psychologists have conducted developmental research that pro- vides evidence of adult learners’ need for inde- pendent, self-directed, problem-centered, and

■ Why is the learning curve steeper, more drawn out, or more irregular for some learners than for others?

■ Can we predict the learning curves of our students depending on their educational or experiential backgrounds?

■ How many times, on average, does a par- ticular skill need to be practiced to improve competency and ensure consistency of performance?

■ What can we do from an educational stand- point to influence the pace and pattern of learning that may result in earlier or more complete achievement of expected outcomes?

■ How can the learning curve concept be ap- plied to improve staff performance, thereby increasing work satisfaction and productivity, decreasing costs of care, and improving the quality and safety of care?

Answers to these questions might provide new approaches for evidence-based practice changes for nurses involved in the teaching and learn- ing process.

Many advantages can result by applying concepts of the learning curve to patient teach- ing and staff and student education. Perhaps the most important understanding of this concept is the realization that the pattern and pace of learn- ing are typically irregular. The learning of any task is initially slow, then more rapid, inevitably decreases, reaches a plateau, and then increases again. After this point, a limit is reached when likely no more significant improvement is likely to be achieved. Understanding this phenomenon can help educators adjust their expectations (or deal with their frustrations) when different paces and patterns of learning occur in individuals as they attempt to master any psychomotor skill.

When the teacher shares with patients, staff, and students that the amount of practice needed to improve performance is very individualized, these learners may find their frustrations are re- duced and their expectations become more real- istic. For example, a patient who is undergoing rehabilitation to learn how to walk again follow- ing an injury may easily become discouraged with

State of the Evidence 453

and presenting information in a coherent manner. Nurses need to develop skills in writing teaching plans that reflect internal consistency of all the components. Learning contracts are an innova- tive, unique, patient-centered alternative to struc- turing an adult learning experience, especially in the home and rehabilitation settings. They are de- signed to encourage learners to be self-directed, which increases their level of active involvement and accountability. For the nurse, understanding the concept of the learning curve is essential to teaching psychomotor skills. More nursing re- search needs to be done to yield findings from evidence-based practice in applying the learning curve concept to patient care and staff and stu- dent education.

Review Questions 1. What are the definitions of the terms goal

and objective? 2. Which two major factors distinguish goals

and objectives from each other? 3. What reasons justify the importance of

using behavioral objectives in teaching? 4. What are the four components that should

be included in every written behavioral objective?

5. Which types of mistakes are commonly made when writing behavioral objectives?

6. What are the three domains of learning? 7. What levels of behavior are considered

the more simple and the more complex in the cognitive, affective, and psychomotor domains?

8. Why is it important for the nurse educator to keep psychomotor skill instruction for the novice learner separate from the cognitive and affective components of skill development?

9. Which factors influence the amount of practice required to learn any new skill?

10. What are the eight basic components of a teaching plan?

11. Why is the concept of the learning curve important in the development of psycho- motor skills?

participatory learning. In contrast, the concept of the learning curve—although a term superfi- cially and widely adopted by educators—has not been well defined or well explored for its theoret- ical application to teaching and learning in the health professions. Only recently has evidence been uncovered regarding its reliability and va- lidity in patient and nursing education for psy- chomotor skill acquisition. Indeed, more research needs to be conducted in nursing to demonstrate that the learning curve concept is a useful prin- ciple for nurse educators to incorporate into the process of teaching and learning.

▸ Summary The major portion of this chapter focused on dif- ferentiating goals from objectives, preparing accu- rate and concise objectives, classifying objectives according to the three domains of learning, and teaching cognitive, affective, and psychomotor skills using appropriate teaching methods and instructional materials. Writing behavioral ob- jectives accurately and effectively is fundamen- tal to the education process. Goals and objectives serve as a guide to the educator in the planning, implementation, and evaluation of teaching and learning. The communication of desired behav- ioral outcomes and the mechanisms for accom- plishing behavioral changes in the learner are essential elements in the decision-making pro- cess with respect to both teaching and learning.

Assessment of the learner is a prerequisite to formulating objectives. The teacher must have a clear understanding of what the learner is ex- pected to be able to do well before selecting the content to be taught and the methods and mate- rials to be used for instruction. Objectives set- ting must be a partnership effort engaged in by both the learner and the teacher for any learn- ing experience to be successful and rewarding in the achievement of expected outcomes.

Also, this chapter outlined the development of teaching plans and briefly discussed learning contracts and the concept of the learning curve. Teaching plans provide the blueprint for organizing

454 Chapter 10 Behavioral Objectives and Teaching Plans

Atherton, J. S. (2003). Learning and teaching: Learning contracts. Retrieved from http://faculty.uml.edu/cryan/48.404 /Documents/Readings%20by%20week/Week%201 /ATHERTON-learning_contract.doc

Atherton, J. S. (2013) Learning and teaching: Learning curve. Retrieved from http://doceo.co.uk/l&t/learning/learning _curve.htm

Bailey, M. E., & Tuohy, D. (2009). Student nurses’ experiences of using a learning contract as a method of assessment. Nurse Education Today, 29(7), 758–762. http://dx.doi.org/10 .1016/j.nedt.2009.03.012

Barker, L. M. (1994). Learning and behavior: A psychobi- ological perspective. New York, NY: Macmillan College Publishing.

Bell, M. L. (1991). Learning a complex nursing skill: Student anxiety and the effect of preclinical skill evaluation. Journal of Nursing Education, 30(5), 222–226.

Bloom, B. J., Englehart, M. S., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook 1: Cognitive domain. New York, NY: David McKay.

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Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K. A., Mayer, R. E., Pintrich, P. R., . . . Wittrock, M. C. (2001). A taxonomy for learning, teaching, and assessing (Rev. ed.). New York, NY: Longman.

Arends, R. I. (2015). Learning to teach (10th ed.). New York, NY: McGraw-Hill.

CASE STUDY Suppose you are a new nurse working the day shift on a busy postpartum unit. You have an assignment of five mother–baby units and expect at least one more mother–baby admission later in the morning. Two nurses have called in sick. Three of your patients are Anna B. and her twin boys born at 37 weeks. Anna B. is a 21-year-old first-time mother who delivered yesterday morning by cesarean section under spinal anesthesia. Because Anna has as a history of asthma and pneumonia as well as being a half-pack- per-day smoker, she needs to start using an incentive spirometer every 2 hours while awake.

Anna was last medicated 4 hours ago with oral pain medication and states her pain is currently 5 out of 10. Her vital signs are stable, her incision is clean and dry, she has moderate lochia, and her lungs are clear on auscultation. She has been out of bed to ambulate and her Foley catheter was removed by the night shift nurses. She has not yet voided on her own.

Anna takes an oral antihistamine daily and occasionally uses a bronchodilator via an inhaler. Her asthma was well controlled during her pregnancy. She has not smoked while she has been in the hospital.

Anna is bottle feeding her twins. Anna is married and works as a library aide at an area middle school and states that she graduated from a local high school. She speaks English, although Ukrainian is her primary language.

You are responsible for doing the teaching with Anna on using the incentive spirometer.

1. List two factors or variables that might affect the practice time needed by Anna to learn this new skill.

2. List the goal and purpose for learning in Anna’s teaching plan. 3. List one cognitive, one affective, and one psychomotor objective to achieve the goal for

learning. 4. List the teaching methods and instructional materials you will use to teach Anna, including the

reasons they were selected. 5. What evaluation methods will you use to identify that Anna has met the goal?

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Teaching Methods and Settings Kathleen Fitzgerald Kara Keyes

CHAPTER HIGHLIGHTS

■ Teaching Methods • Lecture • Group Discussion • One-to-One Instruction • Demonstration and Return Demonstration • Gaming • Simulation • Role Play • Role Model • Self-Instruction

■ Selection of Teaching Methods ■ Evaluation of Teaching Methods ■ Increasing Effectiveness of Teaching

• Techniques to Enhance the Effectiveness of Verbal Presentations • General Principles for Teaching Across Methodologies

■ Settings for Teaching • Sharing Resources Among Settings

■ State of the Evidence

In the section “Settings for Teaching” in this chapter, the information was taken directly from Virginia E. O’Halloran’s Chapter 14, Instructional Settings, in Bastable, S. B. (Ed). (2003). Nurse as educator: Principles of teaching and learning for nursing practice (2nd ed., pp. 465–492). Sudbury, MA: Jones and Bartlett Publishers.

459

CHAPTER 11

After an excellent learning experience, someone might comment, “Now, there is a born teacher!” This statement would seem to indicate that effective teaching comes naturally. Actually, being able to teach well is a learned skill. Developing this skill requires un- derstanding the educational process, includ- ing which teaching methods to use under what circumstances. Determining the most appro- priate teaching methods depends on a vari- ety of differences: the age and developmental level of the learners; what the learners already know and what they need to know to succeed; the subject-matter content; the objectives for learning; the available people, time, space, and material resources; and the physical setting. Stim- ulating and effective teaching–learning experi- ences are designed, not accidental or automatic, and involve the use of one or several methods

of teaching to achieve the desired learning out- comes ( Rothwell, Benscoter, King, & King, 2016; Rothwell & Kazanas, 2008).

A teaching method is the way informa- tion is taught that brings the learner into con- tact with what is to be learned. Examples of such methods include lecture, group discussion, one-to-one instruction, demonstration and re- turn demonstration, gaming, simulation, role play, role model, and self-instruction modules. As the use of technology evolves, these teach- ing methods also are being offered as blended opportunities by integrating online and hybrid learning strategies (Cook et al., 2008; Johnson, Adams, & Cummins, 2012). See Chapter 13 for more information on technology in education.

Instructional materials or tools, in con- trast, are the objects or vehicles used to trans- mit information that supplement the act of

KEY TERMS

teaching method lecture group discussion team-based learning cooperative learning case studies seminars one-to-one instruction

demonstration return demonstration scaffolding gaming simulation role play role model self-instruction

skill inoculation pacing settings for teaching healthcare setting healthcare-related setting nonhealthcare setting

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the term teaching method. 2. Explain the various types of teaching methods. 3. Describe how to use each method effectively. 4. Identify the advantages and limitations of each method. 5. Discuss the variables that influence the selection of the various methods. 6. Recognize techniques to enhance teaching effectiveness. 7. Explain how to evaluate teaching methods. 8. Classify settings for teaching according to the primary purpose of the organization or agency

in which the nurse functions as educator.

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teaching. An audience response system (ARS), books, printed handouts, videos, podcasts, and posters are examples of materials and tools that serve as adjuncts to communicate information by complementing the teaching method. It is important at this point to draw a distinction between the terms teaching methods and in- structional materials. Although they often are treated as being the same thing, they are very distinct and separate. See Chapter 12 for more information on instructional materials.

This chapter focuses on the types of teach- ing methods available and considers how to choose and use them most efficiently and effec- tively. In doing so, the advantages and limita- tions of each method, the variables influencing the selection of various methods, and the ap- proaches for evaluating the methods are iden- tified to improve the delivery of instruction. In all types of situations and settings, nurses are expected to teach a variety of audiences. There- fore, throughout this chapter, examples are pro- vided about how to apply the various methods to enhance teaching and learning experiences. Settings in which the nurse educator functions also are highlighted.

▸ Teaching Methods There is no one perfect method for teaching all learners in all settings. Also, no one method is necessarily more effective for changing behav- ior in any of the three learning domains (cog- nitive, affective, and psychomotor). Whatever the method chosen, people learn best when it is used in conjunction with another method or with one or more of the instructional materials available to accompany the teaching approach (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011).

The importance of selecting appropriate teaching methods to meet the needs of learn- ers should not be underestimated. The popular Chinese proverb “Tell me; I forget. Show me; I remember. Involve me; I understand” (au- thor unknown) clearly implies that information

retention rates vary with different teaching meth- ods. Using methods of instruction that actively involve learners improves the amount of infor- mation they retain and their ability to think crit- ically and, thus, positively affects their learning outcomes (Ridley, 2007; Tedesco-Schneck, 2013).

The nurse educator functions in the vital role of teacher by facilitating, guiding, and sup- porting the learner in acquiring new knowledge, attitudes, and skills. Even though an educator may tend to rely on one teaching method, he or she rarely adheres to that single method in a pure fashion. Instead, various methods are of- ten used in combination with one another. For example, an educator may choose lecture as the primary teaching approach but also allow the op- portunity for question-and-answer periods and short discussion sessions throughout the lecture.

Deciding which method(s) to select must be based on a consideration of such major fac- tors as the following:

■ Audience characteristics (size, diversity, learning style preferences)

■ Educator’s expertise as a teacher ■ Objectives of learning ■ Potential for achieving learning outcomes ■ Cost-effectiveness ■ Setting for teaching ■ Evolving technology

These and many other variables are ad- dressed in the following review of the meth- ods of instruction available for teaching and learning.

Lecture Lecture can be defined as a highly structured method by which the educator verbally trans- mits information directly to a group of learn- ers for the purpose of instruction. It is one of the oldest and most often used approaches to teaching. The word lecture comes from the me- dieval Latin term legere, which means “to read.”

The lecture method has been highly criti- cized in recent years because, in its purest form, the lecture format allows for only minimal

Teaching Methods 461

exchange between the educator and the learner. Also, critics of the lecture method have specifi- cally expressed concern about the passive role of learners (DeYoung, 2014). However, as Brookfield (2006) points out, “An abused method calls into question the expertise of those abusing it, not the validity of the method itself ” (p. 99). There- fore, if a lecture is well organized and delivered effectively, it can be a very useful method of in- struction (Bain, 2004; Bartlett, 2003; Brookfield, 2006; Woodring & Woodring, 2014).

The lecture format is useful in describ- ing patterns, highlighting main ideas, and presenting unique ways of viewing informa- tion, such as introducing an agency’s mission statement to new nursing staff orientees or explaining diabetes mellitus to a group of pa- tients. The lecture should not be employed, however, to give people the same information that they could read independently at another time and place. It is the lecturer’s expertise, both in theory and experience, that contrib- utes significantly to the learner’s understand- ing of a topic.

The lecture is an ideal way to provide foun- dational background information as a basis for follow-up group discussions. Also, it is a means to summarize data and current research findings not available elsewhere (Boyd, Gleit, Graham, & Whitman, 1998; Brookfield, 2006). In addition, the lecture can easily be supplemented with in- structional materials, such as printed handouts and audiovisual tools.

Lecturing is an acquired skill that is learned and perfected over time, and it is a more com- plex task than commonly thought (Young & Diekelmann, 2002). Specific strategies exist to strengthen the effectiveness of a lecture (Cantillon, 2003). According to Silberman (2006), five ap- proaches to the effective transfer of knowledge during a lecture are the following:

■ Use opening and summary statements. At the beginning of the lecture, present major points to help learners become oriented to the subject and at the end provide conclu- sions to remind learners about the main points made.

■ Present key terms. Reduce the major points in the lecture to some key words that act as verbal cues or memory jogs.

■ Offer examples. When possible, provide real-life illustrations of the ideas in the lecture.

■ Use analogies. If possible, compare the con- tent that is being presented to the knowl- edge that learners may already have.

■ Use visual backups. Use a variety of media to help learners see as well as hear what is being said.

Each lecture should include three main parts: introduction, body, and conclusion. These three parts are described in the fol- lowing subsections (Miller & Stoeckel, 2016; Woodring & Woodring, 2014).

Introduction During the introduction phase of a lecture, the educator should present learners with an over- view of the behavioral objectives related to the lecture topic, along with an explanation as to why these objectives are significant. The use of set (the opening to a presentation) engages learners’ attention and focuses the group on the teacher, which creates the stage for learners to be ready to listen (Kowalski, 2004). This tech- nique of set captures attention, clarifies goals and objectives, motivates the learner, and demon- strates the relevance of the content in a way that can stimulate the interest of learners in the sub- ject. For example, prior to a lecture on creative problem solving, the educator might ask each member of the audience to solve a puzzle that requires them to think in a different manner (Kowalski, 2004). Educators might also engage learners’ attention by conducting an informal survey of the group or stating the behavioral objectives as questions that will be answered during the body of the lecture.

If the lecture is one of a series, the educa- tor needs to make a connection with the over- all subject and the topic being presented as well as explain its relationship to previous top- ics covered in prior lectures and those that will

462 Chapter 11 Teaching Methods and Settings

follow. Last, the educator should establish a rapport with the audience by letting his or her personality shine through and by using humor, if appropriate.

Body The next portion of the lecture involves the ac- tual delivery of the content related to the topic being addressed. Reading a printed copy of the entire presentation word for word is extremely boring and is a sure way to turn off the audi- ence. Careful preparation is needed so that the important aspects are covered in an organized, accurate, logical, and interesting manner. Exam- ples should be used throughout to enhance the salient points, but extraneous facts and redun- dant examples should be avoided so as not to reduce the impact of the message. Because the lecture format tends to be a passive approach to learning, the educator can enhance the effective- ness of the presentation by combining it with other teaching methods, such as discussion or question-and-answer sessions, to engage learn- ers to actively participate.

Conclusion The educator should include a wrap-up with every lecture. This final section of the lecture format is reserved for summarizing the infor- mation provided in the presentation. At this point, the educator can review the major con- cepts presented. Try to leave some time for questions and answers. During this time, ques- tions asked should be repeated so that the rest of the audience can hear them and understand the response. If time runs short, the educator can limit the question-and-answer session but then welcome immediate follow-up by meeting with interested individuals alone or in a smaller group or by suggesting relevant readings.

The educator’s speaking skills also are im- portant to the delivery of a lecture. According to Jacobs (2009), the following variables of speech need to be considered:

■ Volume ■ Rate

■ Pitch/tone ■ Pronunciation ■ Enunciation ■ Proper grammar ■ Avoiding annoying habits such as the use

of “ums”

Not only are speaking skills important, but body language also should be considered:

■ Demonstrate enthusiasm. ■ Make frequent eye contact with audience. ■ Use posture and movement.

• Convey self-confidence. • Demonstrate professionalism.

■ Use gestures. • Avoid repetitive movement. • Rely on head and hands to emphasize

points and to keep the audience’s attention.

Nervous or inexperienced educators should practice first before a mirror, a video camera, or a colleague (Germano, 2003). They should outline just the key points of their presentation on index cards, handouts, overhead projec- tions, or PowerPoint slides. During the actual lecture, they can use this outline information to elaborate on the topic by giving examples and further explanations.

Educators should address a large audi- ence as if speaking to an individual listener (Woodring & Woodring, 2014). Also, they should move around the stage or room and vary their presentation style and tone of voice to avoid monotony. Demonstrating enthusiasm, exper- tise, and interest in the topic will capture and hold the audience’s attention. Finally, educa- tors should be sure to keep within the time allotted. Lectures of long duration can result in loss of attention and boredom on the part of the learners.

Using audiovisual materials, such as a video, a podcast, an ARS, or PowerPoint slides, also can add variety to a lecture. The wide- spread availability of technology makes it easy to enhance a presentation—but only if the technology is used wisely. When develop- ing PowerPoint slides, for example, educators

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learners in locations remote from one another. Distance learning is an ideal way to maximize resources and to transmit current information to people separated by space and time. Through this strategy, the cost, time, and inconvenience of travel no longer can keep an audience from meeting face to face with an expert (Cook et al., 2008; DeGolia, 2016).

Although the lecture method is considered efficient and cost effective, the effort put into its design and delivery should not be determined just by calculating the educator–learner ratio of contact hours. Educators must take into consid- eration other factors, such as educator prepara- tion time, the frequency with which the same material needs to be repeated to different audi- ences, and follow-up time required to individu- alize learning and evaluate outcomes. TABLE 11-1 highlights the major advantages and limitations of lecture as a method of instruction.

Group Discussion Group discussion is defined as a method of teaching whereby learners get together to

should adhere to the following general guide- lines (DeGolia, 2016; Evans, 2000):

■ Do not put all content on slides, but in- clude only the key concepts to supplement the presentation.

■ Use the largest font possible. ■ Do not exceed 25 words per slide. ■ Choose colors that provide a high level of

contrast between background and text if pre- senting in a large room with bright lights.

■ Use graphics (figures and tables) to sum- marize important points, to succinctly pres- ent information, or to share large amounts of numerical data.

■ Do not overdo the use of animation (mov- ing figures), which can be very distracting to the audience.

Overall, it is important to keep the following points in mind: Make sure that the visual aids are large enough and positioned well enough for all to see, and keep them simple and easy to understand (Jacobs, 2009).

Thanks to new technologies, lectures are now being delivered to an even wider variety of

TABLE 11-1 Major Advantages and Limitations of Lecture

Advantages Limitations

An efficient, cost-effective means for transmitting large amounts of information to a large audience of people at the same time and within a relatively reasonable time frame.

Useful to describe patterns, highlight main ideas, summarize data, and present unique ways of viewing information.

An effective approach for cognitive learning, especially at lower levels of the cognitive domain.

Useful in providing foundational background information as a basis for subsequent learning, such as group discussion.

Easily supplemented with printed handouts and other audiovisual materials to enhance learning.

Largely ineffective in influencing affective and psychomotor behaviors.

Does not provide for much stimulation or participatory involvement of learners.

Very instructor centered and thus the most active participant is frequently the most knowledgeable one—the teacher.

Does not account for individual differences in background, attention span, or learning style.

All learners are exposed to the same information regardless of their cognitive abilities, learning needs, or stages of coping.

The diversity within groups makes it challenging, if not impossible, for the teacher to reach all learners equally.

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structured, student-centered learning environ- ment (Mennenga, 2012). Team-based learning is meant to enrich the students’ learning expe- rience through active learning strategies. Team- based learning uses a structured combination of preclass preparation, individual and group readiness assurance tests, and application ex- ercises (Mennenga, 2012). According to Sisk (2011), team-based learning incorporates four key principles:

■ Forming heterogeneous teams ■ Stressing student accountability ■ Providing meaningful team assignments

focusing on solving real-world problems ■ Providing feedback to students

Heterogeneous teams consist of 5 to 10 stu- dents, who work together as a team throughout the semester. The team members are required to be prepared for class and contribute to the team. Preparation is evaluated through indi- vidual quizzes given in the beginning of class that are handed in; the same quiz is then taken as a group. Team learning grades are assigned based on group performance, quiz grades, and peer evaluation (Sisk, 2011). BOX 11-1 summa- rizes what team-based learning is, how it works, which rules govern its use, and how grading is accomplished.

Cooperative Learning The terms team-based learning and cooperative learning sometimes are used interchangeably. This is a reasonable response because interac- tive student participation is observed with both methods. However, cooperative learning is the methodology of choice for transmitting foundational knowledge. Additionally, coop- erative learning is distinguished by the educa- tor’s role, in which the educator is the center of authority in the class, with group tasks usually more closed ended and often having specific answers (Conway, 2011). Cooperative learn- ing is highly structured group work focusing on problem solving that leads to deep learn- ing and critical thinking. According to Millis

actively exchange information, feelings, and opinions with one another and with the educa- tor. Group discussion, as a broad active teaching method, can incorporate other specific types of instruction, such as guided learning, collabora- tive learning, small-group learning, team-based learning, cooperative learning, case studies, and seminars. Group discussion teaching methods such as team-based learning and cooperative learning in most instances is not be pertinent for patient and family teaching but is an effec- tive strategy for staff development and nurs- ing students.

In general, the benefits of group dis- cussions are that they lead to deeper under- standing and longer retention of information, increased social support, greater transfer of learning from one situation to another, more positive interpersonal relationships, more fa- vorable attitudes toward learning, and more active learner participation (Brookfield, 2006; Johnson, Johnson, & Smith, 2007; Oakley & Brent, 2004; Springer, Stanne, & Donovan, 1999). As a commonly used instructional tech- nique, this method is learner centered as well as subject centered. Group discussion is an effec- tive method for teaching in both the affective and cognitive domains (Feingold et al., 2008; Springer et al., 1999).

Group size is a major consideration and should be determined by the purpose or task to be accomplished and concepts for application in practice situations. Group size can vary some- what, but discussion is most effective with rel- atively small groups (ideally between four and eight people). This allows learners the oppor- tunity to ask questions and to be more interac- tive with one another (DeYoung, 2014). Small groups will allow learners to question the mean- ing of content and internalize the significance to practice (Feingold et al., 2008).

Team-Based Learning Team-based learning is an innovative and newly popular teaching method in nursing educa- tion. Team-based learning offers educators a

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BOX 11-1 Team Learning Handbook

What Is Team Learning? An approach that promotes active learning in large-group, lecture-oriented sessions

An opportunity for students to use knowledge to make and defend judgments

An opportunity for instructors to facilitate development of conceptual frameworks

An opportunity for students to develop and enhance skills that will allow them to work productively in team environments

How Does Team Learning Work? Advance preparation. Students will gain the foundational knowledge for the team learning activity through advance preparation. This includes lecture, reading assignments, and/or laboratory activities that students are expected to complete prior to the team learning session.

Individual Readiness Assurance Test (IRAT ). The IRAT is a short multiple-choice quiz that assesses students’ preparation. IRATs are completed by individuals prior to or at the beginning of a team learning session.

Group Readiness Assurance Test (GRAT ). The same multiple-choice quiz completed by individual students is then completed by the team. Teams have time to discuss the questions and arrive at consensus before selecting their answers.

Review of IRAT/GRAT answers. When groups have turned in the GRAT, the instructor will facilitate a discussion of the correct answers to clarify confusion that may exist regarding key concepts. This discussion is an opportunity for students to ask questions and address misconceptions regarding their responses to the IRAT and the GRAT.

Appeals process. If groups or individuals disagree with the “declared correct answer” to an IRAT/GRAT question, they may file an appeal with the instructor. Appeals must be completed on the appeal form and submitted to course faculty by 9 a.m. on the day following the team learning session. If an appeal is granted, the point(s) will be added to the GRAT score of the team and the IRAT score of the individual that appealed. Team members who had the “declared correct answer” will still receive credit for that answer.

Group application problem. Teams will be given an application problem that requires them to use knowledge from advance preparation to make decisions. Groups record their decisions and the rationale for their decisions and submit these to the instructor prior to the large class discussion. The rationale presented by the group will determine if the group gets any points for answers other than the one designated by the instructor, so the rationale must be presented as clearly and completely as possible.

Large group discussion. Each group will simultaneously report their answer to the application problem using colored answer cards. Groups will then provide rationale and support for that answer. This discussion will provide students with the opportunity to question other groups’ reasoning and debate key issues related to the problem.

What Are the Rules for Team Learning? To receive credit for team learning activities, students must attend the team learning session.

During GRAT and group application problems, the group must select a team captain. This individual is responsible for standing up and sharing the group’s conclusions and rationale(s) during the large- group discussions. We strongly suggest that teams also pick a scribe. This person is responsible for recording the group’s rationale for the answer selected. The position of team captain may be assumed by different team members throughout the semester.

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During large-group discussion, each team captain will present the team’s decision and provide support for this decision as well as addressing why other answers are incorrect.

When all presentations have been given, teams will have additional time to discuss information presented. Discussion should be directed toward classmates, not the supervising faculty. Faculty will clarify misconceptions or misinformation.

Students must take responsibility for their own learning. This includes listening when peers are speaking, asking questions when confused, or correcting incorrect or faulty reasoning.

Disclaimer: Questions for team learning activities are intentionally ambiguous. This fosters discussion and encourages students to use knowledge to build coherent arguments.

How Are Team Learning Grades Determined? Team learning accounts for 15% of the final course grade in theory for this course. Team learning grades are based on three components: individual performance, group performance, and peer evaluation.

How Are the Three Components Weighted? Classmates will work together to decide the weights for the components of the final team learning grade. The entire class must come to consensus regarding the weights of each component. As these weights are considered, bear in mind research tells us that over time, a well-functioning group will consistently outperform any single member of the group, often significantly.

Reproduced from Feingold, C. E., Cobb, M. D., Givens, R. H., Arnold, J., Joslin, S., & Keller, J. L. (2008). Student perception of team learning in nursing education. Journal of Nursing Education, 47(5), 214–222.

(2010), cooperative learning includes four key components:

■ Extensive structuring of the learning tasks by the teacher

■ Strongly interactive student–student exe- cution of the tasks

■ Immediate debriefing or other assessments to provide the teacher and students with prompt feedback about the success of the intended learning

■ Instructional modifications by the teacher based on feedback

In the profession of nursing, the use of co- operative learning stresses the importance of foundational knowledge and understanding.

Case Studies The case study approach offers learners an op- portunity to become thoroughly acquainted with a patient situation before discussing patient and family needs and identifying health-related problems. Case studies lead to the development

of analytical and problem-solving skills, explo- ration of complex issues, and application of new knowledge and skills in the clinical prac- tice arena. Additionally, case studies increase learner motivation and engagement and help to develop reading, writing, and listening skills as learners work on teams to make decisions based on their problem-solving skills (Bonney, 2015; Brattseva & Kovalev, 2015). An example of the creative use of this teaching method with staff is arranging a panel presentation by patients who are coping with a specific disease or problem. Following the panel, a group session is most beneficial—in particular, for affective learn- ing. This was found to be a useful approach to breaking down the negative stereotypes of persons living with AIDS on the part of some healthcare workers (Peters & Connell, 1991).

Seminars Interactions in seminar groups are stimulated by the posing of questions by the educator. The ed- ucational format of seminars consists of several

Teaching Methods 467

little input while they work out a complex patient problem. In contrast, a new group of patients or family members with little understanding of a topic will need to access information directly from the educator or another source before they can meaningfully participate in problem solv- ing as part of the discussion process.

No matter which type of instructional ap- proach outlined in this section is used to engage learners in group discussion, the educator’s re- sponsibility is to make sure that every member of the group has interpreted information cor- rectly, because failure to do so will lead to con- clusions based on faulty data. Although diversity within a group is beneficial, a wide range of lit- eracy skills, states of anxiety, and experiences with acute and chronic conditions within the group may lead to difficulty in meeting any one member’s needs. For this reason, patient groups need to be prescreened.

Carkhuff (1996), Musolino and Mostrom (2005), and Wainwright, Shepard, Harman, and Stephens (2010) address the reflection-on-action technique for workgroups as learning groups to develop the critical thinking skills of nursing staff in the workplace. With this approach, the educator facilitates staff in critically analyzing their actions and determining whether a viable alternative to their action exists. Such an ap- proach helps learners “learn to learn.”

It is important for the educator to sustain trust within the group. Everyone must feel safe and comfortable enough to express his or her point of view, otherwise the relationship be- tween the educator and the learners will break down, which creates an environment unsuitable for learning. One helpful approach is for the ed- ucator to tell the group at the beginning of the session that the goal is to hear from all mem- bers by asking for their input and points of view during the discussion period. Learners who tend to dominate the discussion should be requested to hold questions that can be handled privately at the end of class, because these inquiries are important but unique to their circumstances.

Respectful attention and tolerance toward others should be modeled by the educator and

sessions in which a group of staff nurses or stu- dents, facilitated by an educator, discuss questions and issues that emerge from assigned readings on a topic of practical relevance (Jaarsma et al., 2009). Seminars should be designed so that each learner reads an assignment and considers ques- tions prior to the discussion; with such prepara- tion, all learners can actively participate in the discussion. The active engagement of sharing ideas and thoughts provides the learners with a deeper understanding of the content. When disagreements arise, students are expected to search for new explanations and new justifica- tions of knowledge (Jaarsma et al., 2009).

Preset behavioral objectives should be the focus when using guided, collaborative, and small-group discussions. These objectives drive the achievement of the learning outcomes for the interaction and should be presented at the beginning of each session. Careful adher- ence to them will prevent the discussion from becoming an aimless wandering of ideas or a forum for the strongest group member to ex- pound on his or her opinions and feelings (Bill- ings & Halstead, 2015). The group, functioning as a “dynamic whole,” motivates its members to move toward accomplishing one or more common goals (Johnson et al., 2007). The ed- ucator’s role is to act as a facilitator to keep the discussion focused and to tie important points together. The educator must be well versed in the subject matter to field questions, to move the discussion along in the direction intended, and to give appropriate feedback (Miller & Stoeckel, 2016).

Educator involvement and control of the process will vary with the needs of the group members. Group discussion requires the edu- cator to be able to tolerate less structure and or- ganization than other teaching methods, such as lecture or one-to-one instruction. In addition, the group itself must have some knowledge of the content before this method can be effective (Billings & Halstead, 2015); otherwise, the dis- cussion will be based on pooled ignorance. For ex- ample, a group of staff with a significant amount of practical knowledge and expertise may need

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information for cognitive growth as well as an opportunity to learn self-efficacy. The resulting increase in the confidence levels of patients en- hances their ability to handle an illness (Coo- per, Booth, Fear, & Gill, 2001; Deakin, McShane, Cade, & Williams, 2005; Lorig & Gonzalez, 1993).

The group process informs people about how to respond to situations, improves their coping mechanisms, and explores ways to incor- porate needed changes into their lives. Group self- management education for people with di- abetes, for example, has been found in some in- stances not only to be more cost effective but also to result in greater treatment satisfaction and to be slightly better in supporting lifestyle changes (Tang, Funnell, & Anderson, 2006). TABLE 11-2 highlights the main advantages and limitations of group discussion as a method of instruction.

Be aware that third-party reimbursement for some types of group patient education pro- grams may be difficult to obtain when the tra- ditional fee-for-service payment system is not in place. Nevertheless, these programs may be economically valuable in preventing hospitaliza- tion or reducing time in acute care. Document- ing these benefits based on measurable outcomes can justify the importance of group discussion as a cost-effective method of instruction.

One-to-One Instruction One-to-one instruction, which may be given either formally or informally, involves face-to- face delivery of information specifically de- signed to meet the needs of an individual learner. Teaching methods such as one-to-one instruc- tion have a positive effect on patient education and compliance (Martin, Williams, Haskard, & DiMatteo, 2005; Vermeire, Hearnshaw, Van Royen, & Denekens, 2001). Formal one-to-one instruction is a planned activity, whereas infor- mal one-to-one instruction is an unplanned interaction, such as capitalizing on a teach- able moment that occurs unexpectedly when the patient demonstrates a readiness to learn (Miller & Stoeckel, 2016). Such instruction of- fers an opportunity for both the educator and

required of all group members. Of course, this consideration does not preclude correcting er- rors or disagreements. A clear message must be given that although personal opinions may be debatable, the inherent value of what each member says and the member’s right to partic- ipate are guaranteed (Ridley, 2007).

Teaching people in groups rather than in- dividually allows the educator to reach numbers of learners at the same time. The group discus- sion method is economically beneficial from a time-efficiency perspective when compared with educating each learner individually. With healthcare costs rising, this method should be considered as an efficient and effective method to teach simultaneously individuals who have similar learning needs, such as information to prepare for childbirth or cardiac bypass surgery. In a study on the effects of educational interven- tions on patient satisfaction, Oermann (2003) reported that a group of patients in a waiting room of an ambulatory care center were edu- cated via a videotape about glaucoma, which was then followed by group interaction with an ed- ucator to discuss key points and answer ques- tions. This approach led to higher satisfaction with the education received during their visit.

Discussion is effective in assisting learners to identify resources and to internalize the topic being discussed by helping them to reflect on its personal meaning (Brookfield & Preskill, 2005). Through group work, members share common concerns and receive reinforcement from one another. The idea that everyone is in the same boat or if one person can do it so can the oth- ers serves to stimulate motivation for learning resulting from peer support.

Group discussion has proved particularly helpful to patients and their families dealing with chronic illness. This teaching method is most effective during the accommodation stage of psychological adjustment to chronic illness, be- cause the interactions reduce isolation and fos- ter identification with others who are in similar circumstances (Fredette, 1990; Olsson, Boyce, Toumbourou, & Sawyer, 2005). Discussion in a group offers members a forum in which to share

Teaching Methods 469

One-to-one teaching can be tailored to meet objectives in all three domains of learn- ing. It begins with an assessment of the learner and the mutual setting of objectives to be ac- complished (Burkhart, 2008). As part of the assessment process, it is very important to de- termine whether any problem behaviors exist, such as smoking, and at which stage of change the person is with respect to dealing with such behaviors. Once this information is determined, the educator can tailor educational interven- tions to that stage (Prochaska, DiClemente, Velicer, & Rossi, 1993).

The stages of change model can be general- ized across a broad range of behaviors, includ- ing but not limited to smoking cessation, weight control, avoidance of high-fat diets, safer sex, and exercise initiation (Prochaska et al., 1994). The following describes how educators can fo- cus their interactions to help a learner through the stages of change (Saarmann, Daugherty, & Riegel, 2000):

■ Precontemplation stage—Provide informa- tion in a nonthreatening manner so that the learner becomes aware of the negative as- pects or consequences of his or her behavior.

the learner to communicate knowledge, ideas, and feelings primarily through oral exchange, although nonverbal messages can be conveyed as well. Thus, this method of teaching is a pro- cess of mutual interchange between the patient and the health professional. It requires inter- personal skill and sensitivity on the part of the educator and the ability to establish rap- port with the learner (Falvo, 2010; Gleasman- DeSimone, 2012).

One-to-one instruction should never be a lecture delivered to an audience of one to meet the educator’s goals. Instead, the experience should actively involve the learner and be based on his or her unique learning needs. Ideally, a one-to-one teaching session should be 15 to 20 minutes in length, and the educator should offer information in small, bite-sized portions to allow time for processing (Haggard, 1989). Research shows that the more information that is given at any one time, the less it is remem- bered and correctly recalled (Martin, Williams, et al., 2005). Thus, effective communication de- pends more on the quality of the information presented than on the quantity to increase ad- herence to, and patient participation in, a rec- ommended plan of care (Kessels, 2003).

TABLE 11-2 Major Advantages and Limitations of Group Discussion

Advantages Limitations

Enhances learning in both the affective and cognitive domains.

Is both learner centered and subject centered.

Stimulates learners to think about issues and problems.

Encourages members to exchange their own experiences, thereby making learning more active and less isolating.

Provides opportunities for sharing of ideas and concerns.

Fosters positive peer support and feelings of belonging.

Reinforces previous learning.

One or more members may dominate the discussion. Easy to stray from the topic, which interferes with

achievement of the objectives. Shy learners may refuse to become involved or may

need a great deal of encouragement to participate. Requires skill to tactfully redirect learners who go off

on tangents or who dominate without losing their trust and that of other group members.

Particularly challenging for the novice teacher when members do not easily interact.

More time consuming to transmit information than other methods such as lecture.

Requires teacher’s presence at all sessions to act as facilitator and resource person.

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the opportunity to state their understanding of information allows the educator to evalu- ate the extent of learning. The teach-back or tell-back strategy that asks learners to restate in their own words what they understood should always be used by the educator to be sure pa- tients heard and interpreted the information correctly and completely (Fidyk, Ventura, & Green, 2014; Hyde & Kautz, 2014; Jager & Wynia, 2012; Kemp, Floyd, McCord-Duncan, & Lang, 2008). So often educators ask learners “Do you understand what I just taught you?” A question that is closed ended and requires only a “yes” or “no” response does not provide information for the educator to confirm that the message was, in fact, received as intended. This type of question should almost always be avoided. This is because, more likely than not, learners will say “yes,” indicating they under- stood something even when research shows that on average only about half of the infor- mation taught the first time is remembered, and only about 20% of it is recalled accurately (Kessels, 2003; Ley, 1972; Martin, Williams, et al., 2005). Also, communicating to learn- ers what further information is forthcoming allows them to connect what they have just learned with what they will be learning in the future (Falvo, 2010). For example, the educator teaching a patient about hypoglycemia might say, “Now that you understand what causes low blood sugar, we will talk about how to tell when you have it and what to do if you expe- rience it after discharge.”

The process of one-to-one instruction in- volves moving learners from repeating the in- formation that was shared to applying what they have just learned. In the previous ex- ample regarding hypoglycemia, the educator might offer the learner a hypothetical situa- tion similar to what the patient might expe- rience given his lifestyle and have him work through how to respond to it. In this type of one-to-one exchange, a potentially threatening situation can be presented in a nonthreaten- ing manner (Boyd et al., 1998). For instance, the educator might ask a busy executive who

■ Contemplation stage—Support decision mak- ing for change by identifying benefits, con- sidering barriers to the change, and making suggestions for dealing with these obstacles.

■ Preparation stage—Support a move to ac- tion by contracting with the learner in es- tablishing small, realistic, and measurable goals; providing information on effective ways to achieve the desired change; and giving positive reinforcement.

■ Action stage—Encourage constant practice of the new behavior to instill commitment to change by pointing out the benefits of each step achieved, providing rewards and incentives, and assisting the learner to mon- itor his or her behavior through the imple- mentation of such strategies as keeping a food diary.

■ Maintenance stage—Continue encourage- ment and support to consolidate the new behavior and prevent relapses.

For example, the patient with a chronic problem such as obesity must consider the options available for weight control; only then can he and the nurse educator mutually design an action plan that they think can be accom- plished. This patient’s confidence level can be assessed by asking on a scale of 0–10 how cer- tain he is of achieving this goal. A score of 7 or higher makes it more likely he will be success- ful (Lorig, 2003). See Chapter 6 for the stages of change model that explains motivation and compliance for behavioral change.

Mutual goal setting is a very important first step to be undertaken between the educator and the learner. Contracting, which clearly spells out the roles and expectations of both educator and learner, is one effective way to facilitate mutual goal setting. Contracts should be written in spe- cific terms and planned and evaluated by both participants in the teaching–learning process.

Whenever teaching is done on a one- to-one basis, instructions should be specific and time should be given for an immediate response from the learner, followed by direct feedback from the educator. Giving learners

Teaching Methods 471

uncomfortable waiting in silence for an answer or are impatient and attempt to correct an an- swer before learners complete their responses. Questioning is ineffective as a technique when educators do not give learners enough time to process information. Preliminary interruption may further interfere with a learner’s thinking abilities and create a tense atmosphere.

Many nurse educators conduct individu- alized teaching of other staff nurses or student learners in the skills laboratory and clinical settings. Clinical instruction is not a discrete teaching method but rather can be an exten- sion of one-to-one teaching in a very complex setting for experiential learning. Educators can use a variety of methods other than one-to- one instruction, such as role model, role play, demonstration, return demonstration, and group discussion. However, one-to-one instruction very well may be involved as a teaching approach during new employee orientation, student pre- ceptorship, or a staff continuing education ac- tivity. The learner is singularly guided in the actual practice setting, and each learning ex- perience requires specific objectives, known to both the educator and the learner, that are tai- lored to meet the individual’s needs (Emerson, 2007; Gaberson, Oermann, & Shellenbarger, 2013; O’Connor, 2015).

Preceptors who assume clinical teaching roles are usually expert clinicians but may not necessarily be expert educators. If this is the case, to carry out their roles effectively, they need to be taught how to be educators through workshops and coaching sessions. One-to-one instruction has much strength as a teaching method. However, it also has its drawbacks. TABLE 11-3 summarizes the major advantages and limitations of this method.

From an economic standpoint, one-to-one instruction is a very labor-intensive method and should be thoughtfully tailored to make the expense worthwhile in terms of achieving learner outcomes. One-to-one teaching of pa- tients and their families is often considered an inefficient approach to learning because the ed- ucator is reaching only one person at a time.

has diabetes how he would respond to feeling shaky and sweaty at 2:00 p.m. on a day when a meeting runs late and he misses lunch.

Educators should clearly state that these types of scenarios are not meant to be a test but rather a dress rehearsal for real-world sit- uations. They can change the scenarios with further questioning to help learners plan how they could prevent such occurrences in the future. This technique gives learners a chance to use the information at a higher cognitive level and provides an opportunity for the ed- ucator to evaluate the client’s learning in a safe environment.

With the one-to-one method of instruc- tion, questioning is an excellent technique. It en- courages learners to be active participants in the learning process and gives educators important feedback on their progress (Falvo, 2010). Ques- tions can be matched with the behavioral objec- tives to be achieved. For example, to determine a client’s knowledge level in the cognitive do- main, the educator might ask, “What is the next step that you should take?” For the higher level of synthesis in the cognitive domain, the edu- cator might ask a staff nurse to plan for how he or she would respond to an angry family mem- ber (Abruzzese, 1996).

Questioning should not be interpreted by learners as a test of their knowledge but rather as a way to exchange information and stimu- late thinking. However, two problems can occur with questioning: (1) questions can be so un- clear that the learner does not know what the question is, or (2) they can contain too many facts to process effectively (House, Chassie, & Spohn, 1990). The educator should watch the learner’s nonverbal reactions and rephrase the question if he or she detects either of these prob- lems. If the learner seems confused, it is helpful to state that perhaps the question was not clear. This technique guards against the learner feel- ing guilty or becoming discouraged if the an- swer to a question was incorrect (Falvo, 2010).

Also, it is important to give learners time to process information and respond to questions posed by the educator. Sometimes educators are

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member develop interactive skills for crisis in- tervention or assertiveness training.

Prior to giving a demonstration, the edu- cator should inform learners of the purpose of the procedure, the sequential steps involved, the equipment needed, and the actions expected of them. It is important to stress why the demon- stration is important or useful to the partici- pants. Equipment should be tested prior to the demonstration to ensure that it is complete and in good working order. For the demonstration method to be employed effectively, learners must be able to clearly see and hear the steps being taught. Therefore, the demonstration method is best suited to teaching individuals or small groups. A large screen or multiple screens for video or for streaming presentations of demon- strations can allow larger groups to participate.

Demonstrations can be a passive activity for learners, whose role is to observe the educator presenting an exact performance of a required skill. Demonstrations are more effective when instructions are explained verbally either prior to or during the demonstration. This method of instruction can be enhanced if the educa- tor slows down the pace of performance, exag- gerates some of the steps (Radhakrishna, John, & Edgar, 2011), or breaks lengthy procedures into a series of shorter steps. This incremental

Clinical teaching of students and continuing education for staff are vital for professional de- velopment, but they are costly endeavors when carried out on a one-to-one basis. Also, orien- tation of new staff is a significant expense to an institution or agency in terms of payroll dol- lars and the lack of short-term productivity of the employee being oriented (Del Bueno, Grif- fin, Burke, & Foley, 1990); hence one-to-one instruction in this scenario is likely to be eco- nomically infeasible.

Demonstration and Return Demonstration It is important to begin this discussion by mak- ing a clear distinction between demonstration and return demonstration. Demonstration by the educator is done to show the learner how to perform a certain skill. Return demonstration by the learner is carried out as an attempt to es- tablish competence by performing a task with cues from the educator as needed. These two methods require different abilities of both the educator and the learner. They are especially ef- fective in teaching psychomotor domain skills. However, demonstration and return demonstra- tion also may be used to enhance cognitive and affective learning, such as when helping a staff

TABLE 11-3 Major Advantages and Limitations of One-to-One Instruction

Advantages Limitations

The pace and content of teaching can be tailored to meet individual needs.

Ideal as an intervention for initial assessment and ongoing evaluation of the learner.

Good for teaching behaviors in all three domains of learning.

Especially suitable for teaching those who are learning disabled, low literate, or educationally disadvantaged.

Provides opportunity for immediate feedback to be shared between the educator and the learner.

The learner is isolated from others who have similar needs or concerns.

Deprives learners of the opportunity to identify with others and share information, ideas, and feelings with those in like circumstances.

Can put learners on the spot because they are the sole focus of the educator’s attention.

Questioning may be interpreted by learners as a technique to test their knowledge and skills.

The learner may feel overwhelmed and anxious if the educator makes the mistake of cramming too much information into each session.

Teaching Methods 473

a type of assistive device if called on to learn to use a newly purchased piece of equipment from a different manufacturer.

Return demonstration should be planned to occur as close as possible to when the demon- stration was given. Learners may need reassur- ance to reduce their anxiety prior to beginning the performance because they may view the opportunity for return demonstration as a test. Such a perception may lead them to believe they are expected to carry out a perfect performance the first time. Once a learner recognizes that the educator is a coach and not an evaluator, the cli- mate will be less tense and the learner will be more comfortable in attempting to practice a new skill. Educators can stress the fact that the initial performance is not expected to be perfect.

In addition, allowing the learner to manip- ulate the equipment before being expected to use it may help to reduce anxiety levels. Some clients, however, may experience an increased sense of unease when faced with learning a new skill because they identify the need to learn a skill with their illness. For example, a young woman learning to care for a venous access device may be very anxious because her diagnosis of can- cer has necessitated the need for this device.

It is important to note that when the learner is giving a return demonstration, the educator should remain silent except for offering cues when necessary or briefly answering questions. Learners may be prompted by a series of pictures or coached by a partner with a checklist. The first time that learners perform a return demonstration, they may need a significant amount of coaching. Educators should limit their help to coaching— they should not do the task for the learner who is struggling. The next time the learner practices the skill the educator should observe and coach only if needed (Lorig, 2003). Also, the educator should avoid casual conversations or asking ques- tions because they merely serve to interrupt the learner’s thought processes and interfere with ef- forts to focus on mentally imprinting the proce- dure while performing the task.

Breaking the steps of the procedure into small increments will give the learner the opportunity

approach to sequencing discrete steps of a proce- dure is known as scaffolding and provides the learner with a clear and exacting image of each stage of skill development (Brookfield, 2006).

In the process of demonstrating a skill to ei- ther nurses or clients, it is important to explain why each step needs to be carried out in a cer- tain manner to prevent bad habits from being acquired prior to the learner performing a new skill set (Brookfield, 2006; DeYoung, 2014; Lorig, 2003). Demonstration as a teaching method pro- vides educators with the opportunity to model their commitment to a learning activity, builds credibility, and inspires learners to achieve a level of excellence (Brookfield, 2006).

The key to performing the demonstration is practice, practice, and practice. If the demon- stration is difficult for the educator, how can you expect your learner to perform the skill? De- termine whether the skill is appropriate for the experience level of your learner (Radhakrishna et al., 2011). The educator’s performance should be flawless, but it is important that the educa- tor take advantage of a mistake to show how er- rors can be handled. If an error does occur, it may serve to increase rapport with the learn- ers and allow them to relax and not feel intim- idated, knowing mistakes do happen and can be corrected (Brookfield, 2006). However, too many mistakes disrupt the mental image that the learners are forming.

When demonstrating a psychomotor skill, if possible, the educator should work with the exact equipment that the learner is expected to use. This consideration is particularly import- ant for novice learners. For instance, the patient or family member who is learning to carry out an activity of daily living at home will be anx- ious and frustrated if taught in the hospital or community-based agency with one type of as- sistive device, such as a wheelchair or shower seat, when another type is used after discharge. Often the learner is too inexperienced to fol- low the skill pattern and, instead, may become confused when using a different device. The seasoned staff nurse, in contrast, might find it easier to transfer what is already known about

474 Chapter 11 Teaching Methods and Settings

properly use aseptic measures if she also must learn how to manage home intravenous therapy.

Return demonstration sessions should be planned to occur close enough together that the learner does not lose the benefit of the most re- cent practice session. As with demonstration, the equipment for return demonstration needs to exactly match that used by the educator and expected to be used by the learner. Learners also will require help in compensating for in- dividual differences. For instance, if you are right handed and the learner is left handed, sit- ting across from each other during instruction would be more helpful than sitting next to one another. The person with difficulty seeing the increments on a syringe may need a magnifying device to accurately perform the skill.

TABLE 11-4 summarizes the advantages and limitations of demonstration and return demonstration. Perhaps the biggest drawbacks to demonstration and return demonstration are the expenses associated with these methods. Group size must be kept small to ensure that each learner is able to visualize the procedures being performed and to have the opportunity for practice. Individual supervision is required during follow-up practices. Furthermore, the cost of obtaining, maintaining, and replacing

to master one sequence before attempting the next one. Praising the learner along the way for each step correctly performed reinforces behav- ior and gives the learner confidence in being able to successfully accomplish the task in its en- tirety. Emphasis should be on what to do, rather than on what not to do. Practice should be su- pervised until the learner is competent enough to perform steps accurately. It is important that the initial skill pattern be correct before allow- ing for independent practice. To ensure safety, high-risk skills should be performed first on a model prior to actual clinical application.

Different learners will need different amounts of practice to become competent, but once they have acquired the skill, they can then practice on their own to increase speed and proficiency. The value of practice should not be underes- timated. For a new skill to become automatic and long lasting, repeated practice beyond the point of mastery is essential (Willingham, 2004). However, if a new task to be performed is sim- ilar to a task previously acquired, less time will be needed to master the new skill. For example, a mother who has already learned to use ster- ile technique at home to change the dressing on her son’s abdominal wound will likely learn more quickly and with much more ease how to

TABLE 11-4 Major Advantages and Limitations of Demonstration and Return Demonstration

Advantages Limitations

Especially effective for learning in the psychomotor domain.

Actively engages the learner through stimulation of visual, auditory, and tactile senses.

Repetition of movement and constant reinforcement increases confidence, competence, and skill retention.

Provides opportunity for overlearning 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.

Equipment can be expensive to purchase and replace.

Extra space and equipment is needed for practicing certain skills.

Competency evaluation requires 1:1 teacher to learner ratio.

Teaching Methods 475

educational objectives. Gaming is primarily effective for improving cognitive functioning but also can be used to enhance skills in the psychomotor domain and to influence affec- tive behavior through increased social inter- action (Berbiglia, Goddard, & Littlefield, 1997; Beylefeld & Struwig, 2007; Henry, 1997; Rob- inson, Lewis, & Robinson, 1990). Through this active learning, gaming has the potential to con- nect theory with experience for nurses without any risk to patient safety (Henry, 1997; Royse & Newton, 2007).

In comparison with other didactic meth- ods, gaming is an interactive teaching method that creates a dynamic environment for learn- ing. As an experiential approach to learning, the use of games has been found to stimulate en- joyment of learning, increase active participa- tion and engagement of learners, provide variety from a teaching/learning perspective, enhance skill acquisition, and improve problem-solving abilities (Jaffe, 2014; Raines, 2010). Also, evi- dence suggests that gaming may improve re- call and long-term retention of information (Allery, 2004; Beylefeld & Struwig, 2007; Blakely, Skirton, Cooper, Allum, & Nelmes, 2008; O’Leary, Diepenhorst, Churley-Strom, & Magrane, 2005). For more information on the key principles of game-based learning and low- cost gaming strategies to motivate, engage, and assess learners, see http://www.gametrain learning.org, a nonprofit educational organi- zation that promotes a variety of game-based learning solutions.

Games can be placed anywhere in the se- quence of a learning activity (Joos, 1984). For example, they can be used as a device to con- duct a needs assessment, introduce a topic, check learner progress, or summarize infor- mation. However, some games may require prerequisite knowledge for the learner to par- ticipate effectively and, therefore, may require a prior session of teaching before the game can be played (Henry, 1997; Royse & New- ton, 2007). For purposes of a needs assess- ment, Rowell and Spielvogle (1996) used an infection-control game to determine whether

equipment can be significant and must be fac- tored into the process.

Nevertheless, there are some ways to re- duce the cost of these methods. If, for example, the audience is composed of a homogeneous group of health professionals who need yearly cardiopulmonary resuscitation (CPR) review, demonstration can be done via videotape or web cameras. Also, return demonstration can initially be performed with a partner supervis- ing the competency of the skill. Nevertheless, the final evaluation of staff competency must be carried out by an expert to ensure the ac- curacy of learning. In addition, expenses can be reduced by reusing equipment if doing so will not interfere with the accuracy, safety, or completeness of the demonstration/return demonstration.

Gaming Gaming is a method of instruction requiring the learner to participate in a competitive activity with preset rules (Allery, 2004). The goal is for learners to win a game by applying knowledge and rehearsing skills previously learned. Games can be simple, or they can be more complex to challenge the learner’s ability to use higher or- der thinking and problem-solving strategies (Jaffe, 2014).

The use of gaming in higher education is of growing interest to teachers seeking ways to engage learners. This development is based on the perception that many of today’s students be- long to the “gamer generation” or “Net gener- ation,” meaning the generation that has grown up with computer games and other technology affecting their preferred learning styles, social interaction patterns, and technology use gen- erally (Bekebrede, Warmelink, & Mayer, 2011). Higher education is in a unique position to look at the diversity of the student body and to provide teaching methods that correlate with their active, collaborative, and technology-rich learning style.

Gaming activities do not have to reflect reality, but they are designed to accomplish

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should be sure to test any games prior to wide- spread use. Examples of games used in health- care settings include a word search puzzle for foods (FIGURE 11-1) known to elevate serum po- tassium, which is appropriate for use by patients with end-stage renal disease (Robinson et al., 1990), and Emergency Pursuit, which has con- tent related to emergency situations that staff might encounter on a medical–surgical unit (Schmitz, MacLean, & Shidler, 1991). Bauman (2012) provides a comprehensive resource for educators interested in integrating gaming to teach nursing students in a classroom and lab- oratory setting.

Computer games, although much more ex- pensive, are becoming increasingly available and are a popular option for many learners (Begg, 2008). Such games, which are also referred to as edutainment (meaning educational software disguised in a game format), introduce con- tent or involve the process of competition to at- tain a learning goal. They are an enjoyable and

a knowledge deficit among staff was contrib- uting to rising rates of methicillin-resistant Staphylococcus aureus (MRSA) infections. The staff members were asked to identify violations of infection-control practices in a mock isola- tion room. Participants completed and turned in an answer sheet and then proceeded to an answer station. Not only did staff have an op- portunity to test themselves and correct wrong information, but participants also provided in- formation that was helpful in planning future education programs.

Games can be designed for a single indi- vidual, such as puzzles, or for a group of play- ers, such as bingo or Jeopardy!. For gaming activities that involve multiple participants, the educator’s role is that of a facilitator. At the be- ginning of a game, the educator tells learners the objectives and the rules, distributes any mate- rials required to play the game, and assigns the various teams. Once the game starts, the edu- cator needs to keep the flow going and inter- pret the rules. The game should be interrupted as seldom or as briefly as possible so as not to disturb the pace (Joos, 1984).

When the game is completed, winners should be rewarded. Prizes do not have to be expensive because the main purpose of them is to acknowledge achievement of learners in a public manner (Robinson et al., 1990). At the end of the game, the educator should conduct a debriefing session to evaluate the gaming ex- perience. Learners should be given a chance to discuss what they learned, ask questions, receive feedback regarding the outcome of the game, and offer suggestions for improving the process.

Games may be either purchased or de- signed. Well-known commercial games such as Trivial Pursuit, Bingo, Monopoly, and Jeop- ardy! have the advantage in that their formats can be modified, the equipment is reusable for different topics, and many players already have familiarity with the rules of the games (Bender & Randall, 2006). Word searches, crossword puz- zles, treasure hunts, and card and board games also are flexible in format and can be developed inexpensively and with relative ease. Educators

FIGURE 11-1 Sample word search game for patients. Reproduced from Robinson, K. J., Lewis, D. J., & Robinson, J. A. (1990). Games: A way to give laboratory values meaning. ANNA Journal, 17(4), 306–308. Reprinted with permission of the American Nephrology Nurses Association.

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PG O OT A

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G O E S U T

A B T F OA

AR S ET

R A N DL RI I T T

IA N O

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Teaching Methods 477

Lewis, Saydak, Mierzwa, and Robinson (1989) designed a game suitability checklist that remains relevant today for determining whether gaming is a viable alternative to meet the objec- tives for learning (EXHIBIT 11-1). Bruce Whitehall’s Game Evaluation Sheet that can be used to rate games old and new (http://thebiggamehunter .com/game-evaluation-sheet).

It is particularly important to remember that games, whether purchased or self-developed, must serve the purpose of helping the learner accomplish the predetermined behavioral ob- jectives. Are people learning while they are hav- ing fun? Lieberman (2001) also reported that children and adolescents improved their self- care after engaging in interactive games related to smoking prevention, asthma, and diabetes. Other research indicates that electronic games

effective way to teach specific cognitive, psy- chomotor, and affective skills. The Game Show Presenter— software that is now available to ed- ucators to create many types of games—can be accessed at http://www.gameshowpresenter.com.

Gaming is a teaching method that is par- ticularly attractive to children, who enjoy the challenge of learning through playlike activ- ity. Lieberman (2001) described an interactive video game designed for patients aged 8–16 years with type 1 diabetes. This game modeled the daily challenges of self-care, and partici- pants were told to play the game as much or as little as they wished. By the end of the 6-month trial, there was a 77% drop in diabetes-related urgent care as well as an increase in self-efficacy in communication with parents about diabetes and in self-care related to diabetes.

EXHIBIT 11-1 Game Suitability Checklist

Criteria Yes No

Does the game meet the program objectives? _____ _____

Can the game be completed within the time allotted? _____ _____

Is the size and layout of the room conducive to playing the game? _____ _____

Will the available participants meet the minimum number required for the game?

_____ _____

Do staff members have the time and interest to design or adapt games? If not, are funds available to purchase games?

_____ _____

If the game requires equipment or supplies, are they readily available? a. Are resources or funds available to design or purchase needed

materials? b. Does the game require replacement of materials following each use?

_____

Does the game require preparation or cleanup time? _____ _____

Reproduced from Lewis, D. J., Saydak, S. J., Mierzwa, I. P., & Robinson, J. A. (1989). Gaming: A teaching strategy for adult learners. Journal of Continuing Education in Nursing, 20, 80–84. Reprinted with permission from The Journal of Continuing Education in Nursing.

478 Chapter 11 Teaching Methods and Settings

simulation has grown rapidly as a way to hone the knowledge and practice skills of the health- care workforce for the ultimate purpose of im- proving patient safety, patient care outcomes, and teamwork (Beaubien & Baker, 2004; Chiniara et al., 2013; Gaba, 2004). No longer seen as a technological toy for learning basic skills, simulation is now used to teach critical thinking and high-level decision-making skills and to serve as a feedback tool for an assess- ment cycle of repeated performance, clinical practice, and improvement (Bluestone et al., 2013; Gaba, 2009; Kaufman & Ireland, 2016). It is also a means to foster collaborative inter- disciplinary education to improve teamwork, communication, and role valuing among the various healthcare disciplines (Dillon, Noble, & Kaplan, 2009).

To some extent, overlap exists between the methods of gaming, simulation, and role play, in that all three instructional approaches re- quire learners to engage in experiential learning (Allery, 2004). Simulation allows participants to make decisions in a safe and controlled envi- ronment, witness the consequences, and evalu- ate the effectiveness of their actions (Corbridge et al., 2008; DeYoung, 2014).

A follow-up discussion with learners after use of these experiential methods is important

as a tool for client education have the potential to improve health outcomes (“Editorial,” 2009).

TABLE 11-5 outlines the advantages and lim- itations of gaming as a teaching method. Eco- nomic considerations include either the cost of purchasing a game or the time taken by the ed- ucator to design, test, and update the gaming material. Also, some types of games require the educator to be present as facilitator each time that they are played.

Simulation Simulation is a trial-and-error method of teaching whereby an artificial experience is created that engages the learner in an activity that reflects real-life conditions but without the risk-taking consequences of an actual situ- ation. Simulation is a highly innovative teaching method to teach health professionals about the complex world of health care in their respec- tive disciplines in an effective, efficient, safe, and high-quality fashion. As Gaba (2004) ex- plains, “Simulation is a technique, not a tech- nology, to replace or amplify real experiences with guided experiences that replicate substan- tial aspects of the real world in a fully inter- active manner” (p. i2). Over the past 25 years, but especially in the last few years, interest in

TABLE 11-5 Major Advantages and Limitations of Gaming

Advantages Limitations

Fun with a purpose. Retention of information promoted by

stimulating learner enthusiasm and increasing learner involvement.

Easy to devise or modify for individual or group learning.

Adds variety to the learning experience. Excellent for dull or repetitious content that must

be periodically reviewed.

Creates a competitive environment that may be threatening to some learners.

Requires group size to be kept small for participation by all learners.

Requires more flexible space for teamwork than a traditional conference or classroom.

Potentially higher noise level; special space accommodations are needed as a result.

May be more physically demanding than many other methods.

Not possible for learners with some disabilities to participate.

Teaching Methods 479

serve as a buddy or a coach for the inex- perienced nurse who is running the code. This simulation allows the novice to prac- tice these skills in a nonthreatening situa- tion with immediate feedback. Participants in such simulations have reported that these sessions helped them validate their think- ing and allowed for ongoing thinking out loud in formulating questions they might otherwise not have asked.

■ Model simulations are frequently used to teach a variety of audiences. An effective and economical method to teach certain non- invasive skills is to ask a peer, educator, or trained individual to act as a patient. Stan- dardized patients—people trained to act as patients—were found to be a more effective method of simulation to teach fundamen- tals to nursing students than were lectures and laboratory practice with a model. An innovative technology is high-fidelity whole-body patient simulators, such as SimMan, that reproduce in a sophisticated, lifelike manner the cardiovascular, respi- ratory, urinary, and neurological systems. The more sophisticated models (SimMan 3G) are able to respond to selected drugs; mimic heart, lung, and bowel sounds; and give oximeter and vital sign readings in response to a variety of interventions. However, widespread use within clinical settings remains limited by the high cost of this technology.

■ Computer simulations are used in learning laboratories to mimic situations whereby information and feedback are given to learn- ers in helping them develop decision-making skills.

The learning laboratory is a commonplace teaching environment for nursing students on college campuses and has been used in the last 15 years to update the skills of nurses reenter- ing the workforce. Nevertheless, these simu- lated experiences are not yet widely available to train patients or family providers in self-care skills because of lack of space and the high cost of simulators. In the future, simulation with

to facilitate their analysis of the experience. Sim- ulation should always be followed by a debrief- ing session that includes a discussion of events that happened during the experience, the deci- sions made, the actions taken, the consequences of the choices, the possible alternatives, and sug- gestions for improvement in skill performance. Simulations provide the opportunity for antici- patory learning (Allery, 2004; Childs & Sepples, 2006; Jeffries, 2005).

When planning a simulation, it is most ef- fective if the educator makes the learning experi- ence resemble real life as much as possible but in a nonthreatening way. The activity should chal- lenge the decision-making ability of the learner by imposing time constraints, providing realis- tic levels of tension, and using actual equipment or other important features of the environment in which the specific skill will be performed. For example, a scenario could be developed to help parents prevent sudden infant death syn- drome (SIDS) by working through a situation in which a monitor signals respiratory difficulty in their baby. As another example, a staff nurse along with other staff team members might be expected to make a rapid assessment and inter- vene with accuracy, coordination, and speed in caring for a chest trauma victim in a simulated emergency room setting. Such simulations are created to determine whether the learner has the necessary skills to perform the activity correctly.

Many types of simulations are possible, in- cluding the following (Beaubien & Baker, 2004; Childs & Sepples, 2006; Epstein, 2007; Gaba, 2004; Jeffries, 2005, 2013; Turner, 2007; Yoo & Yoo, 2003):

■ Written simulations may use case studies about real or fictitious situations, with the learner being asked to respond to these sce- narios. Staff nurses, for example, might be asked to describe how they would handle a personnel communication problem on a unit or manage a physiologically complex patient in the critical care environment.

■ Clinical simulations can be set up to repli- cate complex care situations, such as a mock cardiac arrest. An experienced nurse can

480 Chapter 11 Teaching Methods and Settings

to play an assigned character as they think the character would act realistically. This technique is intended to arouse feelings and elicit emo- tional responses in the learners. It is used pri- marily to achieve behavioral objectives in the affective domain. Unlike high-fidelity simula- tion, which teaches learners to master skills for application to their own real-life situations, role play—a form of simulation—places learners in real-life situations to help them develop under- standing of other people and why they behave the way they do (Comer, 2005; Lowenstein & Harris, 2014; Redman, 2007). For example, a nurse attending an education program on sen- sory disabilities might be given the experience of wearing special glasses to see how it feels to function with impaired vision. Children can use role play with puppets to explore their re- sponses to such illnesses as asthma (Ramsey & Siroky, 1988).

Role play is a technique that, according to Comer (2005), can be used to substitute for or supplement costly high-tech simulations to teach students various skills and develop clin- ical judgment at varying levels of difficulty. As a teaching method, role play is a very useful technique because it serves multiple functions: It helps learners to explore their own and oth- ers’ feelings; gain insight into their values, at- titudes, and beliefs; develop problem-solving and decision-making skills; explore a topic in more depth; and develop a better understanding of interpersonal relationships (Baile & Blatner, 2014; Billings & Halstead, 2015; Chan, 2012; Dawood, 2013; Lowenstein & Harris, 2014).

high-tech, portable equipment could revolu- tionize client education.

Simulated experiences for the learner should be followed with actual experiences as soon as possible. Simulation is never the same as the real thing to prepare the learner. There- fore, the learner will need help with the transfer of skills acquired in a simulated experience to the actual situation. Virtual reality technology, which is emerging in healthcare education and practice settings, has the potential to narrow the distance even more between simulation and real life for the education of patients, nursing stu- dents, and staff (Cook et al., 2011; Gaba, 2009; Jenson & Forsyth, 2012; Kaphingst et al., 2009).

Simulation can be made more cost effec- tive by reuse of supplies and the interdisciplin- ary sharing of simulation equipment. Given the shortage of healthcare faculty, the diminish- ing number of clinical sites available for prac- tice teaching, and the growing knowledge base and skills needed to produce competent and confident care providers, simulation offers a cost-effective approach to student teaching, staff orientation, and continuing staff develop- ment (Jeffries, 2005, 2013). TABLE 11-6 summa- rizes the main strengths and drawbacks of the simulation method of instruction.

Role Play Role play, sometimes alternatively referred to as role playing, is a method of instruction by which learners actively participate in an unre- hearsed dramatization. Participants are asked

TABLE 11-6 Major Advantages and Limitations of Simulation

Advantages Limitations

Excellent for psychomotor skill development. Enhances higher level problem-solving and interactive abilities in the

cognitive and affective domains. Provides for active learner involvement in a lifelike situation with

consequences determined by variables inherent in the situation. Guarantees a safe, nonthreatening environment for learning.

Can be expensive. Very labor intensive in

many cases.

Not readily available to all learners yet.

Teaching Methods 481

The actual length of a role-play session can be as short as 5 minutes, but it should not ex- ceed 15 to 20 minutes (Lowenstein & Harris, 2014). Role play is best done in small groups so that all learners can serve as either players or observers. Active participation by learners is particularly important during a postactivity discussion or debriefing session. Because this teaching method is most effective for learn- ing in the affective domain, all participants need to discuss how they felt and share what they observed to gain insight into their un- derstanding of interpersonal relationships and their reactions to role expectations or conflicts (Comer, 2005).

TABLE 11-7 summarizes the main advan- tages and limitations of role play.

Role Model The use of self as a role model is often over- looked as a teaching method. Learning from a role model is called identification and em- anates from learning and developmental the- ories, such as Bandura’s social learning theory and Erikson’s psychosocial stages of develop- ment, which explain how people acquire new behaviors and social roles (Crandell, Crandell, & Vander Zanden, 2012; Snowman & McCown, 2015). This teaching method primarily is known to achieve behavior change in the affective domain.

Preceptors and mentors are excellent exam- ples of experienced health professionals who,

The responsibility of the educator is to de- sign a situation with enough information for learners to be able to assume the role of some- one else without giving a script to them to fol- low. Occasionally, people are assigned to play themselves to rehearse desired behavior, or the educator takes a part in the role-play session to act as a positive role model for the learners. Most often, however, the educator acts as the facilitator and designates members in a group to play certain characters. They then pretend to be these people for the duration of the ex- ercise. Participants do and say things that they perceive actual persons would do, say, and feel.

For role play to be employed effectively, the educator must be sure that the group has attained a comfort level that allows each mem- ber to feel secure enough to participate in a dra- matization. This method should never be used with learners at the beginning of a group ses- sion encounter. Members need time to establish a rapport with one another as well as with the educator, or else learners may feel embarrassed or self-conscious about playing a part. All mem- bers of the group should be given an assignment to ensure that they are actively involved in the teaching– learning experience (Comer, 2005; Haggard, 1989; Lowenstein & Harris, 2014). Those who are actual participants need to be informed about the roles they are to portray so that they can effectively develop the appropriate actions. Those who are designated as observers require specific instructions about what to at- tend to during the role-play session.

TABLE 11-7 Major Advantages and Limitations of Role Play

Advantages Limitations

Opportunity to explore feelings and attitudes.

Potential for bridging the gap between understanding and feeling.

Narrows the role distance between and among patients and professionals.

Limited to small groups. Tendency by some participants to overly exaggerate

their assigned roles. A role part loses its realism and credibility if played

too dramatically. Discomfort felt by some participants in their roles or

inability to develop them sufficiently.

482 Chapter 11 Teaching Methods and Settings

Self-Instruction Self-instruction is a teaching method used by the educator to provide or design instruc- tional activities that guide the learner in inde- pendently achieving the objectives of learning. Each self-study module usually focuses on one topic, and the hallmark of this format is inde- pendent study. The self-instruction method is effective for learning in the cognitive and psy- chomotor domains, where the goal is to master information and apply it to practice. Self-study also can be an effective adjunct for introducing principles and step-by-step guidelines prior to demonstration of a psychomotor skill.

This teaching method is sometimes diffi- cult to identify as a singular entity because of the variety of terms used to describe it, such as minicourse, self-instructional package, individu- alized learning activities, self-directed learning, and programmed instruction. For the purposes of this discussion, the term self-instruction is used. It is defined as a self-contained educa- tional activity that allows learners to progress by themselves at their own pace (Abruzzese, 1996).

Self-instruction modules come in a variety of forms, including, but not limited to, work- books, study guides, workstations, videotapes, Internet modules, and computer programs. They are specifically designed to be used in- dependently. With this teaching method, the educator serves as a facilitator/resource per- son to provide motivation and reinforcement for learning. This method requires less educa- tor time to give information, and each session with the learner is intended to meet individ- ual needs.

through use of role model, guide, support, and socialize students and novice practitioners in their transition to a new level of functioning (Doherty, 2016). Preceptors help bridge the gap between theory and practice. Role model, also referred to as role modeling, is a teaching method that also can help new health profes- sionals develop critical thinking competencies and interpersonal skills, as well as assist them to assume the responsibilities and values of the profession with which they identify (Sorensen & Yankech, 2008).

Nurse educators have many opportunities to demonstrate behaviors they would like to instill in learners, whether they are patients or family members, nursing staff, or students. The competency with which the educator performs a skill, the way he or she interacts with others, the personal example he or she sets, and the en- thusiasm and interest he or she conveys about a subject or problem all can influence learners’ motivation levels and the extent to which they successfully perform a desired behavior.

Behavior is regulated by the social norms and professional expectations that specify what is appropriate versus inappropriate behavior. Role conflict can arise when a learner’s past behavior patterns are incompatible or different from an- other role that person must assume (Crandell et al., 2012). Educators can teach students and staff new behaviors by consistently setting ex- amples and living the standards of the nursing profession. “Actions speak louder than words” is a popular saying relevant to the use of self as a role model (de Tornyay & Thompson, 1987).

TABLE 11-8 summarizes the advantages and limitations of this method of instruction.

TABLE 11-8 Major Advantages and Limitations of Role Model

Advantages Limitations

Influences attitudes to achieve behavior change primarily in the affective domain.

Potential of positive role models to instill socially desired behaviors.

Requires rapport between the role model and the learner.

Potential for negative role models to instill unacceptable behaviors.

Teaching Methods 483

■ An estimated total length of time to com- plete the module. A well-designed module is kept relatively short so as not to dampen the motivation to learn.

■ Different presentations for the material based on the objectives and the resources available. For example, information may be given via programmed instruction or through a series of readings. This can be followed by a video presentation of a rele- vant case study, with the requirement that the learner write a response to what has been read and observed.

■ Periodic self-assessments to provide feed- back to the learner throughout the module. The user is frequently able to do periodic self-assessments prior to moving on to the next unit. This allows the learner to decide whether the previous information has been processed sufficiently enough to move on to the next unit.

■ A posttest to evaluate the learner’s level of mastery in achieving the objectives. If learners are aware that a posttest needs to be completed, this requirement encour- ages them to pay attention to the informa- tion. Keeping a record of final outcomes is helpful in both staff and client education as documentation of competency, as proof that standards were met, and in planning for continuing education.

Self-instruction represents an attractive alter- native to traditional classroom and group learning methods in today’s rapidly changing healthcare environment. Hospitals and community agen- cies are not always able to release staff in large numbers for continuing education programs that are rigidly timed—a constraint that con- flicts with the need to share information on the newest advances and documentation of con- tinuing competence of staff. Self-instruction modules, therefore, are excellent choices for annual training updates on selected topics or skills that require periodic review to deter- mine competency (Markiewicz & Wells, 1997; O’Very, 1999).

Some learners and educators resist the self-instruction method because it appears to depersonalize the teaching–learning pro- cess. That perception is not necessarily valid. Communication can still occur between the educator and the learner, but the focus of in- struction is different. The amount of time for direct interaction is more limited than with other methods of teaching such as lecture, group discussion, and one-to-one instruc- tion. This method adheres to the principles of adult education whereby the learner assumes responsibility for learning and is self-directed (Knowles, Holton, & Swanson, 2011).

A self-instruction module is carefully de- signed to achieve preset objectives by bring- ing learners from diverse knowledge and skill backgrounds to a similar level of achievement prior to undertaking the next step in a series of learning activities. For example, a self- instructional activity might be made available to educate all staff on new infection-control practices in an agency, and clients might learn breast self-examination or CPR techniques by using specifically prepared self-study materials.

Modules can be made readily accessible to learners along with any resources that are needed to complete the self-study program. Each self-instruction module needs to contain the following elements:

■ An introduction with statement of purpose and directions for how to use the module.

■ A list of prerequisite skills that the learner needs to have to use the module.

■ A list of behavioral objectives, which are clear and measurable statements describing which skills the learner is expected to acquire.

■ A pretest to determine whether the learner needs to proceed with the module based on his or her areas of strength or weakness.

■ An identification of resources and learn- ing activities, such as videos, slides, or writ- ten materials.

■ An outline of the actual learning activities that will be presented in small units of dis- crete information called frames.

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CAI offers consistent presentation of material and around-the-clock accessibility. This teach- ing method not only saves time but also accom- modates different types of learners. It allows slow learners to repeat lessons as many times as necessary, whereas learners who are already familiar with material can skip ahead to more advanced material (DeYoung, 2014).

Some concern has been voiced that com- puter instruction might depersonalize the learn- ing process (DeYoung, 2014). However, the use of CAI does not preclude the educator’s avail- ability for guidance in learning. Although this technology delivers content, it allows more time for the educator to concentrate on the personal aspects of individual reinforcement and ongo- ing assessments of learning. For example, CAI has been used with good patient acceptance for precolposcopy education (Martin, Hoffman, & Kaminski, 2005). Recently, computer programs, known as interactive health communication ap- plications (IHCAs), have been used by people with chronic disease. Research findings indi- cate that IHCAs can improve user knowledge, have a positive effect on social support, lead to better clinical outcomes, and increase self- efficacy (a person’s belief in his or her capacity to take specific action) when compared to non- users of IHCAs (Murray, Burns, Tai, Lai, & Nazareth, 2005).

TABLE 11-9 lists major advantages and lim- itations of this method of instruction.

The Internet also offers a myriad of con- tinuing education self-instruction modules. Nurse practitioners, for example, can be edu- cated about numerous problems and issues in primary care through use of interactive, realis- tic case studies. E-mail to and from faculty can facilitate communication (Hayes, Huckstadt, & Gibson, 2000).

The information explosion coupled with the rapidly advancing technology of comput- ers has made web-based teaching and learning available for client education, staff development, and student instruction. Self-instruction mod- ules have been found to be cost effective because they are designed for use by large numbers of individuals with minimal and infrequent revi- sions. It may be less time consuming and more efficient to purchase, rather than produce, a self-instruction module if the information pre- sented in a commercial product is appropriate for the target audience.

Computer-assisted instruction (CAI) is an individualized method of self-study using tech- nology to deliver an educational activity. CAI al- lows learners to proceed at their own pace with immediate and continuous feedback on their progress as they respond to a software program. Most computer programs assist the learner in primarily achieving cognitive domain skills (DeYoung, 2014), but psychomotor skills can be effectively taught through a web-enhanced approach (Bluestone et al., 2013; Salyers, 2007).

TABLE 11-9 Major Advantages and Limitations of Self-Instruction

Advantages Limitations

Allows for self-pacing. Stimulates active learning. Provides opportunity to review and

reflect on information. Offers built-in, frequent feedback. Indicates mastery of material

accomplished in a particular time frame.

Limited with learners who have low literacy skills. Not appropriate for learners with visual and hearing

impairments. Requires high levels of motivation. Not good for learners who tend to procrastinate. May induce boredom in a population if this method is

overused with no variation in the activity design.

Teaching Methods 485

TABLE 11-10 General Characteristics of Teaching Methods

Methods Domain Learner Role Educator Role Advantages Limitations

Lecture Cognitive Passive Presents information

Cost effective Targets large groups

Not individualized

Group discussion

Affective Cognitive

Active—if learner participates

Guides and focuses discussion

Stimulates sharing ideas and emotions

Shy or dominant member High levels of diversity

One-to-one instruction

Cognitive Affective Psychomotor

Active Presents information and facilitates individualized learning

Tailored to individual’s needs and goals

Labor intensive Isolates learner

Demonstra- tion

Psychomotor Cognitive

Passive Models skill or behavior

Preview of exact skill/ behavior

Small groups needed to facilitate visualization

Return demonstra- tion

Psychomotor Active Individualizes feedback to refine performance

Immediate individual guidance

Labor intensive to view individual performance

▸ Selection of Teaching Methods

The process of selecting a teaching method re- quires a prior determination of the behavioral objectives to be accomplished and an assess- ment of the learners who will be involved in achieving the objectives. Also, consideration must be given to available resources such as time, money, space, and materials to support learning activities as well as the comfort level of the educator using certain teaching methods.

TABLE 11-10 summarizes the general character- istics of teaching methods.

Educators are at different levels of teaching on the novice-to-expert continuum, which in- fluences their choices of teaching methods. For example, an expert skilled at facilitating small- group discussion may be a novice in the design and selection of games. A nurse may be an ex- pert clinician but have only limited education and experience that would enable him or her to be effective in the teaching role. Nurses are ex- pected to teach but may not have adequate time, inclination, energy, or capability for developing

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support the idea that a teaching method should match the learning style(s) of the audience. In- stead, learners should be challenged with a vari- ety of learning experiences and “educators should worry about matching their instruction with the content they are teaching. Some concepts are best taught through hands-on work, some are best taught through lectures, and some are best taught through group discussion” (Glenn, 2009, para. 16).

A novice should begin instruction with very familiar content so that he or she can fo- cus on the teaching process itself and feel more confident in trying out different techniques and strategies for instruction. He or she should ask questions of learners and peers in the evalua- tion process to determine whether the teaching method chosen was appropriate for accomplish- ing the behavioral objectives and for meeting

the quality and variety of instruction neces- sary. Teaching is a skill that can be developed in formal academic settings, in continuing ed- ucation programs, or through guidance by an expert peer mentor.

Educators tend to focus on a specific teach- ing method because it is the one they feel most comfortable using without considering all the criteria for selection. There is no one right method, because the best approach depends on many variables, such as the audience, the con- tent to be taught, the setting in which teaching and learning are to take place, and the resources available. For many years, it has been thought that the ideal method for any given situation is the one that best suits the learner’s needs, not the educator’s preferences. However, as Glenn (2009) and Rogowsky, Calhoun, and Tallal (2015) point out, no strong scientific evidence exists to

Methods Domain Learner Role Educator Role Advantages Limitations

Gaming Cognitive Affective

Active—if learner participates

Oversees pacing Referees Debriefs

Captures learner enthusiasm

Environment too competitive for some learners

Simulation Cognitive Psychomotor

Active Designs environment Facilitates process Debriefs

Practice reality in safe setting

Labor intensive Equipment costs

Role play Affective Active Designs format Debriefs

Develops understanding of others

Exaggeration or underdevelopment of role

Role model Affective Cognitive

Passive Models skill or behavior

Helps with socialization to role

Requires rapport

Self- instruction

Cognitive Psychomotor

Active Designs package Gives individual feedback

Self-paced Cost effective Consistent

Procrastination Requires literacy

Selection of Teaching Methods 487

colleagues, and use resources to help create an effective teaching approach. If the teaching– learning process is to be a partnership, not only is it crucial to assess the learner, but it is equally important that the nurse assesses him- self or herself as the educator. Often educators fail to take into consideration their own circum- stances and needs.

▸ Evaluation of Teaching Methods

An important aspect of evaluating any instruc- tional program is to assess the effectiveness of the teaching method (Friedman et al., 2011). Was the option selected as effective, efficient, and appropriately used as possible? Educators should ask five major questions to help decide which teaching method to choose or whether the method of instruction selected should be revised or rejected:

1. Does the teaching method help the learners to achieve the stated objectives? This question is the most import- ant criterion for evaluation—if the method does not help to accomplish the objectives, then all the other criteria are unimportant. Examine how well the method matches the learn ing domain of the predeter- mined objectives. Will the method expose learners to the necessary information and training so that they can learn the desired behaviors?

2. Is the learning activity accessible and acceptable to the learners who have been targeted? Accessibility includes such issues as the timing of informa- tion presentation, the location and setting in which teaching takes place, and the availability of resources and equipment to deliver the message. Clients and their family members need programs to be offered at suit- able times and accessible locations.

the expectations of different learners in terms of their learning needs, learning styles, and read- iness to learn.

Narrow (1979) emphasized the importance of educators periodically examining their role as educators and assessing the factors of energy, attitudes, knowledge, and skills, which influence the priority they assign to teaching and the abil- ity to teach effectively. The following is a sum- mary of her suggestions that—even many years after they were offered—remain very relevant to the teaching role.

At any given point in time, the educator’s energy level is influenced by both psychologi- cal and physical factors, such as the amount of satisfaction derived from work, the demands and responsibilities of the educator’s profes- sional and personal life, and the educator’s state of health. Feelings toward the learner also in- fluence the enthusiasm the educator brings to the teaching–learning situation. Nurse educa- tors may feel drawn to or satisfied with teach- ing because of the learner’s interest in the topic, or academic concerns or anxieties may create a bond between the teacher and the learner. In contrast, if the learners are demanding or dis- play inappropriate behavior, educators may feel negatively about them and find the teaching– learning encounter more difficult and less ful- filling. Ideally, educators will develop the abil- ity to accept individuals without necessarily approving of their behavior.

Another factor to consider is the educator’s comfort with and confidence in the subject mat- ter to be taught. Those who find certain con- tent to be stressful to teach because of a lack of relevant knowledge or skills can increase their understanding of the subject and relieve their stress and apprehension with additional study and practice. This allows them to function more effectively in the teaching role.

Educators who have difficulty communi- cating with learners about what they may con- sider sensitive material, such as sexual behavior, mental illness, abortion, birth defects, disfig- urement, terminal illness, and the like, should examine their own feelings, seek support from

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and injury, minimizing the severity and extent of illness, and reducing the length of hospital stays and read- missions. Healthcare agencies want the best staff performance with the most reasonable use of resources and the least amount of time taken away from actual practice.

▸ Increasing Effectiveness of Teaching

Excellent educators have one thing in common— a passion to keep improving their abilities. A person does not ever fully arrive at being an expert educator; instead, the drive toward ex- cellence is an ongoing process that continues throughout the educator’s entire professional life. What constitutes creative teaching? The following are techniques, not listed in any pri- ority order, that the nurse as educator can use to enhance the effectiveness of verbal presen- tations. In addition, some general principles for teaching are presented here that can be applied when using almost any instructional methodology (Bradshaw & Lowenstein, 2013; Brookfield, 2006; Caputi, 2010; Cunningham & Baker, 1986; Freitas, Lantz, & Reed, 1991; Irvin, 1996; Musinski, 1999; Narrow, 1979; Orlando, 2013; Parrott, 1994; Phillips, 1999; Stanford University, n.d.).

Techniques to Enhance the Effectiveness of Verbal Presentations Present Information Enthusiastically The educator who comes across as invested in the material excites the learner to identify with the subject at hand. No matter how well a les- son is planned or how clearly it is presented, if

For example, childbirth preparation classes scheduled during the daytime hours likely would not be convenient for expectant couples who are work- ing. Also, does the teaching method appeal to the learner(s) in terms of their learning needs, learning style(s), and readiness to learn characteristics?

3. Is the teaching method efficient given the time, energy, and resources available in relation to the number of learners the educator is trying to reach? To teach large numbers of learners, educators must choose a method that can accommodate groups, such as lecture, discussion sessions, or role play, or a method that can reach many individuals at one time, such as the use of various self-instructional formats. Sufficient resources and equipment are needed to adequately deliver the message intended.

4. To what extent does the teaching method allow for active participation to accommodate the needs, abilities, and style of the learner? Active par- ticipation has been well documented as an approach to increase interest in learning and the retention of infor- mation. Evaluate how active learners want to be or can be in the process of gaining knowledge and skills. No one method can satisfy all learners, but adhering to one method exclusively addresses the preferred style of only a segment of the audience.

5. Is the teaching method cost effective? It is vital to examine the cost of ed- ucational programs to determine whether similar outcomes might be achieved by using less costly meth- odologies. In this era of cost contain- ment, employers and insurers want their money invested in patient pro- grams that will yield the best possible outcomes at the lowest price as mea- sured in terms of preventing illness

Increasing Effectiveness of Teaching 489

express their ideas focus more on the process than on the result.

Deliver Material Dramatically Effective educators seek ways to engage the learner emotionally by using surprise, controlled tension, or ploys. The educator uses strategies that connect the educational material directly to the learner’s life experiences so that infor- mation is made more understandable and rel- evant. Learners may be asked to participate in simulations, games, or role play to act out a part, live an experience, or test their capacities. These activities involve the learner in the learn- ing experience and can leave a profound, last- ing impression that can be recalled vividly and drawn upon when faced with a real situation. A dramatic teaching method engages learners by arousing their emotions.

Choose Problem-Solving Activities Whether the learners are staff members or pa- tients, the nurse educator must recognize that learners need to be immersed in activities to help them develop problem-solving skills. In today’s world, professionals must have the abil- ity to identify both patient and system needs by searching and sorting data, uncovering prob- lems, and finding solutions. Increasingly, they are expected to work within interdisciplinary teams to determine and implement solutions to healthcare problems. Learning activities, in turn, must be designed to help nursing staff members and students develop critical- thinking and collaborative skills.

Patients, especially those with chronic conditions, also need problem-solving skills to know how to respond to the flexibility de- manded by their condition. What should they do differently on a sick day? What constitutes an emergency? Patients and their families need more than just low-level cognitive information to make the needed adjustments in their lives. To help them develop the necessary problem- solving skills, the educator must devise and

it is delivered in a dry and dull monotone, it will likely fall on deaf ears.

The educator should try to vary the qual- ity and pitch of his or her voice, use a vari- ety of gestures and facial expressions, change position if necessary to make direct and fre- quent eye contact with everyone in the group, and demonstrate an ardent interest in the topic to attract and fascinate an audience. The en- thusiastic educator is aware that an energetic attitude is contagious and enticing. However, one must exercise caution regarding overuse of body language and overt actions because man- nerisms can be distracting and can adversely affect learning.

Include Humor Many educators use humor as a technique to grab, arouse, and maintain the attention of the learner. Appropriate humor can help establish a rapport with learners by humanizing the ed- ucator. Humor does not necessarily require the educator to tell jokes, and joke telling should not be attempted if this is not a skill an educa- tor possesses. Furthermore, the educator should avoid making someone the object of humor if it results in a put-down.

Humor establishes an atmosphere that al- lows for human error without embarrassment and encourages freedom and comfort to explore alternatives in the learning situations. Humor is a means to reduce anxiety when dealing with sensitive material, to provide poignant exam- ples of everyday life experiences, and to rein- force information.

Exhibit Risk-Taking Behavior Effective educators are willing to develop exer- cises in which many variables can lead to any number of possible outcomes. They use this technique to encourage learners to reach their own conclusions about controversial issues. Regardless of the outcome, educators should be prepared to deal with uncertainty. Exercises that allow learners freedom to experiment and

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infection understand in concrete terms how his body is working to heal itself.

Use Technology Innovative educators use technology to broaden and add variety to the opportunities for teach- ing and learning. They continue to increase the level of their own skills by taking advantage of the advances in technology to introduce and coach others in new ways of learning. They rec- ognize that the sophisticated use of technology is a primary skill that will be needed for educa- tional programs of the future.

The use of different types of technology as- sists the educator in helping learners meet their individual needs and styles of learning. Technol- ogy has the potential for making the teaching– learning process more convenient, accessible, and stimulating. Effective educators must be future oriented. A mastery of technological skills ensures that they will possess the ability to teach in innovative and eclectic ways to pre- pare students for learning in the 21st century.

General Principles for Teaching Across Methodologies No matter which teaching method is chosen to reach the intended learner(s) and to accomplish the behavioral objectives set forth, it is import- ant to consider some basic rules that will en- hance the teaching–learning experience. The following, in no order of priority, are some of the key principles that educators should adhere to when teaching patients and their significant others (Bradshaw & Lowenstein, 2013; Crandell et al., 2012; Falvo, 2010; Miller & Stoeckel, 2016; Phillips, 1999; Snowman & McCown, 2015).

Give Positive Reinforcement Educational research clearly indicates the effects of positive reinforcement on learning. Acknowl- edging ideas, actions, and opinions of others by using words of praise or approval, such as “That’s a good answer,” “I agree with you,” and “You have a very good point,” or using nonverbal

orchestrate opportunities that challenge learn- ers to critically analyze situations as well as sup- port learners in exploring possible alternative solutions to meet their needs.

Serve as a Role Model Educators should constantly seek out new infor- mation by keeping abreast of current research, theories, and issues in clinical practice for ap- plication relevant to the teaching situation. By expanding their own knowledge base, educators give credence to what they teach and gain the confidence of learners in the educator’s exper- tise. A commitment to lifelong learning trans- mits an important value to others regarding their own need to pursue continuous personal or professional development.

Educators are viewed as credible role mod- els when they are actively engaged in scholarly activities, are experienced in the field, and have advanced credentials to teach complex skills. The believability of a role model is greatly af- fected by the values displayed and the congru- ence demonstrated between what the educator says and does (Miller & Stoeckel, 2016). If the learners regard the behavior of the creative ed- ucator as desirable, they will likely imitate that behavior, which they perceive as eliciting pos- itive effects.

Use Anecdotes and Examples The creative educator uses stories and examples of incidents and episodes to illustrate points. Anecdotes, whether amusing, alarming, sad, or anger provoking, may be valuable in driv- ing a point home, clarifying a topic under dis- cussion, or helping someone better relate to an issue. The educator can reinforce the learning principle that simple representations can assist the learner to grasp complex ideas by using ex- amples relevant to past experiences. The knowl- edge base of learners helps them identify and connect in a concrete way with the material be- ing taught. For example, using the analogy of po- lice cells (lymphocytes) fighting against outlaw cells (bacteria) can help a child with a serious

Increasing Effectiveness of Teaching 491

which serves as an invitation for them to learn. When the educator exercises patience and sen- sitivity with respect to age, race, culture, and gender, this attitude projects an acceptance of others, which serves to establish a rapport and opens avenues of communication for the shar- ing of ideas and concerns.

People learn better in a comfortable and supportive environment. Not only is it import- ant that the physical environment be condu- cive to learning, but the psychological climate also should be respectful of learners and fo- cused on their need for an atmosphere of sup- port and acceptance. Educators must have a clear view of their role as facilitators and ex- pert coaches and avoid acting as controlling givers of information.

Be Organized and Give Direction Excellent discussions, meaningful experiences in role play, and successful attempts at self-study are examples of teaching that do not happen by accident. Instead, they result from hours of skilled preparation, careful planning, and orga- nization, all of which allows the learner to stay focused on the objectives. Teaching should be logically organized, objectives clearly defined and presented up front, and directions given in a straightforward, specific, and easily under- stood manner. Audiovisual materials selected to supplement various methods of teaching should clarify or enhance a message.

Teaching sessions should be relatively brief, so as not to overload the learner with too much detail and extraneous content. Regardless of the teaching method used, the attention span of the learner waxes and wanes over time, and what is learned first and last is retained the most (Ley, 1972). Need-to-know information should take precedence over nice-to-know information, thereby ensuring that enough time is allotted to cover the essentials. As Kessels (2003) has clearly documented, “40–80% of medical infor- mation provided by healthcare practitioners is forgotten immediately. The greater the amount

expressions of acceptance, such as smiling, nod- ding, or a reassuring pat on the back, encour- ages learners to participate more readily or try harder to improve their performance. Reward- ing even a small success can instill satisfaction in the learner. Positive reinforcement, in the form of recognition, tangible rewards, or opportuni- ties, should closely follow the desired behavior. The clearer the correlation between the desired behavior and the reward, the more meaning- ful the reinforcement. Criticism, on the other hand, dampens motivation and causes learn- ers to withdraw.

A powerful incentive is to ask learners to share their experiences with others. In a group, it is important to recognize the contributions of each member rather than to focus primar- ily on the more aggressive learner or high achiever. What constitutes positive reinforce- ment for one individual may not suffice for an- other, because rewards are closely tied to value systems. Also, the quantity of reinforcement varies in its effectiveness from one individual to another. A small amount of praise can have a strong effect on the learner who is not used to succeeding, whereas significant praise may be relatively ineffective for a consistently high achiever. In addition, an incentive that works for a learner at one time may not work well at another time depending on the circumstances.

Project an Attitude of Acceptance and Sensitivity The ease with which educators conduct them- selves, the willingness to receive and answer questions, the simple courtesies extended, and the responsiveness demonstrated toward an audience are all actions that set the tone for a friendly, warm, and receptive atmosphere for learning. If the educator exhibits self- confidence and self-respect, the learner will feel comfortable, confident, and secure in the learn- ing environment. If the educator comes across as believable, trustworthy, considerate and compe- tent, he or she helps to put the audience at ease,

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Whether positive or negative, verbal or nonver- bal, feedback enables the educator to determine whether he or she should maintain or modify his or her approach to teaching. Feedback in- dicates whether to proceed, take time to review or explain, or cease instruction altogether for the moment.

The educator should be direct in requesting feedback from the learners by asking questions such as “What questions do you have?” “How clear is this to you?” “What needs to be explained further?” or “What more can I help you with?” In addition, the educator should be sensitive to nonverbal expressions such as a nod, a smile, a look of bewilderment, or a frown indicating an understanding or lack thereof.

Feedback is neutral unless it is compared with established norms, preset criteria, or past behavior. How much someone learned, for example, is meaningless unless compared to what the person knew previously or how the person stacks up against other learners under similar conditions.

Feedback, either positive or negative, is needed by both the learner and the teacher. Praise rein- forces behavior and increases the likelihood that the behavior will continue. Constructive criti- cism tends to redirect behavior to conform to expected norms. Labeling someone’s personality as cooperative, smart, stubborn, unmotivated, or uncaring is harmful, but it is helpful to label someone’s performance as excellent or in need of further practice to give that person specific information for improving, correcting, or con- tinuing the behavior.

Use Questions Questioning is a means by which both the edu- cator and the learner can elicit feedback about performance. If the educator is skillful in the use of questioning, it serves multiple purposes in the teaching–learning process. Questions may help to clarify concepts, assess what the learner already knows about the topic, stimu- late interest in a new subject, or evaluate the

of information presented, the lower the pro- portion correctly recalled; furthermore, almost half of the information that is remembered is incorrect” (p. 219).

Advance organizers—that is, topic head- ings that clue the learner into what will be pre- sented and help focus the learner’s attention on the message—should be used to structure in- formation. These headers assist the learner in identifying the subject to be addressed and an- ticipating in which order the information will be presented.

Elicit and Give Feedback Feedback should be a two-way process. It is a strategy to give information to the learner as well as to receive information from the learner. Both the educator and the learner need to seek infor- mation about the quality of their performance. Feedback should be encouraged during and at the end of each teaching–learning encounter as well as at the completion of an educational program. It can take the form of either verbal or nonverbal responses to a situation.

Feedback that learners receive can be subjec- tive or objective. Subjective data, whether physi- ological or psychological, come from within the learners themselves. People sense how they are reacting to a situation. Internally, they usually know how well they performed or how they feel by their own responses, such as fatigue, anxi- ety, disinterest, or satisfaction. Feedback allows learners to compare their own performance to what they expect of themselves or what they think others expect of them.

Objective data come to learners from the educator, who measures their behavior based on a set of standards or criteria and who gives them an opinion on the progress they have made. To get feedback, the learner might ask, “How well did I do?” “Am I on track?” “Did I do all right?” or “What do you think?”

Feedback to the educator is equally import- ant, because the effectiveness of teaching de- pends to a large extent on the learners’ reactions.

Increasing Effectiveness of Teaching 493

the learner to think about the answer before re- sponding. In a group, this strategy also allows all participants to have a chance to think through their responses to the questions, which gives them the opportunity to make more thought- ful and deliberate responses. How long an ed- ucator should wait for a response depends on many variables, such as how complex the ques- tion is, who the learners are, and what they are expected to know. Wait time is a matter of judg- ment on the part of the educator.

Questioning helps the educator appropri- ately pace the material being presented. Also, answers to questions allow the educator to ar- rive at an evaluative judgment as to the prog- ress the learner is making in the achievement of the behavioral objectives.

Use the Teach-Back or Tell-Back Strategy Many patients who have been taught about their health problem, how to prevent disease, or how to follow recommended treatment reg- imens to promote or maintain their health do not always fully and accurately understand the information that has been given to them. When patients are asked to explain what they have been told by their nurse or other health- care provider, it becomes evident that for vari- ous reasons there are many gaps and errors in the information they interpreted and remem- bered (Floyd, Lang, McCord, & Keener, 2004; Kessels, 2003; Ley, 1972, 1979).

Thus, nurses who teach patients using var- ious teaching methods and instructional ma- terials must assess how well and how much patients understood the information given to them before they are expected to independently care for themselves. It is important that educa- tors ask patients to restate in their own words what they learned to confirm their retention of information and the effectiveness of the patient education interventions. A key strat- egy to determine the extent of patients’ un- derstanding following each patient education

learner’s mastery of the predetermined behav- ioral objectives.

Miller and Stoeckel (2016) identify three types of questions that can be used to elicit dif- ferent types of answers:

1. Factual or descriptive questions be- gin with words such as who, what, which, where, how, or when and ask for recall-type responses from the learner. Factual questions such as “Which foods are high in fat?,” “Who should you call if you run out of medication?,” or “How often on av- erage do you use your inhaler?” elicit straightforward facts. Descriptive questions take a more open-ended approach, such as “Which kinds of exercise do you get daily?,” “What problems do you have with activi- ties of daily living?,” or “What are the signs and symptoms of infection?” These questions require a more de- tailed and organized response from the learner.

2. Clarifying questions ask for more information and help the learner to convey thoughts and feelings. Such questions might include “What do you mean when you say . . .?” or “When do you feel most anxious?”

3. Higher order questions require more than memory or perception to an- swer. They ask the learner to draw conclusions, establish cause and ef- fect, or make comparisons. Exam- ples include “Why does a low-salt diet help to control blood pressure?,” “What do you think will happen if you don’t take your medication?,” and “What do you see as the advan- tages and disadvantages in following the treatment plan?”

After asking questions, a period of silence may occur. This gap can be uncomfortable for both the educator and the learner. Educators can reduce anxiety over silence by encouraging

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learner population. For further information on teaching styles from Concordia University, see http://education.cu-portland.edu/blog/teaching -strategies/5-types-of-classroom-teaching-styles/.

Use Repetition and Pacing Repetition, if used in the right amount, is a tech- nique that strengthens and reinforces learning by aiding in the retention of information (Will- ingham, 2004). If overused, however, repetition can lead to boredom and frustration because the educator is repeating what is already understood and remembered. If used carefully, it can assist the learner in focusing on important points and can help to keep the learner on track.

Repetition is especially important when pre- senting new or difficult material. The opportu- nity for repeated practice of behavioral tasks is called skill inoculation. Repetition can take the form of a simple reminder, a review of previously learned material, or the continued practice of a skill. Assessing if the learner understands helps educators use repetition effectively.

Pacing refers to the speed at which informa- tion is presented. Some self-instruction methods of teaching, such as programmed instruction, allow for individualized pacing so that learners can move along at their own speed, depending on their abilities and style of learning. Other methods, such as group learning, require the educator to take command of the rate at which information is presented and processed.

Many factors determine the optimal rate of teaching, such as the following:

■ Learner’s previous history with learning ■ Attention span of the learner ■ The domain and level of domain in which

learning is to take place ■ The learner’s eagerness and determination

to obtain a reward or attain a goal ■ The degree of progress in learning ■ The learner’s ability to cope with frustra-

tion and discomfort

Keeping in touch with the audience helps educators pace their teaching. It should be slow

encounter is known as the teach-back, tell- back, closing the loop, or show me approach to evaluate learning.

This specific teaching method is patient and family centered and results in improved nurse– patient communication, increased patient sat- isfaction with care, improved quality of care, decreased healthcare costs, and the opportu- nity to assess patient health literacy (Fidyk et al., 2014; Jager & Wynia, 2012; Kandula, Malli, Zei, Larson, & Baker, 2011; Nigolian & Miller, 2011; Xu, 2012). It also has been shown to decrease average lengths of hospital stay and readmission rates (Fidyk et al., 2014). Multiple studies have demonstrated that patients prefer and perceive the teach-back, tell-back, or show me strategy because they find it most effective for learning (Hyde & Kautz, 2014; Kemp et al., 2008).

Know the Audience The effectiveness of teaching can be severely limited when the choice of teaching method is based only on the interest and comfort level of the educator and not on the assessed needs of the learner. Educators must use methods that match the topic rather than their own person- ality (Glenn, 2009).

Most educators have a preferred style of teaching and tend to rely on that approach re- gardless of the content to be taught. Nurses skilled at teaching, however, adapt themselves to a teaching method appropriate to the subject matter, setting, and various styles of the learn- ers. Flexibility is their hallmark in tailoring the instructional design to the unique needs of each population of learners. All educators should be willing to use a variety of teaching methods to provide the best possible experience for achieve- ment of objectives. Because different styles of teaching exist, it is possible for teachers to con- duct a personal inventory (self-evaluation) of a teacher’s strengths and weaknesses so that a spe- cific teaching style can be integrated with effec- tive classroom management skills. In that way, teachers can determine what fits best with their personalities, the content to be taught, and their

Increasing Effectiveness of Teaching 495

have become increasingly varied in terms of the types of learners encountered, their spe- cific learning needs, and the settings in which healthcare teaching occurs. Because health ed- ucation has become an increasingly important responsibility of nurses in all practice environ- ments, it is important to acknowledge the var- ious settings where clients, well or ill, may be consumers of health care.

Settings for teaching are classified accord- ing to the need for health education in relation- ship to the primary purpose of the organization or agency that provides health instruction. These settings are defined as any place where nurses engage in teaching for disease prevention, health promotion, and health maintenance and reha- bilitation. They comprise any environment in which health education takes place to provide individuals with learning experiences to improve their health or reduce their risk for illness and injury. O’Halloran (2003) identified three types of settings for the education of clients:

1. A healthcare setting is one in which the delivery of health care is the primary or sole function of the institution, organization, or agency. Hospitals, visiting nurse home care associations, public health depart- ments, outpatient clinics, extended- care facilities, health maintenance or- ganizations, physicians’ offices, and therapist-owned and -managed cen- ters are some examples of organiza- tions whose primary purpose is to deliver health care. Health education is a part of the overall care delivered within these settings. Nurses func- tion to provide direct client care in this setting, and their role encom- passes the teaching of clients as part of that care.

2. A healthcare-related setting is one in which healthcare-related ser- vices are offered as a complementary function of the agency. Examples of this type of setting include the American Heart Association, the

enough to allow learners to absorb the informa- tion presented yet fast enough to maintain their interest and enthusiasm.

Summarize Important Points Summarizing information at the completion of the teaching–learning session gives a perspec- tive on what has been covered, how it relates to the objectives, and what the educator expects the learner to have achieved. Summarizing also reviews key ideas to instill information in the mind and helps the learner to see the parts of a whole. Closure should be achieved at the end of one lesson before proceeding to a new topic. Summary reinforces retention of information. It also provides feedback as to the progress made, thereby leaving the learner with a feeling of sat- isfaction with what has been accomplished.

▸ Settings for Teaching Traditionally, the primary focus of nursing practice has been on the delivery of acute care in hospital settings. In recent years, however, the practice of nursing in community-based settings has experienced tremendous growth. The reasons for the shift in orientation of nurs- ing practice from inpatient to outpatient care sites relate to the trends affecting the nation’s healthcare system in its entirety. These trends include public and private reimbursement pol- icies, changing population demographics, ad- vances in healthcare technology, an emphasis on wellness care, and increased consumer inter- est in health. In response to these trends, nurs- ing practice has broadened its focus to include a greater emphasis on the delivery of care in com- munity settings, such as homes, clinics, health maintenance organizations, physicians’ offices, public schools, and the workplace.

With the increased focus on prevention, promotion, and independence in self-care activ- ities, today’s newly emerging healthcare system mandates the education of consumers more than ever before. Opportunities for client teaching

496 Chapter 11 Teaching Methods and Settings

accomplished. The role and functioning of the nurse are affected differently by these compo- nents in each of the identified settings.

Nurses must recognize the numerous op- portunities available for the teaching of those individuals who are currently or potentially consumers of health care. Given that teach- ing is an important aspect of healthcare deliv- ery and that nurses function as teachers in a multitude of settings, they will inevitably en- counter clients of differing ages and at various stages along the wellness-to-illness continuum. Wherever and whenever teaching takes place, nurses need to recognize the importance of consciously applying the principles of teach- ing and learning to these encounters for max- imum effectiveness in helping clients to attain and maintain optimal health.

Sharing Resources Among Settings Professional nurses involved in client health ed- ucation should use available opportunities to share resources among the three identified set- tings (FIGURE 11-2). Many already perform this service, as printed or audiovisual materials are borrowed, rented, or purchased for small fees from area institutions, organizations, or agencies; nurse educators from healthcare or healthcare- related settings are contracted for or voluntarily provide health education programs to small and large groups in another setting; and nurses from each category of setting collaborate on in- dividual client situations or on major commu- nity health projects.

Nurses from each of these settings can es- tablish a health education committee in their community to coordinate health education pro- gramming, ensure effective use of all resources, and reduce duplication of efforts. The mem- bers of this committee can develop standard- ized health education content, delineate roles and services for each of the teaching settings, and share resources to provide a well-planned, comprehensive community program of health education for a wide spectrum of clients.

American Cancer Society, the Amer- ican Arthritis Association, and the Muscular Dystrophy Association. These organizations provide client advocacy, conduct health screenings and self-help groups, distribute health education information and materials, and support research on disease and lifestyle issues for the benefit of consumers within the community. Education on health promotion, disease prevention, and improving the quality of life for those who live with an illness or disability is the key function of nurses within these agencies.

3. A nonhealthcare setting is one in which health care is an incidental or supportive function of an organization. Examples of this type of setting include businesses, industries, schools, and military and penal institutions. The primary purpose of these organiza- tions is to produce a manufactured product or offer a non-health-related service to the public. Industries, for example, are involved in health care only to the extent of providing health screenings and non-emergency health coverage to their employees through a health office within their place of employment, making available instruction in job-related health and safety issues to meet Occupational Safety and Health Administration (OSHA) regulations, or providing opportunities for health education through wellness programs to reduce absenteeism or improve employee health status and morale.

Classifying teaching settings in which the nurse functions as educator provides a frame of reference through which to better understand the interrelationship between the components of the organizational climate, the target audi- ence, and the resources within the environ- ment influencing the educational tasks to be

Settings for Teaching 497

clients. The determination of effects by type of educational intervention was hampered by inadequate descriptions of the interventions. Another problem was the fact that the inter- ventions comprised more than one educational method. Cooper et al.’s conclusion was that effect by educational approach could not be differentiated. Some evidence suggested that didactic and psychosocial strategies produced smaller outcome effects than a combination of behavioral, cognitive, and affective therapies.

Deakin et al. (2005) systematically re- viewed 11 studies of group-based, patient- centered educational programs for people with type 2 diabetes to assess the effects on clini- cal, lifestyle, and psychosocial outcomes. This review provided evidence that group-based diabetes education programs for adults with type 2 diabetes resulted in improvements in glycated hemoglobin, fasting blood glucose, and diabetes knowledge when monitored at 4–6 months and at 12 months.

In addition, Deakin et al. (2005) recom- mended more research on the theoretical models underpinning the educational programs. Some

▸ State of the Evidence Education of patients and their families is very complex. They present with a wide variety of chronic and acute illnesses, financial resources, developmental stages, cultural values, reading abilities, learning styles, motivation levels, and social support. Nursing students and staff dif- fer widely in terms of their own educational and experiential backgrounds and also are in- fluenced by generation gaps. This reality makes it difficult to generalize the results of research studies. In addition, it is difficult in some of the literature to analyze the cause-and-effect rela- tionship between the teaching method used and the outcomes achieved. This, in turn, be- comes more challenging when the goal is to compare studies.

Cooper et al. (2001) critically reviewed 12 meta-analysis studies concerning patient education for people with chronic diseases where the treatment regimen required be- havior change. In their review, they sought to determine which types of educational inter- ventions produced the most benefit for these

FIGURE 11-2 Examples of settings for health teaching. Reproduced from O’Halloran, V. E. (2003). Instructional settings. In S. B. Bastable (Ed.), Nurse as educator: Principles of teaching and learning for nursing practice (2nd ed., pp. 465–492). Sudbury, MA: Jones and Bartlett Publishers.

HEALTH- CARE

SETTING

HEALTH- CARE-

RELATED SETTING

NON- HEALTH-

CARE SETTING

Diabetic Club Planned Parenthood of America

Businesses

Schools YMCAs/YWCAs

Shelters Church Associations Sheltered Workshops Professional Associations Senior Centers PTAs Military and Govern- mental Groups Social/Civic Groups

Outpatient Clinics HMOs VNAs Hospitals Wellness Centers

SHARED RESOURCES Staff

Facilities Instructional Materials

Emergency Care Centers Nurse Managed Centers Surgery Centers Physician Offices Diagnostic Centers

Alzheimer's Association American Cancer Society American Heart Association Leukemia Society of America Muscular Dystrophy Association Arthritis Foundation American Lung Association Head Injury Support Group

498 Chapter 11 Teaching Methods and Settings

consideration the learner characteristics, the behavioral objectives, the educator’s character- istics, and available resources prior to select- ing and using any of the vast array of methods at the educator’s disposal.

In many instances, guidelines were put forth to assist educators in planning and developing their own teaching activities. In addition, the major questions to be considered when evalu- ating the effectiveness of teaching methods were assessed in detail. Finally, some general princi- ples to increase the effectiveness of all teaching methods were discussed.

What must be stressed are the qualities spe- cific to each method and the fact that no one method is better than another. The effectiveness of any method depends on the purpose for and the circumstances under which it is used. Nurses in the role of teachers are urged to take differ- ent approaches to teaching rather than rely on any one method. Varying the teaching methods or using methods in combination with one an- other can assist educators in accomplishing the objectives for learning while meeting the differ- ent needs and styles of every learner.

Multisensory stimulation is best for in- creasing the acquisition of skills and the reten- tion of information. Research regarding patient, staff, and student education is increasing. It is imperative that nurse educators demonstrate a willingness to make decisions about choosing and using teaching methods based on the evi- dence that is emerging as to the most effective ways to teach in relation to learner and situa- tional variables.

Review Questions 1. How is the term teaching method defined? 2. What are the advantages and limitations

of each teaching method? 3. Which teaching methods are most effec-

tive in encouraging active participation by the learner?

4. Which teaching methods are best for learning cognitive skills? Psychomotor skills? Affective skills?

of the studies suggested that group education is more effective if based on adult learning princi- ples, patient empowerment, and participation. The authors also commented on the need for more research to determine whether this type of program is appropriate for all ethnic back- grounds. Cost-effectiveness was included un- der their implications for future research, which is an especially important factor to be consid- ered in the current resource-constrained health- care environment.

The difficulty with measuring the effec- tiveness of different teaching methods is that many studies do not make a distinction be- tween teaching methods and instructional ma- terials (tools), such as the study conducted by Dougal and Gonterman (1999) and Friedman et al. (2011). Instead, the authors treat them as one and the same—which means that the studies’ findings cannot be compared or ap- plied as evidence in this chapter, which deals exclusively with methods of teaching. Chap- ter 12 addresses instructional materials as a separate entity.

Many empirical studies and expert reviews have focused on the effectiveness of the vari- ous teaching methods available to educate dif- ferent patient, student, and staff populations, and this chapter discusses selected reports. Further research needs to be conducted on specific populations in relation to effective- ness of teaching methods for reaching vari- ous audiences about selected topics they need to learn. For example, what is the most effec- tive and efficient method to teach healthcare consumers about important safety behaviors for optimal self-care management?

▸ Summary This chapter presented an in-depth review of the various teaching methods and com- pared the advantages and limitations of each approach. Also, it briefly addressed the set- tings in which teaching takes place. Empha- sis was given to the importance of taking into

499Review Questions

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CASE STUDY A well-known university in the Boston area offers programs in nursing, occupational therapy, physical therapy, athletic training, and exercise physiology. These programs attract a diverse group of students from all over the nation and abroad. Professors at the university meet before the school year to discuss the challenges and opportunities awaiting the incoming entry-level graduate students in their healthcare profession disciplines. One professor remarks, “This is a very eclectic group of students in terms of age, professional experience, ethnicity, and cultural background. I am not sure how to stimulate group interaction in a class with such diversity.” The faculty members discuss various teaching methods they have used to facilitate empathy and understanding in groups of students. Mary comments, “I tried role play once for team building, but it didn’t seem to work too well. Was role play a bad choice? Which other teaching approaches can be used to actively engage these students?”

1. Discuss the advantages and limitations of the teaching method of role play to facilitate group cohesiveness.

2. If professors want to encourage learners to actively participate in their courses, which other teaching methods can they select?

3. An evaluation of any educational program is vitally important to determine the effectiveness of the teaching method(s) used. Which five major questions should be asked to determine if a teaching method was appropriate?

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settings for teaching?

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KEY TERMS

instructional materials characteristics of the learner characteristics of the medium characteristics of the task delivery system

realia illusionary representations symbolic representations tailored instruction replica

analogue symbol audiovisual materials multimedia learning blended learning

Instructional Materials Diane Hainsworth Kara Keyes

CHAPTER HIGHLIGHTS

■ General Principles ■ Choosing Instructional Materials ■ The Three Major Components of Instructional Materials

• Delivery System • Content • Presentation

■ Types of Instructional Materials • Written Materials • Demonstration Materials • Audiovisual Materials

■ Evaluating Instructional Materials ■ State of the Evidence

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CHAPTER 12

OBJECTIVES

After completing this chapter, the reader will be able to

1. Differentiate between instructional materials and teaching methods. 2. Discuss general principles that apply to all types of instructional materials. 3. Identify the three major variables (learner, medium, and task characteristics) to be considered

when selecting, developing, and evaluating instructional materials. 4. Cite the three components of instructional materials required to effectively communicate

educational messages. 5. Identify the many types of instructional materials—printed, demonstration, and audiovisual

media—available for client and professional education. 6. Describe the general guidelines for development of printed materials. 7. Analyze the advantages and disadvantages specific to each type of instructional material. 8. Evaluate the type of materials suitable for instruction depending on such variables as the size of

the audience, the resources available, and the characteristics of the learner. 9. Identify where instructional materials can be found.

10. Critique instructional materials for value and appropriateness. 11. Recognize the supplemental nature of instructional materials in client, staff, and student

education.

Whereas teaching methods are the ap-proaches the nurse uses to deliver education, instructional materi- als are the objects or vehicles by which infor- mation is communicated. Often these terms are used interchangeably and are frequently referred to in combination with one another as teaching strategies and techniques. Nevertheless, teaching methods and instructional materials are not the same, and a clear distinction can and should be made between them. Teaching methods are the way information is taught. Instructional materi- als, which include printed, demonstration, and audiovisual media, are the tools used to enhance teaching and learning. How effective these mul- timedia approaches are must be based on the- ory about the way people learn, on studies that examine the effects of each tool on the learner, and on evidence from practice (Mayer, 2014).

Instructional materials are the tools and aids used to transmit information that supple- ment, rather than replace, the act of teaching and the role of the nurse as educator. These ma- terials by which information is shared with the learner must be examined closely because they

represent an important aspect of the education process. Given the numerous factors affecting both the teacher and the learner, such as the in- crease in nursing staff workloads, the decrease in length of inpatient stays or outpatient visits, the increase in patient acuity, the alternative settings in which education is now delivered, the varied learner characteristics and preferences, and the shrinking resources for educational services, it is imperative that the nurse educator under- stand the various types of printed, demonstra- tion, and audiovisual materials available to help nurses teach efficiently and effectively.

Instructional materials provide the nurse educator with tools to deliver education mes- sages creatively, clearly, accurately, and in a timely manner. They help the educator reinforce infor- mation, clarify abstract concepts, and simplify complex messages. Multimedia resources serve to stimulate a learner’s senses as well as add va- riety, realism, and enjoyment to the teaching– learning experience. They have the potential to assist learners not only in acquiring knowledge and skills but also in retaining more effectively what they learn. Research indicates that a variety

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of printed, demonstration, and audiovisual ma- terials do, indeed, enhance teaching and learn- ing (Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011).

This chapter provides an overview of how to select, develop, implement, and evaluate in- structional materials. The advantages and dis- advantages of the various types of instructional materials are discussed. The choice of one or more of them often depends on availability and cost. This chapter is intended to assist nurse educators to make informed decisions about choosing and using appropriate instructional materials that fit the learner, that affect the mo- tivation of the learner, and that accomplish the expected learning outcomes. Whether nurses educate patients and their families, nursing staff, or nursing students, the same principles apply in making decisions about the type of materials selected for instruction.

▸ General Principles Before selecting or developing instructional materials from the many available options, nurse educators should be aware of the follow- ing general principles regarding the effective- ness of these tools:

■ The teacher must be familiar with the con- tent and mechanics of a tool before using it.

■ Printed, demonstration, and audiovisual materials can change learner behavior by influencing cognitive, affective, and psy- chomotor development.

■ No one tool is better than another to en- hance learning because the suitability of any particular instructional material depends on many variables.

■ Instructional materials should complement, reinforce, and supplement—not substitute for—the nurse educator’s teaching efforts.

■ The choice of material should match the content and the tasks to be learned.

■ The instructional material(s) selected should match available financial resources.

■ Instructional aids must be appropriate for the physical conditions of the learning en- vironment, such as the number of learners, the space, the lighting, the sound projection, and the hardware (delivery mechanisms) used to display information.

■ Instructional materials should match the sensory abilities, developmental stages, and educational level of the learners.

■ The messages conveyed by instructional materials must be accurate, up to date, appropriate, unbiased, and free of any unintended content.

■ The tools used should contribute in a meaningful way to the learning situation by adding or clarifying information.

▸ Choosing Instructional Materials

Nurse educators must consider many important variables when selecting instructional materi- als. The role of the nurse educator goes beyond the giving of information only; it also involves skill in designing and planning for instruction. Learning can be made more enjoyable for both the learner and the teacher if the nurse educator knows which instructional materials are avail- able, as well as how to choose and use them to best enhance the teaching–learning experience.

Knowledge of the different instructional materials available and their appropriate use helps nurses make education more interesting, challenging, and effective for all types of learn- ers. With current trends in healthcare reform, educational strategies to teach patients need to include instructional materials for health promotion, illness prevention, health main- tenance, and rehabilitation.

Making appropriate choices of instructional materials depends on a broad understanding of three major variables: (1) characteristics of the learner, (2) characteristics of the me- dium, and (3) characteristics of the task to be achieved (Frantz, 1980). A useful mnemonic for

Choosing Instructional Materials 507

remembering these variables is LMAT—stand- ing for learner, medium, and task.

1. Characteristics of the learner. Many variables are known to influence learning. Nurse educators, therefore, must know their audience so that they can choose those tools best suited to the needs and abilities of various learners. They must con- sider sensory and motor abilities, reading skills, motivational levels (locus of control), developmental stages, learning styles, gender, so- cioeconomic characteristics, and cultural backgrounds.

2. Characteristics of the medium. A wide variety of media—printed, demonstra- tion, and audiovisual—are available to enhance teaching methods. Print materials are the most common form through which information is com- municated, but demonstration tools and nonprint media, which include a large range of audio and visual possibilities, are popular and useful choices. Because no single medium is more effective than all other options, the educator should be flexible in considering a multimedia approach to complement methods of instruction.

3. Characteristics of the task. Identifying the type of learning domain (cogni- tive, affective, and/or psychomotor), as well as the complexity of behaviors to be achieved to meet identified objectives, defines the task(s) that must be accomplished.

▸ The Three Major Components of Instructional Materials

Depending on the teaching methods chosen to communicate information, educators must

decide which instructional materials are poten- tially best suited to assist with the process of teach- ing and learning. The delivery system (Weston & Cranston, 1986), content, and presentation (Frantz, 1980) are the three major components that educators should keep in mind when select- ing print and nonprint materials for instruction.

Delivery System The delivery system includes both the software and the hardware used in presenting informa- tion. For instance, the educator giving a lecture might choose to enhance the information being presented by using PowerPoint slides (software) delivered via a computer (hardware). The con- tent on DVDs (software), in conjunction with a DVD player (hardware), and CD-ROM programs (software), in conjunction with computers (hard- ware), are other examples of delivery systems.

The choice of the delivery system is influ- enced by the number of learners to be taught at one time, the pacing and flexibility needed for the effective delivery of information, and the sensory aspects most suitable to an individual patient or group. More recently, the geograph- ical distribution of the audience has emerged as a significant influence on choice of delivery systems, given the popularity of distance edu- cation modalities.

Content The content (intended message) is independent of the delivery system and is the actual informa- tion being communicated to the learner. When selecting instructional material(s), the nurse ed- ucator must consider several factors:

■ The accuracy of the information being conveyed. Is it up to date and accurate?

■ The appropriateness of the medium to convey the chosen information. Pamphlets, posters, and podcasts, for example, can be very useful tools for sharing information to change behavior in the cognitive or affective domain but are not ideal for skill develop- ment in the psychomotor domain. Videos

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as well as real equipment or models with which to perform demonstrations and return demonstrations are much more effective tools for learning psychomotor behaviors.

■ The appropriateness of the readability level of materials for the learner(s). Is the content written at a literacy level suitable for the learner’s reading and comprehension abil- ities? The more complex the task, the more important it is to write clear, simple, succinct instructions enhanced with illustrations so that the learner can understand the content.

Presentation The form of the message is a very important com- ponent for selecting or developing instructional materials. However, a consideration of this as- pect of any tool is frequently ignored. Weston and Cranston (1986) describe the form of the message as occurring along a continuum from concrete (real objects) to abstract (symbols).

Realia Realia (the condition of being real) refers to the most concrete form of stimuli that can be used to deliver information. For instance, a woman demonstrating breast self-examination is the most concrete example of reality. Because this form of presentation might be less acceptable for a wide range of teaching situations, the next best choice would be a manikin. Such a model, which is similar in appearance to a human fig- ure, has many characteristics that simulate reality, including size and three dimensionality (width, breadth, and depth), but without being the true figure that may very well cause embarrassment for the learner. The message is less concrete, yet using an imitation of a person as an instructional tool allows for an accurate presentation of in- formation to stimulate the learners’ perceptual abilities. Further along the continuum of realia is a video presentation of a woman performing breast self-examination. The learner could still visualize a breast self-examination done accu- rately, but the aspects of only two types of di- mensionality are present (depth is absent) in a

video format. Thus, the message becomes less concrete and more abstract.

Illusionary Representations Illusionary representations is a term that applies to a less concrete, more abstract form of stimuli through which to deliver a message, such as moving or still photographs, audiotapes projecting true sounds, and real-life drawings. Although many realistic cues, such as dimen- sionality, are missing, this category of instruc- tional materials has the advantage of offering learners a variety of real-life visual and auditory experiences to which they might otherwise not have access or exposure because of such factors as location, availability, or expense. For example, pictures that show how to stage decubitus ulcers and audiotapes that help learners discriminate between normal and abnormal lung sounds, al- though more abstract in form, do to some de- gree resemble or simulate realia.

Symbolic Representations Symbolic representations is a term that refers to the most abstract types of messages, though they are the most common form of instructional ma- terials to communicate information. These types of representations include numbers and letters of the alphabet, symbols that are written and spo- ken as words that convey ideas or represent ob- jects. Audiotapes of someone speaking, graphs, written texts, handouts, posters, flip charts, and whiteboards on which to display words and images are vehicles to deliver messages in symbolic form. The chief disadvantage of symbolic representations is that they lack con- creteness. The more abstract and sophisticated the message, the more difficult it is to compre- hend. Consequently, symbolic representations may be inappropriate as instructional materi- als for learners who are very young, from dif- ferent cultures, or who have significant literacy problems or cognitive and sensory impairments.

When making decisions about which tools to select to best accomplish teaching and learning objectives, the nurse educator should carefully

The Three Major Components of Instructional Materials 509

■ Becoming more widely available in langu- ages other than English due to the recognition of significant cultural and ethnic shifts in the general population.

■ Suitable for large numbers of learners who prefer reading as opposed to receiving messages in other formats.

■ Flexible in that the information is absorbed at a speed controlled by the reader.

The disadvantages of printed materials in- clude the following facts:

■ Written words are the most abstract form through which to convey information.

■ Immediate feedback on the information presented may be limited.

■ A large percentage of materials are written at too high levels for reading and comprehen- sion by many patients (Doak, Doak, Friedell, & Meade, 1998; Mayer & Villaire, 2009).

■ Written materials are inappropriate for persons with visual or cognitive impairment.

Commercially Prepared Materials A variety of brochures, posters, pamphlets, and client-focused instructional sheets are avail- able from commercial vendors. Whether such materials enhance the quality of learning is an important question for nurse educators to con- sider when evaluating these products for con- tent, readability, and presentation. Commercial products may or may not be produced in collab- oration with health professionals, which raises the question of how factual and understandable the information may be. For example, materi- als prepared by pharmaceutical companies or medical supply companies might not be free of bias and may contain complex language. Edu- cators must ask several questions when review- ing printed materials that have been prepared commercially, including the following:

■ Who produced the item? Evidence should make it clear whether input was provided by a nurse or other healthcare professional with expertise in the subject matter.

consider these three media components. When choosing from a wide range of print, demon- stration, and audiovisual options, key issues to be considered include the various delivery sys- tems available, the content or message to be con- veyed, and the form in which information will be presented. Educators must remember that no single medium is suitable for all learners to ac- quire and retain information. Most important, the function of instructional materials must be understood—that is, to supplement, complement, and support the educator’s teaching efforts for the successful achievement of learner outcomes.

▸ Types of Instructional Materials

Written Materials Handouts, such as leaflets, books, pamphlets, brochures, and instruction sheets (all sym- bolic representations), are the most widely used and most accessible type of tools for teaching. Printed materials have been described as “fro- zen language” (Redman, 2007, p. 34) and are the most common form of teaching aid because of the distinct advantages they provide to enhance teaching and learning.

The greatest strengths of written materi- als are as follows:

■ Available as a reference to reinforce infor- mation for learners when the nurse is not immediately present to answer questions or clarify information.

■ Widely used at all levels of society, so this medium is acceptable and familiar to the public.

■ Easily obtained through commercial sources, usually at relatively low cost and on a wide variety of subjects, for distribution by educators.

■ Provided in convenient forms, such as pam- phlets, which are portable, reusable, and do not require software or hardware resources for access.

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■ Fit the institution’s policies, procedures, and equipment

■ Build in answers to those questions asked most frequently by clients

■ Highlight points considered especially im- portant by the team of physicians, nurses, and other health professionals at their institution or agency

■ Reinforce specific oral instructions that clarify difficult concepts and address spe- cific patient needs

Doak et al. (1998) outline specific sugges- tions for tailoring information to help clients want to read and remember the message and to act on it. These authors define tailored in- struction as personalizing the message so that the content, structure, and image fit an individ- ual’s learning needs. To accomplish this goal, they suggest techniques such as writing the cli- ent’s name on the cover of a pamphlet and open- ing a pamphlet with a client and highlighting the most important information as it is verbally reviewed. In another example, Feldman (2004) describes successful use of childcare checklists that had simple line drawings (no more than two to a page) along with brief written descrip- tions that led parents with cognitive disabilities through specific care tasks, such as bathing a baby, in a step-by-step fashion. Audiotapes also accompanied these pictures and simple instruc- tions. Additional studies support the effective- ness of tailored instruction over nontailored messages in achieving reading, recall, and fol- low-through in health teaching (Campbell et al., 1994; Skinner, Strecher, & Hospers, 1994).

Of course, composing materials also has dis- advantages. Educators need to be extra careful to be sure that materials are well written, attrac- tive, and well laid out, which can be a time- consuming task. Although nurse educators are expected to enhance their methods of teaching with instructional materials, few have ever had formal training in the development and applica- tion of written materials. Many tools produced by nurses are too long, too detailed, and writ- ten at too high a level for the target audience

■ Can the item be previewed? The educator should have an opportunity to examine the accuracy and appropriateness of content to ensure that the information needed by the target audience is provided.

■ Is the price of the instructional tool consis- tent with its educational value?

■ Can the tool be used with large numbers of learners? Simple printed instruction sheets may do the job just as well at less expense and can provide the educator with the ability to update the information on a more frequent basis.

■ How quickly will the information become outdated?

The main advantage of using commercial materials is that they are readily available and can be obtained in bulk for free or at a relatively low cost (Fraze, Griffith, Green, & McElroy, 2010). A nurse educator might need to spend hours researching, writing, and copying mate- rials to create informational resources of equal quality and value, so commercially produced ma- terials can save valuable time. Also, some com- mercial materials are available online that can be customized to the needs of individual clients.

The disadvantages of using commercial materials include issues of cost, accuracy and adequacy of content, and readability of the ma- terials. Some educational booklets are expen- sive to purchase and impractical to give away in large quantities. Fraze et al. (2010) have de- veloped a checklist (BOX 12-1) to help health- care providers determine the appropriateness of printed education materials for use by their clients for improvement of health outcomes in various clinical settings.

Self-Composed Materials Nurse educators may choose to write their own instructional materials to save costs or to tailor content to specific audiences. Composing mate- rials offers many advantages (Brownson, 1998; Doak et al., 1998). For example, by writing their own materials, educators can tailor the informa- tion to accomplish the following points:

Types of Instructional Materials 511

BOX 12-1 Checklist for Selecting Printed Education Materials for Patients

Is the Material Appropriate? ■ Is this clinical issue relevant to my practice and my patients? ■ Is the material consistent with current evidence-based guidelines? ■ Is the source of this material credible? ■ Does the material help fill an unmet need or does it meet my needs better than the ones I am

currently using? Does it:

• Appeal visually and appear culturally, gender, and age appropriate to my patients? • Have an attractive cover? • Emphasize a desired behavior change? • Contain four or fewer main points with a summary recapping them? • Have a conversational writing style, in active voice, with minimal technical jargon? • Have ample white space, high contrast between the print and paper, and a font size of

12 points or larger with serif type? • Have relevant graphics that support the text? • Meet the appropriate reading level? • Refer to specific types of healthcare providers, such as midwives or nurses, or use inclusive

general terms, such as clinicians or providers?

Is the Material Practical? ■ What is the financial cost of the material and ordering process? ■ Is there educational support for use of this material? ■ How easily can the material be incorporated into my practice? ■ Is the patient material available in multiple languages?

Summary ■ Will I recommend this material for my clinical practice? ■ How will I know if this material is making a difference with my patients?

Reproduced from Fraze, J., Griffith, J., Green, D., & McElroy, L. (2010). So many materials, so little time: A checklist to select printed education materials for clinical practice. Journal of Midwifery & Women’s Health, 55(10), 70–73.

(Doak, Doak, & Root, 1996; Brownson,1998). See Chapter 7 for the 27 guidelines on how to simplify printed education materials so that they are more readable.

Also, Doak et al. (1996), Brownson (1998), and Aldridge (2004) suggest the following import- ant tips to be sure self-composed printed educa- tion materials (PEMs) are clear and appropriate:

■ Make certain the content is accurate and up to date.

■ Organize the content in a logical, step-by-step, simple fashion so that learners are being

informed adequately but are not overwhelmed with large amounts of information. Avoid giving details because they may unnecessarily lengthen the written information and make it more complex than it should be. Prioritize the content to address only what learners need to know. Content that is nice to know can be addressed verbally on an individual basis.

■ Make sure the information clearly and con cisely discusses the what, how, and when. Follow the KISS rule: Keep it sim- ple and smart. This can best be accom- plished by putting the information into a

512 Chapter 12 Instructional Materials

calculated. For individuals who are not lite- rate, pictures can increase recall of spoken medical instruction (Houts et al., 1998; Houts, Doak, Doak, & Loscalzo, 2006; Kessels, 2003).

Always state things in positive, not neg- ative, terms. Never illustrate incorrect mes- sages. For example, showing a hand holding a metered-dose inhaler in the mouth not only in- correctly illustrates a drug delivery technique (Weixler, 1994) but also reinforces that mes- sage through the image’s visual impact alone. FIGURE 12-1 illustrates the correct way to use an inhaler and reinforces a positive message.

In addition to the guidelines for clarity in constructing written materials, format and

question-and-answer format or by dividing the content into subheadings according to key topics to be addressed.

■ Avoid medical jargon whenever possible, and define any technical terms using sim- ple, everyday language. If it is important to expose patients to technical terms because these are what they will hear when dealing with their medical situation and with the medical team, define the terms carefully and simply and be consistent with the words used.

■ Find out the average grade in school com- pleted by the targeted client population, and write the client education materials two to four grade levels below the average

FIGURE 12-1 Diagram illustrating proper technique for inhaler use.

Shake inhaler well.

Hold upright with cap off.

Hold inhaler 1 to 2 inches from mouth. Breathe out.

Hold breath 10 seconds, then repeat puffs.

Press down on inhaler. Breathe in slowly (3 to 5 seconds).

Types of Instructional Materials 513

also do not like to read. Informa- tion in the form of simple pictures, graphs, and charts can be included with the content of printed materi- als for the benefit of those individ- uals who have low literacy skills or who are visual and conceptual learn- ers (Houts et al., 2006).

In addition, does the audience have any sensory deficits? Vision problems are common among older adult clients, and deficits in short- term memory may pose a problem for comprehension. Having materi- als that can be reread at the learner’s own convenience and pace can re- inforce earlier learning and reduce confusion over treatment instruc- tions. For those individuals with vi- sion impairments, use a large typeface and lots of white space, separate one section from another with plenty of spacing, highlight important points, and use black print on white paper.

2. Literacy level required. PEMs for help- ing the learner accomplish behavioral

appearance are equally important in motivat- ing learners to read the printed word. If the for- mat and appearance are too detailed, learners will feel overwhelmed; in such a case, instead of attracting the learners, you will discourage and turn them off. FIGURE 12-2 illustrates how a simple rather than lengthy format is much more appealing to any reader.

Evaluating Printed Materials When evaluating PEMs, nurses should keep in mind the following considerations.

1. Nature of the audience. What is the average age of the audience? For instance, adults who are literate tend to prefer printed materials that they can read at their leisure. Children or clients who have low literacy skills, however, like short and simple printed materials with many illustrations.

Also, what is the preferred learn- ing style of the chosen audience? Printed materials with few illustra- tions are poorly suited to clients who not only have difficulty reading but

FIGURE 12-2 Inadequate versus adequate appearance and formatting.

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CLUTTERED APPEARANCE BETTER VISUAL APPEARANCE

514 Chapter 12 Instructional Materials

exist, such that there may be greater availability of Asian-language ma- terials on the West Coast and more Spanish-language materials in the Southwest and Northeast than in other parts of the United States.

4. Clarity and brevity. Simpler is better. Shorter also is better. Remind yourself of the KISS rule: Keep it simple and smart. Address the important facts only. What does the client need to know? Choose words that explain how; the why can be filled in later during, for example, one-to-one instruc- tion or group discussion. Include uncomplicated pictures and basic illustrations that show the written instructions step by step. FIGURE 12-3 provides a good example of a clear, brief, and easy-to-follow instructional tool that is used to teach a patient with asthma how to determine when a metered-dose inhaler is empty. By using simple, clear graphics and few words, the learner is guided through the procedure with very little room for misunderstanding, and this tool is suitable for a wide range of audiences.

5. Layout and appearance. How written materials look is crucial in attracting

objectives will not be effective if the materials are written at a level beyond the ability of the learner to understand (Mayer & Villaire, 2009; Wolf & Bailey, 2009). The Joint Commission (2007) mandates that health information be presented in a manner that can be understood by patients and family members. Therefore, it is important to screen potential educational tools that will be used with various teach- ing methods. A variety of formulas (e.g., Fog, SMOG, Fry) are available to determine the reading difficulty level of written materials as outlined in Chapter 7 and Appendix A.

3. Linguistic variety available. This re- fers to choices of printed materials in different languages that may be accessed. However, these options often are limited because duplicate materials in more than one lan- guage are costly to publish and not likely to always be produced unless the publisher anticipates a large demand. The growth of minority populations in the United States has promoted increasing attention to the need for non-English teach- ing materials. Regional differences

FIGURE 12-3 Example of a clear, easy-to-follow instructional tool for an asthma patient.

Full 1/2 Full Empty

Types of Instructional Materials 515

6. Opportunity for repetition. Written materials can be read later and again and again by the learner to reinforce the teaching when the educator is not there to answer questions. Thus, it is an advantage if materials are laid out in a simple question-and-answer format. Questions demand answers, and this format allows clients to find information easily for repeated rein- forcement of important messages. If educators write their own materials, they also must be mindful of the need to keep information current and to update it for changing protocols and varied patient populations.

7. Concreteness and familiarity. Using the active voice (present tense) is more immediate, directive, and concrete. For example, “Shake the inhaler very well three times” is more effective than “The inhaler should be shaken thoroughly” (see Exhibit 12-1). Also, the importance of using plain langu- age instead of medical jargon cannot be stressed enough. Inadequate client understanding of common medical terms used by healthcare providers is a significant factor in noncompliance with medical regimens. Numerous studies indicate that clients under- stand medical terms at a much lower

the attention of patients and getting them to read the information. If a tool has too much wording, with few spaces between sentences and para- graphs, small margins, and many pages of content, the learner may find it much too difficult and too time consuming to read (see Figure 12-2).

Allowing plenty of white space is the most important step that ed- ucators can take to improve the ap- pearance of written materials. This means creating a lot of blank space between and around the words by double spacing, leaving wide mar- gins, indenting important points, us- ing bold lettering, and separating key statements with extra space. Putting a graphic in the middle of the text can break up the print and provide a way to reinforce the written infor- mation. Redman (2007) states that pictures rather than spoken words are better for learning because they increase recognition and recall. An example used earlier in this chapter is teaching the psychomotor task of using a metered-dose inhaler (see Figure 12-1). EXHIBIT 12-1 includes simple step-by-step instructions writ- ten in the active voice on how to carry out this technique correctly.

EXHIBIT 12-1 Example of Instructions Written in the Active Voice

Steps for Correct Inhaler Technique 1. Shake the inhaler very well three times. 2. Remove cap and hold inhaler upright. 3. Hold the inhaler 1 to 2 inches from your mouth. 4. Tilt your head back slightly and breathe out fully. 5. Press down on the inhaler and start to breathe in slowly. 6. Breathe in slowly and deeply (3 to 5 seconds) to pull the medicine down into your lungs. 7. Hold your breath for 10 seconds to keep the medicine in your lungs. 8. Take a few normal breaths. 9. Repeat puffs by following steps 1–8 again.

516 Chapter 12 Instructional Materials

rate than nurses expect (D’Alles- sandro, Kingsley, & Johnson-West, 2001; Estey, Musseau, & Keehn, 1994; Friedman et al., 2011; Lerner, Jehle, Janicke, & Moscati, 2000; Mayer & Villaire, 2009).

In summary, educator-designed or com- mercially produced PEMs are widely used for a broad range of audiences. They vary in liter- acy demand levels and may be found written in several languages. Studies of the effectiveness of PEMs on patient health outcomes have reported varied results. If PEMs are used alone, the effect has been small (Giguere et al., 2012). If used in combination with written and verbal informa- tion, they improved learners’ knowledge and sat- isfaction with care (Johnson & Sandford, 2005). The literacy level of written communication ma- terials is a major factor in the usefulness of print materials (D’Allessandro et al., 2001; Mayer & Villaire, 2009). TABLE 12-1 summarizes their ba- sic advantages and disadvantages.

Demonstration Materials Demonstration materials include many types of visual, hands-on media. Models and real equipment are one type, and a combina- tion of printed words and visual illustrations

(diagrams, graphs, charts, photographs, and drawings) in the form of displays are another type. Displays include such instructional tools as posters, bulletin boards, flannel boards, flip charts, chalkboards, and whiteboards. These types of media represent unique ways of com- municating messages to the learner. Demon- stration materials primarily stimulate the visual senses but can combine the sense of sight with touch and sometimes even smell and taste.

From these various forms of demonstra- tion materials, the educator can choose one or more to complement teaching efforts that will help patients achieve the objectives for learning. Just as with written materials, these tools must be accurate and appropriate for the intended audience. Ideally, they will bring the learner closer to reality and actively engage him or her in a visual and active manner. As such, demon- stration tools are useful for cognitive, affective, and psychomotor skill development. The major forms of demonstration materials—models and displays—are discussed in detail here.

Models Models are three-dimensional objects that al- low the learner to immediately apply knowledge and psychomotor skills by observing, examin- ing, manipulating, handling, assembling, and

TABLE 12-1 Basic Advantages and Disadvantages of Printed Materials

Advantages Disadvantages

Materials are easily accessible and available on many topics

The rate of reading is controlled by the reader Complex concepts can be explained both fully

and adequately Procedural steps can be outlined Verbal instruction can be reinforced The learner is always able to refer to instructions

given in print

They are impersonal There is limited feedback; the absence of an

instructor lessens opportunity to clear up misinterpretation

Printed materials are passive tools Highly complex materials may be overwhelming

to the learner Literacy skill of the learner may limit

effectiveness Materials may not be available in different

languages

Types of Instructional Materials 517

aids. Resuscitation dolls are a popular type of replica used to teach the skills of cardiopulmo- nary resuscitation. Learners who regularly re- fresh their skills using demonstration models as instructional tools are more likely to main- tain their knowledge of and ability to use tech- niques as compared with those learners who do not (Pinto, 1993).

By using a replica first to teach a technique, educators can desensitize learners before they are taught to do an invasive procedure on them- selves or on a loved one. Instructional models have been found to be effective in reducing fear and enhancing acceptance of certain procedures (Cobussen-Boekhorst, Van Der Weide, Feitz, & DeGier, 2000). For example, teaching a client with diabetes how to draw up and inject insu- lin can best be accomplished by using a combi- nation of real equipment and replicas. Clients first draw up sterile saline in real syringes, prac- tice injecting oranges, and then progress to a model of a person before injecting themselves. Sometimes showing a video before directly han- dling equipment may be helpful if learners are very anxious about performing various proce- dures. For lessons aimed at psychomotor learn- ing, educators can use skills checklists as a way to evaluate the accuracy of return demonstra- tions. Simulation laboratories, for example, often use this evaluation method (Jeffries, 2005; Siwe, Bertero, Pugh, & Wijma, 2009).

The second type of model is known as an analogue because it has the same properties and performs like the real object. Unlike repli- cas, analogue models are effective in explaining and representing dynamic systems. Although costly, a sophisticated human patient simulator is an analogue. The patient simulator is a man- ikin that physiologically responds to treatment in a similar manner to what would occur in live human beings. Clinical simulators for patient education have been an untapped resource for teaching and learning that shows promise in changing knowledge and attitudes (Siwe et al., 2009). Web-based patient simulation programs for teaching clinical reasoning to health profes- sionals, such as physical therapists, is growing

disassembling them while the teacher provides feedback (Rankin & Stallings, 2005). In addi- tion, these demonstration aids encourage learn- ers to think abstractly and to use many of their senses (Boyd, Gleit, Graham, & Whitman, 1998). Whenever possible, the use of real objects and actual equipment is preferred—but a model is the next best thing when the real object is not available, accessible, or feasible, or is too com- plex to use. Because approximately 30–40% of people are visual learners and 20–25% are kinesthetic (hands-on) learners, using mod- els not only capitalizes on their learning styles (preference for learning) but also enhances their retention and understanding of new informa- tion (Aldridge, 2009).

Three specific types of models are used for teaching and learning, as differentiated by Bab- cock and Miller (1994):

■ Replicas, associated with the word resemble ■ Analogues, associated with the words act like ■ Symbols, associated with the words stands for

A replica is an exact copy constructed to scale that resembles the features or substance of the original object. The dimensions of the reproduction may be decreased or enlarged in size to make demonstration easier and more understandable. A replica of the DNA helix is an excellent example of a model used to teach the complex concept of genetics. Replicas can be examined and manipulated by the learner to get an idea of how something looks and works. They are excellent choices for teaching psycho- motor skills because they give the learner an opportunity for active participation through hands-on experience. Not only can the learner assemble and disassemble parts to see how they fit and operate, but the learner can also control the pace of learning.

Replicas are used frequently by the nurse educator when teaching the anatomy and phys- iology of different parts of the body. Models of the brain, limbs, heart, kidney, ear, eye, joints, and pelvic organs, for example, allow the learner to visualize parts of the body not readily viewed or impossible to see without these teaching

518 Chapter 12 Instructional Materials

are very large, they cannot be observed and ma- nipulated by more than a few learners at any one time. However, this drawback can be overcome by using team teaching and by creating different stations at which to arrange replicas for demon- stration purposes (Miller & Stoeckel, 2016).

Displays Whiteboards, posters, storyboards, flip charts, and bulletin boards are examples of displays found in most educational settings. In addi- tion, the SMART Board is a large whiteboard that uses touch technology for detecting user input; it is similar in that respect to devices that use personal computing input, such as a mouse or keyboard (SMART, 2009). SMART Boards are growing in popularity but are still costly to purchase.

Displays are two-dimensional objects that serve as useful tools for a variety of teaching purposes. They can be used to convey simple or short messages and to clarify, reinforce, or summarize information on important topics and themes. Although they have been referred to as static instructional tools given that they are of- ten stationary (Haggard, 1989), some displays can be transported, and some can be altered to change the message when necessary. Demon- stration tools can effectively achieve behavioral objectives by vividly representing relationships between subjects or objects. Whiteboards, flip charts, and SMART Boards are particularly ver- satile means of delivering information. Story- boards—visual tools that use pictures and written text to explain a sequence of events—are effec- tive in providing consistent messages to clients in a simple, easy-to-understand format (Lowen- stein, Foord-May, & Romano, 2009).

These board devices are most useful in formal classes, in group discussions, or during brainstorming sessions to spontaneously make drawings or diagrams (with contrasting colored chalk or markers) or to jot down ideas gener- ated from participants while the educator is in the process of teaching. Information can be added, corrected, or deleted quickly and easily

in popularity, and the feasibility of these com- puter analogues is being investigated (Huhn, Anderson, & Deutsch, 2008).

The third type of model is a symbol, which is used frequently in teaching situations. Writ- ten words, mathematical signs and formulas, di- agrams, cartoons, printed handouts, and traffic signs are all examples of symbolic models that convey a message to the receiver through a vi- sual image or association. International signs, for example, communicate familiar messages that individuals with different language abili- ties or from multicultural backgrounds can un- derstand. However, abbreviations common to healthcare personnel, such as NPO, PRN, and QD, should be avoided when interacting with consumers because they are likely to be unfa- miliar with these abbreviations.

The advantage of models is that they can adequately take the place of a real object, which may be too small, too large, too expensive, too complex, unavailable, or inappropriate for use in a teaching–learning situation. A variety of models can be purchased from commercial ven- dors at varying prices (some for free) or can be made by the teacher. Models do not need to be expensive or elaborate to get concepts and ideas across (Aldridge, 2009; Rankin & Stallings, 2005). Models enhance learning in the following ways:

■ Allow learners to practice acquiring new skills without being afraid of hurting them- selves or others

■ Stimulate active learner involvement ■ Provide the opportunity for immediate testing

of psychomotor and cognitive behaviors ■ Allow learners to receive instant feedback ■ App eal to the kinesthetic (movement-oriented)

learner who prefers the hands-on approach to learning

In terms of their disadvantages, some models may not be suitable for learners with poor ab- stract thinking skills or visual impairments un- less every individual is given the chance to learn about the object using other senses. Also, some models can be fragile, very expensive, bulky to store, and difficult to transport. Unless models

Types of Instructional Materials 519

■ Some displays (e.g., posters and bulletin boards) are not suitable for large audiences if information needs to be viewed at the same time.

■ Only limited amounts of information can be included at one time.

■ Displays are not effective for teaching psy- chomotor skills.

■ They may become too cluttered when a lot of information is placed on them.

■ If permanently mounted, they cannot be transported.

■ The symbolic nature of the message may not be well understood by some learners.

Posters Although they are a type of display material, posters are addressed separately here because they have become an increasingly popular and important instructional tool (visit www.cdc .gov and www.publichealth.va.gov to search for posters for patient education). Essentially hy- brids of print and visual media, posters use the written word along with graphic illustrations. Posters are an effective and reasonable option for conveying information (Daley, 1997; Duchin & Sherwood, 1990; Flournoy, Turner, & Combs, 2000; Moneyham, Ura, Ellwood, & Bruno, 1996; Pulley, Brace, Bernard, & Masys, 2007). They serve as a visual supplement to oral instruc- tion of patients and families in various health- care settings, and they are a common format for communicating health information to pa- tients. However, a recent review of multiple studies on the effectiveness of posters in pro- moting knowledge determined that further evidence is needed to determine how effective they are in comparison to other teaching and learning approaches (Ilic & Rowe, 2013).

Posters can serve as an independent source of information or can be used along with other instructional methods and materials. Some crit- ics view the poster as a passive instructional medium, but if posters are designed and used properly, the message conveyed is brief, con- stant, and interactive for teaching and learning

while the learners are actively following what the teacher is doing or saying. Such tools are excel- lent means of encouraging active participation, keeping the learners’ attention on the topic at hand, and reinforcing the contributions of oth- ers. Flexible and handy, they provide opportuni- ties for the teacher, in an immediate and direct fashion, to organize data, capture ideas, perform on-the-spot problem solving, and compare vari- ous points of view. Also, unlike some other types of visuals, these display tools can allow learn- ers to see parts of a whole picture while assist- ing the teacher in filling in the gaps.

The following are important guidelines sug- gested by Babcock and Miller (1994) and Miller and Stoeckel (2016) for educators using chalk- boards and whiteboards to teach:

■ Be sure writing is legible and large enough to be seen.

■ Step aside and face the learner(s) after put- ting notes on the board to maintain contact with the audience.

■ Allow learners time to copy or think about the message.

■ Ask a note taker to capture a creative design or record an idea before the contents on the board are erased or changed.

The following are some specific advantages of displays as teaching tools:

■ They are a quick way to attract attention and get an idea across.

■ Most are flexible, easily modified, and reusable. ■ Many are portable and easily assembled or

disassembled. ■ They stimulate interest or ideas in the observer. ■ They are effective ways of influencing cog-

nitive and affective behaviors.

In contrast, some of the disadvantages of dis- plays include the following:

■ They may take up a lot of space. ■ The more static types, such as posters, can

be time consuming to have prepared and for that reason tend to be used as displays for a long time, which increases the risk of them becoming outdated.

520 Chapter 12 Instructional Materials

joints can be affected over time, why pain oc- curs, and the actions certain treatments have on reducing inflammation. The value of posters is that the messages being conveyed are repeated every time they are viewed (Bach, McDaniel, & Poole, 1994; Daley, 1997; Duchin & Sherwood, 1990; Pulley et al., 2007) and can be used for a variety of purposes such as serving to remind the public of the importance of getting a flu shot. Posters serve as an important teaching tool to help bring about a change of behavior by adding knowledge, reinforcing information, or appealing to attitudes. By using short, sim- ple, and eye-catching imagery, posters ensure that a message can be circulated quickly and simultaneously to several potential learners in a variety of healthcare and community-based settings (Saldana, 2014). These demonstra- tion materials also can be used with individ- uals and small groups to transmit or reinforce

(Daley, 1997; Duchin & Sherwood, 1990; Ilic & Rowe, 2013). Because the primary purpose of a poster is visual stimulation, it is meant to attract attention (Flournoy et al., 2000). Effective post- ers instill a mental image that may be remem- bered long after they are seen. This mental image serves as a cue to the viewer to remember the message being delivered. Much like a bumper sticker on a car, effective poster displays can po- tentially leave lasting impressions that are eas- ily recalled at some future date. FIGURE 12-4 is an excellent example.

The advantages of posters are that they can be used as a way to reinforce and condense in- formation, and they can be used multiple times for different teaching–learning encounters. For example, when nurses in clinic and office set- tings are teaching a patient and significant other about osteoarthritis (degenerative arthritis), a poster with a series of pictures can show how

FIGURE 12-4 Example of an effective poster for HIV/AIDS awareness. Line drawing courtesy of Katherine Batruch-Meadows.

Last night Jennifer had a bad accident. She just doesn't know it yet.

Types of Instructional Materials 521

Because aesthetic appeal is critical in capturing learners’ attention, educators should adhere to the following tips when making and critiquing a poster for use as a teaching tool (Bach et al., 1994; Bushy, 1991; Duchin & Sherwood, 1990; Haggard, 1989):

■ Complementary (opposite-spectrum) color combinations are visually appealing.

■ One color should make up as much as 70% of the display. No two colors should be used in equal proportions, and a third color should be used only to accent or highlight printed components such as titles and subheadings. Too many colors make the design appear cluttered and complicated.

■ Because a picture is worth a thousand words, graphics should be used to break up blocks of print.

■ Use simple, high-quality (but not neces- sarily sophisticated or ornate) drawings or graphics that can be easily understood.

■ Balance the written message with white space (or another background color) and graphics to add variety and contrast.

■ Use simple, high-quality photographs with colored borders and different sizes and shapes.

■ Deliver the written message in common, straightforward language, avoiding unfa- miliar terms, abbreviations, or symbols.

■ Adhere to the KISS principle (keep it simple and smart) when using words to decrease length, detail, and crowding. Simplicity and neatness attract attention.

■ Be concise; do not repeat information. Include only essential information, but be sure the message is complete.

■ Keep the learning objectives in mind to ensure the appropriate focus of information in this display tool.

■ Be sure content is current and free of spell- ing, grammar, and mathematical errors.

■ Add textures, if desired, by using a variety of paper and fabrics.

■ Make titles catchy and crisp, using 10 or fewer words (no longer than two lines) and

information with or without the teacher pres- ent. In addition, they are relatively inexpensive and easy to produce.

With practice, and with access to computer technology, an educator can become skilled at creating attractive, impressive posters in an ef- ficient and timely manner. Software programs such as Print Shop Deluxe, PaintShop Pro, Adobe Photoshop, and Microsoft Publisher are excel- lent resources to produce professional-looking visuals. The major disadvantage of posters is that the content in the final product is static and, therefore, may become quickly dated. Also, if the same poster is kept on display for too long, the potential audience may begin to disregard its message.

The key to a poster’s effectiveness lies in its planning and design. Bushy (1991) states that “good ideas do not speak for themselves . . . a good poster display cannot rescue a bad idea, but a poor one can easily sink the best idea” (p. 11). In turn, this author highlights import- ant aesthetic considerations when preparing and evaluating poster presentations specifically for research purposes. Duchin and Sherwood (1990) and Bach et al. (1994) provide guide- lines that remain relevant today for develop- ing attractive, simple, yet effective posters that consider variations in learner needs and patient education settings. Bushy (1991) and Duchin and Sherwood (1990) emphasize the applica- tion of design elements, such as color, spac- ing, graphics, lettering, and borders, required to create posters that not only catch the eye but also ensure that the message persists in mem- ory. Also, effective imagery can take the form of graphic designs or photographs, so great ar- tistic skill is not required to create the graphic elements of posters. Simple pictures, such as schematics, outlines, and stick figure draw- ings, work well and can be created using col- ored pencils, markers, construction paper, or computer printouts.

The ability of a poster to influence behav- ior or increase awareness can be greatly en- hanced by careful consideration of these factors.

522 Chapter 12 Instructional Materials

today—that further assists nurses in critiqu- ing posters specifically designed for research. This tool can be modified for use in prepar- ing and eval uating posters as tools for educa- tional purposes.

The ability of a poster to influence behavior or expand awareness can be greatly enhanced by careful consideration of its content, intended audience, and design elements. The poster for HIV/AIDS awareness presented earlier in this chapter (Figure 12-4) is a stunning example. The interaction of the viewer with the message is the key to a poster’s success. This HIV/AIDS aware- ness poster and the classic World War I poster “Uncle Sam Wants YOU!” are examples of the element of visceral connection between viewer and message that linger in memory.

TABLE 12-2 summarizes the basic advantages and disadvantages of demonstration materials.

Audiovisual Materials Technology has changed the traditional ap- proach to teaching. Nowhere is this trend more evident than with the audiovisual me- dia. Audiovisual materials support and en- rich the education process by stimulating the senses of seeing and hearing, adding variety to the teaching– learning experience, and instill- ing visual memories, which have been found to be more permanent than auditory memo- ries (Kessels, 2003). Audiovisual elements have

keeping lettering large enough to be read from a distance of at least 20 feet.

■ Letters should be straight and at least 1 inch in height to be read easily at 4 to 6 feet away. Avoid using all-capital letters except for very short titles and labels. Use capitals for only the first letter of each word in titles with more than two to three words or as the first word of a sentence.

■ Use a title or introductory statement that orients readers to the subject.

■ Logically sequence the written and graphic components.

■ Use letter-quality script or laser print in- stead of dot matrix print if using computer- generated type.

■ Use arrows, circles, or directional lines to merge the parts to achieve correct focus, flow, sequence, and unity.

■ Achieve balance in visual weight on each side by positioning information around an imaginary central axis running vertically and horizontally.

■ Handouts can be used to supplement, high- light, and reinforce the messages conveyed by the poster.

■ If a poster is to be transported, use durable backboards and overlays (Styrofoam, heavy cardboard, lamination, or acrylic sprays).

Bushy (1991) devised a 30-item research poster appraisal tool (R-PAT)—still relevant

TABLE 12-2 Basic Advantages and Disadvantages of Demonstration Materials

Advantages Disadvantages

Brings the learner closer to reality through active engagement

Useful for cognitive learning and psychomotor skill development

Stimulates learning in the affective domain Relatively inexpensive Opportunity for repetition of the message

Static, easily outdated content Can be time consuming to make Potential for overuse Not suitable for simultaneous use with large

audiences Not suitable for visually impaired learners or for

learners with poor abstract thinking abilities

Types of Instructional Materials 523

have physical or cognitive limitations that re- quire the nurse to avoid certain types of au- diovisual tools.

In a riveting article, Prensky (2001) de- clares that today’s young people are no longer the audiences the educational system was orig- inally designed to teach. A growing number of younger learners have been raised wholly in the digital technology era, surrounded by and oriented to computers—for example, desktop computers, notebooks, and netbooks—as well as smartphones and many other electronic de- vices that are integral to their everyday lives. Such individuals are known as digital natives. Many educators and adult learners, in contrast, who may not have been born during this age of technology, have been forced to acquire new ways of communicating—a process somewhat akin to learning a second language. Prensky (2001) refers to these individuals as digital im- migrants. The challenge for many educators who have for years spoken a different language, then, is to adapt to as well as adopt the new- est forms of instructional tools to teach natives of the digital age. Digital natives are comfort- able with multitasking and receiving infor- mation rapidly. Use of hypertext and random access comes naturally to them. Likewise, use of streaming video media such as YouTube and interactive computer learning modules, as well as video gaming and streaming videos, is com- monplace for this generation. Conversely, for educators not well versed in the use of digital technologies to assist and supplement instruc- tion, the challenge to use such technologies ef- fectively is ongoing.

As with any instructional materials, major concerns affecting which tools nurses choose include accuracy and appropriateness of con- tent; resources available for the purchase or rental of software programs and hardware equipment; and the time, money, and expertise needed to either introduce new technologies or self-produce audiovisual materials.

Audiovisual materials can be categorized into five major types of media: projected, audio,

been known to increase understanding and re- tention of information as well as satisfaction with care by combining what people hear with what they see (Gysels & Higginson, 2007; Jeste, Dunn, Folsom, & Zisook, 2008). Technology software and hardware are exceptional aids be- cause many can influence all three domains of learning (cognitive, affective, and psychomotor) by promoting cognitive development, stimulat- ing attitude change, and helping to build psy- chomotor skills.

The term multimedia learning refers to the use of two or more types of learning modes (e.g., audio, visual, or animation) that can be accessed via a computer to engage the learner in the content. Blended learning—a more recent term in education—combines e-learn- ing technology with more traditional instruc- tor-led teaching methods, such as a lecture or demonstration. Audiovisual technologies of- ten offer learners more control over content as well as over the sequencing, pacing, and tim- ing of information, which allows teaching and learning experiences to be tailored to meet be- havioral objectives for every individual. In- novations in instructional media, particularly e-learning technologies, are revolutionizing ed- ucation, permitting learning to be more individ- ualized (Petty, 2013) and transforming the role of educators to become “facilitators of learning and assessors of competency” (Ruiz, Mintzer, & Leipzig, 2006, p. 207).

In our increasingly technological age, edu- cators must be aware of which audiovisual tools are available, how tools in actuality and poten- tially have an effect on the ability to learn, and how they might apply the various tools at their disposal effectively and efficiently. When and to what extent educators should use such tools to enhance teaching depends on many variables, not the least of which is the educator’s comfort level and expertise in operating these techno- logical devices. Also, it should not be forgotten that some adult learners may have difficulty be- coming oriented to the newer modes of teach- ing and learning and that some learners may

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or downloaded from a server for presentation through a portable notebook computer. Digital photographs and graphics can easily be scanned and added to PowerPoint slides. Animation also can be included as a feature. Finally, slides can be personalized or tailored to meet specific learner needs.

Careful composition of slides is necessary to avoid clutter. Too much detail makes it diffi- cult for the viewer to identify the major message (Brown, 2001; Polyakova-Norwood, 2009). Du- Frene and Lehman (2004) provide a four-step process for assisting educators to develop and deliver lively PowerPoint presentations designed to avoid the “death by PowerPoint” experience for intended audiences. Educators should ad- here to the following suggestions when prepar- ing a PowerPoint slide presentation:

■ Illustrate one idea per slide. ■ Keep images simple by using clear pictures,

symbols, or diagrams. Put long lists of words or complex figures on handouts that supplement the slides.

■ Avoid distorted images by keeping the im- ages’ proportion of height to width at 2:3.

■ Use large, easily readable, and professional- looking lettering.

Brown (2001) and Microsoft (2017) suggest ad- ditional important tips for employing this inno- vative tool productively:

■ Use this medium to generate interaction between the teacher and the learner, rather than as a tool that provides an outline of content to be followed for presenting information only in a traditional lecture format.

■ On various slides, leave out some points to be made or ideas that should be included so that the learner must figure out what may be missing. This omission encourages critical thinking by the audience.

■ During the presentation, open a blank slide and type in the main points as they emerge from interactive discussion.

video, telecommunications, and computer for- mats. Computer technology, particularly, is rap- idly altering the ways in which educators share information and interact with students. For ex- ample, students are using text messaging as a primary means of communication with one an- other, whereas educators may be more familiar with using e-mail.

Projected Learning Resources The projected learning resources category of media includes overhead transparencies, Pow- erPoint slides, SMART Board systems, and other computer outputs that are projected onto a screen. These media types are appropriate for audiences of various sizes. A SMART Board is a large whiteboard that uses touch technology to project messages via a personal computing input system, such as a mouse or keyboard. Al- though very flexible and one of the newest tech- nology instruments for teaching, they are still costly to purchase and not widely adopted yet for patient education (SMART, 2009).

Microsoft PowerPoint. Microsoft’s computer- generated slideshow software program, Pow- erPoint, has replaced conventional slides and overheads as tools for instruction. PowerPoint slides are easy to design, economical to produce, effective as an instructional tool if used properly, and an impressive medium by which to share information with a large or small audience (deWet, 2006). The software program offers the flexibility to make changes in the slides whenever necessary as well as flexibility during the presentation to repeat slides, add new slides, or skip slides to move ahead to other content.

PowerPoint slides have many advantages. They are an excellent medium for conveying a message because they are an attractive mode for learning at all ages in a manner that facili- tates retention and recall. They can enhance an oral presentation by adding visual dimensions to the narration. Presentations can be burned onto a CD or DVD, transferred to a flash drive,

Types of Instructional Materials 525

with enough space between bullets for learners to fill in critical information developed during a presentation. For further information helpful to the nurse educator, deWet (2006) addresses both the advantages and disadvantages of these types of presentations, as well as best appli- cations for effective use of PowerPoint slides. Thus, the medium of PowerPoint must be used judiciously to avoid overuse and abuse as a tool for effective teaching and learning.

Overhead Transparencies. Overhead trans- parencies are still used for teaching in a variety of settings, both in the classroom and for small- group presentations. Since the advent of Pow- erPoint, however, overheads are used less fre- quently. Nevertheless, use of transparencies as the software and the overhead or doc cam (document camera) projector as the hardware offers some advantages. As with PowerPoint presentations, large numbers of people can see the projected images at one time, and images can be enlarged for easier viewing. Most important, transparencies can be shown in fully lighted rooms, they are inexpensive to produce or purchase, diagrams and figures can readily be photocopied and made into transparencies, and multiple transpar- encies can be laid over one another to illustrate changes in the content or to build in progression of an idea. With doc cam projectors, an actual document can be cast on a screen, which elimi- nates the need to create transparencies.

Among the disadvantages of overhead transparencies are the need for both special- ized equipment for projection and the support of verbal feedback. For these reasons, this me- dium is more appropriate for use in a classroom than for purposes of individual self-instruction. Another disadvantage is that it is not easy for the educator to go back or skip ahead to a spe- cific transparency, and transparencies are diffi- cult for the presenter to keep in order while the educator is trying to stay focused on a presen- tation. Also, the projector itself is awkward to transport. Moreover, for traditional overhead hardware, the noise given off by the fan of the machine can be distracting in a small room. The newer doc cam projectors, which generate

■ Use text sparingly on each slide to keep details to a minimum, by including no more than six points about any one idea per slide and limiting the word count to approximately six words per point.

■ Use contrasting but bold complementary colors so that the text of each slide is clearly visible. Be sure the background color is dark enough that the words in print are not washed out.

■ Be sure the print size on each slide is large enough for the audience to read with ease at a distance. The floor test is one simple method to determine appropriate print size—that is, can you clearly read a printout of the slide placed on the floor in front of you when in a standing position?

■ Minimize or avoid animated text, sounds, and fancy transitions, which can distract the reader from the message being conveyed.

■ Keep unity of design from slide to slide by using a master slide as a template for the entire presentation.

■ Provide audience members with handouts of the slides (three slides per page) for purposes of note taking.

■ Limit the number of slides to be projected for teaching to no more than one to two slides per minute (not to exceed 60 slides for a 1-hour presentation) to avoid including too much content during an allotted period of time. It is important to provide time for cognitive processing, which allows learners to internalize the concepts being presented, and to give learners a chance to discuss content and ask questions.

Remember—visuals should enrich the mes- sage, not become the message. Overuse of slides may discourage audience participation, poten- tially sacrificing rich interactive discussions (Brown, 2001; DuFrene & Lehman, 2004). Dick- erson (2005) reminds educators that audiovisual resources are simply tools that they should use to help achieve teaching objectives. She notes a common complaint that PowerPoint presenta- tions encourage learners to think only in bul- let points and suggests laying out presentations

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■ Display only one point at a time by masking the rest with a piece of paper if you have listed several ideas on one transparency. This approach allows listeners to focus on what you are saying and gives them time for note taking.

■ Use a screen large enough for the audience to read the information projected.

■ Use a light-colored blank wall as a projec- tion surface if a screen is unavailable or too small.

■ Pull the projector closer to or farther away from the screen to change the size of the projection. This requires that the room be large enough to accommodate moving the equipment at a distance far enough away for adequate projection.

■ Use tinted film to reduce glare of light. ■ Use colored pens to help organize infor-

mation, to provide contrast to images, or to make specific points. Color is known to attract attention and help differentiate information for better retention and recall (D’Allessandro et al., 2001).

■ Use overlays to help illustrate complex or sequential ideas. Note, however, that too many overlays can make the picture fuzzy.

TABLE 12-3 summarizes the basic advantages and disadvantages of projected learning resources.

no noise, are preferable to the older-style mod- els in this regard.

It is essential that transparencies be viewed ahead of time for an assessment of their read- ability, specifically related to the size of the let- tering. Usually letters 0.25 inches high or letters that can be read at 10 feet away before projection are sufficient for easy reading. As with Power- Point slides, including too much content on an overhead transparency decreases its efficacy as a teaching tool. The following helpful guide- lines for the use of traditional overhead pro- jectors and transparencies are recommended (Babcock & Miller, 1994; Heinich, Molenda, Russell, & Smaldino, 2002):

■ Do not block the audience’s view of the screen by standing in front of the machine. This common error can best be solved by making a habit of sitting or standing to the side to avoid interference with the projected image.

■ Turn the projector off when you have fin- ished referring to the transparency to keep the learners’ attention on you and away from what is being projected. Constant use of the machine is also distracting because of the fan noise.

■ Keep the message on the transparency simple. Use handouts to cover complex information as a supplement to your message.

TABLE 12-3 Basic Advantages and Disadvantages of Projected Learning Resources

Advantages Disadvantages

Most effectively used with groups May be especially beneficial for

hearing-impaired, low-literate patients

Good for teaching skills in all domains

Flexible to add, delete, or revise slides easily and quickly

Do not require darkened room for projection

May stifle active learner participation if overused May encourage learners to think only in bullet points Easy to pack too much content into each slide, making the

print too difficult to read and presenting more than one concept per slide

Animations, sounds, and fancy transitions may be distracting Lack of time for cognitive processing if too many slides

included for the scheduled teaching session Some forms may be expensive Requires darkened room for some forms Requires special equipment for use

Types of Instructional Materials 527

a variety of health topics, from stress reduc- tion to programs on how to quit smoking, can be prepared specifically to meet the needs of a learner by reinforcing facts, giving feedback and directions, or providing support. As early examples of the effective use of audio media, Hagopian (1996) described how audiotapes in- creased knowledge and self-care behaviors of persons undergoing radiation therapy, and Na- perstek (1993) developed a large line of CDs on guided imagery that are used by practitioners and clients dealing with illness, surgery, and broad treatment modalities. Feldman (2004) described the development, implementation, and evaluation of self-directed learning us- ing audiocassettes and pictures to teach basic child care, health, and safety skills to parents with intellectual disabilities. This study indi- cated that a significant number of these par- ents improved their parenting skills with these low-cost, low-tech materials.

If digital sound files and CDs are instructor made, the learner will derive much comfort from hearing the nurse’s familiar voice and reassuring words. Learners can listen to this information at their leisure and can review it as often as neces- sary. These media can be used almost anywhere, such as in the home, office, clinic, or hospital setting, and can be played while simultaneously driving a car or fixing a meal, thereby filling what normally would be considered wasted time.

The versatility of CDs and digital sound players for application to education is currently growing at a rapid rate in academia as well as for patient and staff education in a clinical setting. As with all technologies, over time the cost of dig- ital sound players is becoming very reasonable, and the software availability of digital sound files and CDs for healthcare education has increased.

The disadvantages are few with using this type of medium. The biggest drawback is that they address only one sense—hearing—and, therefore, cannot be used by individuals with hearing impairment. Also, some learners may be easily distracted from the information being presented unless they have visuals to accom- pany the recorded information. There is also no

Audio Learning Resources Audio technology, although it has existed for a long time, has not been used to any great ex- tent for education purposes until recently. For years, audiotapes and radio have been useful tools to get information for people who are vi- sually impaired or blind or for those with se- rious motor impairment who could not easily get to a location for an education session. How- ever, with significant advances in audio soft- ware and hardware, as well as the adoption of audio technology for more than purely com- mercial use, CDs, digital sound players (e.g., MP3 players, iPods), radio, and podcasts have become more popular tools for teaching and learning. These resources can be used to de- liver many different types of messages, can help learners who benefit from repetition and rein- forcement, and are well suited for those indi- viduals who enjoy or prefer auditory learning (Heinich et al., 2002). They are also useful me- dia resources for teaching individuals who are illiterate or have low literacy (Santo, Laizner, & Shohet, 2005).

Compact Discs and Digital Sound Players. Digital sound files and CDs, which have re- placed traditional vinyl records and audiotapes, are very popular formats today. Use of these media for teaching has been growing because they have major advantages, such as being small in size, portable, inexpensive, simple to operate, easy to prepare or duplicate, and offering superior sound that does not dete- riorate over time.

Digital sound files and CDs (software) in conjunction with digital sound players and computers (hardware) are powerful tools to en- hance, reinforce, or supplement information previously presented in other formats or to expose learners to information not otherwise easily available or accessible (Preston, 2009). For example, recorded lung sounds, which al- low comparison between normal and abnor- mal breathing, are available in both CD and digital sound file form. Such audio media on

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Nations Educational, Scientific, and Cultural Organization [UNESCO], 2007).

Podcasts are becoming an increasingly popu- lar form of student and client education as well. With this technology, audiences of learners can download lectures and informational sessions about various health topics. They can then listen to these broadcasts on their computers or digital audio players (Kay, 2012; Moore & Smith, 2012)

The disadvantage of radio and podcasts re- lates to the difficulty of consistently delivering information on major topics to general as well as specific populations. That is, the nurse as educa- tor has little control over the variety and depth of topics discussed or how regularly learners lis- ten to a program. In addition, the general nature of radio programs and podcasts is not tailored to meet individual needs. Unlike CDs and digi- tal sound files, radio does not allow the oppor- tunity for repetition of information. However, because of its widespread use and versatility, it has the potential for becoming a major source for important and useful healthcare informa- tion, especially if airtime is funded by private foundations or sponsored by special groups or agencies dedicated to health teaching.

TABLE 12-4 summarizes the basic advantages and disadvantages of audio learning resources.

Video Learning Resources Digital video files and DVDs (software), along with camcorders, DVD recorders, television sets, and computer monitors (hardware) as electronic

opportunity for interactive feedback between the listener and the speaker. As with any instruc- tional tool, digital sound files and CDs should be used only as supplements to the various methods of teaching.

Radio and Podcasts. The radio has tremen- dously affected the lives of many people for many years and is one of the oldest forms of audio technology. As early as the 1930s, the effectiveness of radio for health education was reported as influencing listeners’ health behaviors (Turner, Drenckhahn, & Bates, 1935). Because of its commercial nature and appeal to mass audiences, it has typically been used more for pleasure than for education.

In recent years, the medium of radio has been exploited by both public and private ra- dio stations, which have begun airing commu- nity service and medical talk shows for public education on health issues (Hussain, 2008). Ra- dio is serving as a medium for patient education campaigns because it can reach large numbers of listeners at great distances at relatively low unit cost, it functions in real time, and it is purely auditory, which stimulates the listeners’ imag- ination and abstract thinking abilities. Also, it is effective as a vehicle for teaching health ed- ucation to those who are illiterate or low liter- ate and to culturally diverse populations (Duby, 1990; Romero-Gwynn & Marshall, 1990). These programs are helpful in delivering a message and, because of the convenience and popularity of radio as a communication tool, represent a useful vehicle for teaching and learning (United

TABLE 12-4 Basic Advantages and Disadvantages of Audio Learning Resources

Advantages Disadvantages

Widely available May be especially beneficial for visually impaired,

low-literacy patients May be listened to repeatedly Usually practical, cheap, small of size, and portable

Relies only on sense of hearing Expensive in some forms Lack of opportunity for interaction

between instructor and learner

Types of Instructional Materials 529

images of video by way of digital technology, have incredible storage qualities (similar in ca- pacity to CDs) that allow for long-term use. The market for this technology has increased as the cost of the software and hardware has become more reasonable (Heinich et al., 2002). Origi- nally designed for entertainment purposes only, today these discs are popular with a wide range of audiences in both the fields of higher edu- cation and client/staff education. Healthcare facilities often broadcast client education seg- ments via video files and DVDs over in-house televisions. The convenience and flexibility of these instructional tools allow educators to use video learning resources for individual client teaching situations as well as for large-group instruction.

The usefulness of video derives from the combination of color, motion, different angles, and sound that enhances learning through vi- sual as well as auditory senses. For example, Leiner, Handal, and Williams (2004) compared the effectiveness of printed information about polio vaccination from the Centers for Disease Control and Prevention (CDC) with the same message converted into a production of ani- mated cartoons using marketing and advertis- ing techniques. The findings showed that the animated cartoon was more effective in deliver- ing the same message than the written instruc- tional materials.

The disadvantage of purchased digital video files and DVDs is that they may be beyond the viewers’ level of understanding, inappropriate for learner needs, or too long. This digital tech- nology has become very inexpensive, and the ready portability of recorders allows educators to capture situations unavailable elsewhere for reinforcement of learning.

Williams, Wolgin, and Hodge (1998) and Brame (2016) have outlined detailed steps for creating educational videos. They suggest striv- ing for network-quality production by follow- ing these guidelines:

■ Write a script for the program. Rehearse thoroughly.

devices with which to view them, have become commonplace in homes. Nurse educators are us- ing these resources extensively for teaching in a variety of settings. For example, multimedia streaming video and webinars have satisfied the increasing demand for new ways to educate pro- fessional and paraprofessional staff in all types of healthcare and academic settings. The webi- nar format, which allows for interaction between speaker and participants even though sessions are virtual, and streaming technology, which plays audio and visual files from the Internet, are cost effective, easy to use, time efficient, and available wherever the Internet is accessible (Be- ranova & Sykes, 2007; Manny, 2006; Smaldino, Lowther, & Russell, 2012).

In a review of research studies, Jeste et al. (2008) found that multimedia DVDs for educat- ing consumers about illness management and treatment decision increased learners’ under- standing of medical information and enabled both patients and their caregivers to take a more active role in making healthcare choices. Clark and Lester (2000) conducted a research study on video interventions with an older adult pop- ulation. They found this instructional tool to be as effective in changing behaviors in this group as in teaching and learning of adolescents and younger adults.

In other studies, videos for inservice educa- tion have been found to be a potentially power- ful medium for learning (Brooks, Renvall, Bulow, & Ramsdell, 2000), and Green et al. (2003) re- ported significant usefulness of streamed video as a resource to support learning by students. YouTube has proven to be a popular source of streamed videos for patient and professional education (Emory University School of Med- icine, 2017; Stellefson et al., 2014). Video files and DVDs are among the major nonprint me- dia tools for enhancing client/family, staff, and student education because tapes can be simultaneously entertaining and educational (Beranova & Sykes, 2007; Bussey-Smith & Ros- sen, 2007; Gysels & Higginson, 2007).

Digital video files and DVDs, which incor- porate the sound quality of CDs and superior

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playback as a learning strategy for enhancing their clinical skills. Similar findings were re- ported by Winters, Hauck, Riggs, Clawson, and Collins (2003). TABLE 12-5 summarizes the ba- sic advantages and disadvantages of video learn- ing resources.

Telecommunications Learning Resources Telecommunications is a means by which in- formation can be transmitted via television, telephone, related modes of audio and video teleconferencing, and closed-circuit, cable, and satellite broadcasting. Telecommunications de- vices have allowed messages to be sent to many people at the same time in a variety of places at great distances (Austin & Husted, 1998; Tones & Tilford, 2001).

Television. The television—a very common device in homes worldwide—has been used for many years as an entertainment tool. Today, there are more televisions than telephones in private residences in the United States. The TV is also well suited for educational purposes and has become a popular teaching–learning tool in homes, schools, businesses, and healthcare settings (MDM Commercial, 2015). TV has been found to be more effective than using only written information and as effective as any other audiovisual tool based on a review of over 30 studies on the use of the TV as an education aid. This medium has a definite role to play

■ With a small budget, use a single camera with zoom capacity. A larger budget may allow a professional to be hired to edit the final product.

■ Consider hiring a video technician on a per-hour or per-diem basis to yield a quality production in a time-efficient and cost-effective manner. The operator of the recorder needs to be knowledgeable about motion picture technology, such as the use of close-ups, dramatization of situations, and angle effects, which are not in the usual skill set of many nurse educators.

■ Always be mindful of the learning objectives to avoid going astray with the informational message.

■ Keep the teaching session short. The atten- tion spans of learners vary, but the longer the video, the more risk of losing viewer interest. A video that is 5 to 10 minutes long is ideal.

Digital video cameras are particularly an excellent means to capture real-life and prac- tice experience situations. Role modeling of specific behaviors, attitudes, and values also may be demonstrated powerfully through this medium. Once scenes are captured on tape, a video can serve as an excellent teaching tool to promote discussion and for analyzing and cri- tiquing behaviors that provide direct feedback to learners in the demonstration or rehearsal of complex interpersonal and psychomotor skills.

A study by Hill, Hooper, and Wahl (2000) showed improved performance and learner sat- isfaction among nursing students using video

TABLE 12-5 Basic Advantages and Disadvantages of Video Learning Resources

Advantages Disadvantages

Widely used educational tool Inexpensive, for the most part Uses visual and auditory senses Flexible for use with different audiences Powerful tool for role modeling, demonstration,

teaching psychomotor skills

Viewing formats limited depending on availability of hardware in healthcare settings, especially in patient homes

Expense of some commercial products Excessive length or inappropriateness for the

audience of some purchased materials

Types of Instructional Materials 531

education programs in a cost-effective manner across large geographical areas (Scott & Shan- kar, 2015). In addition, several health networks, such as Lifetime, transmit programs to cable companies and hospitals.

Telephones. It is almost impossible to imagine being without the telephone as a daily tool. Americans have come to depend on their wire- less cell phones and land-based phone lines as fundamental means of communication. It is not surprising, therefore, that the telephone can be used effectively for education.

In recognition of this fact, many healthcare associations have begun to provide telephone services with messages about disease treatment and prevention. The American Cancer Society, for example, has established a toll-free number for the public to obtain short taped messages about various types of cancer. Hospitals, too, have set up call-in services about a variety of health-related topics and sources for referral. Telephones for support and education interven- tions have been used to help patients adjust to breast cancer as well as carry out self-care man- agement of diabetes and other chronic diseases (Chamberlain, Tulman, Coleman, Stewart, & Samarel, 2006; Handley, Shumway, & Schil- linger, 2008; Kivela, Elo, Kyngas, & Kaariainen, 2014; Mons et al., 2013). Telephone consulta- tion also is becoming a popular strategy for pa- tient follow-up after hospital and clinic visits (Eisenburg, Hwa, & Wren, 2014; ElHalwagy & Otify, 2009), and telephone support has been used to motivate patients to increase their phys- ical activity levels (Green et al., 2002).

Such services are relatively inexpensive and can be operated by someone with minimal medical knowledge because the taped message by experts contains the substance of the con- tent. Moreover, this type of service is available in most cases around the clock. The disadvan- tage is that there is no opportunity for questions to be answered directly.

Telecommunications as an instructional tool is becoming increasingly popular and refined. Many hospitals and healthcare agencies have

in increasing knowledge and skills and influ- encing behavior change (Nielsen & Sheppard, 1988; UNESCO, 2007). The power to influence cognitive, affective, and psychomotor behavior is well demonstrated by television commer- cials, whose messages are simple, direct, and repetitive to effectively influence the behavior of intended audiences.

Cable TV is legally obligated to provide public access programming by offering chan- nels for community members and organizations to air their own programs. Health education, if placed on the cable system, can be seen in any home with cable access. The advantage of this national and international option is that dis- tribution of programs is relatively inexpensive (Palmer, n.d.). The disadvantage is that there is no control over who is watching, and this medium cannot serve as an interactive ques- tion-and-answer experience unless call-in phone lines are provided.

Closed-circuit TV, in contrast, allows for education programs to be sent to specific loca- tions, such as patient rooms or staff units. The learner can request a certain program at any given time, much like a guest in a hotel can choose on demand from a variety of movies day and night (Falvo, 2010). Such telecommunications tech- nology allows programs to be played intermit- tently or continuously, with program availability clearly advertised. Because the learner controls program viewing, the nurse educator must follow up to answer questions and determine whether learning has, in fact, occurred.

Satellite broadcasting—a much more so- phisticated form of telecommunications—can reach far more distant locations and carry a variety of programs at any given time. Because of its expense, not many institutions send health information via this mode, but many receive it. More types of satellite systems are being de- veloped to make this form of communication for educational purposes available on a world- wide basis.

Video teleconferencing for continuing edu- cation and staff development has the potential to maintain the quality and viability of continuing

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Miller, 2015; Rice, Trockel, King, & Remmert, 2004). Computers, as a multimedia approach to teaching and learning, usually stimulate learn- ers and transform learning into “an active, en- gaging process” that promotes problem solving and the development of critical-thinking skills (Huang, 2005, p. 224).

Computer-assisted instruction (CAI), also called computer-based learning and computer- based training, promotes learning in primarily the cognitive domain (Grunwald & Corsbie- Massay, 2006). Research has revealed that CAI increases both the efficiency of learning and the retention of information (Fox, 2009; Lewis, 1999). Computers are an efficient instructional tool, computer programs can influence affective and psychomotor skill development, and reten- tion of information potentially can be improved by the interactive exchange between learner and computer, even though the instructor is not ac- tually present (DiGiacinto, 2007). Illustrations (visual information), along with narration (ver- bal information) via computer, increase learn- ers’ recall and comprehension.

Lewis (1999) and Fox (2009) summa- rized the findings from a significant number of studies on computer-based education and concluded that teaching and learning by com- puters is an effective strategy for transfer of knowledge and skill development in patients.

already established hotline consumer informa- tion centers, which are staffed by knowledgeable healthcare personnel so that information can be personalized and appropriate feedback can be given on the spot. The poison control hotline is a good example of the use of this medium.

TABLE 12-6 summarizes the basic advan- tages and disadvantages of telecommunications learning resources.

Computer Learning Resources In our technological society, the computer has changed lives dramatically and has found wide- spread application in industry, business, schools, and homes. Only recently, however, has com- puter-assisted instruction been used for edu- cation in healthcare settings, such as a medical office or clinic waiting rooms (Andersen, An- dersen, & Youngblood, 2011; Wofford, Smith, & Miller, 2005). The computer can store large amounts of information and is designed to dis- play pictures, graphics, and text. The presenta- tion of information can be changed depending on user input. Although computer technology is a relatively recent addition to the educational field, it is becoming very common, especially with the rapid increase of computer literacy among students, professionals, and the public (Duren-Winfield, Onsomu, Case, Pignone, &

TABLE 12-6 Basic Advantages and Disadvantages of Telecommunications Learning Resources

Advantages Disadvantages

Influences cognitive, affective, and psychomotor domains

Relatively inexpensive hardware and software devices Numerous programs on a variety of topics Widely accessible for distribution to many users at a

distance Appealing to many learners because of convenience

and flexibility

Complicated to set up interactive capability Expensive to broadcast via satellite Occasional inability of formats to provide for

repetition of information Cannot control how many and what type of

viewer audiences are reached

Types of Instructional Materials 533

can be programmed to provide feedback to the educator regarding the learner’s grasp of con- cepts, the speed of learning, and those aspects of learning that need reinforcement. The inter- active features of this medium also provide for immediate feedback to the learner. An excellent example demonstrating the efficacy of CAI is re- search conducted on mental health training for long-term staff using computer-based interactive videos (Rosen et al., 2002). The authors of this study partnered with Fox Learning Systems, a company that specializes in eldercare program development using CD-ROM and e-learning formats (http://www.foxlearningsystems.com).

Computers also represent a valuable in- structional tool for those persons with aphasia, motor difficulties, visual and hearing impair- ments, or learning disabilities. Assistive tech- nologies, such as screen readers that convert electronic text to spoken language, are avail- able to individuals with learning or visual disabilities. However, learners with various disabilities are likely to encounter ongoing challenges in trying to access computer files, software programs, and websites, largely be- cause webpages are created in the HTML file format. Other common file formats include Adobe Acrobat’s Portable Document Format (PDF) and PowerPoint.

Hoffman, Hartley, and Boone (2005) ad- dress specific problems of access to computer resources for individuals who are disabled. They provide an excellent resource list for educators and learners who want more information on or- ganizations and websites specializing in assis- tive technologies. In addition, the Center for Applied Special Technology is a nonprofit edu- cational, research, and development organiza- tion whose mission is to expand opportunities for individuals with disabilities through the development of innovative, technology-based educational resources and strategies (http:// www.cast.org). Educators can visit this orga- nization’s website for additional information.

The major disadvantage of CAI is the ex- pense of both the hardware and the software,

For example, telemedicine technology has been found to be as effective an educational tool as in-person teaching for diabetes control (Izqui- erdo et al., 2003). In addition, interactive vid- eodisc programs show promise in improving retention and understanding of information (Green et al., 2004).

Flash-based online resources, which are available to educators and students for free or at low cost, provide high-quality Internet materials for instruction (Lamb & Johnson, 2006). Adobe Flash is required to access such resources, but if it is not already installed on a computer, it is easily downloaded to run on both Windows and Macintosh platforms with any browser. Three key elements of Flash— animation, interaction, and multimedia—give the resulting programs great appeal and versa- tility. The QuickTime format also is frequently used for digital video. Smith and Lombardo (2005) describe development of a patient edu- cation workshop on CD-ROM that used Flash, QuickTime, and Acrobat Reader to provide streaming video clips, audio segments, case studies, and interactive practice activities.

CAI has many advantages. Instruction can be individualized to the learner, lessons can be varied readily, and the learner can control the pace of the learning experience (Heinich et al., 2002). Without time constraints, the learner can move as quickly or as slowly as desired to master content without penalty for mistakes or performance speed. For instance, many educa- tional computer games are designed to teach a subject at a variety of skill levels. Instructions that present to learners more problems with increasing complexity at a pace of the learn- ers’ own choosing can be selected. The ability of computers to internally change the rules or the format of games makes them endlessly chal- lenging and novel to the user.

Another advantage of CAI is that an in- structor can easily track the level of under- standing of the learner because the computer asks questions and analyzes responses to per- form ongoing learner assessment. Computers

534 Chapter 12 Instructional Materials

BOX 12-2 Some Examples of Internet Sites and Companies That Provide Technology-Based Patient Education Materials

Accessible Online Through the Internet (Available to the Public)

General Resources ■ Health Library from EBSCO Publishing—Assists hospitals and other medical facilities to enhance

their patient education websites and services (https://www.ebscohost.com/corporate-research /health-library)

■ Mayoclinic.org (www.mayoclinic.org) ■ WebMD.com (www.webmd.com) ■ National Cancer Institute (www.cancer.gov) ■ Family Doctor—Covers information on prevention and wellness and diseases and conditions by

name, symptom, and drug information (http://familydoctor.org) ■ American Diabetes Association—Creates written and video information in English (www.diabetes

.org/research-and-practice/we-support-your-doctor/patient-education-materials.html) and Spanish (www.diabetes.org/es/)

■ Centers for Disease Control and Prevention—Provides materials in English, Spanish and French on different types of diseases, illnesses, and prevention measures (http://www.cdc.gov/hepatitis /resources/patientedmaterials.htm)

■ 5 Minute Consult—Over 1,000 patient education materials listed in alphabetical order for easy earching in simple language, and in English and Spanish versions (http://5minuteconsult.com)

Videos and Animations ■ Wired.MD—Provides interactive, online videos (www.wiredmd.com) ■ pCare—Videos in multiple languages for targeted patient education populations on

7,000 diagnoses, procedures, and medicines that are designed by leading content producers and reviewed by health literacy and medical experts (www.pcareinteractive.com/education.html)

■ Pritchett & Hull—Uses extensive graphics with a lower reading level in many formats and subjects; online ordering available (www.p-h.com)

■ Hazelden—Emphasis on addiction, recovery, sobriety, and similar health issues; Adobe Reader needed. To locate videos, go to www.hazelden.org/OA_HTML/ibeCCtpSctDspRte.jsp?section =10021 and use Search Bookstore, selecting Videos under All Products

■ Milner-Fenwick Online—Free previews covering most health topics, many available in Spanish and with closed captioning (www.milner-fenwick.com)

■ MedlinePlus in English and Spanish—Interactive tutorials on diseases and conditions, specific tests and diagnostic procedures, surgery and treatment options, and prevention and wellness (e.g., hypertension—slides with audio) (www.medlineplus.gov; www.medlineplus.gov/spanish)

■ The PatientChannel—GE Health care (www.gehealthcare.com)

(continues)

which makes this option not feasible for imple- mentation in some learning situations. In most cases, programs must be purchased because they are too time consuming and too complex

for the educator to develop (Encyclopedia Bri- tannica, 2016; Huang, 2005). BOX 12-2 provides examples of companies that supply client edu- cation materials.

Types of Instructional Materials 535

Accessible Online Through the Internet (Expanded Applications May Be Available Through the Intranet of Individual Organizations)

Print Resources ■ Krames on Demand—Electronic patient education solutions; self-care guides in Spanish and

English; publisher of choice for American Heart Association, American Stroke Association, American Lung Association, and National Cancer Institute (www.kramesstore.com)

■ Hopkins Medicine—Self-management patient education materials on many diseases that can be printed and given to patients (http://hopkinsmedicine.org/gim/core_resources/patient%20 Handouts/)

■ Micromedex (www.micromedex.com)—Medications, diseases, procedures, home care ■ Walters Kluwer—Source Lexi-Comp (https://online.lexi.com)—Medications, diseases,

procedures ■ McKesson (www.mckesson.com)—Health information technology and care management

tools ■ A.D.A.M. Consumer Health—For healthcare information and interactive tools for teaching and

learning and improving health literacy (www.adam.com) ■ ExitCare Patient Information System—Interactive videos, educational handouts, and medication

management tools to help build meaningful communications with patients and engage patients through education (https://www.elsevier.com/solutions/patient-engagement)

■ HealthWise—Print guides, website information, and healthcare organization websites on a wide range of health content, decision aids, and health coaching (www.healthwise.org)

■ American Academy of Allergy, Asthma, and Immunology—Provides low-literacy patient education materials, such as games, puzzles, posters, quizzes, and printed materials in English and Spanish (www.aaaai.org)

Video Resources ■ Emmi Solutions—Outcome-driven patient education communications (www.emmisolutions.com)

Videos—DVD Companies for Purchasing Individual Titles ■ Context Media—Videos specifically designed for TV projection in office waiting rooms (http://www

.contextmediahealth.com) ■ Milner-Fenwick—Videos and digital media for health professionals providing patient education on

most healthcare topics across the continuum of care—free previews; most in Spanish language and closed captioning (http://www.milner-fenwick.com)

■ Aquarius Health Care Media—All videos have an inspirational message of hope and healing; award-winning videos and DVDs on disabilities, cancer, caregiving, children, diseases and health, death and dying, end of life, bereavement, and mental health (www.academicvideostore.com)

■ NIMCO—Education products, such as posters, DVDs, displays (www.nimcoinc.com)

BOX 12-2 Some Examples of Internet Sites and Companies That Provide Technology-Based Patient Education Materials (continued)

536 Chapter 12 Instructional Materials

TABLE 12-7 Basic Advantages and Disadvantages of Computer Learning Resources

Advantages Disadvantages

Promotes quick feedback, retention of learning

Potential database enormous Can be individualized to suit different

types of learners or different paces for learning

Time efficient

Primarily promotes learning in cognitive domain; but can influence affective and psychomotor skill development

Expensive software and hardware, therefore less accessible to a wide audience

Too complex and time consuming for most nurses to prepare independently

Limited use for many elderly, low-literate learners, and those with physical limitations

Another barrier to education via a com- puter is the lack of computer literacy or comfort level with computers among some learners and even some health professionals (Prensky, 2001). Lashley (2005) describes the importance of in- stitutional support for faculty development in the use of technology for the successful design and delivery of computer-based instructional methods and materials. Many older adults are computer shy, are computer illiterate, or lack easy access to computers even if they under- stand how to use this technology. This situation is beginning to change, however, as computers become more of a household item. Although multimedia resources may be important tools to enhance learning in the older adult, much more research also needs to be conducted on age-related cognitive changes that could have implications for the design and use of multi- media learning environments for this growing population of learners (Pass, VanGerven, & Tabbers, 2014).

In addition, people with reading problems unfortunately may experience some degree of difficulty in making sense of the information on the screen. A recent study on CAI with pa- tients of varying health literacy levels found that those who had low health literacy also had lim- ited computer experience. Nevertheless, most of these patients completed the computer-based ed- ucational program on screening for colorectal

cancer without assistance and claimed they un- derstood the information better than they would have if asked to read a brochure (Duren-Win- field et al., 2015). Also, learners with physical limitations, such as arthritis, neuromuscular disorders, pain, fatigue, paralysis, or vision im- pairment, may similarly find computers chal- lenging to use.

Moreover, it should not be forgotten that the computer is a machine, so the learner is neces- sarily deprived of the personal, compassionate, one-to-one interaction that only a teacher can provide to facilitate learning. Because of the in- dependent nature of the computer learning ex- perience, the CAI format is not recommended for nondirected or poorly motivated learners.

Despite these caveats, the tremendous growth of the Internet has opened new doors for many learners to gain access to libraries and to direct learning experiences, such as online discussions with educators at great distances. TABLE 12-7 sum- marizes the basic advantages and disadvantages of computer learning resources.

▸ Evaluating Instructional Materials

Choosing the right tools for client education calls for judgment on the part of the nurse educator,

Evaluating Instructional Materials 537

with one another result in the selection of dif- ferent teaching tools by the educator, who is faced daily with multiple situations, different learners, and varying circumstances. The eval- uation of tools for teaching involves appraising the content, the instructional design, the techni- cal production, and the packaging of any given instructional materials. EXHIBIT 12-2 provides

who must take into consideration the variables of the learner, the medium, and the task. De- cisions as to which instructional materials are or are not appropriate depend on the size and characteristics of the audience, the preset be- havioral objectives to be achieved, and the effec- tiveness and availability of media resources. The values of these three variables in combination

EXHIBIT 12-2 The Patient Education Materials Assessment Tool (PEMAT) for Evaluating Instructional Materials

Domain: Understandability Topic: Content Item 1: The material makes its purpose completely evident (P and A/V ). Item 2: The material does not include information or content that distracts from its purpose (P).

Topic: Word Choice and Style Item 3: The material uses common, everyday language (P and A/V ). Item 4: Medical terms are used only to familiarize audience with the terms. When used, medical terms

are defined (P and A/V ). Item 5: The material uses the active voice (P and A/V ).

Topic: Use of Numbers Item 6: Numbers appearing in the material are clear and easy to understand (P). Item 7: The material does not expect the user to perform calculations (P).

Topic: Organization Item 8: The material breaks or chunks information into short sections (P and A/V ). Item 9: The material’s sections have informative headers (P and A/V ). Item 10: The material presents information in a logical sequence (P and A/V ). Item 11: The material provides a summary (P and A/V ).

Topic: Layout and Design Item 12: The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlighting) to

draw attention to key points (P and A/V ). Item 13: Text on the screen is easy to read (A/V ). Item 14: The material allows the user to hear the words clearly (e.g., not too fast, not garbled) (A/V ).

Topic: Use of Visual Aids Item 15: The material uses visual aids whenever they could make content more easily understood

(e.g., illustration of healthy portion size) (P). Item 16: The material’s visual aids reinforce rather than distract from the content (P). Item 17: The material’s visual aids have clear titles or captions (P). Item 18: The material uses illustrations and photographs that are clear and uncluttered (P and A/V ). Item 19: The material uses simple tables with short and clear row and column headings (P and A/V ).

538 Chapter 12 Instructional Materials

a patient education materials assessment tool (PEMAT) for selecting and evaluating print and audiovisual instructional materials (Shoemaker, Wolf, & Brach, 2013).

Printed materials, as the most popular tool available for client education, require the nurse to determine the reading levels prior to distribution to learners. This is an essential fac- tor when selecting brochures, pamphlets, in- formation sheets, and the like to be sure they are suitable for a given audience of learners. FIGURE 12-5 illustrates the learning pyramid. It emphasizes an important learning principle: Ac- cording to numerous research studies, people retain information at a higher rate if they are actively involved in the learning process (Na- tional Training Laboratories, n.d.). The effec- tiveness of teaching and learning is, therefore, greatly enhanced when instructional materials stimulate multiple senses and modes of learning.

In making their final media selections, educators must ask themselves which materi- al(s) will best support teaching and learning to achieve the behavioral outcomes for their par- ticular audience. They must remember that ac- tive learner involvement and using materials and objects that most closely resemble the real thing (realia) are the best choices for enhancing

Domain: Actionability Item 20: The material clearly identifies at least one action the user can take (P and A/V ). Item 21: The material addresses the user directly when describing actions (P and A/V ). Item 22: The material breaks down any action into manageable, explicit steps (P and A/V ). Item 23: The material provides a tangible tool (e.g., menu planners, checklists) whenever it could help

the user take action (P). Item 24: The material provides simple instructions or examples of how to perform calculations (P). Item 25: The material explains how to use the charts, graphs, tables, or diagrams to take actions

(P and A/V ). Item 26: The material uses visual aids whenever they could make it easier to act on the

instructions (P). P = Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P) A/V = Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V )

Reproduced from Shoemaker, S. J., Wolf, M. S., & Brach, C. (2013). The Patient Education Materials Assessment Tool (PEMAT) and user’s guide. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/pemat /index.html

retention of information. Above all else, nurse educators should remember that instructional materials should be used to support learning only by complementing and supplementing the teaching, not by substituting for it.

▸ State of the Evidence There is broad recognition of the need for healthcare practice, including client, staff, and student education, to be supported by evidence of its efficacy. Rather than simply perpetuat- ing practices because they have always been done that way, today there is greater empha- sis on demonstrating via evidence-based re- search that learning has occurred and that care has improved by the way in which information has been taught and received. In education, the focus is on both the processes and the outcomes of teaching and learning.

This chapter has focused on choosing, using, and evaluating instructional materials for client education, as well as for educating nursing staff and students. Some of the new- est studies that validate the usefulness of the different media are cited within the chapter. It is only relatively recently that research has

State of the Evidence 539

refresher courses, studied the efficacy of videos as an instructional tool. These researchers con- ducted a randomized controlled trial to com- pare the performance of two groups of students (n = 223), one receiving written instructions and the other watching a video, in learning a proper nursing technique (moving an uncoop- erative patient). The results demonstrated that students who viewed the video demonstrated better performance in applying the technique than those who learned by reading how to per- form the skill set. Brame (2016) explored three elements of educational videos (cognitive load, student engagement, and active learning) that make them effective as an important content-de- livery tool in higher education. She conducted a literature review of these elements to suggest principles and guidelines as relevant ways to maximize videos as an educational tool.

FIGURE 12-5 Learning pyramid: information retention based on level of active learner involvement. Modified from National Training Laboratories (n.d.). Learning pyramid. Alexandria, VA: Institute for Applied Behavioral Science. Retrieved from http://homepages.gold.ac.uk/polovina/learnpyramid/about.htm. Institute for Applied Behavioral Science, 300 N. Lee Street, Suite 300, Alexandria, VA 22314. 1-800-777-5227.

Modes of Learning with Average Examples of Instructional Materials Retention Rate

Reading..............................................................10% (pamphlets, books, instruction sheets)

Hearing.................................................................20% (audiotapes, radio, CDs)

Seeing ......................................................................30% (slides, posters, pictures, photos, bulletin boards)

Seeing and Hearing .......................................................50% (videotapes, DVDs, television)

Speaking and/or Writing ................................................70% (teleconferencing, worksheets, CAI)

Speaking and Doing ............................................................90% (practicing with models and real objects)

been conducted to determine the impact of various types of tools on the acquisition, re- tention, and recall of information and on the satisfaction with learning. The following are examples of research studies exploring the effectiveness of written, demonstration, and audiovisual media that stimulate the senses, increase active participation, enhance criti- cal thinking, assist with comprehension and memory of information, and provide oppor- tunities for easier, more rewarding, and more enjoyable learning experiences.

Video recording and playback have become common strategies to help nursing students and staff improve clinical skills performance. Salina et al. (2012), who acknowledge the common use of videos in undergraduate nursing education to reinforce information taught in the classrooms and laboratories as well as to teach staff nurse

540 Chapter 12 Instructional Materials

Also, Orozco, Fossi, and Arevalo (2014) empha- sized the need to select written instructional tools that are effective in reaching a target au- dience for health education. They suggested specific approaches to simplifying written mes- sages appropriate for specific communities.

The advent of distance learning via the In- ternet and various interactive media has begun to blur the lines between instructional meth- ods and instructional materials. It is essential to remember that instructional materials should support learning, rather than constituting the entire learning experience. With fewer quali- fied nurse educators and growing numbers of learners, the challenge of meeting the needs of students is a constant pressure. The reader is referred to other studies that illustrate ef- fective use of interactive video, the Internet, and other multimedia tools to support learn- ing (Green et al., 2004; Jeste et al., 2008; Lash- ley, 2005; Martin & Klotz, 2001; Mayer, 2014).

Rather than having educators base teach- ing strategies on assumptions that one vehicle for instruction is superior to another for learn- ing, research has begun to verify the effective- ness of different tools with a variety of audiences under various circumstances. Much more evi- dence needs to be uncovered, but it is gratifying to see that educators and healthcare providers are taking steps to undertake such investigations into multimedia learning based on the latest re- search and theory in this field.

▸ Summary This chapter reviewed the major categories of instructional materials, identified how to select tools from a range of possible options based on their advantages and disadvantages, and addressed how to evaluate their effective- ness. Nurse educators are expected to be able to make choices for teaching methods and materials every day, whether it be to meet the needs of an individual learner or to design an educational program to satisfy a broader, more

As another example of the application of video learning resources for teaching patients, Stellefson et al. (2014) analyzed the content of YouTube videos as a social media source for pa- tient education about chronic obstructive pul- monary disease (COPD). The study found that YouTube has the potential as an important source for COPD education, but currently the content and quality of existing videos vary significantly. Shah, Mathur, Kathuria, and Gupta (2016) ex- plored the effectiveness of video as an instruc- tional tool to teach prevention of oral diseases. These researchers studied 109 subjects in In- dia who completed a pre- and postintervention questionnaire. They found knowledge scores in- creased after exposure to an educational video in a hospital setting.

Learners with low literacy skills or intellec- tual disabilities are particularly challenging for nurse educators. Creativity by an educator can often help overcome barriers to teaching and learning in such cases. A study by Leiner et al. (2004) compared the effectiveness of printed information about polio vaccination from the CDC with the same message converted into a production of animated cartoons using mar- keting and advertising techniques. In another study, Feldman (2004) described the devel- opment, implementation, and evaluation of self-directed learning using pictorial manuals and accompanying audiocassettes to teach ba- sic childcare, health, and safety skills to parents with intellectual disabilities. This study indi- cated that a significant number of parents with cognitive disabilities improved their parenting skills with these low-cost, low-tech, self-directed materials. Badarudeen and Sabharwal (2010) assessed the readability of education handouts and suggested guidelines to improve the com- prehension of this type of written information tool for orthopedic patients. The challenging goal of providing effective patient education communication can be attained by raising the awareness among healthcare providers of the importance of matching readability of written materials to the patient’s level of health literacy.

541Summary

materials are not suitable for simultaneous view- ing by large audiences, for learners with visual impairments, or for individuals with poor ab- straction abilities.

Audiovisual materials make up the fast- est growing category of instructional tools. Their ability to stimulate the senses of sight and hearing enhances their power to actively engage learners and to potentially increase re- tention of information. Many audiovisual tools can influence all three domains of learning by promoting cognitive development, influenc- ing attitude change, and helping to build psy- chomotor skills.

The audiovisual materials section of the chapter examined the five major categories of audiovisual media—projected, audio, video, telecommunications, and computer formats. Consideration was given to how appropriate each of these tools is depending on learner characteristics, expense of the software and hardware, and convenience of use. General guidelines for selecting and developing audio- visual materials were presented, and the prin- cipal advantages and disadvantages of the five categories were described. Learners with low literacy skills may benefit from most categories of these media except computer formats. Au- dio materials are most appropriate for learn- ers with visual impairments, whereas projected video with captions and computer resources most benefit learners with hearing impairments.

Review Questions 1. How do instructional materials differ

from teaching methods? 2. What are the general principles to con-

sider when determining the effectiveness of instructional tools?

3. What are the three major variables that must be considered when selecting, developing, and evaluating printed, demonstration, and audiovisual tools?

4. What are the three primary components of instructional materials to be kept in

diverse group of learners. In this chapter, the importance of considering characteristics of the learner, the medium, and the task when choos- ing instructional materials was emphasized. The importance of using instructional mate- rials to supplement teaching also was stressed, as was the need to keep the behavioral objec- tives in focus when selecting these materials as adjuncts to instruction.

Print media include both commercially prepared and instructor-composed materials. The problem of matching literacy and cogni- tive levels of learners to printed instructional tools is a real concern. The major advantages of printed tools are that they are widely avail- able, clients can refer back to these materials for review at any time and at their own pace, and the materials have potential to reinforce infor- mation. Disadvantages include the limited op- portunity for feedback. For some learners, the readability level and complexity of informa- tion may be significant barriers to their ability to take full advantage of printed tools. Several guidelines useful to educators in selecting or developing printed materials appropriate to both the audience and the task were presented (see also Chapter 7).

Demonstration materials include many types of visual, hands-on tools, such as mod- els and real equipment, as well as displays such as posters, bulletin boards, and whiteboards. These materials stimulate the senses of sight and touch. They are especially useful for cog- nitive and psychomotor skill development and may even influence attitudes, feelings, and val- ues in the affective domain. Other advantages include bringing the learner closer to reality through active involvement and the opportu- nity for repetition of information.

The major disadvantage of demonstration materials is the potential for content to become outdated or be overused because they are often costly and time consuming to prepare. Because of workload demands, nurses in the teaching role may be reluctant or unable to revise these materials frequently. In addition, most of these

542 Chapter 12 Instructional Materials

8. What are the guidelines to be followed to make sure instructor-composed PEMs are clearly written and appropriate?

9. What are some examples of demonstra- tion materials? Of audiovisual materials?

10. What are the major advantages and disadvantages of computer learning resources?

11. Why is it that instructional materials should not be selected before behavioral objectives are determined?

mind when evaluating their appropriate- ness as tools for teaching?

5. Which instructional materials are exam- ples of illusionary representations?

6. Why are numbers as well as oral and writ- ten words known to be the most abstract forms of messages?

7. Which factors must be considered when reviewing commercially prepared print materials for use in teaching and learning?

CASE STUDY Carlos Padia, RN, a longtime staff member on a medical unit of Midland Health Center, has been assigned to care for Mr. Harry Goldberg, a patient who was admitted late last evening for cardiac monitoring and treatment. Carlos is beginning an initial needs assessment to develop with Mr. Goldberg a teaching plan for patient education during his stay in the hospital and for follow-up care upon his discharge to home.

Mr. Goldberg is a 52-year-old man with a strong family history of heart disease. He never completed high school but did manage to finish the 11th grade. He has been a self-employed carpenter all of his working life, is married, and has three children.

Mr. Goldberg was diagnosed a year ago with coronary artery disease and secondary hypertension; however, he had symptoms indicating cardiovascular problems for a couple of years prior to his diagnoses. His fasting cholesterol levels have ranged from 250 to 300 mg/dL, his triglycerides and HDL levels are also significantly above normal, and his blood pressure readings have averaged 180 systolic and 100 diastolic. His doctor describes these findings as numbers Mr. Goldberg absolutely must decrease to more normal limits for the chance to have a longer, healthier life. At the time of initial diagnoses, he was advised to take medication, increase his exercise, and control his diet to lose weight (at least 25 lbs.), but he has made little progress toward these recommended goals.

During his first contact with Mr. Goldberg, Carlos explores many aspects of his patient’s situation and understanding of his medical status. When asked about monitoring his blood pressure at home, the patient states, “I have one of those blood pressure gadgets, but I don’t use it. What good would it do for me to know the numbers? The doctor already sees that they are high.”

The three major variables to help make the appropriate choice of instructional materials are: characteristics of the learner, characteristics of the medium, and characteristics of the task.

1. What are the characteristics of Mr. Goldberg as a learner that must be taken into account when planning for patient education?

2. What behavioral objectives and domain(s) for learning should be discussed with him as the tasks to be accomplished?

3. Which two types of instructional materials would likely benefit this patient? a. Discuss the advantages and disadvantages of each. b. Identify the three components of each of these instructional materials

543Review Questions

behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84, 783–787.

Chamberlain, W., Tulman, L., Coleman, E. A., Stewart, C. B., & Samarel, N. (2006). Women’s perceptions of the effectiveness of telephone support and education on their adjustment to breast cancer. Oncology Nursing Forum, 33(1), 138–144.

Clark, M. C., & Lester, J. (2000). The effect of video-based interventions on self-care. Western Journal of Nursing Research, 22(8), 895–911.

Cobussen-Boekhorst, J. G. L., Van Der Weide, M., Feitz, W. F. J., & DeGier, R. P. E. (2000). Using an instructional model to teach clean intermittent catheterization to children. BJU International, 85, 551–553.

D’Allessandro, D. Kingsley, P., & Johnson-West, J. (2001). The readability of pediatric patient education materials on the World Wide Web. Journal of the American Medical Association, 155(7), 807–812.

Daley, E. (1997). Effectiveness of poster for nutrition education in an acquired immunodeficiency syndrome clinic. Journal of the American Dietetic Association, 97(9), A28–A30. doi:10.1016/S0002-8223(97)00419-7

deWet, C. F. (2006). Beyond presentations: Using PowerPoint as an effective instructional tool. Gifted Child Today, 29(4), 29–39.

Dickerson, P. S. (2005). Nurturing critical thinkers. Journal of Continuing Education in Nursing, 36(3), 68–72.

DiGiacinto, D. (2007). Using multimedia effectively in the teaching–learning process. Journal of Allied Health, 36(3), 176–179.

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy. Philadelphia, PA: J. B. Lippincott.

Duby, A. (1990). The effectiveness of radio as an educational medium. Educational Media International, 27(3), 154–157. http://dx.doi.org/10.1080/09523989 00270303

Duchin, S., & Sherwood, G. (1990). Posters as an educational strategy. Journal of Continuing Education in Nursing, 21(5), 205–208.

DuFrene, D. D., & Lehman, C. M. (2004). Concepts, content, construction, and contingencies: Getting the horse before the PowerPoint cart. Business Communication Quarterly, 67, 84–88.

Duren-Winfield, V., Onsomu, E. O., Case, D. L., Pignone, M., & Miller, D. (2015). Health literacy and computer-assisted instruction: Usability and patient preference. Journal of Health Communication: International Perspectives, 20(4), 491–498.

Eisenburg, D., Hwa, K., & Wren, S. M. (2014). Telephone follow-up by a midlevel provider after laparoscopic inquinal hernia repair instead of face-to-face clinic visit. Journal of the Society of Laparoendoscopic Surgeons, 19(1). doi:10.4293/JSLS.2014.00205

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Technology in Education Deborah L. Sopczyk

CHAPTER HIGHLIGHTS

■ Health Education in a Technology-Based World ■ The Impact of Technology on the Teacher and the Learner ■ Strategies for Using Technology in Healthcare Education

• The World Wide Web • Healthcare Consumer Education in a Technology-Based World • Professional Education and the World Wide Web • Social Media • Webcasts and Webinars

■ The Internet • E-Mail/Texting • Electronic Discussion Groups • Mailing Lists • Other Forms of Online Discussion • Online Chats

■ Issues Related to the Use of Technology ■ Technology for Professional Development in Nursing

• Workforce Training/Staff Development • Distance Education

■ State of the Evidence

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CHAPTER 13

Life, as we know it today, was greatly influ-enced by technological advances of the last half century, a period in time known as the Third Industrial Revolution or Information Age. These Information Age advances include the birth of the Internet and the World Wide Web, the development of information technology, the wide-scale production of computers, and the development of user-friendly software, all of which have had an impact on every aspect of people’s lives. Now as the United States and other progressive countries move into the Fourth Industrial Revolution, new and disruptive tech- nologies are emerging.

Building upon the advances of the Infor- mation Age, the Fourth Industrial Revolution “is characterized by a fusion of technologies that are blurring the lines between the physical, digital and biological spheres” (Schwab, 2016, para. 2). Rapid advances in disruptive technologies such

as artificial intelligence (AI), biotechnology, 3-D printing, and nanotechnology are serving to merge the real world with the technological world (Medical Futurist, 2017; Newman, 2017). In the 21st century, “new and innovative technology will continue to advance and become the norm in healthcare rather than the exception” (Daniels & Wedler, 2015, p. 28). Technology will influence the way nurses practice with some of the most dramatic advances occurring in the field of ed- ucation, where technology has transformed the way learners learn and the way teachers teach.

Today, learners and teachers alike have a world of information at their fingertips. Com- puters and the Internet, along with mobile de- vices such as smartphones, smart watches, and tablets have made it possible to get information from anyone, anywhere, anytime, with just a click of a mouse, a tap of the fingertip, or a sim- ple voice command. In today’s world, virtually

KEY TERMS

Fourth Industrial Revolution Information Age mobile technology consumer informatics cybersecurity World Wide Web

Internet information literacy social media blogs wiki asynchronous

webcasts webinars LISTSERV digital divide e-learning distance learning

OBJECTIVES

After completing this chapter, the reader will be able to

1. Describe the impact of new and emerging technologies on education. 2. Define the terms Information Age, Fourth Industrial Revolution, mobile technology, consumer

informatics, cybersecurity, computer literacy, World Wide Web, Internet, information literacy, social media, digital divide, blog, e-learning, and distance learning.

3. Identify ways in which the resources of the Internet and World Wide Web could be incorporated into healthcare education.

4. Describe the role of the nurse educator in using technology in patient, staff, and student education.

5. Recognize the issues related to the use of technology. 6. Discuss the effects that technology has had on professional education for nurses.

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all children begin learning on computers when they are in nursery school and are as young as 3 years of age (U.S. Department of Education, 2016). As a result, children of today are often re- ferred to as “digital natives,” as their lifelong ex- posure to digital technology has shaped the way they think and process information (Prensky, 2001). This is a very different beginning from that experienced by most adults who grew up in the 20th century.

Today, educational technologies, which were once viewed as rare and highly desirable resources, have become commonplace. Both on-site and distance learners now interact in a multidimensional learning environment. Like shiny new toys, educational technologies have captured the imagination of the world. At the same time, they have opened a new window for educators and learners alike.

This chapter explores the challenges and opportunities resulting from the use of technol- ogy as they pertain to health, health care, and professional nursing education. Technology in education has tremendous potential. Through wise use of technology, nurses can increase ac- cess, improve educational practices already in place, and create new strategies that empower the individual and transform teaching and learn- ing experiences for both healthcare consumers and nursing professionals.

Of course, technology is not a magic solution that can be implemented without careful plan- ning, monitoring, and evaluation. Even though technology has incredible power, users may find that it has given them results that they neither anticipated nor desired. To use these resources effectively, the nurse who adopts technology to enhance teaching and learning must not only have a basic understanding of the technology it- self but must also be able to integrate the tech- nology into an educational plan that is based on sound educational principles and addresses issues such as access, cost, support, equipment, process, and outcomes.

This chapter is designed as an introduction to the application of technology in education. Because nurses provide both healthcare and

professional education, it addresses technology- based resources and strategies appropriate for use with patients and their significant others as well as with staff nurses, other healthcare pro- fessionals, and nursing students. Although it is not intended to give detailed instruction on the mechanics of computers and other types of hardware and software, the chapter presents a basic overview of the technology involved and its implications for the educator and the learner. Hence, this chapter focuses primarily on the In- ternet, the World Wide Web, and computer-based hardware and software applications that can be used to enhance learning at on-site locations with patients, nursing staff, and nursing students as well as with learners at a distance.

Computer-based technologies, the Internet, and the World Wide Web are developing at a rapid pace that is accelerating with each new genera- tion of discoveries and applications (Mo, 2012). Because of this phenomenon, consumers are of- ten advised that the computers they buy today are not likely to reflect the state-of-the-art tech- nology of tomorrow. The same caution must be given to readers of books on technology. Given the pace of technology and the development cycle of a textbook, it is impossible to capture all that is new and cutting edge in the world of educational technologies in a text such as this one. Rather, this chapter is meant to serve as a starting point from which readers can begin to investigate the wide array of educational tech- nologies and resources available. Ideally, it will stimulate readers to continue to search for new and exciting ways to integrate technology into their teaching and learning activities.

▸ Health Education in a Technology-Based World

The use of technology in education reflects what is happening on a much larger scale in our communities. Hence, it is useful to think

Health Education in a Technology-Based World 551

of educational technology within the broader context of the environment in which we live and work. We have experienced a period of his- tory often referred to as the Information Age. The Information Age, also known as the Com- puter Age or Digital Age, was characterized by a change in focus from industry to information. Beginning in the 1970s, improvements in infor- mation technology and the decreasing cost of computers suddenly made information more accessible, resulting in a dramatically different world (Finnis, 2003). Although this new access to information may seem insignificant, it had an enormous impact on the global economy, culture, and our way of life. New and powerful industries have sprung up, and the world has very quickly become a much smaller place as it is now possible to connect with people and ac- cess services from around the world in a blink of an eye and at very low cost.

The demand for information and for inno- vative technologies continues to grow. Adults and children have come to depend on the mobile technology of the 21st century, from pocket-sized smartphones to media players, electronic readers, cloud-based digital assis- tants, and other computer-driven devices. If one thinks about the many ways in which technology has changed the world, clearly computers and information technologies have become more than tools to make life easier—they have be- come part of the culture of most societies.

Computers and computer-driven infor- mation technologies have also become part of the culture of education—as common in the educational environment today as chalk and blackboards were in years past. Perhaps the most significant effect of computers on our society and on education is related to their capacity to assist in the collection, manage- ment, transportation, and transformation of information at high speed. As a result of this newfound ability to handle information, the world has experienced an “information explo- sion.” As a society, Americans have increased both their use and their production of infor- mation of all kinds.

People living in this information-driven society benefit from the availability of infor- mation but also are challenged to keep up with the vast amounts of information that are con- tinually bombarding them from all directions. Information and knowledge have become valu- able commodities, and the ability to gather and evaluate information efficiently and effectively has become a 21st-century life skill.

Computers and other forms of technology also have altered the skill set required of edu- cators. If technology has changed the way peo- ple learn, then it must also change the way we teach. Educators, including nurses and other health professionals responsible for teaching, must be prepared to meet the learning needs and learning styles of 21st-century children and adults (Henriksen, Mishra, & Fisser, 2016).

How has technology affected health educa- tion? Consider the following points:

■ The infrastructure now exists to link people around the world to one another, to nurses and other healthcare professionals, and to a vast array of Web-based information.

■ Internet World Stats (2017), an interna- tional website that provides comprehensive and current information on Internet usage, reports that the North American continent is home to approximately 365 million peo- ple, of whom 320 million are Internet users and 224 million are Facebook subscribers. Looking specifically at adults living in the United States, only 15% report not using the Internet (Zickuhr, 2013).

■ Once a slow and tedious process, connecting to the Internet has become easier with the advent of high-speed data services. Broadband service is in approximately 67% of American homes (Horrigan & Duggan, 2015).

■ The majority of Americans have the hard- ware necessary to access the Web. A Pew Research Center survey found that 84% of Americans had at least one smartphone, 80% of households have a laptop or desktop computer, and 68% of households contain at least one tablet (Olmstead, 2017).

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■ Tens of thousands of healthcare applica- tions are available online, about half at no charge, to assist healthcare consumers to learn, monitor, and manage their health and illnesses as well as communicate with healthcare providers and other consumers (Aitken & Gauntlett, 2013).

The use of Information Age technology has had such a dramatic influence on health educa- tion that a unique and rapidly expanding field of study, consumer informatics (also referred to as consumer health informatics) has emerged. The American Medical Informatics Association (AMIA), one of the principal professional orga- nizations for people working in the field of in- formatics, has established a pervasive consumer health informatics working group to advance the field through collaboration and dialogue (AMIA, 2017). This group has over 800 members and is focused on “information structures and processes that empower consumers to manage their own health” (AMIA, para. 2). Researchers and other professionals in the field of consumer informat- ics are striving to find ways to use technology to strengthen the relationship between patient and healthcare provider as well as to teach and empower patients dealing with issues related to health and wellness. Although much attention has been given to computer-based educational systems, consumer informatics is not restricted to computer-based programs. It includes the study of a wide range of media that can be em- ployed to deliver health-related information.

The entire field of consumer informatics is growing rapidly (Mancuso & Myneni, 2016). Many colleges offer courses of study in which healthcare professionals can gain knowledge and skills related to technology to meet the in- formation needs of healthcare consumers. In- formaticians and healthcare professionals are conducting research on the use of technology in healthcare education to generate knowledge that will guide future educational endeavors. A review of the literature reveals a growing body of knowledge in the field. Nurses and other health- care professionals are using this knowledge to

guide practice and improve the quality of the education they provide to their clients.

Sophisticated technology will continue to make health and healthcare information more accessible and more meaningful to both health- care consumers and health professionals. How- ever, a number of issues remain to be resolved. An emerging concern is that of cybersecurity or the effectiveness of the “technologies, pro- cesses and practices designed to protect com- puter systems from unauthorized use or harm” (Cybersecurity Forum, 2017, para. 1). The Pew Research Center reports that 35% of Americans have been notified that their personal informa- tion at one or more times has been compromised (Rainie, 2017). Furthermore, a study of health- care organizations found that 94% of them have been victims of cyberattacks (Perakslis, 2014). Given the increased frequency of cyberattacks and data breaches that have occurred in govern- ment agencies and businesses in recent years, many Americans do not trust public and pri- vate institutions to protect their personal data (Olmstead & Smith, 2017).

Although security breaches are often re- lated to financial information, health informa- tion also must be protected. As the amount of health information that is stored and exchanged increases, so too does the risk of compromise. For example, many Americans use their smart- phones for electronic communication, yet a recent study found that many smartphone us- ers failed to take the steps necessary to secure these devices (Anderson & Olmstead, 2017). A study conducted by the Pew Research Center found that nearly 40% of adults have difficulty managing online passwords necessary to secure their online data (Anderson, 2017). Therefore, nurses who engage with healthcare consumers in an online environment must be aware of the risks and teach clients how to safeguard their health information.

In recent years, many healthcare organiza- tions have established patient portals or secure websites that allow consumers to access personal health information, exchange secure e-mails with members of the healthcare team, view educational

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Healthcare education and informatics pro fessionals are working together to develop codes to guide practice and safeguard health- care consumers who use educational infor- mation and services delivered via the World Wide Web and the Internet. The not-for-profit group Internet Healthcare Coalition (http:// www.ihealthcoalition.org/ehealth-code) was founded in 1997 to identify and promote high-quality educational resources on the Internet. One of this organization’s most sig- nificant accomplishments was the establish- ment of the e-Health Code of Ethics, displayed in six languages on its website. The purpose of this code is to ensure confident and informed use of the health-related information found on the Web. The e-Health Code of Ethics is based on the principles of candor, honesty, quality, informed consent, privacy, professionalism, responsible partnering, and accountability, as described in more detail in TABLE 13-1.

▸ The Impact of Technology on the Teacher and the Learner

New and emerging technologies have had a sig- nificant influence on educators and learners in many ways. Most important, access to infor- mation bridges the gap between teacher and learner. When information is widely available, it is no longer necessary for the teacher to “find, filter and deliver” content (Warger, 2006, p. 3). Therefore, the teacher is no longer the person who holds all answers or who is solely respon- sible for imparting knowledge.

Today’s educators are becoming facilitators of learning rather than providers of information and are striving to create collaborative atmo- spheres in their teaching and learning environ- ments. As information becomes more and more accessible, the need for memorization becomes

materials, and perform tasks such as making appointments or requesting prescription refills (HealthIT.gov, 2015; Zychla, 2017). A common security measure for patient portals requires the use of a complex password that includes a com- bination of letters, numbers, and symbols.

Another significant area of concern is the limited oversight and control over the content that is posted on the Internet and World Wide Web, two of the major vehicles for delivering in- formation to a global audience. The increased interactivity and user control inherent in the emerging World Wide Web suggests that issues such as authorship disclosure, quality of infor- mation, and privacy and confidentiality are likely to be of concern for some time (Adams, 2010).

When the World Wide Web was first intro- duced, users were primarily consumers of con- tent developed by organizations and commercial enterprises. Current technology has changed this dynamic and users have become authors of con- tent, participating in blogs, wikis, and social net- work sites—many of which are devoted to health and health-related topics (Gagnon & Sabus, 2015; Miller & Pole, 2010). As a result, the amount of health information created by individuals with- out healthcare education or expertise also has increased. Nurses and other healthcare profes- sionals are concerned that consumers are making serious healthcare decisions based on informa- tion on the Web that has not been reviewed for accuracy, currency, or bias. These concerns are valid as increasing numbers of people are using the Web as a source of health information. Studies have shown, though, that the information they find may be inaccurate or misleading (Fleming, Vandermause, & Shaw, 2014; Modave, Shokar, Peñaranda, & Nguyen, 2014; Seymour, Getman, Saraf, Zhang, & Kalenderian, 2015). According to a Pew Research Center report (Fox, 2014), of those adults who use the Internet:

■ 72% have searched for health information ■ 26% have followed the health experiences

of others ■ 16% have gone online to search for others

with similar health concerns

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with the needs of today’s patients. The first step is to reconceptualize the role of the nurse ed- ucator as someone who does more than im- part knowledge. The nurse must be prepared to be a facilitator of learning by helping indi- viduals to access, evaluate, and use the wide range of information that is available. He or she must be also willing to encourage and support

less important than the ability to think critically. Hence, contemporary educators are helping in- dividuals learn how to refine a problem, to find the information they need, and to critically eval- uate the information they find.

Healthcare education can and should follow a similar path. Nurses must structure their ap- proach to healthcare education to be consistent

TABLE 13-1 Guiding Principles of the e-Health Code of Ethics

Candor ■ Disclose information about the creators/purpose of the site that will help users make a judgment about the credibility and trustworthiness of the information or services provided.

Honesty ■ Be truthful in describing products/services and present information in a way that is not likely to mislead the user.

Quality ■ Take the necessary steps to ensure that the information provided is accurate and well supported and that the services provided are of the highest quality.

■ Present information in a manner that is easy for users to understand and use.

■ Provide background information about the sources of the information provided and the review process used to assist the user in making a decision about the quality of the information provided.

Informed Consent ■ Inform users if personal information is collected and allow them to choose whether the information can be used or shared.

Privacy ■ Take steps to ensure that the user’s right to privacy is protected.

Professionalism in Online Health Care

■ Abide by the ethical code of your profession (e.g., nursing, medicine). ■ Provide users with information about who you are, what your

credentials are, what you can do online, and which limitations may apply to the online interaction.

Responsible Partnering

■ Take steps to ensure that sponsors, partners, and others who work with you are trustworthy.

Accountability ■ Implement a procedure for collecting, reviewing, and responding to user feedback.

■ Develop and share procedures for self-monitoring compliance with the e-Health Code of Ethics.

Modified from Internet Healthcare Coalition. (2000). e-Health code of ethics. e-Health Ethics Initiative. Retrieved from http://www.ihealthcoalition.org /wp-content/themes/IHC-theme/code0524.pdf.

The Impact of Technology on the Teacher and the Learner 555

patients will unquestioningly accept what is told to them. Research studies have shown that twice as many online health information seekers go to the Web after a doctor’s visit than before such an encounter (Rainie, 2017).

Whereas healthcare consumers of the past were often isolated from others with similar di- agnoses and were dependent upon healthcare providers for information, today’s e-consumers and e-caregivers have the means to easily ac- cess networks of other patients and healthcare providers worldwide. Online support groups, blogs, and discussion groups where healthcare consumers can share experiences are readily available. Consumers who are being treated for health problems can readily find detailed infor- mation about their diagnoses, treatments, and prognoses from myriad sources.

In this dynamic environment, it is not sur- prising that the teaching needs of today’s health- care consumers and the expectations they hold for those who will be teaching them are chang- ing. The role of the nurse educator has not been diminished, but it has changed. Nurses must now be prepared not only to use technology in education but also to help patients access in- formation, evaluate the information they find, and engage in discussions about the informa- tion that is available.

In addition to altering the educational needs and expectations of healthcare consumers, the In- formation Age has made a tremendous impact on professional education. Technology has given rise to a dramatic increase in educational oppor- tunities for nurses and other healthcare providers. Nurses seeking advanced degrees and credentials or continuing education credits can now study at colleges and universities offering distance educa- tion programs in a wide range of subject areas.

Computers have made it possible to pro- vide anytime, anywhere access to job training and continuing education. Virtual reality and computer simulation can open opportunities to learn hands-on skills and develop competencies in areas such as diagnostic reasoning and prob- lem solving. Like consumers, health profession- als in the Information Age can use the Internet

patients in their attempts to seek the knowl- edge they require.

The Information Age was witness to some dramatic changes in the behavior of healthcare consumers, making the role changes inevitable for patients and nurses as discussed earlier. Technol- ogy and the increased accessibility to information it offers have empowered and enlightened these consumers, encouraging them to form new part- nerships with their healthcare providers (Foisey, 2015; Fox, 2011; Landro, 2014; U.S. Department of Health and Human Services [USDHHS], 2014). Access to health information online has been shown to encourage consumers to engage in greater dialogue with their healthcare providers as they seek clarification and greater understanding of their health, illness, diagnosis, and treatment (Xiang & Stanley, 2017). Even those patients who are reluctant to assume more responsibility for managing their own health care are moving in that direction as changes in the health delivery system have forced them to assume more active roles. As a result, healthcare consumers are ea- ger to learn about and make use of the many in- formation resources available to them.

Today’s consumers often enter the health- care arena with information in hand. They are prepared to engage in a dialogue with their healthcare providers about their diagnoses and treatments. Surveys of the 113 million clients who have gone online to find health infor- mation show that the information they found caused them to make decisions about treat- ment of a condition and made them more con- fident in asking questions of their care provider (Fox, 2006, 2011). A survey conducted by Fox & Duggan (2013) found that 65% of consumers who go to the Web for health information will follow up with a healthcare provider whereas the remaining 35% will use the information to treat themselves at home.

Given this trend, nurses can no longer as- sume that the patients they see in a hospital or clinic will have little information other than what educators have given them or that they will not have explored the treatment options available to them. Furthermore, nurses cannot assume that

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World Wide Web by way of a web browser, a special software program that locates and dis- plays webpages. Firefox, Safari, Google Chrome, and Microsoft Internet Explorer are examples of web browsers.

Search engines and search directories are computer programs that allow the user to search the Web for specific subject areas. Search en- gines are robots that scour the Web for new websites, read them, and put text from them into a database they can access with queries. Search directories are hierarchical directories compiled by humans with references to web- sites; these directories are then accessed with a user query. Google is an example of a search engine, and Yahoo! is an example of a search directory. The Web is so large that any sin- gle search engine or directory can cover only a small percentage of the webpages available (Pandia.com, 2006).

A common misconception is that the World Wide Web and the Internet are two names that describe the same entity. In fact, the World Wide Web and the Internet are related but different. The Internet is a huge global network of com- puters established to allow the transfer of infor- mation from one computer to another. Unlike the World Wide Web, which was created to dis- play information, the Internet was created to exchange information. That is not to imply that information cannot be exchanged on the Web. Although originally created to display informa- tion, the World Wide Web is evolving from the simple static information delivery system of its early days to a more interactive platform that provides varying degrees of user control and interaction. This evolving version of the Web is sometimes referred to as Web 2.0.

The World Wide Web resides on a small sec- tion of the Internet and would not exist without the Internet’s computer network. Conversely, the Internet could exist without the World Wide Web and, in fact, flourished for many years be- fore the World Wide Web was ever conceived. Despite the immense size of both the Internet and the World Wide Web, the two are relative newcomers to the world of technology.

and the World Wide Web as vehicles for shar- ing resources and for gaining access to the most current information in their fields of practice.

▸ Strategies for Using Technology in Healthcare Education

The World Wide Web The technology-based educational resource that is familiar to most people is the World Wide Web. In simple terms, the World Wide Web is a vir- tual space for information. It is almost impos- sible to track its size because there are billions of webpages in existence, with several million new pages being added every month. These webpages cover a wide range of topics and dis- play a variety of formats, including text, audio, graphic, and video. Thousands of webpages fo- cus on health information, products, and ser- vices. Healthcare consumers can find websites ranging from those that present videos of surgi- cal procedures to those where they can ask ques- tions as well as receive information.

Clearly, the World Wide Web is an excep- tionally rich educational resource for both pro- fessional and consumer use. However, despite people’s familiarity with the Web, there is some confusion regarding terminology. Therefore, it may be helpful to clarify some commonly used terms.

The World Wide Web was first conceived by Tim Berners-Lee and Robert Cailliau, two scientists working at a laboratory in Switzer- land (Livinginternet.com, 2007). From a tech- nical perspective, it is composed of a network of information servers around the world that are connected to the Internet. The servers that make up the World Wide Web support a special type of document called a webpage. Web doc- uments or webpages are written using HTML (Hypertext Markup Language).

Links on a webpage allow the user to eas- ily move from one webpage to another with the click of a mouse. A user moves around the

Strategies for Using Technology in Healthcare Education 557

patients, staff, and students including how to access the information on the Web and how to evaluate the information found.

■ The World Wide Web provides a powerful mechanism for nurses to offer healthcare education to a global audience. An in- creasing number of health organizations are creating websites with pages dedicated to presenting healthcare information for consumers. Although nurses may not be responsible for creating the HTML document that will be placed on the Web, they may work with the website designers to develop the information it contains, evaluate the accuracy of the information presented, and interact with healthcare consumers who access the site.

The World Wide Web is a vital tool for nurses. It is a mechanism for keeping up to date on professional and practice issues as well as a resource to be shared with clients. If it is to be used effectively, however, a plan to incorporate the World Wide Web into practice must be set in place.

Healthcare Consumer Education in a Technology-Based World Given the growth of personal computing and smart technology, a preteaching assessment of a patient must include questions about computer use. It is important for the nurse to determine whether the patient has accessed web-based in- formation prior to a teaching session and whether the patient will be able to take advantage of on- line resources after the session has concluded. Despite the widespread use of computers in our society, it is important to remember that not ev- eryone has access to or interest in using a com- puter. Historically, adults older than the age of 65, African Americans, individuals who have less than a high school education, and individ- uals living in a home without children were less likely to be online than others (Fox & Madden, 2005; Horrigan, 2009). Although gaps still exist in some areas, both computer access and interest

The Internet was originally commissioned in 1969 as a program of the U.S. Department of Defense. The first experimental version of the World Wide Web was released in the late 1980s. Since their inception, both the Internet and the World Wide Web have grown dramatically in size and functionality.

Healthcare consumers need to go no farther than their computers if they wish to learn how to use the Internet or the World Wide Web. Get- ting into the Internet or the World Wide Web requires a computer with a telecommunication link and software to connect to an Internet ser- vice provider (ISP). Once a person is connected, it is simple to find a wide range of websites de- voted to teaching Internet or World Wide Web navigation skills. With a properly worded search term (e.g., “World Wide Web and tutorial”), a search engine will uncover numbers of self- paced tutorials designed to teach novice or in- termediate users the desired skills. Most search engines even provide guidance in creating com- mands that will elicit the information needed.

Both computer and information literacy are essential skills addressed in nursing educa- tion programs. Knowledge of the World Wide Web is critical for nurses who work with and educate healthcare consumers. This is true for the following reasons:

■ Nurses can expect to see patients enter the healthcare arena, having already searched the Web for information. In fact, 35% of adult patients report having gone online to search their symptoms to determine if it is necessary to see a healthcare provider (Fox & Duggan, 2013). Therefore, familiarity with the type of information found on the Web helps direct the assessment of patients prior to teaching to identify the needs of the learner and to determine whether follow-up is necessary.

■ The World Wide Web is a tremendous re- source for both consumer and professional education. To use the Web effectively, nurses must possess information literacy skills and be prepared to teach these same skills to

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Center studies continue to find that web users in the United States found information on the Web that did one of the following:

1. Influenced their decisions about how to treat an illness

2. Led them to ask questions 3. Led them to seek a second medical

opinion 4. Affected their decision about whether

to seek the assistance of a healthcare provider (Fox, 2006)

Because the Web can be so influential, it is imperative to determine that the information a patient has found is accurate, complete, and fully understood. Only 15% of web users report that they always check the source and date of the information found, and many report feeling overwhelmed, confused, or frightened by the complexity and amount of information pre- sented (Fox, 2006; USDHHS, 2017).

These findings are not surprising. The World Wide Web contains information designed for both professional and consumer audiences. Health- care consumers may not have the background necessary to comprehend professional litera- ture and other types of information designed for healthcare professionals. When healthcare consumers do a search on a topic, they will ac- cess websites designed for them as well as for health professionals. Consumers should not be discouraged from accessing these sites, but nurse educators must help patients find information written for them at their level of readability and comprehension. Even websites specifically de- signed for consumers may be difficult for the public to understand. For example, in a review of 25 websites on menopause, Charbonneau (2012) found that the average reading level was grade 10, significantly higher than the recom- mended sixth-grade level.

The Web also contains information that may be biased, inaccurate, or misleading (Rehman, 2012; Wilkes, 2015). Many of the health-related websites are sponsored by commercial enter- prises trying to sell a product. Others contain information posted by nonprofessionals and may

in using a computer has changed over time for many populations.

Approximately one third of adults over the age of 65 years report never using the Internet, and an additional one third report not having broadband access. In other areas, older adults are making great strides. Smartphone ownership among older adults has quadrupled in recent years and Internet usage has increased by 55% in the last 20 years. These data suggest that computer and web-based learning will become increasingly valuable for older adults. However, it is import- ant to note that among the older adult popu- lation, computer usage decreases with age and remains limited among adults over the age of 75 years (Anderson & Perrin, 2017).

The black/white digital divide remains a problem in the United States where African Americans are less likely than whites to use the Internet and to have broadband access in their homes. However, like older adults, this population is making strides in the use of mo- bile technology (Smith, 2014a). Finally, people living with disabilities in the United States are three times less likely to go online than people without disabilities (Anderson & Perrin, 2017).

Because computer access is not universal, it is important to determine whether a patient has a home computer, smartphone, or other mobile devices; has access to the Internet; is knowledgeable about using a computer; and has interest in using a computer to obtain in- formation and resources regarding his or her health care.

If a patient does not have a computer or mo- bile device but has interest in using one to access resources on the Web, places where he or she may gain access should be discussed. Libraries, se- nior centers, and community centers commonly have computers with Internet access for public use and typically offer instruction and assistance for new users. Given the resources available, in- cluding librarians skilled at finding information, libraries are commonly used by adults seeking health information (Horrigan, 2015).

Patients who use computers should be asked about their use of the Web. Pew Research

Strategies for Using Technology in Healthcare Education 559

with the opportunity to respond to whatever questions or concerns patients may have.

It is advantageous to conduct a teaching session in a place where there is computer access. Having a computer available during a teaching session can accomplish several goals. First, it will provide the nurse educator with the opportunity to review Web-based information with the pa- tient. Not only can the nurse introduce websites that are relevant to the patient’s needs, but he or she can also review some of the sites the patient has been using. Nurse educators can then begin to determine the type and amount of informa- tion to which the individual has been exposed, assess the patient’s knowledge, and identify ar- eas in need of further teaching. Nurse educators may also find information that requires further discussion. For example, a patient may have vis- ited a website that provides distressing informa- tion about side effects of treatment, prognosis, or disease progression. Looking at the site to- gether will enable the nurse and patient to talk about what has been discovered and do addi- tional teaching if needed.

A second important advantage of review- ing websites with patients is that this activity provides a chance to teach them information literacy skills. There are many definitions of in- formation literacy. Most agree that individuals who are information literate have the following four competencies:

1. The ability to identify the information they need

2. The skills to access the information they need

3. Knowledge of how to evaluate the information they find

4. The ability to use the information they deem valid

Essentially, if clients are to make effective use of the vast array of information on the Web, they must be able to identify the questions they need answered, find the information they are looking for, judge whether the information they find is trustworthy, and decide how they will use the information to meet their needs.

be opinion rather than fact based. Social me- dia sites with reports of misdiagnoses, compli- cations, and medical errors can be frightening. Because the Web has the potential to change so quickly, it is difficult to regulate. Even webpages sponsored by physicians, nurses, and university medical centers may contain errors or informa- tion that is misleading or difficult to decipher.

Patients may find that the Web has pro- vided too much information; information they are not ready to handle because it is too graphic, too frank, or too discouraging; or information they do not fully understand. For example, a pa- tient newly diagnosed with a serious illness may be overwhelmed with the detailed information found on the Web regarding the course of the disease, prognosis, and treatment. For nurses, then, it is important to ask patients if they are using the Web to find health-related informa- tion and to explore the types of information they have found.

Patients may or may not initially feel com- fortable talking about information they have gathered. They may fear nurses will interpret their research as a lack of trust in the care they receive. Some may be embarrassed to talk about information they do not fully understand. Oth- ers may be anxious about how to bring up infor- mation that conflicts with what they have been told or how they are being treated.

For these reasons, it is important for nurses to establish early in their relationships with pa- tients that they are interested in talking with them about the information they have gathered from the Web or other resources they have avail- able to them. Patients need to feel that nurses are open to discussing whatever information they find. They need to understand that nurses are their partners in seeking the best informa- tion available.

For patients who are being treated for a con- dition over an extended period in time, it is also important to continue the conversation about their Web searches throughout their treatment. Simply asking “What interesting information have you found on the Web lately?” will keep the dialogue open and provide the nurse educator

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are not limited to, advocacy, promo- tion, informational/news, personal, or instructional/tutorial.

3. Identify sources of potential bias that may influence the content or the man- ner by which the content is presented. For example, an advocacy website is likely to present information that favors one side of a debate. A mar- keting or sales site tends to include information that is supportive of a particular product or service.

4. Make a judgment as to the likelihood that the information found on the webpage is accurate and reliable. Clients can be taught to look for the credentials of authors of reports or articles found on the Web. This in- formation can help them determine whether supportive data are provided and look at more than one site to see if they can find similar claims or suggestions. Some of the more reliable health-related websites have links to other sites, such that the original site is not the sole source of information on a chosen topic.

5. Make decisions as to the completeness or comprehensiveness of the informa- tion presented. Because clients may not have the background knowledge needed to quickly recognize when information is missing, they should be encouraged to look at more than one site when researching an area of interest. If educators know that clients are using the Web to investigate a specific topic, they can help them identify a list of things to look for in articles or webpages addressing the topic.

6. Determine the currency of the informa- tion on a webpage. Consumers need to know the importance of looking for a creation or modification date or other signs that the information on a website is up to date.

Information literacy is not synonymous with computer literacy. An individual who is informa- tion literate knows how to find the information needed and can evaluate the information found for accuracy, currency, and bias. By comparison, a person who is computer literate has the technical skills and knowledge of computers necessary to use contemporary hardware and software and can adapt to new technologies that emerge (Shipman, Kurtz-Rossi, & Funk, 2009; Williams, 2003).

Although healthcare consumers may not have the background knowledge to evaluate in- formation to the same extent as a healthcare pro- fessional, they can be taught some simple steps to develop their information literacy skills and to help them begin to identify which websites are useful and which are problematic. These steps include the following:

1. Reduce a problem or topic to a searchable command that can be used with a search engine or search directory. If clients do not know how to narrow their topics or problems to a few words, they will be unable to find the information they desire or to broaden a search to find comprehensive coverage. Once the appropriate search command is identified, using a search engine or search directory is easy, especially if the help function available at most sites is used to solve problems. Using an advanced searching feature that allows the user to enter two terms, for example, “asthma and children,” will return more precise findings (Medical Library Association, 2017).

2. Categorize webpages according to their purpose. A client should be taught to look for the person or organization responsible for the website and then place the website into a category re- flective of its purpose. For example, the purpose of a site created by a drug manufacturer could be categorized as marketing, sales, or promotion. Other categories could include, but

Strategies for Using Technology in Healthcare Education 561

health topics, such as Healthfinder (http://www .healthfinder.gov) where health consumers can locate credible sources quickly (Medical Library Association, 2017). Given concerns about the quality of information available on the Web, some professionals are working together to cre- ate trusted websites that provide information and resources for specific patient populations (eHealthMedia, 2015).

For many reasons it is good practice to teach people where to go on the Web to find in- formation. Web-based information can be ob- tained quickly, the cost of Internet access in the home is minimal, and Web access is free in li- braries and other community service organiza- tions. Many healthcare consumers would benefit from having their questions answered quickly and inexpensively.

For example, families with young children are likely to have frequent questions related to childhood illnesses, growth and development, and behavior problems but they may not have the time or money to make a visit to the pedia- trician to have such questions answered. Senior citizens may have questions about the health- care problems encountered with aging but may have difficulty getting to a healthcare provider because of transportation and financial issues. People with chronic illness may gain some sense of control over their lives when they are able to access information on the Web about their con- ditions. Healthy people may have many ques- tions but few opportunities to talk with a health provider to get answers.

Even when healthcare consumers do have the opportunity to meet with a health provider, they often leave with unanswered questions. Sometimes they forget to ask, at times they are hesitant to ask, and in today’s healthcare deliv- ery system they may not be given sufficient time to ask the many questions that arise when peo- ple are dealing with health issues.

In the role of educator, the nurse can teach patients who access the Web to use this resource more effectively and can be proactive in encour- aging others to give it a try. It may be helpful to compile lists of websites appropriate to the needs of different patient populations. TABLE 13-2

7. Identify resources to answer questions or verify assumptions made about the content of a webpage. If questions arise, healthcare consumers should be encouraged to check out information with their healthcare provider. If the provider does not have the answers or cannot verify assumptions made, he or she can refer the patient to other healthcare professionals.

Additionally, information literacy skills should include those behaviors one would expect of a responsible consumer. For example, consumers should know how and when to report informa- tion found on the Web that is potentially harmful to others (Lau, Gabarron, Fernandez-Luque, & Amoyones, 2012). Also, consumers must know what steps are necessary to protect themselves from others who might use the questions or in- formation they post about their health care in an undesirable way. Consumers need to under- stand how to protect their privacy if it is desired and the implications of posting health-related information on social media sites.

In years past, healthcare consumers were not encouraged to research health topics or to research options, but rather to rely on their healthcare providers for all their health-related information. Providers, including nurses, feared that patients would not understand the informa- tion they found or that they would find infor- mation they would not be able to handle. Today, nurses have more confidence in consumers’ abil- ity to manage their own health care.

More and more nurses are empowering healthcare consumers by teaching and encour- aging them to take advantage of the resources at their disposal. To do so, nurses are using a variety of means to encourage their patients to use the Web and to expose them to web-based resources. For example, computers set to ap- propriate websites are being placed in waiting rooms. Healthcare practices are creating web- sites designed to provide clients with relevant health information. Also, teaching materials on how to use the Web are being distributed, in- cluding information on finding tools on general

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TABLE 13-2 Sample Websites for Healthcare Consumers

Title URL Sponsor/ Author Description

Medline Plus http://www.nlm.nih .gov/medlineplus

National Library of Medicine

Example of a government site that provides access to extensive information about specific diseases/ conditions, links to consumer health information from the National Institutes of Health, dictionaries, lists of hospitals and physicians, health information in Spanish and other languages, and clinical trials. There is no advertising on this site.

Alzheimer’s Association

http://www.alz.org /about_us_about _us_.asp

Alzheimer’s Association

Example of a disease-specific website that provides a range of services, including free educational materials. The site provides a number of resources for caregivers including a 24-hour hotline and a community resource finder.

Mayo Clinic http://www .mayohealth.org

Mayo Clinic Example of a comprehensive hospital site that provides information as well as a variety of interactive tools to help healthcare consumers manage a healthy lifestyle, research disease conditions, and make healthcare decisions. Advertising helps support this site.

Cancer Net http://www.nci.nih .gov

National Cancer Institute

Example of a government site devoted to all aspects of cancer. Provides both professional and consumer-oriented information and resources.

Band-Aides and Blackboards

http://www.lehman .cuny.edu/faculty /jfleitas/bandaides /sitemap.html

Joan Fleitas, EdD, RN

Site provides personal rather than factual information about growing up with health problems from the perspectives of children and teens. Site also provides helpful information for adults working or interacting with children with health problems

(continues)

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Title URL Sponsor/ Author Description

NetWellness http://www .netwellness.org

University of Cincinnati, Ohio State University, and Case Western Reserve University

Nonprofit consumer health website that provides high-quality information created and evaluated by medical and health professional faculty at several universities.

Patients Like Me

http://patientslikeme .com

Jamie Heywood, cofounder and chairman

Multipurpose site where people living with chronic diseases share their health data to help others with similar conditions and to provide the healthcare industry with data about real patient experiences. Over 500,000 people with over 2,700 conditions are registered on this site.

MLA Top Health Websites

http://www.mlanet .org/p/cm/ld/fid =397

Medical Library Association

Example of a website that provides links to a variety of health-related sites that have been evaluated according to standard criteria.

TABLE 13-2 Sample Websites for Healthcare Consumers (continued)

provides examples of the various types of web- sites that are available for consumer use. As il- lustrated in Table 13-2, a variety of types of websites exist, ranging from general sites cov- ering a broad range of topics to sites with a spe- cific focus or theme.

In selecting websites to share with con- sumers, it is important that the nurse review these sources carefully. In recent years, multi- ple rating scales have been developed to assist in the evaluation of such sites. Most scales in- clude criteria that address the accuracy of the content, design, and aesthetics of the site; dis- closure of the authors; sponsors of the site; cur- rency of information; authority of the source; ease of use; and accessibility and availability of the site. TABLE 13-3 summarizes the questions that should be asked in evaluating a health-related website. Resource lists made up of high-quality

sites will not only serve as references for clients but also provide examples of the types of sites they should be accessing.

Finally, nurses can create their own websites to bring their healthcare messages to Web users around the world. Table 13-2 lists two websites that exemplify the types of roles nurses can play to bring health information to various consum- ers via the World Wide Web.

Band-Aides and Blackboards is a creative site designed by a nurse to facilitate understanding of the problems faced by children growing up with health problems. This site is thought pro- voking rather than factual. The nurse who cre- ated it uses the words and drawings of children and parents to bring a real-life perspective to the thoughts, feelings, and experiences of growing up with illness. Band-Aides and Blackboards teaches important messages about not being

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TABLE 13-3 Criteria for Evaluating Health-Related Websites

Accuracy ■ Are supportive data provided? ■ Are the supportive data current and from reputable sources? ■ Can the same information be found on other websites? ■ Is the information provided comprehensive? ■ Is more than one point of view presented? ■ Does the site present fact or opinion?

Design ■ Is the website easy to navigate? ■ Is there evidence that care was taken in creating the site? Do the links

work? Are there typographical errors? ■ Is the information presented in a manner that is appropriate for the

intended audience? ■ Do the graphics serve a purpose other than decoration?

Authors/Sponsors ■ Are the sponsors/authors of the site clearly identified? ■ Do the authors provide their credentials? ■ Do the authors/sponsors provide a way to contact them or give

feedback? ■ Do the authors/sponsors clearly identify the purpose of the site? ■ Is there reason for the sponsors/authors to be biased about the topic?

Currency ■ Is there a recent creation or modification date identified? ■ Is there evidence of currency (e.g., updated bibliography and references

to current events)?

Authority ■ Are the sponsors/authors credible (e.g., is it a government, educational institution, or healthcare organization site versus a personal page)?

■ Are the author’s credentials appropriate to the purpose of the site?

alone, about ways to solve common problems, and about what really matters to this population.

NetWellness, another site in which nurses play a predominant role, is a very different site than Band-Aides and Blackboards. NetWellness is a noncommercial, “electronic consumer health information service” that has been in existence for more than 17 years. Information on the web- site is created and evaluated in collaboration by more than 500 multidisciplinary professionals from the University of Cincinnati, Ohio State University, and Case Western Reserve Univer- sity. Information on this site is checked for ac- curacy, and each revision made is stamped with

its date so that users can easily determine its currency. NetWellness continues to be a won- derful Web resource for healthcare consumers. Individuals can submit health- related questions to the site’s “panel of experts,” with nurses and other healthcare professionals then respond- ing to these queries. The panel of experts also provides information for the section of the site devoted to hot topics.

Development of a website is typically a team effort. In addition to content experts such as nurses who contribute the material to be in- cluded on the site, Web designers with techni- cal and layout expertise can provide valuable

Strategies for Using Technology in Healthcare Education 565

2012; Ventola, 2014). Depending on the nature of the site, it may be advisable to include an at- torney on the website development and main- tenance team to provide advice when needed. It is important to determine whether there are rel- evant legal issues related to practice inherent in the activities of the nurse and other health pro- fessionals on the website.

Although new technology has opened the door to many unique and exciting opportunities, it also has raised many questions about teleprac- tice and licensure. Because technology makes it so easy to provide healthcare services to patients across state lines, the provision of nursing, med- ical, and other types of technology-facilitated healthcare services to patients at a distance has been thrust into the spotlight. Multistate licen- sure and other types of legislation have been and will continue to be proposed, and new practice guidelines are likely to be enacted.

Another issue to be considered is ease of use. For example, patient portals hold great promise for engaging patients in their care and improving long-term outcomes but only if de- signed in such a way that they can use them fully (Devkota, Salas, Sayavong, & Scherer, 2016). The client perspective must be accounted for in the design. Consumers of various levels of health and computer literacy are likely to use portals and, therefore, the design and navigation must be simple. For example, if test results are to be shared with patients via the portal, the data must be presented in a way that they will understand (Baldwin, Singh, Sittig, & Giardina, 2016). Fi- nally, the time commitment required to respond to questions from Web users cannot be under- estimated. If a website provides an opportunity for consumers to ask questions, responses must be researched and checked for accuracy before they are posted. Healthcare consumers are on- line 24 hours a day, 7 days a week. Therefore, consumers must be advised how long they will likely wait before a response to their questions is posted. Adequate coverage must be arranged so that questions are answered on a regular basis and service is not interrupted for long pe- riods of time.

assistance with practical aspects of the site’s development. Many resources are available to healthcare professionals interested in develop- ing websites. For example, the HHS Web Stan- dards and Usability Guidelines website (https:// guidelines.usability.gov/) is sponsored by the U.S. Department of Health and Human Services. This resource contains guidelines that can be used in designing health-related websites. Not only are the guidelines provided here based on research studies and supporting information from the field, but ratings also are assigned to each guideline according to the strength of the evidence available.

For instance, a guideline that is given a rat- ing of 5 is one that is supported by two or more research studies where hypotheses were tested and the guideline was shown to be effective. A score of 0 indicates that although the guideline may be routinely followed on webpages, there is no hard evidence to support its effectiveness.

Many issues must be considered before en- gaging in health education via a website. Web- sites have the potential to reach millions of users over an extended period of time. The healthcare consumers who use the Web have varying lev- els of sophistication, and they may or may not know to check the dates on which the website was created and modified. Given the diversity of the audience, it is very important that the in- formation on the site be accurate and updated as often as necessary. Depending on the topics covered, it may be necessary to include a dis- claimer about the importance of checking with a healthcare provider.

If the site is interactive and health pro- viders will be responding to questions submit- ted by users of the site, liability issues must be carefully considered. Nurses and other health professionals who respond to questions from Web users are providing advice and guidance to people whom they do not see and cannot assess. Nurses and their colleagues need to de- termine whether their malpractice insurance covers this type of activity. They also need poli- cies and procedures for responding to questions that might be considered “urgent” (Dizon et al.,

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do not attempt to discriminate and allow users to decide whether consumer material or profes- sional literature is more appropriate to their needs.

It is impossible to list all the educational op- portunities for professionals found on the World Wide Web. The Web is constantly changing, with new sites being added and others being removed daily. TABLE 13-4 provides examples of the various types of websites that can be used by profes- sional nurses and other healthcare professionals.

Social Media Web 2.0, also known as social networking, has made available a wide array of communication formats for people with similar interests to come together to exchange ideas and share informa- tion. These forums are collectively referred to as social media, which is defined as “Internet

Professional Education and the World Wide Web The World Wide Web provides unlimited re- sources for nurses to use in practice and in pro- fessional education and development. Websites provide access to bibliographic databases, con- tinuing education, online journals, and resources for patient teaching and professional practice. Sites established by nursing organizations and publishing companies serve as resource centers where nurses can find a wide range of informa- tion and services addressing any number of ed- ucational needs.

Many of the informational sites on the World Wide Web provide both consumer and profes- sional education. Some websites include links on the home page directing users to either consumer or healthcare professional resources. Other sites

TABLE 13-4 Sample Websites for Healthcare Professionals

Title URL Sponsor/Author Description

Medline https://www.nlm .nih.gov/bsd /pmresources.html

National Library of Medicine

Example of a government site providing access to a bibliographic database containing more than 15 million references to journal articles in the life sciences.

SchoolNurse.com http://www .schoolnurse.com

School Nurse Alert

Example of a site devoted to a specialty area of nursing practice.

National Institutes of Health

http://www.nih.gov U.S. Department of Health and Human Services

Example of a government- sponsored site with information as well as links to a broad range of health and professional issues.

AllNursing Schools.com

http://www.allnursing schools.com

All Star Directories, Inc.

An example of a resource database listing the nursing programs offered by subscribing colleges and universities.

Strategies for Using Technology in Healthcare Education 567

medium. Since that time, the center’s website has grown to include blogs, webinars, and dis- cussions where healthcare professionals explore issues and best practices in the use of social me- dia. Most recently, the center has created a cer- tification course in the use of social media for health care (Mayo Clinic, 2017b).

Social media provides an effective set of tools that can be used by the nurse to educate healthcare consumers, nursing staff, and nurs- ing students. Social media also provides a means for networking and professional development among nurses and other healthcare profession- als (K. Anderson, 2012; P. F. Anderson, 2012). Several of the more common forms of social media are addressed in this section.

Blogs First developed in the late 1990s, blogs (Web logs) are an increasingly popular mechanism for individuals to share information and ex- periences related to a given topic. Although sometimes referred to as web diaries, blogs are much more than that; for example, they may include images, media objects, and links that allow for public responses (Knapp, 2017; Maag, 2005). Blog topics tend to follow main- stream news and a review of active blogs re- vealed that in any given week, approximately 2% focused on health care (Pew Research Cen- ter, 2011). Blog entries are typically viewed in reverse chronological order (most recent first) and are easy to follow. Other common features include archives, a blogroll (list of recommended blogs), and a reader comment section (Miller & Pole, 2010).

The number of blogs available on the Web has increased dramatically in recent years. A de- cade ago, the Pew Internet and American Life Project (Lenhart & Fox, 2006) reported that approximately 12 million Americans had cre- ated a blog and another 57 million read blogs on the World Wide Web. In 2015, the num- ber of Americans who updated a blog at least once per month in the United States reached 28.2 million, which is projected to rise to

sites and applications that allow users to cre- ate, share, edit and interact with online con- tent” (Gagnon & Sabus, 2015, p. 407). Owing to their quick communication and engaging for- mats, social media sites such as Facebook and LinkedIn have experienced dramatic growth in their use and popularity in recent years. In 2005, only about 7% of Americans participated in social media. In 2015, that number grew to 65% or two thirds of adults living in the United States (Perrin, 2015).

Social media has proven to be a power- ful force to educate and empower people, to quickly send messages to a worldwide audience, to gather information about public perceptions of health issues, and, in some cases, to collab- orate with other users in real time ( Norton & Strauss, 2013; Thackery, Neiger, Smith, & Van Wagenen, 2012; Ventola, 2014). Social media in combination with the growth of mobile tech- nology has changed the way people seek and find health-related information. Consider the following: Prior to social media, a woman re- quiring a hysterectomy relied on her healthcare provider for health teaching and a referral to a surgeon. She most likely talked with a small group of friends about their experiences with the procedure. With social media, a woman can find online reviews of area surgeons and area hospitals, go to YouTube to watch the proce- dure being suggested, and go to a social me- dia site like Hystersisters.com for information and support for everything from diagnosis and treatment to recovery. She can access this in- formation anywhere, anytime using her phone, tablet, or laptop.

This example illustrates the growth and power of social media in health care. A recent study found that in the United States alone, over 1,600 hospitals were actively managing over 6,500 social media sites such as Facebook and YouTube (Mayo Clinic, 2017a). The Mayo Clinic has taken a leadership role in support- ing the use of social media by healthcare pro- fessionals and organizations. In 2010, the Mayo Clinic established the Center for Social Media to improve health care through the use of this

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blogs remain an effective way to provide con- sumers with health-related information. As with other forms of communication, nurses who use blogs to teach must implement a plan for regu- lar maintenance and updating of the site. Fur- thermore, given the time commitment required, nurses should regularly evaluate the use, read- ership, and impact of the blog (Adams, 2011; Knapp, 2017).

Wikis Another form of online communication is a wiki. The term wiki, which means quick in Hawaiian, is a website that allows multiple us- ers to come together to collaboratively write and edit the content and structure of a collec- tion of webpages (LeBar, 2017). In comparison to blogs, wikis are more social in their construc- tion. Such a collection is easily expanded, and all users can add to, edit, and remove content. Wikipedia (http://www.wikipedia.org) is one of the best-known wikis.

Wikis are asynchronous, meaning that they allow users to work in concert with one an- other but not necessarily simultaneously. Conse- quently, authors may contribute to the webpages at their individual convenience. Wikis also have the capacity to hold multimedia content such as text, videos, audio, and photographs (Erardi & Hartmann, 2008), making them a potentially exciting and engaging source of information. Participants also can link to other content or to media by way of hyperlinks (LeBar, 2017).

Health-related wikis are promising tools for consumer education (Boulos, Maramba, & Wheeler, 2006; Boulos & Wheeler, 2007). For example, WikiMd (http://www.wikimd.org) is a free medical encyclopedia moderated by health professionals. Health consumers can go to WikiMD to find interesting and up-to-date information on health, weight loss, and well- ness from a variety of perspectives. Also, wikis are effective tools for professional education. In the classroom, educators are using wikis to encourage group collaboration and sharing of ideas on a given topic (Trocky & Buckley, 2016).

31.7 million by 2020 (Statista, 2017). Specific to health care, in 2011 about 35% of Internet users in the United States reported reading someone else’s commentary on a healthcare issue or a blog or similar application, and another 4% posted comments or questions on a blog (Fox, 2011). Users can search for blogs with a focused com- mand, for example, “breast cancer blogs,” on a search engine such as Google. Blogs also can be found on blog-focused directories such as “spillbean.com” or “eatonweb.com.”

Health-focused blogs on the Web cover a wide range of topics. Many tell the story of the creator’s experience with a given disease or treat- ment. For example, a Google search for blogs on breast cancer revealed several hundred individual breast cancer–related blogs. These blogs covered everything from the stories of cancer survivors and family experiences to information-based blogs describing various breast cancer treat- ments. Other blogs are written by healthcare professionals with stories and commentary on health-related issues (Lippincott Nursing Edu- cation, 2017; Nurse Journal, 2014). A review by Buis and Carpenter (2009) of 398 blog posts also found that commentary on external media—for example, health-related books and newspaper articles—is another common topic in postings.

Given the growing popularity of blogs, it is reasonable to assume that healthcare consum- ers, particularly young people, might turn to blogs for health-related information and sup- port. As for demographics on blogging, 53.3% of bloggers are between the ages of 21 and 35 years, and the difference among the genders is balanced (50.9% women, 49.1% men)—this sug- gests a gender-neutral environment for Internet users (Sysomos, 2010), and most use a pseud- onym rather than their own name. Other blogs, however, are written by health professionals and by consumers who have a story to tell (Buis & Carpenter, 2009). For this reason, clients who are getting information from blogs must be taught the importance of evaluating the credentials of the author as well as the content of the blog.

Because of the ease of use and the popu- larity of this form of electronic communication,

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Formal Twitter chats can be arranged to allow for exploration of specific topics or questions, or for more general discussion. “Hashtags”—that is, keywords preceded by the # symbol that are attached to each message—allow the tweets to be linked together to create a virtual conversa- tion (Mayo Clinic, 2017b; ReferralMD, 2016). Tweets also can be used to provide streamlined messages to patients or other health profession- als, keeping them updated on important news or information. For example, nurses attending a professional conference might tweet key points or reactions to presentations. Others might tweet commentary to news or current events.

YouTube differs from the Web platforms previously discussed in that it is a video-sharing platform where users upload, view, and share videos of varying lengths. Established in 2005, YouTube’s popularity has grown at an astonishing rate. Today YouTube reports having more than 1 billion unique users per month who share more than 300 hours of video that are uploaded to the site every minute (Smith, 2016; YouTube, 2017). YouTube claims to reach more 18–49 year-olds than any cable network in the United States (YouTube, 2017). Users who search on the YouTube site can find multiple video clips on virtually any illness, surgery, or procedure. Videos available on the site have been designed for both professional and lay audiences.

The advantages of social media platforms for health education are numerous. Local or worldwide communities of learners can be created in a relatively simple and cost-effective manner. Learning experiences on these sites can be me- dia rich and enticing, especially for the younger population. Although some patients may need instruction on how to find, register for, and use the site, the sites themselves are easy to use and can be accessed from computers or mobile de- vices (Morgan, 2015).

Despite the many advantages of using so- cial media to disseminate health-related in- formation, some concerns have been raised about their potential risks (Rozenblum & Bates, 2012). Professional organizations in nursing and other health professions have developed

Wikis can be either open to the public or accessible to only a select group. In the open version of a wiki, anyone can access the infor- mation posted to the webpages. A closed wiki can be used for a specific community to develop a certain resource. For example, a nursing pro- fessor might set up a wiki for her online students to develop a resource manual related to building evidence-based practice in a nurse-run clinic.

Other Forms of Social Media Facebook, Twitter, and YouTube are other social media tools that can be employed by nurses for educational purposes. With these media, users create their own profile pages where informa- tion, pictures, and other forms of media such as blogs for comments can be posted. The un- limited storage capacity on the site is a major advantage for users.

Facebook, originally designed in 2004 as a college network at Harvard University, has grown to be an international networking site with more than 500 million members, including a growing number of healthcare professionals. Of all the social media tools available, Face- book remains the most popular (IBT Reporter, 2014). Approximately 79% of American adults using the Internet report visiting one or more Facebook pages on a daily basis (Greenwood, Perrin, & Duggan 2016). Facebook also hosts numbers of health and professional organiza- tions, illness-based support groups, and nurs- ing and other professional journals (George, 2011; Ventola, 2014). It has been used by health- care consumers to chronicle their experiences with illness and health care and by health pro- fessionals and health organizations to convey health-related information.

Twitter is a social media service that offers free microblogging to its members. Microb- logging is defined as the sharing and receiving of “tweets”—that is, messages of 140 or fewer characters—with the members of one’s per- sonal network (George, 2011). Twitter can be used by nurses and other health profession- als and healthcare organizations in many ways.

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Webinars, or web conferencing, are similar to a webcast in that they are Internet-based pro- grams; however, webinars do allow greater inter- action. Webinars often have two components: a computer-based display, such as a PowerPoint presentation or whiteboard, and a live discussion. Participants typically can join a web-based con- ference via telephone or computer. Easy-to-use computer applications are available to assist in running online meetings or webinars.

When well run, webinars can be an effective strategy for teaching or meeting with groups of people at a distance. However, without proper planning and implementation, they can be frus- trating for the individual conducting the session as well as for participants. The following guide- lines can be used to ensure a smooth delivery of content and good audience participation. (Costill, 2015; Griffiths & Peters, 2009).

■ Allow adequate time to publicize the event. Depending on the audience several weeks to several months may be required.

■ Develop a lesson plan or meeting agenda in advance, mapping out both the topics to be covered and the time to be spent on each topic. Build in time for questions and discussion.

■ If slides or media are to be used as part of the program, upload them prior to the we- binar and do a test run, making sure they can be displayed and convey the appropri- ate message. Make sure the font is large and clear enough to be easily read. Avoid clut- ter on the slides by keeping them simple.

■ Make sure adequate staffing is available for the webinar. A common model is to have one person who is responsible for presentation and an assistant who answers participant questions online and provides the presenter with assistance on technical issues. Someone must be familiar with the technological aspects of running the webinar to ensure a problem-free experience.

■ Send instructions and any necessary mate- rials to participants several days in advance. Send a reminder about 24 hours in advance.

an array of policy and procedure documents to assist health professionals to reduce these risks. For example, the American Nurses As- sociation (ANA) has published a set of princi- ples for social networking as well as a tool kit to guide the nurse’s use of these communica- tion mechanisms (ANA, 2015).

When using social media, nurses should be aware of the following:

■ Many social media sites have been used to market products such as tobacco, show unhealthy or harmful behaviors such as various forms of abuse, and convey bullying or biased messages that can result in psycho- logical harm (Lau et al., 2012). Public health officials are concerned about suicide risk, particularly among vulnerable populations who may be subject to bullying behavior on these sites (Luxton, June, & Fairall, 2012).

■ As with other forms of electronic commu- nication, it may be prudent to obtain legal advice before engaging in online patient– professional relationships to avoid uninten- tionally violating state and federal privacy laws (Dizon et al., 2012).

■ Maintaining the privacy and confidenti- ality of patients is of utmost importance. Information, photographs, and deroga- tory comments about them should not be posted (Barry & Hardiker, 2012; Norton & Strauss, 2013).

■ Remember that everything posted on a social media site is public information and may be widely distributed.

Webcasts and Webinars Webcasts, or live broadcasts over the Inter- net, permit audio and/or video to be transmit- ted to participants in multiple locations. They provide a unique mechanism for delivering pre- sentations to users around the globe. Although webcasts allow only limited interaction, they are growing in popularity as a training device for sharing lectures and demonstrations. Pod- casts are audio-only webcasts, and vodcasts are video-based webcasts (Erardi & Hartmann, 2008).

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E-Mail/Texting In a discussion of health care in the 21st cen- tury, the National Institute of Medicine (2001) proclaimed that both patients and clinicians could benefit from improvements in timeli- ness by using Internet-based communication. Electronic messaging is a commonly used In- ternet technology that holds great potential for improving care, communication, and health education. Although electronic communica- tion was once thought to be reserved for the younger generation, it is now widely used and accepted across generations and within many countries and provides a simple and efficient way for nurses and other healthcare provid- ers to connect with patients (Mattison, 2012; Newhouse, Lupianez-Villanueva, Codagnone, & Atherton, 2015).

Two common forms of electronic messag- ing are electronic mail (e-mail) and texting. An e-mail is an electronic file that is sent to an e-mail address using an e-mail program that al- lows the user to create, send, and store messages. E-mail programs are widely available and typi- cally free of charge. E-mail messages can be any length and can include attachments such as pic- tures and video. Users read and send their e-mail messages by accessing their e-mail program ac- count. Text messaging is a way to communicate via a mobile phone using a cell phone number. Although interest in texting in the healthcare environment is growing, e-mail communica- tion is more commonly used.

Studies suggest that many patients are in- terested in communicating with their healthcare providers via e-mail. According to a national survey, 93% of adults 21 years and older indi- cated they would likely choose a doctor if e-mail communication was offered (Catalyst, 2014). In- deed, e-mail is universally used among diverse age groups and is a very popular form of com- munication, employed by almost all Internet users. Patient expectations have evolved in that patients want texts and e-mails from their doc- tor proactively when sick or well (Miliard, 2012).

■ Start early. The individuals running the we- binar should arrive no later than 30 minutes prior to the start of the session and log on to the system at least 15 minutes prior to beginning the presentation. If any presenters are off site, make sure they have a way to contact the individuals running the session through an offline medium.

■ Reduce background noise, including muting all phone lines.

■ As with any meeting, keep the conversation moving and the agenda on track. Make sure everyone has a chance to speak or ask questions. With a small group, you might want to call on people by name. In a large group, do not allow anyone to monopolize the session.

■ Follow up with participants after the ses- sion. Include a postevent survey and/or evaluation form.

▸ The Internet The World Wide Web is merely a small com- ponent of the much larger computer network called the Internet. Although the Internet does not provide the eye-catching webpages and the multimedia found on the World Wide Web, it does offer a wide range of services, many of which can be used to deliver health and healthcare ed- ucation to clients. The Internet services most likely to be of interest to nurse educators in- clude those that allow computer-facilitated communication.

Whereas the World Wide Web provides opportunities to send healthcare messages to large groups of people in the form of educational webpages, the Internet can be used to enhance teaching by enabling individuals to communi- cate with one another and with groups of peo- ple via the computer. E-mail, real-time chat, and e-mail discussion or Usenet newsgroups have all been used to communicate with peo- ple about health and health care, some in very creative ways.

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In some ways, an e-mail system is prefer- able to a voice messaging system. For patients who are anxious about asking questions, e-mail allows them all the time they need to gather their thoughts. In addition, they do not have to remember the answers they are given by the nurse, as the e-mail message provides a written recording of the nurse’s response.

In contrast, many voicemail systems are time limited. Patients are sometimes cut off in the middle of a voice message if the message is long or if they are struggling to make themselves understood. Other patients may hesitate to leave a voicemail in the evening or night hours when they know no one is there to respond. However, by the way e-mail is designed, patients can feel comfortable sending messages at any time.

Unless a mechanism is in place by which patients can contact the nurse with questions, they may be at risk for making a mistake with their self-care that may have serious consequences for their health. Simply telling patients to call if they have questions is often inadequate. A call to a busy office or clinic usually results in a call back by the nurse and the patient having to wait by the phone for an answer. Even calling hours can be problematic because they imply that the patient is free to call only at the designated hour.

An e-mail message system is simple to imple ment. Patient e-mail addresses need to be identified as part of the routine information- gathering process for new clients. Because e-mail addresses are likely to change, they need to be updated, just like telephone numbers, whenever a patient visits the office, clinic, or other setting within the healthcare delivery system.

It is a good idea to have more than one person be responsible for responding to e-mail messages, so that questions and concerns can be addressed even when a staff member is away because of vacation or other time-out of the of- fice. One way to accomplish this goal is to have messages sent to a mailbox rather than to an in- dividual. Because more than one person can be given access to an electronic mailbox, continu- ous coverage can be established. If continuous

However, researchers have found that although patients want to communicate via e-mail or text with their providers, they do not have access to medical and health systems. “All functionality that we live our lives on isn’t available in health care. You use your phone every day to send a text message or e-mail; you can’t do that to over 90% of physicians. . . This is not cutting-edge tech- nology we’re talking about. This is the standard way we live our lives” (Price, 2016, p. 2). Nev- ertheless, a survey of healthcare consumers re- vealed that although people in general like to use e-mail, 40% were unsure whether their physician uses a patient portal system and only 18% pre- ferred e-mail and 14% preferred to receive test results via online messaging (Graham, 2014).

Although e-mail offers a quick, inexpen- sive way to communicate with patients, it is im- portant that health providers encourage patient engagement with familiar as well as emerging technologies, such as e-mail, texting, and pa- tient portal systems, to enhance interaction with them, schedule appointments, and get test results (Crane, 2014). For example, e-mail has the advantage of being asynchronous—that is, a message can be sent at the convenience of the sender, and the same message can be read when the receiver is online and ready to read it. Messages can be sent and responded to any time, day or night.

As a form of enhanced communication with clients, e-mail is an approach worthy of further study by nurses. An e-mail message sys- tem gives patients who identify questions after leaving a healthcare facility a chance to get an- swers from a reliable source familiar with their history. Patients who are not sure how to phrase a question or feel rushed when instructions are being given in a clinical setting have a chance to compose their thoughts at home and prepare an e-mail message. Also, from the nurse’s per- spective, an e-mail message system provides a simple way to check on patients—that is, to see whether they understood the instructions they were given and to respond to new questions that have arisen.

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A description of the service and instructions for use should be distributed as well. For exam- ple, it may be helpful for patients to know who will be answering their questions, the types of questions that can be submitted, and the typical response time. Also, it is very important that pa- tients understand that an e-mail message system is not intended to replace a visit or phone call when they need to see or talk with a healthcare provider about an immediate problem.

When sending e-mail messages, nurses should remember that electronic communication differs from face-to-face communication:

■ Electronic communication lacks context. Without cues such as facial expressions, tone of voice, and body posture, e-mail messages can appear cold and unfeeling. Although emoticons and emojis (symbols like smiley faces used to express emotion) are commonly used by people who send e-mail messages, they may not be appropriate for all professional correspondences. However, a carefully constructed e-mail message can convey the intent of the sender.

■ Although electronic communication is con- venient, it may take longer in that the sender could wait hours or days before the message is received and answered. For this reason, it is very important that an e-mail response to a patient question be clear and provide sufficient detail so that it does not generate more questions that cannot be answered im- mediately. Furthermore, using e-mail may be inappropriate for communicating ur- gent issues or messages that need be read or responded to quickly.

■ E-mail messages provide a written record. A printed copy can serve as a handy reference for a patient and eliminates any question about which information was shared. Conversely, e-mail messages can serve as documentation of inaccurate or inappro- priate information. When responding to a patient question, it is vital that the patient’s record be reviewed and that the response to the question be accurate and carefully

coverage is not provided, it is important that pa- tients know how long they can expect to wait to receive answers to their questions.

E-mail systems can be set up to serve a variety of purposes. If postteaching follow-up is desired, for example, e-mail offers one way for the nurse to initiate contact after the patient has left the healthcare delivery system. The nurse can get in touch with the patient via e-mail fol- lowing a teaching session to convey interest in how he or she is doing with a medication regi- men, treatment, or other types of instructions given. For example, the e-mail message could stress important points that were made during the teaching session, such as, “Remember to take your pill around the same time every day.” Also, an e-mail message could be used to assess the patient’s understanding of what was taught. For example, a nurse might ask, “At what time of day have you decided to give your child his medication?”

Informational resources also can be shared via e-mail by embedding links to websites in the e-mail message. In all cases, the nurse should encourage the patient to get in touch if ques- tions remain. Any follow-up system will take time and commitment on the part of the orga- nization. Time and resources must be allocated if the system is to work effectively.

An e-mail system can also be established as a mechanism to answer questions and exchange health-related information with patients who have received services at a specific healthcare organization. An e-mail question box can pro- vide simple access to the nurse or other health educator who can serve as a reliable source of information.

For this type of system to work, the e-mail address for the mailbox needs to be widely dis- tributed and easy to remember. For example, a mailbox address such as [email protected] would be easy to remember because it includes the purpose of the mailbox and the name of the organization. The e-mail address can be placed on the bottom of written instructions, teaching materials, appointment cards, and other sources of communication with the patient.

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e-mail. For this reason, a backup system such as voicemail should be made available so that the needs of all patients will be met.

Text messages differ from e-mails in that they are short messages that are exchanged via cell phone or another handheld device. Unlike e-mail messages, which are free, text messages involve a small charge. In recent years, texting has become a common form of electronic com- munication, especially among the younger pop- ulation where texting has replaced e-mail as the preferred method of communication (Woolford, Blake, & Clark, 2013). Surveys indicate that over 70% of all mobile phone users send text mes- sages (Burke, 2016).

Text messaging is growing in popularity because ease of use and immediacy of delivery. Because large numbers of people carry their cell phones with them all the time, delivery of text messages is very quick. Furthermore, text mes- sages can be sent and received anywhere cell phone connectivity is available. Despite the ad- vantages, the following are reasons why health- care professionals should be cautious about sending text to clients (Greene, 2012; HealthIT. gov, 2013; Nield, 2017).

■ Text messages are not considered to be secure as they are not encrypted and may be stored by the wireless carrier.

■ Text messages can be stored on a cell phone or handheld device indefinitely. Because mobile devices are not always password protected and may be shared with others or recycled, text messages may not be kept private.

■ Within healthcare organizations, IT depart- ments do not typically monitor text messages and text messaging may not be part of the organization’s HIPAA compliance plan.

Electronic Discussion Groups The Internet provides many opportunities for patients and healthcare professionals to par- ticipate in electronic discussion groups with other people who share a common interest. In the case of health and healthcare education,

thought out. Copies of the e-mail message sent to the patient should be placed in his or her medical record.

■ Electronic communication can never be assumed to be private. This reminder is especially important in the era of Health Insurance Portability and Accountability Act (HIPAA) regulations. The healthcare provider must take steps to ensure privacy at both the healthcare facility and the patient’s computer. It is suggested that pa- tients sign a consent form if health-related information is to be shared via e-mail and that they be given instructions for safe use of the e-mail system (American Medical Association, 2017).

Not all information may be appropriate to share in an e-mail message. For example, it may not be appropriate to send abnormal test results to a patient in electronic form. It is also important that both nurses and patients un- derstand that violations of privacy can occur in many ways. For example, patients who send e-mail messages from work may not be aware that their messages may be stored on servers and hard drives even after they have been deleted. In some cases, the employer may have legal ac- cess to this information (Guerin, 2017a, 2017b).

E-mail messages also can be easily for- warded. The nurse, therefore, should assume that the client may choose to share a response with others. Privacy can be ensured at health- care facilities by requiring a password-protected screen saver at all workstations. The American Medical Association has issued guidelines on physician–patient e-mail exchange and the Joint Commission prohibits texting to issue patient care orders, citing patient safety concerns and the increased burden on nurses to enter text orders accurately in the HER (JD Supra, 2017).

E-mail communication between nurses and patients has tremendous potential to enhance teaching. However, despite the increased use of e-mail among the general population, it is important to remember that not every patient has a computer, computer skills, or access to

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Whether the group is large or small, the asynchronous nature of electronic discussion groups makes it possible for people to com- municate with one another despite different time zones and work schedules. Also, no mat- ter whether the nurse chooses to create an elec- tronic discussion group or uses one already in existence, this form of online communication provides for a creative way to learn and to teach.

Mailing Lists Automated mailing lists are one of the most pop- ular means of setting up an electronic discussion group. With an automated mailing list, people communicate with one another by sharing e-mail messages. The principle by which these groups work is simple. Individuals who have subscribed to the mailing list send their e-mail messages to a designated address, where a software program then copies the message and distributes it to all subscribers. Therefore, when a message is sent to the group, everyone gets to see it. The most popular of the e-mail list management software programs is LISTSERV. Although LISTSERV refers to a commercial product, all automated mailing lists are sometimes incorrectly referred to as “Listservs.”

Although mailing lists are owned or man- aged by an individual, much of the work in- volved in running the list is automated by the software program used. Subscribers are given two e-mail addresses to use when interacting with the mailing list: one to use when posting messages to the entire group and another to use for administrative issues such as requests to stop mail for a specific period of time. Both functions—distributing messages and handling routine requests—are automated and handled by the software program rather than by a person. Subscribers must use the correct address and precisely worded commands when attempting to interact with the list because the computer program cannot solve problems.

Upon enrolling in the mailing list, sub- scribers are sent directions and a list of prop- erly worded commands that should be used

common interests can focus on a specific health- care problem such as cancer, a life circumstance such as death of a spouse, a health interest such as nutrition, or a professional issue such as nursing research.

Although different types of electronic dis- cussion groups are available, all share a com- mon feature—the ability to connect people asynchronously from various locations via computer. People like electronic discussion groups because they are easy to use and are available 24 hours a day. Because electronic discussion involves faceless communication with strangers from all over the world, there is a sense of anonymity even when real names are used. With the growth of Facebook, blogs, and other forms of social media, electronic dis- cussion groups are not as popular as they once were. However, electronic discussion groups covering a wide range of topics are still avail- able and active.

Electronic discussion groups can be struc- tured in different ways. Some are moderated, whereas others have little or no oversight. Some electronic discussion groups have thousands of subscribers, whereas others are very small closed groups created for specific purposes.

For the nurse, electronic discussion groups can serve several purposes. Such groups can be used as vehicles for teaching or as learning re- sources to share with patients and other health- care professionals. The nurse who chooses to create an electronic discussion group can use it to reach large or small groups of healthcare con- sumers or healthcare professionals from within the immediate vicinity or worldwide.

For example, electronic discussion groups have been created and moderated by nurses to promote networking and information sharing among nurses within a certain specialty area. These groups are open to anyone who is inter- ested and typically have memberships of sev- eral hundred people from countries around the world. In comparison, nurses in a hospital or clinic might choose to set up a small private electronic discussion group as a means to facil- itate a journal club.

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and group members come to count on others in the group for their counsel.

For these same reasons, automated mailing lists have become popular as mechanisms for on- line support for health consumers (Coulson & Shaw, 2013; Mayo Clinic, 2015). With the in- creased use of computers by the general pop- ulation, an increasing number of people have turned to their computers to access information and resources that can help them deal with their health issues. As a result, the need has been iden- tified for electronic discussion groups devoted to specific health problems and online support groups have been established (Medina, Filho, & Mesquita, 2013).

For example, the Association of Cancer On- line Resources, Inc. (ACOR, 2017) has been a major player in the move to bring online support to healthcare consumers. This nonprofit organi- zation, which is devoted to assisting people with cancer, has established more than 142 different online support groups since 1996, each devoted to a certain type of cancer or cancer-related prob- lem. Memberships in the various groups range from about 25 people in the smaller groups to almost 2,000 individuals in the larger groups.

Other individuals and organizations have established similar online groups covering a wide range of healthcare issues. Sometimes these groups are started by individuals who have an interest in a special topic; others are started by professional or advocacy groups interested in providing service to a specific group of peo- ple. In addition to the many public groups that have open enrollments, private groups can be established to meet the needs of a group of peo- ple associated with a certain healthcare pro- vider or organization (Thompson, Parrott, & Nussbaum, 2011).

Online support groups are particularly rel- evant to the discussion of technology for educa- tion. Wright (2016) reviewed the literature on online support groups/communities to uncover predictors of participation, explore the appli- cation of relevant theoretical frameworks, and critique coping strategies and health outcomes for individuals with different health concerns.

when communicating with the software pro- gram. New subscribers are encouraged to save the instructions and refer to them as needed. Despite these precautions, new users frequently make mistakes. It is not uncommon to read mes- sages from frustrated subscribers who cannot stop their mail because they are either posting to the wrong address or failing to use the cor- rect command.

Automated mailing groups are wonderful tools for the nurse when used as a means for de- livering education to large numbers of people or when shared with clients and colleagues as a learning resource. Mailing lists are easy to use once a user understands how the system works. Multiple free tutorials are available on the Web to help the novice subscriber.

With multiple automated mailing lists avail- able, it is possible to find an online group to cover almost any issue. The quality of the messages is usually very high in both health-related and professional mailing lists. Nurses who choose to create a group rather than to participate in an established one can learn to manage a large or small electronic mailing list without too much difficulty. Even so, it is helpful for list manag- ers to have either the support of computer pro- fessionals in their institution or the knowledge and skill necessary to handle the routine com- puter issues that arise from time to time.

Mailing lists can be used effectively as vehi- cles for education or information exchange with groups desiring these opportunities over time. Because mailing lists facilitate group rather than individual communication, they work especially well for people who are interested in collabora- tive learning or learning from the experiences of others. Mailing lists designed for professional audiences are good examples. Multiple lists are available covering everything from nursing his- tory to nursing research to specific areas of nurs- ing practice. Most of these automated mailing lists are quite active, and at any given time, sev- eral discussion topics can be addressed by the group. Members post questions, ask advice, and comment on current issues. Relationships be- tween active members are established over time,

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to continue their participation. Subscribers can withdraw from a group at any time.

Online support groups have some disad- vantages that should be shared with patients who are thinking about joining one. Most peo- ple who have participated in a LISTSERV or other type of mailing list note that the volume of messages received each day can be problem- atic (Aranda, 2014). Some e-mail boxes are flooded with responses and the receipt of un- wanted e-mails per day.

Experienced users learn to sort messages and delete the unnecessary or irrelevant ones quickly. Others find requesting that messages be sent in digest form (in which all messages received in a day are combined and sent in one mailing) helps control the volume of e-mails received. In any case, the daily volume of mes- sages initially can be overwhelming and may present a problem for people with low literacy levels or for people for whom English is a sec- ond language.

Patients also should be made aware of the fact that most online groups do not have a pro- fessional facilitator. Instead, online groups are often run by someone who is interested in the health problem being discussed either because he or she has the condition or has a family mem- ber with the healthcare problem. Consequently, inaccurate information may be shared and prob- lems with group dynamics may not be addressed.

Although online support groups have been found to be beneficial for most individuals, it should be noted that some people report leav- ing groups because of the intensity of the discus- sion or because they felt that some participants were unkind to others. It has been suggested that the anonymity associated with the online format may result in some individuals feeling less inhibited, which results in people posting remarks that might not have been posted in a face-to-face environment (Hammond, 2015).

Although this chapter classifies online sup- port groups within the category of automated mailing groups, it should be noted that online support groups take many forms. Many groups use the mailing list or LISTSERV format described

Coulson and Shaw (2013) discussed the factors contributing to the success of online support groups. A review of the purposes and goals of several online support groups revealed educa- tion and information sharing as the reason for starting and maintaining a group.

The emphasis on information sharing in online support groups is not surprising. Many people join online support groups after they or their loved ones have been diagnosed with a se- rious illness. They come to the support group not only to receive reassurance and encourage- ment but also to gather as much information as possible so that they can begin to make neces- sary decisions about treatment. By joining an online support group, they are turning to peo- ple who know what they are going through and who can give practical advice based on real-life experience. The desire to share the most current information is commonly what brings group members together, and a discussion of new treat- ments and other discoveries found in the liter- ature is commonplace (Mou & Coulson, 2013; Silence & Bussey, 2017; Thompson et al., 2011).

Nurses may wish to teach their patients about the benefits of online support groups. If an appropriate group is not available, nurses can start an online support group of their own. On- line support groups may be especially helpful to people who find it difficult to leave home be- cause of illness or care responsibilities.

Patients who are unfamiliar with online communication should be reassured that there is no pressure for them to contribute to the discussion and that many people benefit just from reading the comments of others. Patients who are insecure about their ability to express themselves in written format may find it help- ful to initially compose their messages using a word processor so that they can take the time to think about what they want to say and use the spelling and grammar check function to edit their remarks. Those who are unsure whether an online support group will meet their needs should be encouraged to give one a try. There are no costs involved other than the cost of be- ing online, and users are under no obligation

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with a telephone conference call. In both sce- narios, several people from different locations participate in a conversation at the same time. Both also allow people to join or leave the ses- sion as needed.

Patients and healthcare professionals have many opportunities to engage in online chats related to health issues. A search of the World Wide Web can uncover a vast array of sched- uled chats where a specific topic is being dis- cussed at a given time as well as ongoing chats where people are invited to stop in at any time to ask questions or engage in conversation with persons who happen to be in the chat room. In addition to public chat rooms, many organiza- tions sponsor chats for their own clients or staff to offer ongoing educational programs or infor- mation exchange among groups.

When leading or facilitating a chat group, it is important in advance to plan for the inter- action. The discussion in a chat room can move quickly, and it is very easy to get so involved in the process of chatting that the content to be cov- ered gets lost or forgotten. Also, without adequate control systems in place, chats can experience communication problems, such as multiple on- going conversations, lack of focus, and periods of silence. The following suggestions may help to organize a successful chat session:

■ E-mail or post the purpose of the chat ses- sion several days in advance. If appropriate, include an agenda, assignments to be com- pleted ahead of time, or other resources that participants will need to prepare for the session.

■ Make a list of the discussion points to be covered during the session. The list should be well organized, easy to follow, and placed so that it can be easily seen during the chat. Chat sessions often move so quickly that there is little time for the facilitator to make sense of crumpled or scribbled notes.

■ Depending on the topic and the experience of the facilitator, it may be appropriate to limit the number of participants. The larger the group, the more difficult the challenge

here. Others use Facebook as their platform for group information sharing. Still others main- tain a website that provides many avenues for communication, including scheduled and un- scheduled chats, bulletin boards, mailing lists, and electronic newsletters. Regardless of the for- mat, online support groups provide a mechanism for meeting the teaching and learning needs of many different client populations.

Other Forms of Online Discussion Online discussion can take place through many other mechanisms. Although mailing lists and blogs are two of the more common approaches to online discussion, others are worthy of men- tion. When choosing a method for teaching or exchanging information online, it is important to consider all options and select the method that is most appropriate for the content to be deliv- ered and the audience to be targeted.

Online forums, message boards, and bul- letin boards are systems that provide a way for people to post messages for others to read and respond to. These systems are found on websites that allow users to post directly to the discussion board rather than indirectly via e-mail. Many people may find discussion boards easier to use.

Although most discussion board–type fo- rums require some system of registration, users can often select a user name of their choosing and e-mail addresses are not displayed. This added privacy is a boon to many people who are reluc- tant to share their names and e-mail addresses with strangers. Online forums, message boards, and bulletin boards for health consumers and healthcare professionals can be found on many health-related sites on the World Wide Web.

Online Chats Chats differ from e-mail and the other electronic communication modalities previously discussed in that they provide an opportunity for online conversation to take place in real time. Although chat conversations take the form of text rather than audio, a chat session shares many features

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overwhelming for new users. The following guidelines for chat participation should be shared with patients or colleagues who will be joining a chat session for the first time:

■ Allow enough time before the chat starts to download software if it is needed. First-time users are often required to download soft- ware, called a chat client, before beginning. This software is typically offered as freeware or shareware on the Internet and is easy to install.

■ Be prepared to choose a user name. Par- ticipants in public chats with strangers are often advised not to use their real names to protect their privacy.

■ Keep comments short and to the point. If a user takes a long time to compose a mes- sage, the group may have moved on to an entirely new topic by the time the message gets posted.

■ Be prepared for chat lingo in public chat rooms. Abbreviations like BTW (“by the way”) and emoticons (typographical symbols that represent emotions or facial expressions such as ;) for winking) are commonly used.

■ Do not worry about typographical errors and grammar. Chat programs do not have spell checks, and not everyone is an experienced typist. People who are frequent chat users learn to overlook spelling errors.

Chat works well as an online communica- tion modality for many people. Patients who are homebound or isolated may benefit from having the opportunity to participate in education pro- grams or to receive answers to their questions without leaving home. Likewise, many health- care professionals would benefit from being able to access professional education that allows real- time discussion and dialogue.

However, some limitations of chat must be considered. Because chat requires that people be online at the same time, scheduling conflicts and time-zone issues may result in less acces- sibility than asynchronous forms of electronic discussion. Also, as mentioned earlier, because of the fast pace of most chat discussions, it may

of running a smooth and productive on- line chat.

■ Sign on to the chat session early and encour- age participants to do so as well. You want to be able to handle unexpected problems before the session begins.

■ Watch the clock. Time in a busy chat session goes by quickly. If the chat was designed as a question-and-answer period, it may be helpful to ask people to e-mail import- ant questions ahead of time so they are not forgotten.

■ Help the group to follow the conversation taking place. It is easy for chat discussions to become disjointed or off topic. When responding to a question, refer to the query and the person asking it. For example, “Karen asked about pain management. I think . . .” If the group is losing focus, bring the participants back to the agenda and the points being discussed.

■ Limit the amount of time spent discussing the detailed questions or concerns of one participant. If someone in the group needs individualized attention, suggest that he or she e-mail or call you after the chat has ended.

■ If appropriate, ask participants who have not joined the conversation if they have any questions. Some participants choose not to make comments during a chat, which is acceptable. However, there may be others who were not quick enough to get their comments online and who have questions that need to be asked. A statement such as “Our conversation moved very quickly tonight, so I want to give those who haven’t had a chance some time to ask their ques- tions” may slow down the conversation long enough for everyone to have an opportunity to contribute.

■ Begin to wrap up the session about 10 minutes before the scheduled end time. Announce that there are 10 minutes left and ask for final questions or comments.

It also may help to prepare participants for the chat experience. Chat sessions can be

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As educators, nurses must be aware of the spe- cial issues involved in the use of computer and Internet technology in healthcare education and be prepared to make accommodations as needed.

As previously discussed, one of the most widely publicized issues related to the use of computers and Internet technology is the digital divide, referring to the gap between those indi- viduals who have access to information technol- ogy resources and those who do not. Although computer and Internet access is improving in most areas, gaps remain. According to a Pew Foundation report, 15% of American adults are disconnected; that is, he or she does not use the Internet (Zickuhr, 2013). Studies conducted by the Pew Foundation have found that factors in- fluencing the likelihood that someone will have access to information technology resources in- clude age, income, level of education, and abil- ity (Zickuhr, 2013). The top four reasons why adults 18 years and older do not use the Inter- net or e-mail are (1) the Internet is not rele- vant to them, (2) the Internet is not easy to use, (3) it is too expensive to own a computer or pay for Internet connection, and (4) they physically lack access to the Internet. These studies revealed that those at risk for limited access included people older than 65, those with household incomes of less than $30,000, adults who did not complete high school, and people with disabilities. In addition, house- holds without children are less likely to have Internet access. However, African Americans and English-speaking minority adults are as likely as whites to own and use a mobile phone, reducing some of the racial and ethnic dispar- ities of years past ( Zickuhr, 2013).

Because of the digital divide, some healthcare consumers do not have the resources necessary to gain entry to computer- and Internet-based health education programs. Thus, although tech- nology can increase access to healthcare educa- tion for some people, nurse educators must be aware that some segments of the population will be denied access if attempts are not made to pro- mote digital inclusion. The first step in promot- ing digital inclusion is recognizing those groups

be difficult for some patients to keep up with the dialogue. Patients with certain disabilities, who are ill, and/or with low literacy levels may find it difficult to participate if the group moves along quickly.

The future for electronic communication is exciting. The technology to add audio and video components to online conferencing is available and is becoming more refined and less expensive every day. Chat and other types of conferencing software also are becoming more sophisticated, allowing for more control and greater ease of use.

▸ Issues Related to the Use of Technology

Despite the power of computer and Internet technology to enhance learning, the use of these technologies in healthcare education presents some unique challenges. Think for a moment about the many ways in which healthcare edu- cation differs from more traditional classroom education. The characteristics of the learners, the setting, and the access to hardware, software, and technological support are all likely to be dif- ferent. In addition, issues related to the infor- mation technology itself can create challenges. These factors include considerations about the accuracy of online content and the accessibil- ity of electronic resources.

Whereas traditional classroom education is likely to take place in a structured setting, healthcare education takes place in a wide range of settings, many of which are unstructured. Stu- dents who are part of an educational system are likely to have some access to the hardware, soft- ware, and technological support necessary for facilitating technology-based learning. By com- parison, access to resources and support varies considerably among healthcare consumers and in healthcare organizations. Students in a class- room also often share many common character- istics related to age and ability, whereas patients in healthcare education programs may cover a wide range of ages, abilities, and limitations.

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size, a supportive chair, and a reminder to get up and walk around three to four times per hour will help older adults to avoid dis- couraging physical symptoms that may in- terfere with computer use.

■ Identify resources that will provide computer access and support in older adults’ home com- munities. Supply older adults with a com- prehensive resource list identifying places where free computer and Internet access is available, places where computer training is provided for them, and contact people who will assist them if they encounter problems with the technology. In addition to public libraries and community centers, numerous projects nationwide are committed to digi- tal inclusion for all segments of the popula- tion, including the older adult population. Many of these projects and resources can be identified on the Web. For example, AARP (formerly the American Association of Re- tired People) has a wide range of services designed to promote and support computer use by older adults available on its website (http://www.aarp.org).

■ Motivate older adults to use a computer by helping them to identify how the computer can meet their needs. It is important to talk to older adults about their needs and abili- ties. Find out how they like to learn, which kinds of things they enjoy doing, and what their healthcare needs are. Matching a com- puter program or website to the individual’s unique circumstances will encourage com- puter use. For example, an older adult who is caring for a spouse with cancer might ap- preciate an online support group if he or she enjoys interacting with and learning from the experiences of others. In this way, you will help to generate interest in learn- ing how to use a computer for health edu- cation by starting at a place that piques the older adult’s interest.

■ Create a supportive and nonthreatening environment to teach older adults about using a computer for health education. Today’s older adults did not grow up with computers and may not have confidence

who are at risk for limited access and attempt- ing to understand why the gap exists.

People over the age of 65 are one of the risk groups that must be addressed. Older adults are more likely to be retired without employer access to a computer, are less likely to have children in the home who typically bring an enthusiasm and knowledge of computers with them, may have less disposable income with which to purchase computer hardware and software, and did not grow up using this technology.

Nevertheless, it would be a mistake to dis- count computer-delivered education as a pos- sibility for the older adult population. The first time that more than half of older adults used the Internet was in 2012. By 2013, 59% of older adults reported going online, which was a sig- nificant increase in 1 year. Research studies have shown that with education and support, older adults enjoy using and learning from computer- based programs (Smith, 2014b). Although many older adults have limited incomes, numerous gov- ernment and private initiatives are available to provide free or low-cost computer and Internet access for this population. Although some older adults have physiologic and neurologic problems that make computer use difficult, many others enjoy good health and functionality.

Health and healthcare education are both important to older adults, and computer- and Internet-based technology holds much promise for this segment of the population. Therefore, it is important that the nurse be prepared to support computer-based learning among older clients. The following interventions may be helpful in encouraging older adults to engage in computer- based learning activities:

■ Reinforce principles of ergonomics by making suggestions about equipment and posture that will minimize physical problems related to computer use. Ergonomics is important for everyone but is an especially critical con- sideration for older adults, who may have visual problems as well as arthritic changes in the neck, hands, and spine. Proper pos- ture, correct positioning of the keyboard and monitor, adjusted screen colors and font

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computer that require hand–eye coordination. When identifying obstacles related to visual im- pairments, it is important to think broadly and address the wide range of conditions that affect the way we see. Color blindness, which affects approximately 8% of all males and 0.5% of fe- males, can cause significant problems for com- puter users if the website or software used does not display the correct color combinations, if the contrast between background and foreground is inadequate, and if color rather than text is used to convey directions (Liu, 2010).

Although hearing impairments cause fewer problems for computer users than visual im- pairments, some accessibility issues neverthe- less need to be addressed for users with such challenges (Burgstahler, 2012a). An individ- ual with a hearing problem may not be able to hear the sounds that are often used as prompts when a wrong key is struck or when an e-mail message is delivered. Accessibility for individ- uals with hearing impairments is becoming a bigger issue now that it is easier to send audio signals across the Web and audio messages are becoming more commonplace.

Despite the protections offered by the Amer- icans with Disabilities Act (ADA) and other fed- eral legislation, accessibility issues on the Web and constraints with hardware and software still exist. Federal legislation outlined in Section 508 of the Workforce Investment Act requires government agencies and institutions receiv- ing government funding to make their websites accessible to people with disabilities. However, many websites and programs do not fall under this umbrella of protection (Burgstahler, 2012b).

Nurses who use the Internet and the World Wide Web to teach also need to consider web- site design when creating or selecting websites that might be used by disabled learners. The World Wide Web contains multiple resources that can be used by Web designers or Web us- ers to learn design principles for accessibility. For example, submitting the search command “color blindness” to a search engine will turn up websites that explain color blindness, illus- trate how various types of color blindness affect what might be seen on a website, describe good

in their ability to learn this new skill at this point in their lives. The language of computers may seem foreign to them, so nurse educators should avoid jargon and define new terms. Teachers should pace their teaching according to the older adults’ responses. Teachers may need to proceed slowly at first and provide opportunities for practice and for reinforcement of skills. Written computer instructions should be provided before the teaching session ends so that older adults do not go home with unanswered questions.

Computers can open a whole new avenue of support and information to older adults who are struggling with their own health problems and those of their partners. Older adults who en- joy good health can find resources to help them maintain their health and to become educated healthcare consumers. It is important that older adults be given the same opportunities to take advantage of the Information Age resources that are available to younger clients. The nurse can play a key role in promoting digital inclusion among this segment of the population.

People with disabilities make up another special population who may require additional planning before using technologies in health and healthcare education. Not only are peo- ple with disabilities less likely to have com- puter and Internet access than are members of the general population, but they also may have difficulty using hardware and software (Burg- stahler, 2012b). The ability to use a computer without adaptive devices requires the fine mo- tor coordination and mobility necessary to use a mouse and keyboard, the strength to sit and hold the head in an upright position, and the ability to comprehend information presented on the computer screen. Furthermore, individuals who use a wheelchair may find that they require special equipment for mobility, as some wheel- chairs do not fit under a standard computer ta- ble (Burgstahler, 2012b).

Individuals with visual impairments may have difficulty seeing text or graphics on a computer screen or performing tasks on the

Issues Related to the Use of Technology 583

a result, it is no longer necessary for nurses to quit working or to relocate to earn a higher de- gree. Technology has contributed to the growth of distance education programs at all levels in nursing. Likewise, technology is making it pos- sible for nurses in the workplace to engage in a variety of continuing education activities de- signed to keep their practice current, to provide career mobility, and to enhance professional development.

Workforce Training/Staff Development Technology has had such an impact on work- force training that it has given birth to a new in- dustry and a new set of buzzwords that define a contemporary approach to staff education. Pro- fessional development and training organiza- tions have capitalized on the power of computer technology to provide businesses with learning solutions referred to as e-learning, an abbrevi- ation for electronic learning.

Although no consensus has been reached on a precise definition of e-learning, there is some agreement that it involves the use of technology-based tools and processes to provide for customized learning anytime or anywhere. Although the term e-learning can be applied to any learning that is delivered via technology, it is most commonly used to describe professional development and training programs. Higher ed- ucation typically uses the term distance learn- ing to describe academic programs delivered via computers.

The emphasis on e-learning in industry is on outcomes, with the goal of providing an individ- ual with the information or practice opportuni- ties required to perform a task or solve a problem at the point of need. E-learning in nursing has the potential to deliver training programs that are efficient and cost effective, promote positive patient outcomes, and lead to nursing staff sat- isfaction (Erin, 2015). The nature of the work of health care makes nursing workforce training a critical issue, and e-learning appears to have

Web design principles for promoting accessibil- ity, and provide tools that can be used to select color combinations that will not create barriers for individuals with color blindness.

Several resources are available to assist Web developers in creating websites that meet the needs of people with disabilities. The Web Ac- cessibility Initiative website (http://www.w3.org /wai) provides guidelines that are recognized by many as the international standard for accessi- bility. Another website is the Center for Applied Special Technology (CAST; http://www.cast.org), which has earned an international reputation for developing educational opportunities for all individuals. CAST created the program called “Bobby” to assist webpage authors to identify and correct problems that could make their sites inaccessible to individuals with disabil- ities (Coggan, 2017). Disabled World (2017) defines computer accessibility (also known as accessible computing) and gives many examples of assistive computer technology for individu- als with all types of sensory, speech, and phys- ical disabilities.

Age, disabilities, and other factors that place an individual on the “wrong side” of the digital divide can isolate and diminish access to health- care resources. Therefore, every effort should be made to help these individuals connect to the wealth of resources that are and can be made available through technology. The nurse can play a vital role in providing the support, educa- tion, and advocacy needed to reduce the barriers that still exist for these special groups of people.

▸ Technology for Professional Development in Nursing

From worksite training to higher education, tech- nology is making professional education more accessible and more meaningful for nurses. As

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■ E-learning programs can be customized at a variety of levels: the organization, the staff position, and the individual. Customization personalizes the program and helps to make it relevant to the individual and to the orga- nization. For example, e-learning programs can accommodate a learner’s need to move quickly or slowly through a program and can be repeated as many times as necessary.

■ E-learning programs can track completion and create a performance report for indi- vidual staff members.

■ E-learning modules are interactive and reality based. For example, a patient simulation that allows the participant to manage the care of a virtual patient can be created.

Nurses have many potential roles in the de- velopment and implementation of an e- learning program within an institution. As content ex- perts, they may be hired by e-learning compa- nies to create products designed to meet the needs of practicing nurses. Nurses within a healthcare organization may be able to work with the e-learning company by customizing the training package purchased and develop- ing a plan for its implementation. Those who use the e-learning system can contribute to the program by completing the modules offered and submitting thoughtful evaluations of the products used.

Staff training programs are important to the individual staff members, to the organization, and to the patients served. Every staff member has a responsibility to do what he or she can to ensure the success of the program.

Distance Education Because of technological advances, distance ed- ucation for nurses is flourishing in the 21st cen- tury (Billings, 2007; Lowery & Spector, 2014). This success was not always the case, however. When distance education programs were first introduced, they were quite controversial. For example, when the Regents External Degree Program was first created in 1974, many people

provided a solution to the problem of keeping staff current in a world where new treatments and new techniques are always on the horizon.

What is the e-learning approach to work- force training in nursing? First and foremost, it provides learning opportunities at the point of need. In healthcare professions such as nurs- ing, this statement means that training is avail- able 24 hours a day, 7 days a week. Because the point of need in health care is often related to patient care, e-learning must be structured in a way that it can be delivered to nurses on a clin- ical unit. Point-of-need training also must be efficient. In this era of nursing shortages and increasing complexity of care, such training must be provided in a way that fits into the busy schedules of nurses.

Finally, e-learning in health care must be distributed so that it can be made available to nursing staff across any number of environ- ments and situations. Many healthcare organi- zations employ staff in a wide range of settings and locations. A centralized approach to train- ing will not work well if it means that nurses must travel to the staff education office for all training programs.

Multiple approaches to e-learning in health care are possible. Examples of some features of e-learning products that have proved attrac- tive to healthcare organizations are as follows:

■ E-learning training modules can be deliv- ered via the World Wide Web. Web-based products are attractive because they are easily accessed in a variety of environments and situations. A computer workstation can easily fit into a clinical unit, and laptops can be carried into the field.

■ E-learning can be delivered in small mod- ules that can be completed in as little as 15 minutes. Many nurses are unable to leave their work area for long periods of time. However, most can find 15 to 30 minutes in any given day to engage in continuing education, particularly if they do not have to leave the unit. Time permitting, staff can complete several modules in one sitting.

Technology for Professional Development in Nursing 585

schools offer online degree programs as well as online courses (U.S. News & World Report, 2017). Some of these courses are totally Inter- net based, whereas others are hybrid or blended courses that incorporate a mixture of classroom instruction and online discussion.

Nursing education has followed a similar pat- tern, with a wide array of distance options being offered to students. Once considered nontradi- tional, distance education today is commonplace in the nursing education community. It should be noted that such online education is not re- stricted to higher education programs. Online continuing education programs are also avail- able to nurses from a variety of sources such as their own professional organizations.

Research has shown that distance educa- tion provides much more than a flexible ap- proach to learning. Comparisons of students from distance education courses and from tra- ditional classrooms have repeatedly shown that distance education can be a very effective mode for delivering education (Billings, Dickerson, Greenberg, Wu, & Talley, 2013; Cook et al., 2008). A meta-analysis of outcomes in allied health distance education programs indicates that a small but significant positive effect is re- alized by distance students relative to traditional students (Williams, 2006). Particularly, students with professional experiences have significant learning gains in distance education courses that incorporate elements of social interaction, innovation, and introspection into the learning design (Williams, 2006).

In discussions of best practice for online teaching, authors have consistently noted that the online environment is simply a tool to facil- itate teaching and learning (Abel, 2005; Billings et al., 2013; Dolphy, 2015; Williams, 2006). The technology itself is not what promotes posi- tive student outcomes; rather, it is the instruc- tional design and techniques within the online classroom that provide for an enriching learn- ing experience.

Several education and professional organiza- tions have developed guidelines and standards for distance education to assist faculty and to ensure

believed that a distance model was inappropri- ate for nursing education. Today, the Regents Ex- ternal Degree Program, now known as Excelsior College, is one of the largest nursing programs in the world, with more than 14,000 nursing students enrolled in its associate, baccalaureate, and master’s degree programs (Excelsior College, 2017). In 1994, another milestone was reached in nursing education when Duquesne University in Pennsylvania opened the first online distance education program leading to a PhD in nursing.

Today, the Excelsior College and Duquesne University programs represent a small sample of the many distance education programs in nurs- ing currently available in the United States. Dis- tance education programs in nursing are at the associate, baccalaureate, master’s, and doctoral levels from a wide range of for-profit and not- for-profit institutions of higher education. These distance education programs are offered by on- line institutions as well as traditional brick and mortar colleges and universities.

The term distance learning means differ- ent things to different people. Online courses, correspondence courses, independent study, and videoconferencing are just a few of the techniques that can be used to deliver educational programs to students studying at a distance. The diversity of distance education programs in the United States reflects the myriad approaches that can be used to meet the needs of students who are separated from the traditional classroom set- ting. In all cases, distance education means that the teacher and the learner are separated from each other (Lowery & Spector, 2014).

A variety of strategies are being used to pro- vide courses to students who are not in the same location as the teacher. However, online courses are growing at such a rapid pace that the Inter- net is becoming the primary vehicle for deliv- ering distance education (Frith & Clark, 2013). According to the results of a survey of more than 2,500 higher education institutions in the United States, approximately 62% of institutions offer fully online degree programs compared to 32.5% a decade earlier (Sheehy, 2013) and many undergraduate and graduate health profession

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with their online learning engage in discussion with classmates and instructors, believe their education matches their expectations, are sat- isfied with student services and supports, feel adequately oriented to their online learning pro- gram, and strive for learning outcomes that are useful for their career and professional and aca- demic development (Lorenzo, 2012; Swenson & Bauer, 2012).

Given the growth and development of online courses, it is likely that this teaching methodol- ogy will be incorporated into health and health- care education for the consumer as well. Nurses who are responsible for providing education for patients need to begin thinking about how on- line courses may fit into their programs. On- line courses not only provide learning activities and resources but also facilitate teacher–learner and learner–learner interactions. Internet-based courses might work very well in areas such as parenting and diabetes education where there is an extended program of instruction and the need for group support.

▸ State of the Evidence Teaching with technology is not a new con- cept. Indeed, nurses and other educators have been using technology to teach patients and students for many years. However, in today’s world, technology is advancing so quickly that researchers are struggling to keep up with the new products and technology-based strategies that are emerging every day. We live in a world where cars can drive themselves and handheld devices have the capacity to perform computer functions that were only dreamed of in the last century. As we enter the Fourth Industrial Rev- olution, “the boundaries between the internet, the physical world and people are becoming more blurred by each passing day and the need for education to be place-based is diminishing (Mezied, 2016, para. 4).

A growing body of research is focusing on the use of technology in patient and profes- sional education. Data suggest that computer

program quality, including the American Coun- cil on Education, the National Education Asso- ciation, the Commission on Higher Education of the Middle States Association of Colleges and Schools, the American Association of Colleges of Nursing, the National Council of State Boards of Nursing (NCSBN), and the Western Interstate Commission on Higher Education (Billings, 2007; Billings et al., 2013; NCSBN, 2015). Par- ticularly, the Western Interstate Commission on Higher Education’s Principles of Good Practice for Electronically Offered Academic Degree and Certificate Programs (https://www2.ed.gov/about /offices/list/ope/fipse/lessons4/wiche.html) has been used as a guide for the creation and pro- vision of high-quality higher education online programs since 1995 (Howell & Baker, 2006). These principles fall under seven main areas:

1. A high-quality curriculum and instruction

2. An online program consistent with the institution’s role and mission

3. Faculty support 4. Resources for learning 5. Students and student services 6. Commitment to support faculty

and students 7. Evaluation and assessment of students

and the program as a whole

A report by the Alliance for Higher Ed- ucation Competitiveness (A-HEC) similarly emphasized the importance of an institution’s motivation for and commitment to a full online program as a means of delivering high-quality online education. Successful programs work with students and faculty to move beyond tech- nological challenges and focus on a better edu- cational product (Abel, 2005).

Online educators and students share respon- sibility for successful learning. Faculty members work to generate innovation in ideas, intro- spection by students, integration of concepts, building of information, and social interaction among students and instructors to promote a high-quality learning experience (Williams, 2006). Students who are satisfied and successful

State of the Evidence 587

learning. The benefits of technology-based edu- cation are numerous, as are the challenges for ed- ucators and learners. Nurses have a responsibility to learn to use new tools to promote health and wellness in their patients and professional growth and development in themselves. The future for these teaching–learning approaches looks very bright, and nurse educators can help to shape it by continuing to think creatively about how to use technology in education and by participat- ing in research about its effectiveness.

Review Questions 1. How have the Information Age and the

Fourth Industrial Revolution as import- ant periods in history influenced and will continue to influence education in general, healthcare education specifically, and healthcare consumers?

2. Which skills are required by nursing professionals and healthcare consumers in today’s technology-based world?

3. What are the various standards that have been established to ensure quality on the World Wide Web and access to the Web by people with disabilities?

4. How can resources on the World Wide Web be used as a source of health infor- mation for both healthcare consumers and nursing professionals?

5. What are the advantages and disadvantages of using the Internet to facilitate electronic communication between and among nurse educators and healthcare consumers?

6. When using computer resources with healthcare consumers, which segments of the population require special consider- ations because of limited access or special needs? What are those considerations, and how can they be addressed?

7. What is e-learning, and what advantages does it offer in providing staff education in healthcare settings?

8. How has technology influenced profes- sional and continuing education options for nurses?

and Internet technology has become an integral part of daily life in the United States and other parts of the world. A review of the literature re- veals studies covering a broad range of topics, including the use of online support groups, the effectiveness of online education, and the use of computer-based programs for patient and professional education in clinical, educational, and home settings. The focus to date has largely been on ways in which technology is being used, the obstacles presented, and learning outcomes. Most of these studies are small in scope.

Despite a comprehensive body of research on the use of technology in higher education and a growing body of research on patient ed- ucation, there is much yet to learn, particularly in patient education. Technology is exciting and offers many advantages for both consumers and nurses. However, technology devoid of teaching and learning principles cannot stand alone in consumer or professional education. The chal- lenge for nurse educators is to keep abreast of the best technology and the educational principles that together enable and support a high-quality, enriching consumer learning experience.

▸ Summary This chapter focused on Information Age and Fourth Industrial Revolution technology and its use in healthcare education. Specifically, this chapter discussed ways in which the World Wide Web and the Internet could be used by nurse educators to enhance health and healthcare ed- ucation for consumers and healthcare profes- sionals. The impact of technology on teachers and learners was addressed, and special consid- erations for older adults and other client groups were identified. Trends in distance education for nurses were explored.

Information Age technology has the poten- tial to transform health and healthcare education. This powerful tool must be used thoughtfully and carefully, however. Education is about learning, not technology. Technology is merely a vehicle to deliver educational programs and to promote

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American Medical Association. (2017). Guidelines for physician– patient electronic communication. Retrieved from http://www .ama-assn.org/ama/pub/category/2386.html

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CASE STUDY Sarah is a registered nurse working with Steve, a 66-year-old patient in a rehabilitation outpatient clinic. Steve experienced a stroke 2 months ago and has recently returned home. He is now physically able to live independently but is still working on his ability to communicate effectively with others. Since his stroke, Steve has had difficulty with finding words when speaking with others. As a retired human resources specialist, this communication barrier is frustrating to Steve.

During her initial interview with Steve, Sarah learns that he is hesitant to return to many of his former activities with friends and is feeling socially isolated. Steve feels that his only successful social interactions since returning home are e-mail exchanges with family and friends in different parts of the country. Sarah realizes that because e-mails are written, asynchronous forms of communication, Steve has more time to find words when composing his messages than he would in a spoken conversation. She asks Steve if he has Internet access at home. He indicates that he has a high-speed Internet connection and computer in his living room that he uses daily.

Based on this preassessment of Steve’s ability and interest in this technology, Sarah asks him if he has found any online support groups for individuals who have experienced strokes. She explains that such groups would be an excellent resource for information about others’ experiences with stroke and would serve as a social venue and as another type of written activity to enhance his interaction with others. Sarah suggests that a support group could be educational and socially engaging and would offer a chance for Steve to continue building his communication skills during his rehabilitation. Steve expresses interest in this idea, and he and Sarah plan to seek out such groups online during their next therapy session.

1. Given Steve’s condition and age, how can technology be used to foster social participation? What is Sarah’s role in encouraging his social engagement?

2. Which potential problems might Steve face when trying to use the Web? 3. As a healthcare educator, which criteria should Sarah use for evaluating health-related websites?

Explain how she can apply each criterion to determine which websites are appropriate for Steve.

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Evaluation in Healthcare Education Priscilla Sandford Worral

CHAPTER HIGHLIGHTS

■ Evaluation, Evidence-Based Practice, and Practice-Based Evidence ■ Evaluation Versus Assessment

• Determining the Focus of Evaluation ■ Evaluation Models

• Process (Formative) Evaluation • Content Evaluation • Outcome (Summative) Evaluation • Impact Evaluation • Total Program Evaluation

■ Designing the Evaluation • Design Structure • Evaluation Methods • Evaluation Instruments • Barriers to Evaluation

■ Conducting the Evaluation ■ Analyzing and Interpreting Data Collected ■ Reporting Evaluation Results

• Be Audience Focused • Stick to the Evaluation Purpose • Use Data as Intended

■ State of the Evidence

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CHAPTER 14

the learner and for the organization, must be measurably effective.

OBJECTIVES

After completing this chapter, the reader will be able to

1. Define the term evaluation. 2. Discuss the relationships among evaluation, evidence-based practice, and practice-based evidence. 3. Describe the differences between the terms evaluation and assessment. 4. Identify the purposes of evaluation. 5. Distinguish between five basic types of evaluation: process, content, outcome, impact, and program. 6. Discuss characteristics of various models of evaluation. 7. Explain the similarities and differences between evaluation and research. 8. List the major barriers to evaluation. 9. Examine methods for conducting an evaluation.

10. Explain the variables that must be considered in selecting appropriate evaluation instruments for the collection of different types of data.

11. Identify guidelines for reporting the results of evaluation. 12. Describe the strength of the current evidence base for evaluation of patient and nursing staff

education.

KEY TERMS

evaluation evidence-based practice

(EBP) external evidence internal evidence practice-based evidence

assessment process evaluation

(formative evaluation) content evaluation outcome evaluation

(summative evaluation)

impact evaluation total program evaluation evaluation research reflective practice

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education efforts. The Institute for Healthcare Improvement (2012) has been sponsoring and conducting studies since 2009 linking hospital admissions and readmissions to patient educa- tion programs that are primarily nurse driven (Bates, O’Connor, Dunn, & Hasenau, 2014).

The importance of evaluating continuing staff development and student nurse education to improve professional practice is equally as im- portant. Nurse educators must ensure that staff nurses and nursing students have the knowl- edge, attitudes, and skills that demonstrate es- sential competencies for the delivery of safe, high-quality, evidence-based patient care. Eval- uation includes identifying and measuring ed- ucational activities and learner outcomes that indicate that the learning needs of registered nurses and student nurses have been met (American Nurses Credentialing Center, 2014; Bunyan & Lawson, 2013; Houghton, 2015).

Evaluation is a process within other pro- cesses—a critical component of the nursing practice decision-making process, the education process, and the nursing process. Evaluation is the final component of these three processes. Because these processes are cyclical, evaluation serves as the critical bridge at the end of one cy- cle that provides evidence to guide direction of the next cycle.

The sections of this chapter follow the steps in conducting an evaluation. These steps include (1) determining the focus of the eval- uation, including use of evaluation models; (2) designing the evaluation; (3) conducting the evaluation; (4) determining methods to analyze and interpret the data collected; (5) reporting results and a summary of the findings from the data collected; and (6) using evaluation results. Each of these aspects of the evaluation process is important, but all of them are meaningless if the results of evaluation are not used to guide fu- ture action in planning and carrying out educa- tional interventions. In other words, the results of evaluation provide practice-based evidence to either support continuing an educational in- tervention as it has been designed or support revising that intervention to enhance learning.

▸ Evaluation, Evidence-Based Practice, and Practice-Based Evidence

Evidence-based practice (EBP) is defined as “the conscientious use of current best evidence in making decisions about patient care” (Melnyk & Fineout-Overholt, 2015, p. 3). More broadly, EBP may be described as “a lifelong problem- solving approach to clinical practice that inte- grates . . . the most relevant and best research . . . one’s own clinical expertise . . . and patient pref- erences and values” (Melnyk & Fineout-Over- holt, 2015, p. 3). The definition of a related term, known as evidence-based medicine, includes these same three primary components but also adds “patient circumstances” to account for both the patient’s clinical state and the clinical setting in which the care has been delivered (Straus, Glasziou, Richardson, & Haynes, 2011, p. 1).

With the advent of evidence-based medi- cine in 1992 and the founding of the Cochrane Collaboration a year later, evidence generated from systematic reviews of clinically relevant randomized controlled trials (RCTs) has been acknowledged as the strongest evidence upon which to base practice decisions. Systematic reviews of RCTs remain important, especially for decisions about treatment. Not every clini- cal question can be answered by conducting an RCT, however. More recent literature describes evidence generated from metasyntheses of rig- orously conducted qualitative studies as provid- ing strong evidence for informing nurses’ care of patients through a more thorough understand- ing of the patients’ experience, the processes of care delivery, and the context within which care is delivered (Eddy, Jordan, & Stephenson, 2016; Goethals, Dierckx de Casterlé, & Gastmans, 2011; Taylor, Shaw, Dale, & French, 2011). Ev- idence from research is also called external

Evaluation, Evidence-Based Practice, and Practice-Based Evidence 597

evidence, reflecting the fact that it is intended to be generalizable or transferable beyond the specific study setting or sample.

When evidence generated from research is not available, the conscientious use of inter- nal evidence is appropriate. Internal evidence might be defined as data generated from a dil- igently conducted quality improvement proj- ect or EBP implementation project within a specific practice setting or with a specific pop- ulation (Melnyk & Fineout-Overholt, 2015). Internal evidence is not intended to be gen- eralizable beyond the original practice setting or population that yielded the data collected. Melnyk and Fineout-Overholt (2015) describe results of a systematically conducted evaluation as one example of internal evidence. Evaluations are not intended to be generalizable but rather are carried out to determine the effectiveness of a specific intervention in a specific setting with an identified individual or group. Although not considered external evidence, results of a sys- tematically conducted evaluation are still im- portant from an EBP perspective.

Nurses’ understanding and use of EBP have evolved and expanded over the past 2 de- cades. With the advent of electronic health re- cords and availability of real-time clinical data, healthcare professionals have been able to en- gage in timely evaluation of whether the care they have provided has resulted in improved out- comes for their patients. The Institute of Medi- cine’s Roundtable of Evidence-Based Medicine published a report titled The Learning Health- care System (Olsen, Aisner, & McGinnis, 2007) in which use of practice-based evidence along with EBP was recommended to narrow the gap between research and practice. Practice-based evidence is defined as “the systematic collection of data about client progress generated during treatment to enhance the quality and outcomes of care” (Girard, 2008, p. 15), which comprises internal evidence that can be used both to iden- tify whether a problem exists and to determine whether an intervention based on external evidence effectively resolved that problem. Put another way, practice-based evidence can be

equally useful for assessment and for evaluation. Practice-based evidence also can be used to gener- ate research questions. Results of practice-driven research that is both rigorous and relevant are more likely to reach the point of care (Cogan, Blanche, Diaz, Clark, & Chun, 2014; Kovacs, 2015; Mason & Barton, 2013).

The results of evaluations, the outcomes of expert-delivered patient-centered care, and the results of quality improvement projects all repre- sent internal evidence. This information should be gathered by nurses and other healthcare providers on an ongoing basis as an integral and important component of professional prac- tice. Recognizing these findings about current practice as a source of evidence to guide future practice and to identify needs for future research requires that nurses think critically before acting and carry out ongoing critical appraisal during and after each nurse–patient interaction.

▸ Evaluation Versus Assessment

Although assessment and evaluation are highly interrelated and the terms are often used in- terchangeably, they are not synonymous. The process of assessment focuses on initially gath- ering, summarizing, interpreting, and using data to decide a direction for action. In contrast, the process of evaluation involves gathering, sum- marizing, interpreting, and using data after an activity has been completed to determine the extent to which an action was successful.

Thus, the primary differences between these two terms are in the timing and purpose of each process. For example, an education program begins with an assessment of learners’ needs. From the perspective of systems theory, assess- ment data might be called the “input.” While the program is being conducted, periodic eval- uation lets the educator know whether the pro- gram and learners’ progress are proceeding as planned. After program completion, evaluation identifies whether and to what extent identified

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needs were met and learning outcomes were achieved. Again, from a systems theory perspec- tive, these evaluative data might be called “in- termediate output” and “output,” respectively.

An important note of caution: Although an evaluation is conducted at the end of a program, that is not the time to plan it. Evaluation as an afterthought is, at best, a poor idea and, at worst, a dangerous one. At this point in the educational program, data may be impossible to collect, be incomplete, or even be misleading. Ideally, as- sessment and evaluation planning should be concurrent activities. When feasible, the same data collection methods and instruments should be used. This approach is especially appropri- ate for outcome and impact evaluations, as is discussed later in this chapter. “If only . . .” is an all too frequently heard lament, which can be avoided or minimized by planning ahead.

Determining the Focus of Evaluation In planning any evaluation, the first and most crucial step is to determine the focus of the eval- uation. This focus then guides evaluation de- sign, conduct, data analysis, and reporting of results. The importance of a clear, specific, and realistic evaluation focus cannot be overempha- sized. Usefulness and accuracy of the results of an evaluation depend heavily on how well the evaluation is initially focused.

Evaluation focus includes five basic compo- nents: (1) audience, (2) purpose, (3) questions, (4) scope, and (5) resources (Ruzicki, 1987). To identify these components, ask the follow- ing questions:

1. For which audience is the evaluation being conducted?

2. For what purpose is the evaluation being conducted?

3. Which questions will be asked in the evaluation?

4. What is the scope of the evaluation? 5. Which resources are available to con-

duct the evaluation?

Audience The audience includes the persons or groups for whom the evaluation is being conducted (Dil- lon, Barga, & Goodin, 2012; Ruzicki, 1987). The primary audience is the individuals or groups who requested the evaluation or who will use the evaluation results and the general audience is those who might benefit from the findings of the evaluation. Thus, the audience for an evalu- ation might include patients and their families, peers, other professional colleagues, the manager of a unit or ambulatory care area, a supervisor, the chief nursing officer, the staff development director, the chief executive officer of the institu- tion or agency, or a group of community leaders.

When an evaluator reports results of the eval- uation, all members of the audience must receive feedback. In focusing the evaluation, however, the nurse educator carrying out the evaluation must first consider the primary audience. Giving pri- ority to the individual or group that requested the evaluation makes it easier to focus the evalu- ation, especially if several groups representing di- verse interests will use the results of an evaluation.

Purpose The purpose answers the question, “Why is the evaluation being conducted?” For exam- ple, the purpose might be to decide whether to continue a specific education program or to determine the effectiveness of the teaching pro- cess. If an individual or group has a primary interest in the results of an evaluation, input from that group can clarify the purpose.

An important note of caution: Why an eval- uation is being conducted is not synonymous with who or what is being evaluated. For ex- ample, nursing literature on patient education commonly distinguishes among three types of evaluations: (1) learner, (2) teacher, and (3) ed- ucational activity. This distinction answers the question of who or what will be evaluated and is extremely useful in designing and conduct- ing an evaluation. The question of why under- take an evaluation of a learner, for example, is answered by the need to know how well the

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Scope Scope considers the extent of what is being ex- amined, such as, “How many aspects of educa- tion will be evaluated?,” “How many individuals or representative groups will be evaluated?,” and “What time frame is to be evaluated?” For ex- ample, will the evaluation focus on one class or on an entire program? Will it focus on the learn- ing experience for one patient or for all patients being taught a certain skill? Evaluation could be limited to the teaching process during a patient education class, or it could be expanded to en- compass both the teaching process and related patient outcomes of learning.

The scope of an evaluation is determined in part by the purpose for conducting the eval- uation and in part by available resources. For example, an evaluation addressing learner sat- isfaction with educators for all programs con- ducted by a staff development department within a given year is necessarily broad and long term in scope; such a vast undertaking requires ex- pertise in data collection and analysis. By com- parison, an evaluation to determine whether a patient understands each step in a learning ses- sion on how to self-administer insulin injections is narrow in scope, is focused on a specific point in time, and requires expertise in clinical prac- tice and observation.

Resources Resources include time, expertise, personnel, materials, equipment, and facilities. A realis- tic appraisal of which resources are accessible and available relative to the resources that are required is crucial in focusing any evaluation. Anyone who is conducting an evaluation should remember that time and expertise are required to collate, analyze, and interpret data as well as to prepare a report of the evaluation results.

▸ Evaluation Models Evaluation can be classified into different types, or categories, based on one or more of the five components just described. The most common

learner performed. If the purpose for evaluat- ing learner performance is to determine whether the learner gained sufficient skill to perform a self-care activity (e.g., foot care), the educator might design a content evaluation that includes one or more return demonstrations by an indi- vidual learner prior to hospital discharge. If the purpose for evaluating learner performance is to determine whether the learner can conduct the same self-care activity at home on a regular basis, the educator might design an evaluation determining outcomes that includes both observ- ing the learner perform the activity in his or her home environment and measuring other related clinical parameters (e.g., skin integrity), which would improve and be maintained with regular and ongoing self-care. Content evaluation and outcome evaluation are terms that are defined and discussed in more detail later in this chapter.

In stating the purpose of an evaluation, an excellent rule of thumb is to keep it singu- lar. In other words, the evaluator should state, “The purpose is . . .,” not “The purposes are . . .”. Keeping the purpose singular and focused on the audience helps avoid the frequent tendency to attempt to do too much in one evaluation. An exception to this rule is when undertaking a total program evaluation. As discussed later in this chapter, program evaluations are natu- rally broad in scope, focusing simultaneously on learners, teachers, and educational offerings.

Questions Questions to be asked must be directly related to the purpose for conducting the evaluation, must be specific, and must be measurable. Ex- amples of such questions include “To what extent are patients satisfied with the cardiac discharge teaching program?” and “How frequently do staff nurses use the diabetes teaching reference materials?” Asking the right questions is crucial if the evaluation is to fulfill the intended pur- pose. As discussed later in this chapter, formu- lating clear, concise, and appropriate questions is both the first step in selecting the evaluation design and the basis for analyzing the data that are collected from evaluation.

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designed to evaluate staff development educa- tion, the RSA model remains useful for con- ceptualizing types of evaluation from both staff development and patient education perspectives. Examples of use of the RSA model are given by Dilorio, Price, and Becker (2001) in their dis- cussion of the evaluation of the Neuroscience Nurse Internship Program at the National In- stitutes of Health Clinical Center and by Un- derwood, Dahlen-Hartfield, and Mogle (2004) in their study of nurses’ perceived expertise fol- lowing three continuing education programs. More recently, Sumner, Burke, Chang, McAd- ams, and Jones (2012) used the RSA model to support development of a study to evaluate pro- cess, content, and outcome evaluation of a basic arrhythmia course taught to registered nurses.

The RSA model provides a visual of five basic types of evaluation in relation to one an- other based on focus, purpose, related questions, scope, and resources available (FIGURE 14-1). The five types of evaluation include process, content,

types of evaluation identified include some com- bination of process (also known as formative) evaluation, and outcome (also known as sum- mative) evaluation. Other types of evaluation include context, content, outcome, impact, and total program evaluations. Evaluation models defining these types and their relationship to one another have been developed (Abruzzese, 1992; Frye & Hemmer, 2012; Losby, Vaughan, Davis, & Tucker-Brown, 2015; Milne, 2007; Noar, 2012; Ogrinc & Batalden, 2009; Rankin & Stallings, 2005; Rouse, 2011; Stavropoulou & Stroubouki, 2014). Because not all models de- fine types of evaluation in the same manner, the nurse educator should choose the model that is most appropriate for the given purpose and most realistic given the available resources.

Abruzzese (1992) constructed the Roberta Straessle Abruzzese (RSA) evaluation model for conceptualizing, or classifying, educational evaluation into different categories or levels. Although developed in 1978 and originally

FIGURE 14-1 RSA evaluation model. Reproduced from Abruzzese, R. S. (1992). Evaluation in nursing staff development. In R. S. Abruzzese (Ed.), Nursing staff development: Strategies for success (pp. 235–248). St. Louis, MO: Mosby–Year Book. Copyright Mosby 1992.

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framework for designing, conducting, and eval- uating education.

Consistent with the purpose of process eval- uation, the primary question here is, “How can teaching be improved to facilitate learning?” The nurse’s teaching effectiveness, the elements of the education process, and the learner’s responses are monitored on an ongoing basis. Abruzzese (1992) describes process evaluation as a “happiness index.” While teaching and learn- ing are ongoing, learners are asked their opin- ions about the educator(s), learning objectives, content, teaching methods, instructional ma- terials, physical facilities, and overall learning experience. For the nurse educator, specific ques- tions could include the following:

■ Am I giving the learners time to ask questions? ■ Is the information I am giving orally consistent

with information included in instructional materials being provided?

■ Are the learners actively participating? ■ Is the environment, such as room tem-

perature, privacy, and level of distraction, conducive to learning?

■ Should I include more opportunities for return demonstration or teach-back?

The scope of process evaluation generally is limited in breadth of content and time frame allotted to a specific learning experience, such as a class or workshop, yet is sufficiently de- tailed to include as many aspects of the specific learning experience as possible while they oc- cur. Thus, learner behavior, teacher behavior, learner–teacher interaction, learner response to teaching methods and materials, and char- acteristics of the environment are all aspects of the learning experience within the scope of pro- cess evaluation. Whether they engage in the ed- ucational program online or on-site, all learners and all teachers participating in a learning ex- perience should be included in process evalu- ation. If resources are limited and participants include different groups, a representative sam- ple of individuals from each group—rather than everyone in the groups—may be included in the evaluation.

outcome, impact, and total program. Abruzzese describes the first four types as levels of evalu- ation leading from the simple (process evalua- tion) to the complex (impact evaluation). Total program evaluation encompasses and summa- rizes all four levels.

Process (Formative) Evaluation The purpose of process evaluation (forma- tive evaluation) is to make necessary adjust- ments to an educational activity as soon as they are identified, such as changes in personnel, materials, facilities, teaching methods, learn- ing objectives, or even the educator’s own at- titude. One or more adjustments may need to be made after a class or teaching session and before the next is taught or even in the mid- dle of a single learning experience. Consider, for example, evaluating the process of teaching an adolescent with newly diagnosed type 1 di- abetes and her family how to administer insu- lin. The nurse might facilitate learning by first injecting himself or herself with normal saline so that the learners can see someone maintain a calm expression during an injection. If the nurse educator had planned to have the par- ent give the first injection but the child seems less fearful, the nurse might consider revising the teaching plan to let the child first perform self-injection.

Process (formative) evaluation is a compo- nent of the ongoing education cycle of assessment, planning, and implementation. Process evalua- tion helps the nurse anticipate and prevent prob- lems before they occur or identify problems as they arise. Milne’s (2007) evaluation framework consists of the elements of structure–content– outcomes–procedures–processes– efficiencies (SCOPPE). Noar’s (2012) framework includes the elements of audience–channel–message– evaluation (ACME). Both of these frameworks focus on the characteristics of the teacher and the learner as well as on examining teaching methods and instructional materials as aspects of process evaluation. Noar (2012) speaks to the importance of using a consistent theoretical

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activities specific to the behavioral outcomes to be achieved (Bradshaw, 2007).

EBP is not a “cookbook” approach to provid- ing health care. Similarly, CPGs are not intended to disregard the individual learner’s needs. Vari- ance from a CPG, though, should not occur in a haphazard manner. As attention to practice-based evidence evolves, the importance of using inter- nal evidence gathered from process evaluation is becoming an increasingly critical component of every teaching–learning experience.

For instance, Chan, Richardson, and Richard- son (2012) describe a process evaluation con- ducted to examine which factors might sup port successful delivery of an intervention to im- prove symptom management for patients re- ceiving palliative radiation therapy for their lung cancer. Although two nurses were using the same procedure to provide the intervention, patients were more satisfied with the nurse who had prior experience in oncology. Patients also were less likely to practice their muscle relax- ation protocol if they had not yet experienced the level of pain that the muscle relaxation was intended to alleviate. Based on these findings, Chan and colleagues modified the intervention protocol to have patient education be provided by nurses with prior oncology experience and to allow patients flexibility to decide on the fre- quency with which they practiced muscle relax- ation techniques.

As other examples, Jones et al. (2016) used the context, input, process, product (CIPP) model to include stakeholders in determining what problems might be anticipated in teaching self- management skills to people with Parkinson’s disease. During each education session, patients, caregivers, and healthcare professionals were sur- veyed for input as to what might be revised to improve the next session. Vaartio- Rajalin et al. (2015), aware that patients undergoing chemo- therapy may experience cognitive changes, in- volved patients with cancer and their caregivers on how, when, and by whom their education about treatment should be conducted.

The importance of practice-based evi- dence to process evaluation encompasses staff

Resources usually are less costly and more readily available for process evaluation than for the other types of evaluation, such as impact or total program evaluation. Although process evaluation occurs more frequently—during and throughout every learning experience—than any other type of evaluation, it occurs concur- rently with teaching. Therefore, the need for additional time, facilities, and dollars to con- duct process evaluation is minimal and limited.

From the perspective of EBP, process evaluation is important in providing patient- centered care based on clinical practice guide- lines (CPGs). CPGs also are sometimes referred to as clinical pathways or critical pathways (Ferguson, 2010; Hoesing, 2016), although they are at different levels of precision and exactness. A well-constructed CPG includes not only the spe- cific intervention, such as teaching a patient how to take his discharge medication, but also how to evaluate the effectiveness of that intervention.

A CPG is intended as a guide in caring for all patients who have similar characteristics and learning needs. Its development requires a high level of rigor. As discussed later in this chapter, CPG development is conducted as eval- uation research. Evaluation of the process of us- ing a CPG, however, focuses on the fit of a CPG for a specific learner or learners. To the extent that a patient is the same as those patients who were studied in development of the CPG, the pa- tient’s nurse will follow the guideline as written. To the extent that the patient has unique learn- ing needs or responses to teaching, the nurse should use informal process evaluation to vary from the guideline to ensure that the patient is able to learn and is receiving individualized patient-centered care. CPGs are also useful for orientation of new healthcare employees, for quality improvement, and for evaluating clinical learning in student-precepted situations. These pathways are used by members of the healthcare team as cost-effective and time-efficient mea- sures to note learner progress and the achieve- ment of goal-based outcomes. Implementing this education-focused evaluation method al- lows educators to choose teaching and learning

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evaluation. In other words, the purpose of con- tent evaluation is to focus on how the teaching– learning process affected immediate, short-term outcomes. A question to be asked is: “Were spec- ified objectives met based on the teaching that was done?” The evaluation design to answer this question is different from an evaluation that an- swers the question “Did learners achieve speci- fied objectives?” An important point to be made here is that questions must be carefully consid- ered and clearly stated because they dictate the basic framework for design and conduct of the evaluation. Evaluation designs are discussed in some detail later in this chapter.

The scope of content evaluation is limited to a specific learning experience and to spe- cifically stated objectives for that experience. Content evaluation occurs immediately after completion of teaching but accounts for all teaching– learning activities included in that specific learning experience. Data are obtained from all learners involved in a specific class or group teaching session. For example, if both parents and the adolescent patient with diabe- tes are taught insulin administration, all three are asked to complete a return demonstration. Similarly, all nurses attending a workshop are asked to complete the cognitive posttest at the end of the workshop.

Also, resources used to teach content can be evaluated as to how well that content was learned. For example, the exact equipment included in teaching a patient how to change a dressing also can be used by the patient to perform a return demonstration or teach-back. In the same man- ner, a pretest used at the beginning of a continu- ing education seminar can be readministered as a posttest at seminar completion to measure change resulting from program delivery.

Content evaluation, like process evalua- tion, focuses on collecting internal evidence to determine whether objectives for a specific group of learners were met. Gathering data about the learner prior to a teaching session and then collecting data again immediately after the teaching session can be used to compare if any change in learner behavior occurred. For

education as well as patient education. Rani and Byrne (2012) conducted a multimethod evalu- ation of a training course geared toward teach- ing providers how to care for patients presenting with dual diagnosis of mental illness. A process evaluation conducted with an initial group of participants included daily collection of quan- titative data using Likert scales to determine the extent to which participants found teach- ing methods and content covered that day to be helpful for their learning.

Milne’s SCOPPE framework and Noar’s ACME framework focus heavily on initial plan- ning of the educational activity as an essential component of process evaluation that includes design of the education activity and exam- ination. The CIPP model used by Jones and colleagues also focuses on initial planning, in- cluding the context in which the education pro- cess should take place. Grant, Dreischulte, and Guthrie (2017) also focus on initial planning as well as feedback during a multicomponent intervention to learn from clinicians what as- pects of a quality improvement program were most likely to influence clinicians to reduce pre- scribing high-risk medications to patients seek- ing primary care.

Content Evaluation The purpose of content evaluation is to de- termine whether learners have acquired the knowledge or skills taught during the learning experience. Abruzzese (1992) described con- tent evaluation as taking place immediately after the learning experience to answer the guid- ing question, “To what degree did the learn- ers learn what they were taught?” or “To what degree did learners achieve preset behavioral objectives?” Asking a patient to give a return demonstration of a teaching session on psycho- motor skill development or asking participants to complete a cognitive test at the completion of a 1-day seminar are common examples of content evaluation.

The RSA model shows content evaluation as the level in between process and outcome

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Outcome (Summative) Evaluation The purpose of outcome evaluation (sum- mative evaluation) is to determine the effects of teaching efforts. Outcome (summative) eval- uation measures the changes that result from teaching and learning. This type of evaluation summarizes what happened based on the edu- cation intervention. Guiding questions in out- come evaluation include the following:

■ Was teaching appropriate? ■ Did the individual(s) learn? ■ Were behavioral objectives met? ■ Did the patient who learned a skill before

discharge use that skill correctly once home? Did the student nurse who acquired a new skill in a laboratory setting or the staff nurse who learned a new skill in a continuing education session demonstrate the ability to independently perform that skill accurately in practice?

Unlike process evaluation that occurs con- currently with the teaching–learning experi- ence, outcome evaluation occurs after teaching has been completed or after an educational pro- gram has been carried out. Outcome evaluation measures the changes that result from teaching and learning.

Abruzzese (1992) clearly explains the dif- ference in scope between outcome evaluation and content evaluation. She notes that outcome evaluation measures more long-term change that “persists after the learning experience” (p. 243). Changes can include institution of a new pro- cess, habitual use of a new technique or behav- ior, or integration of a new value or attitude. Which changes the nurse educator measures usually are dictated by the objectives established based on the initial needs assessment.

Thus, the scope of outcome evaluation fo- cuses on a longer time period than does content evaluation. Whereas evaluating the accuracy of a patient’s return demonstration of a skill prior to discharge may be appropriate for content evaluation, outcome evaluation should include

instance, Walker (2012) describes development and implementation of Skin Protection for Kids, a primary prevention education project aimed at school-aged children, their parents, and their teachers to decrease unnecessary sun exposure. Content evaluation included pretests conducted prior to providing informational materials and posttests conducted 24 to 48 hours later. Teach- ers’ scores, for example, improved from an av- erage of 56.25% on the pretest to an average of 87.5% on the posttest, indicating that teachers improved their short-term knowledge of sun safety. Also, this study supported the use of in- formational guidelines as an effective inter- vention for parents of school-aged children in kindergarten through fifth grade.

As another example, patients who undergo kidney transplant must become knowledgeable in self-management of a complex medication regimen. To provide nurses with the necessary knowledge and skill to teach posttransplant pa- tients, Mangold (2016) reports on use of stan- dardized patients to provide transplant nurses an opportunity to practice the teach-back they would eventually be using to evaluate patient learning. Content evaluation of nurses’ learning included test–retest analysis of knowledge re- tention and confidence in the use of teach-back method. Transplant nurses also participated in debriefing sessions immediately after training to reflect on what they had learned that could be taken back to their practice setting.

Cibulka (2011) also provides an example of content evaluation in her description of a con- tinuing education program on research ethics in which nurses completed quizzes after each module to determine short-term knowledge re- tention. Cibulka’s use of quiz scores already de- veloped and integrated into a well-known and widely used research ethics educational activity exemplifies an important rule of thumb: Use ex- isting data if those data are relevant and already available. Asking any individual to spend his or her time to complete a quiz, survey, or any data collection activity should be viewed by the per- son collecting those data as a promise to appro- priately use the data collected.

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failure to take their medications on a consistent basis. To search the literature efficiently for ways in which they might better educate their patients, the nurses would pose the following PICO ques- tion: Does nurse-directed patient education on symptoms and related treatment for heart failure provided to adult outpatients with heart failure result in improved compliance with treatment regimens? In this example, the P is the popula- tion of adult outpatients with heart failure, the I is the nurse-directed patient education inter- vention on symptoms and related treatment for heart failure, the C is the comparison of the education currently being provided (or lack of education, if that is the case), and the O is the outcome that, it is hoped, will result in improved compliance with treatment regimens.

The Skin Protection for Kids program (Walker, 2012) described earlier in this chapter included outcome evaluation as well as the con- tent evaluation. Whereas content evaluation of teachers’ knowledge was conducted 24 to 48 hours after the educational activity, outcome evaluation took place several months later to measure whether sun-safety practices were im- plemented by children and parents who were enrolled in this educational program.

Prior to making a change in practice, es- pecially if that change will require additional resources or might increase patient risk if un- successful, a review of several well-conducted studies providing external evidence directly rel- evant to a PICO question should be conducted.

Implementation of the Skin Protection for Kids program (Walker, 2012) is an excellent ex- ample of a practice change based on review and appraisal of extensive external evidence, which included a critique of 39 studies plus peer-re- viewed guidelines and systematic reviews that focused on sun-safety measures for children.

Ferrara, Ramponi, and Cline (2016) con- ducted an outcome evaluation 2 months af- ter an educational intervention intended to increase physicians’ and nurses’ knowledge and compliance as well as to change their atti- tudes about family presence during resuscita- tion in the emergency department. Follow-up

measuring a patient’s competency with a skill in the home setting after discharge. Similarly, nurses’ responses on a workshop posttest may be suf- ficient for content evaluation, but if the work- shop objective states that nurses will be able to incorporate their knowledge into practice on the unit, outcome evaluation should include measur- ing nurses’ knowledge or behavior at some time after they have returned to the unit. Abruzzese (1992) suggests that outcome data be collected 6 months after the original baseline data to de- termine whether a change has really taken place.

Resources required for outcome evalua- tion are costly and complex compared to those needed for process or content evaluation. Com- pared to the resources required for the first two types of evaluation in the RSA model, outcome evaluation requires knowledge of how to estab- lish baseline data, greater expertise to develop measurement and data collection strategies, more time to conduct the evaluation, and the ability to collect reliable and valid data for compara- tive purposes after the learning experience has occurred. Postage to mail surveys and time and personnel to carry out observation of nurses on the clinical unit or to complete patient/family telephone interviews are specific examples of resources that may be necessary to conduct an outcome evaluation.

From an EBP perspective, outcome evalua- tion might arguably be considered as “where the rubber meets the road.” Once a need for change has been identified, the search for evidence on which to base subsequent changes commonly begins with a structured clinical question that will guide an efficient search of the literature. This question is also known as a PICO question, where the letters P, I, C, and O stand for pop- ulation (patient, family member, staff, or stu- dent), intervention, comparison, and outcome, respectively.

For example, nurses caring for an outpatient population of adults with heart failure might dis- cover that many patients are not following their prescribed treatment regimen. Upon question- ing these patients, the nurses learn that most pa- tients do not recognize symptoms resulting from

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The scope of impact evaluation is broader, more complex, and usually more long term than that of process, content, or outcome evaluation. For example, whereas outcome evaluation fo- cuses on whether specific teaching results in achievement of specific outcomes, impact evalu- ation goes beyond that point to measure the ef- fect or worth of those outcomes. In other words, outcome evaluation focuses on a learning ob- jective, whereas impact evaluation focuses on a goal for learning. Consider, for instance, a class on the use of body mechanics. The objective is that staff members will demonstrate proper use of body mechanics in providing patient care. The goal is to decrease back injuries among the hos- pital’s direct-care providers. As another exam- ple, consider a teaching session on healthy food choices for patients who have had bariatric sur- gery. The objective is that patients will choose healthy foods regardless of whether they are in a restaurant or in the grocery store. The goal is for these patients to increase and sustain their weight loss. This distinction between outcome and impact evaluation may seem subtle, but it is important to the appropriate design and con- duct of an impact evaluation.

Good impact evaluation is like good sci- ence: rarely inexpensive and never quick. The re- sources needed to design and conduct an impact evaluation generally include reliable and valid instruments, trained data collectors, personnel with research and statistical expertise, equip- ment and materials necessary for data collection and analysis, and access to populations who may be culturally or geographically diverse. Ching, Forte, Aitchison, and Earle (2015) describe an impact evaluation of interprofessional educa- tion for physicians and nurses who worked in 26 primary care practices managing 4,167 pa- tients with diabetes. An evaluation 15 months after the education intervention of these pro- fessionals revealed that a significantly higher (p = 0.0001) proportion of patients had achieved HbA1c targets. Healthcare professionals’ confi- dence and collaborative behavior were sustained for at least 3 years after completing the educa- tion. These characteristics exemplify the scope

observations demonstrated that families were present during resuscitation 87.5% of the time when staff had received the educational inter- vention versus only 23% of the time when staff had not received the education.

Another example of an outcome evaluation was a study conducted by Sumner et al. (2012) to determine whether nurses completing a basic arrhythmia course retained knowledge 4 weeks after course completion and accurately identi- fied cardiac rhythms 3 months later. An initial content evaluation demonstrated that the 62 nurses who completed the course improved their short-term knowledge from pretest to posttest to a statistically significantly degree (p < 0.01). Nurses’ scores on a simulated arrhythmia expe- rience conducted 3 months later demonstrated no significant change from posttest scores ob- tained immediately after course completion. Ideally, an outcome evaluation to answer the question “Were nurses who completed a ba- sic arrhythmia course able to use their skills in the practice setting?” should be conducted by directly observing those nurses during patient care. However, given the logistical challenges of unobtrusively observing nurses when patients are experiencing the arrhythmias included in the course, the use of simulation may be con- sidered a feasible alternative—so long as the ed- ucator remembers that simulation is merely a proxy for reality.

Impact Evaluation The purpose of impact evaluation is to deter- mine the relative effects of education on the in- stitution or the community. Put another way, the purpose of impact evaluation is to obtain infor- mation that will help decide whether continuing an educational activity is worth its cost (Adams, 2010). Examples of questions appropriate for impact evaluation include “What is the effect of an orientation program on subsequent nursing staff turnover?” and “What is the effect of a car- diac discharge teaching program on long-term frequency of rehospitalization among patients who have completed the program?”

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Total Program Evaluation Within the framework of the RSA model (Abru- zzese, 1992), the purpose of total program eval- uation is to determine the extent to which all activities for an entire department or program over a specified time meet or exceed the goals originally established. In turn, goals for the de- partment or program are based on goals for the larger organization (DeSilets, 2010). Ammerman and colleagues (2014) extend program evalua- tion even further, stating that program evaluation strategies to address broad public health issues began introducing practice-based evidence even before the term “practice-based evidence” was identified. Guiding questions appropriate for a total program evaluation from this perspective might be “To what extent did programs under- taken by members of the nursing staff develop- ment department during the year accomplish annual goals established by the department?” and “How well did patient education activities implemented throughout the year meet annual goals established for the institution’s patient ed- ucation program?”

The scope of program evaluation is broad, generally focusing on overall goals rather than on specific learning objectives. Given its scope, total program evaluation is also complex, usually focusing on the learner and the teacher and the educational activity, rather than on just one of these three components. Abruzzese (1992) de- scribes the scope of program evaluation as en- compassing all aspects of educational activity (e.g., process, content, outcome, impact) with input from all the participants (e.g., learners, teachers, institutional representatives, and com- munity stakeholders).

It is not surprising, then, that quite a few other models and related theories have been de- veloped to conceptualize and organize total pro- gram evaluation. Kirkpatrick’s four-level model, known as the logic model, consists of four com- ponents: inputs, activities, outputs, and out- comes (Rouse, 2011). Stufflebeam and Zhang (2017) describe how the CIPP model can be used to evaluate program improvement and ac- countability. Zhang and Cheng (2012) developed

and time frame commonly found with this type of evaluation. Also, an example illustrating how an impact evaluation can be global in nature is provided by Padian et al. (2011) in their dis- cussion of challenges facing those persons who conduct large-scale evaluations of combination HIV prevention programs.

Because impact evaluation requires many resources, including time, money, and research expertise, this type of evaluation is usually be- yond the scope of the individual nurse educa- tor. Conducting an impact evaluation may seem to be a monumental task, but this reality should not dissuade the determined educator from the effort. Rather, one should plan well in advance, proceed carefully, and obtain the support and assistance of stakeholders and colleagues. Keep- ing in mind the purpose for conducting an im- pact evaluation should be helpful in maintaining the level of commitment needed throughout the process. The current managed care envi- ronment requires justification for every health dollar spent. The importance of patient and staff education may be intuitively beneficial in improv- ing the quality of care, but evidence of the posi- tive impact of education must be demonstrated if it is to be recognized, valued, and funded.

A literature search conducted to determine the state of the evidence on impact evaluation in patient education found that the term impact is used generically to describe both evaluations of patient outcomes resulting from education and evaluations of long-term effects from education. What is important to remember when reviewing this literature is not which term the authors use, but what their purpose for evaluation is. As noted earlier, the purpose of an outcome evaluation is to determine whether an educational intervention results in the intended behavior change, whereas the purpose of an impact evaluation is to deter- mine whether long-term education goals are met. As the importance of EBP and practice-based ev- idence continue to grow, impact evaluations are becoming recognized as essential for examining the long-term effectiveness of different educa- tional interventions used to disseminate practice guidelines to healthcare providers (Ammerman, Smith, & Calancie, 2014; Boivin et al., 2010).

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patients with both psychological and medical comorbid illness. Evaluation included observa- tion, surveys, and network analysis conducted before, immediately after, and 3 months after completion of training. Results demonstrated that confidence and knowledge increased im- mediately after training and these increases were sustained 3 months later among members of seven healthcare disciplines. In addition, phy- sicians sustained increased use of motivational interviewing after 3 months.

As stated earlier, the RSA model developed by Abruzzese (1992) remains useful as a general framework for categorizing the basic types of evaluation: process, content, outcome, impact, and total program. As depicted in this model, differences between these types are largely a mat- ter of degree. For example, process evaluation occurs most frequently; total program evalu- ation occurs least frequently. Content evalua- tion focuses on immediate effects of teaching; impact evaluation concentrates on more long- term effects of teaching. Conducting process evaluation requires fewer resources compared with impact and program evaluation, which re- quire extensive resources for their implemen- tation. The RSA model further illustrates one way that process, content, outcome, and impact evaluations can be considered together as com- ponents of total program evaluation.

According to Abruzzese (1992), resources re- quired for total program evaluation may include the sum of resources necessary to conduct pro- cess, content, outcome, and impact evaluations. A program evaluation may require significant expenditures for personnel if the evaluation is conducted by an individual or team external to the organization. Additional resources required may include time, materials, equipment, and per- sonnel necessary for data entry, analysis, and re- port generation. The time span over which data are collected may extend from several months to one or more years, depending on the time frame established for meeting the goals to be evaluated.

DuHamel and colleagues (2011) exemplify Abruzzese’s definition of total program evalua- tion in their description of a 14-week medical– surgical nursing certification review course they

the planning, development, process, and prod- uct (PDPP) model to systematically evaluate e-learning in all educational institutions in China and Hong Kong. The 26 items included in their model range from initial market demand for an e-learning program to technical support throughout the educational activity to both teach- ing and learning effectiveness once education is completed. Frye and Hemmer (2012) have au- thored a guide for educators to use in choosing a program evaluation model that is theoreti- cally and practically consistent with the purpose for and scope of evaluation. These authors’ in- tent is to help those evaluating educational pro- grams to appreciate and adequately account for how complex program evaluation really is.

Kirkpatrick’s logic model for program eval- uation has been popular for more than 2 decades and remains perhaps the most frequently used model in federal program evaluations (e.g., the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report) as well as in the development of evaluation guidelines by many well-known nongovernmental organiza- tions, such as the W. K. Kellogg Foundation and the United Way (Frye & Hemmer, 2012; Torghele et al., 2007). Consistent with its roots in general system theory, the logic model views an educa- tion program as “a social system composed of component parts, with interactions and inter- relations among the component parts, all exist- ing within, and interacting with, the program’s environment” (Frye & Hemmer, 2012, p. 290).

Another recent use of Kirkpatrick’s model for program evaluation is described by Nocera et al. (2016) in their report of a statewide nurse training program to prevent infant abuse. Stan- dardized training developed by the National Cen- ter on Shaken Baby Syndrome was provided to nurses in 85 hospitals and one birthing center in North Carolina from 2008 to 2010 in prepa- ration for statewide adoption. Satisfaction with training content and methods as well as long- term adherence were among evaluative findings.

Phillips, Hall, and Irving (2016) describe use of the logic model to evaluate interprofessional education of practitioners from mixed health professional backgrounds who provide care to

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and the learning activities. What Abruzzese describes as a happiness index, Rouse labels a “smile sheet,” commenting that although sat- isfaction does not imply learning, dissatisfac- tion may prevent it. Kirkpatrick’s second, third, and fourth levels are learning, behavior, and re- sults, respectively. Rouse describes these levels, in turn, as evaluation of knowledge immedi- ately after education is completed, evaluation of whether actual change has occurred in the workplace, and systemwide evaluation of the impact of the program. Kirkpatrick’s levels of program evaluation closely match Abruzzese’s model. Nurse educators can find clinical ex- amples of how different types of evaluation included in Abruzzese’s RSA model relate to one another in Haggard’s (1989) description of three dimensions in evaluating teaching ef- fectiveness for the patient and in Rankin and Stallings’s (2005) four levels of evaluation of pa- tient learning. The three dimensions described by Haggard and the four levels identified by Rankin and Stallings are consistent with and can be compared to the basic types of evalua- tion included in the RSA model, as shown in TABLE 14-1. As depicted in this table, models

conducted. The evaluators focused on long-term goals of advancing professional development and changing professional practice as well as the goal of improving patient outcomes. Evaluative data collected over several years included more traditional measures, such as the percentage of participating nurses who passed the certifica- tion examination, the evaluation of the use of practice tests, clinical examples to promote ac- tive learning, and analysis of comments made by participants describing their use of reflection and their desire to continue learning. As noted by the authors, demonstration of effectiveness of con- tinuing education is essential in the current cli- mate of limited resources, and a focus that goes beyond knowledge obtained to address knowl- edge transferred into practice is imperative.

Another example of a program evaluation consistent with Abruzzese’s definition of total program evaluation is Rouse’s (2011) use of Kirkpatrick’s four-level model to comprehen- sively evaluate the effectiveness of health in- formation management courses and programs. Rouse describes reaction (the first level) as ad- dressing immediate reactions of the attendees to the setting, the instructor, the materials,

TABLE 14-1 Comparison of Levels/Types of Evaluation Across Staff/Patient Education Evaluation Models

Abruzzese (1992) Haggard (1989) Rankin and Stallings (2005)

Process Patient assimilation of information during teaching

Patient education interventions

Content Patient information retention after teaching

Patient/family performance following learning

Outcome Patient use of information in day-to-day life

Patient/family performance at home

Impact N/A Overall self-care and health maintenance

Program N/A N/A

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Design Structure An important question to be answered in de- signing an evaluation is “How detailed should the evaluation be?” The obvious answer is that all evaluations should have some level of rigor, which means they must be precise, exact, and logically organized. In other words, all evalua- tions should be systematic, carefully and thor- oughly planned or structured before they are conducted. How rigorous the design structure must be depends on the questions to be an- swered, how complex the scope of the evalua- tion is, and how evaluation results will be used. The more the questions address cause and effect, the more complex the scope of the evaluation. Likewise, the more critical and broad reaching the expected use of results, the more the eval- uation design should be structured from a re- search perspective.

Evaluation Versus Research Evaluation and research are not synonymous, but they are related activities. Traditionally, the primary difference between the two has been related to the purpose for conducting the eval- uation or the study. The purpose of an evalu- ation is to measure whether a practice change is effective in a specific setting with a specific group of individuals—learners and/or teachers, in the case of education evaluation—during a specified time frame. In contrast, the purpose

developed from an education theory base, such as the RSA model, have much in common with models developed from a patient care theory base, such as the two models put forth by Hag- gard and Rankin and Stallings.

At least one important point about the dif- ference between the RSA and other models needs to be mentioned, however. That difference is depicted in the learner evaluation model that is shown in FIGURE 14-2. This learner-focused model emphasizes the continuum of learner participation determined from needs assess- ment to learner performance over time once an adequate level of participation has been re- gained or achieved. This model and the RSA model have value in focusing and planning any type of evaluation but are especially important for impact and program evaluations.

▸ Designing the Evaluation

Nurse educators can design an evaluation within the framework, or boundaries, already estab- lished by focusing the evaluation appropriately. In other words, the design must be consistent with the purpose, questions, and scope of the evaluation and must be realistic given the avail- able resources. Evaluation design includes at least three interrelated components: structure, methods, and instruments.

FIGURE 14-2 Five levels of learner evaluation. Data from Rankin, S. H., & Stallings, K. D. (2005). Patient education in health and illness (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins; Rouse, D. (2011). Employing Kirkpatrick’s evaluation framework to determine the effectiveness of health information management courses and programs. Perspectives in Health Information Management, 8, 1c–5c.

LEVEL 0 Learner’s dissatisfaction and readiness to learn (Needs assessment)

LEVEL I Learner’s participation and satisfaction during intervention (Initial; process)

LEVEL II Learner’s performance and satisfaction after intervention (Initial; process)

LEVEL III Learner’s performance and attitude in daily setting (Long-term; outcome)

LEVEL IV Learner’s maintained performance and attitude (Ongoing; impact)

Designing the Evaluation 611

must design and conduct the evaluation con- sistent with the purpose and related questions identified by the primary audience. Evaluation research, by contrast, does not have an identi- fied primary audience. Consequently, research- ers have the autonomy to develop a protocol to answer one or more questions posed by them. A second difference between evaluation and eval- uation research is related to timing. The neces- sary timeline for usability of evaluation results may not be sufficient to prospectively develop a research proposal and obtain institutional re- view board approval prior to beginning data collection.

Given the differences between evaluation and evaluation research, how are decisions about level of rigor of an evaluation translated into an evalua- tion structure? The structure of an evaluation de- sign depicts the number of groups to be included in the evaluation, the number of evaluations or periods of evaluation, and the time sequence be- tween an educational intervention and evaluation of that intervention. A group can comprise one individual, as in the case of one-to-one nurse– patient teaching, or several individuals, as in the case of a nursing inservice program or workshop.

A process evaluation might be conducted during a single patient education activity where the nurse observes patient behavior during in- struction/demonstration and engages the pa- tient in a question-and-answer exchange upon completion of each new instruction. Because the purpose of process evaluation is to facili- tate better learning while that learning is hap- pening, education and evaluation occur at the same time in this case.

Evaluation also may be conducted imme- diately after an educational intervention. This structure is probably the most commonly em- ployed in conducting educational evaluations, although it is not necessarily the most appropri- ate. If the purpose of conducting the evaluation is to determine whether learners who have just completed a class know specific content that they did not know before attending that class, then a structure that begins with collection of baseline data is more appropriate. Collection of baseline

of research is to generate new knowledge that can be used across settings and individuals with similar characteristics and demographics. As de- scribed earlier in this chapter, this distinction between research and evaluation is analogous to the distinction between external and internal evidence (Melnyk & Fineout-Overholt, 2015).

Differences between evaluation and eval- uation research have become less distinct over the past several years with the explosion of what was once called applied research into a myriad of research types that include comparative ef- fectiveness, translational, dissemination, im- plementation, and so on. What these types of research commonly share is that all are intended to measure change in the “real world” setting as opposed to the tightly controlled setting of tra- ditional randomized, placebo-controlled trials. Participatory action research is perhaps the best example of research in which the “real world,” with all its inherent complexity and confound- ing variance, is combined with rigor. Froggatt and Hockley (2011) present two participatory action research studies to illustrate how evalu- ation fits within this type of research. More re- cently, mixed-methods research, which usually includes both qualitative and quantitative data and shares several characteristics with participa- tory action research, has emerged as a frequent design for conducting evaluation research (Marks- Maran, 2015; Phillips et al., 2016). It should be noted that every example of process, content, outcome, impact, and total program evaluation published since 2007—as well as many reports published before that year—and included in this chapter was conducted as evaluation re- search, which is one type of applied research.

Of course, not all outcome, impact, and program evaluations should be conducted as research studies. Some important differences do exist between evaluation and evaluation re- search. One of the most significant relates to the influence of a primary audience. As discussed earlier in this chapter, the primary audience— meaning the individual or group requesting the evaluation—is a major component to be consid- ered in focusing an evaluation. The evaluator

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Another type of quasiexperimental de- sign, called a time-series design, might in- clude only one group of learners from whom evaluative data are collected at several points in time, both before and after receiving an ed- ucational intervention. If data collected before the intervention consistently demonstrate lack of learner ability to comply with a treatment regimen, whereas data collected after the in- tervention consistently demonstrate a signifi- cant improvement in patient compliance with that regimen, the evaluator could argue that the education intervention was the reason for the improvement in this case.

As noted previously, mixed-methods designs, once called pluralistic designs, are appearing more frequently in the literature as approaches especially suited for evaluation of projects that have a community base, that include participants from diverse settings or perspectives, or that require both program processes and outcomes to be included in the evaluation (Allen et al., 2012; Balas et al., 2013; Zhang & Cheng, 2012). Because these designs often are comprehensive, resource intensive, and long term in nature, they are most appropriate for program evaluation.

This chapter does not provide an exhaus- tive description of evaluation designs. Rather, it is intended to increase awareness of the value and usefulness of these designs, especially when the results of an evaluation will be used to make major financial or programmatic decisions. The literature on evaluation of nursing staff educa- tion and patient education has become an in- creasingly rich source of examples of how to conduct rigorous evaluation.

A literature search that includes many of the following journals is recommended for planning evaluation of healthcare education in a cost-conscious and outcome-focused health- care environment: Canadian Journal of Nursing Research, Clinical Effectiveness in Nursing, Eval- uation & the Health Professions, Evidence-Based Nursing, Health Education Research, Journal of Advanced Nursing, Journal of Continuing Edu- cation in Nursing, Journal of Nursing Staff De- velopment, Nurse Educator, Journal of Nursing

data via a pretest, which can be compared with data collected via a posttest at one or more points in time after learners have completed the educa- tional activity, provides an opportunity to measure whether change has really occurred. The ability to measure change in a certain skill or level of knowl- edge, for example, also requires that the same in- struments be used for pretest and posttest data collection at both points in time. Data collection is discussed in more detail later in this chapter.

If the purpose of conducting an evaluation is to determine whether learners know content or can perform a skill resulting from an educa- tional intervention, the most appropriate struc- ture will include at least two groups: one receiving the new educational intervention and one re- ceiving the usual education or standard of care. Both groups are evaluated at the same time, even though only one group is exposed to the new ed- ucation. The group receiving the new education program is called the treatment or experimental group, and the group receiving standard care or the traditional education program is called the comparison or control group. The two groups may or may not be equivalent. Equivalent groups are those with no known differences between them prior to some intervention, whereas non- equivalent groups may be different from one an- other in several ways. For example, patients on nursing unit A may receive an educational pam- phlet to read prior to attending a class, whereas patients on nursing unit B may attend the class without first reading the pamphlet. Because pa- tients on the two units probably are different in many ways (e.g., in terms of age and diagnosis), they would be considered nonequivalent groups.

Use of the term nonequivalent is commonly encountered in discussions of traditional re- search designs. Quasiexperimental designs, such as nonequivalent control group designs, should be among those considered in planning an out- come, impact, or program evaluation. Especially if the purpose of an evaluation is to demonstrate that an education program caused fewer patient returns to the clinic or fewer nurses to leave the institution, for example, the evaluation struc- ture must have the rigor of evaluation research.

Designing the Evaluation 613

to this question is that you should collect data that will answer the questions that were asked when deciding the evaluation focus. The like- lihood that the evaluator will collect the right amount of the right type of data to answer evalu- ation questions can be significantly improved by (1) remembering that any data collected must be used and (2) using operational definitions allows everyone who is involved to understand what is being evaluated.

An operational definition must clearly de- fine one or more words or phrases being used and must be written in measurement terms. Functional health status, for example, can be theoretically defined as an individual’s ability to independently carry out activities of daily liv- ing without self-perceived undue difficulty or discomfort. Functional health status can be op- erationally defined as an individual’s composite score on the SF-36 (Short Form 36-item) survey instrument (Stewart, Hays, & Ware, 1988; Ware, Davies-Avery, & Donald, 1978). The SF-36, which has undergone years of extensive reliability and validity testing with a wide variety of patient populations and in several languages, is gener- ally considered the gold standard for measur- ing functional health status from the individual’s perspective. Continuously updated information about the SF-36 as well as different versions of the actual instrument, including a version for children, can be found online at https://www .rand.org/health/surveys_tools/mos/36-item -short-form.html

As another example, patient compliance can be theoretically defined as the patient’s reg- ular and consistent adherence to a prescribed treatment regimen. For use in outcome evalu- ation of a specific educational activity, patient compliance might be operationally defined as the patient’s demonstration of unassisted and error-free completion of all steps in the ster- ile dressing change as observed in the patient’s home on three separate occasions at 2-week time intervals.

These examples show that an operational defi- nition states exactly which data will be collected. In the first example, measurement of functional

Education, Nursing Research, Research in Nurs- ing & Health, Worldviews on Evidence-Based Nursing, and Implementation Science.

Evaluation Methods The focus of evaluation determines the evaluation design structure. The design structure, in turn, provides the basis for determining what evalu- ation methods should be used to collect data. Answers to the following questions can assist in selecting the most appropriate, feasible meth- ods when conducting a particular evaluation in a particular setting and for a specific purpose:

■ Which types of data will be collected? ■ What data will be collected and from whom? ■ How, when, and where will data be collected? ■ Who will collect the data?

Types of Data to Collect Evaluation of healthcare education includes collecting data about people, about the educa- tional program or activity, and about the envi- ronment in which the educational activity takes place. Data about all three of these aspects are required for process, outcome, impact, and pro- gram evaluations. Content evaluations may be limited to data about the people and the pro- gram, although this limitation is not necessary.

Types of data that are collected about peo- ple can be classified as demographic (e.g., age, gender, health status) as well as cognitive, af- fective, or psychomotor behaviors. The types of data that are collected about educational activi- ties or programs generally include such factors as cost, length, number of educators required, teaching–learning methods used, amount and type of materials required, and so on. The types of data that are collected about the environment in which a program or activity is conducted gen- erally include such characteristics as temperature, lighting, location, layout, space, and noise level.

Given the possibility that an unlimited and overwhelming amount of data could be col- lected, how do you decide which data should be gathered? The most straightforward answer

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both quantitative and qualitative data, it is re- source intensive to do so, such that evaluators must be certain that the focus of the evaluation justifies the decision to collect both types of data.

What Data to Collect and from Whom Data can be collected directly from the indi- viduals whose behavior or knowledge is being evaluated, from family caregivers or significant others as representatives of these individuals, or from documents or databases that have already been created. Whenever possible, researchers should plan to collect at least some data directly from the individuals being evaluated. In the case of process evaluation, data should be collected from all learners and all educators participat- ing in the educational activity. Content and out- come evaluations should include data from all learners at the completion of one or more edu- cational activities.

Because impact and total program evalua- tions have a broader scope than do process, con- tent, and outcome evaluations, collecting data from all individuals who participated in an ed- ucational program over an extended time may be impossible. This difficulty arises because data collectors may not be able to locate every par- ticipant or they may lack sufficient resources to gather data from such large numbers of people.

When all participants cannot be counted or located, data may be collected from a sample (subset) of participants who are considered to represent the entire group. If an evaluation is planned to collect data from a sample of par- ticipants, it should include representatives of the entire group. A random selection of partic- ipants from whom data are collected can min- imize bias in the sample but cannot guarantee representativeness.

For example, an impact evaluation was con- ducted to determine whether a 5-year program supporting home-based health education im- proved the general health status of individuals in the community served by the program. If all members of the community could be counted,

health status requires collection of patient survey data using a specific self-administered question- naire. The second example provides even more information about data collection than does the first, by including where and how many times the patient’s performance of the dressing change is to be observed, as well as stating that criteria for compliance include both unassisted and er- ror-free performance on each occasion.

In addition to data being categorized as de- scribing people, programs, or the environment, data also can be categorized as quantitative or qualitative. Quantitative data are expressed in numbers and generally are stated as statistics, such as the frequency, mean, median, ratio, F statistic, t statistic, or chi-square. Numbers can be used to answer such questions as how much, how many, how often, and so on, in terms that are commonly understood by the audience for the evaluation. Mathematical analysis of data can, for example, demonstrate with some level of precision and reliability whether a learner’s knowledge or skill has changed since complet- ing an educational program, or how much im- provement in a learner’s knowledge or skill is the result of an educational program.

Qualitative data, on the other hand, include feelings, behaviors, and words or phrases that generally are summarized into themes or cate- gories. Such data also can be described in quan- titative terms, such as percentages or counts, but this transformation eliminates the richness and insight into the responses expressed by individ- uals about their experiences. Qualitative data also can be used as background to better inter- pret quantitative data, especially if the evalua- tion is intended to measure such value-laden or conceptual terms as “satisfaction” or “quality.”

Any evaluation may be strengthened by collecting both quantitative and qualitative data. For example, an evaluation to determine whether a stress reduction class resulted in de- creased work stress for participants could in- clude participants’ qualitative expressions of how stressed they feel plus quantitative data, such as pulse and blood pressure readings. Al- though intuitively appealing to want to collect

Designing the Evaluation 615

more complete information about the program or performance being evaluated than could be accomplished using a single method. For ex- ample, the nurse teaching patients might use both observation and teach-back to determine whether a family caregiver can correctly per- form a dressing change and explain why each step of the dressing change is important (Visit- ing Nurse Associations of America, 2012).

The evaluator can conduct observations in person or can videotape them for viewing at some later time. In the combined role of ed- ucator–evaluator, the nurse educator who is conducting a process evaluation can directly observe a learner’s physical, verbal, psychomo- tor, and affective behaviors to respond to them in a timely manner. Using videotape or a non- participant observer also can be beneficial for picking up the educator’s own behaviors, which the educator is unaware of but might be influ- encing the learner.

The timing of data collection, or when data collection takes place, has already been addressed both in discussion of different types of evaluation and in descriptions of evaluation design struc- tures. Process evaluation, for example, generally occurs during an educational activity. Content evaluation takes place immediately after com- pletion of education. Outcome evaluation oc- curs sometime after completion of education, when learners have returned to the setting where they are expected to use new knowledge or per- form a new skill. Impact evaluation generally is conducted from weeks to years after the edu- cational program, because its purpose is to de- termine which change has occurred within the community or institution resulting from an ed- ucational intervention.

The timing of data collection for program evaluation is less obvious than for other types of evaluation, in part because different descrip- tions of what constitutes a program evaluation can be found both in the literature and in prac- tice. As discussed earlier, Abruzzese (1992) de- scribes data collected for program evaluation as occurring over a prolonged period because program evaluation is itself the culmination of

a random sample of community members could be generated by first listing and numbering all members’ names, and then drawing numbers using a random numbers table until a 10% sam- ple is obtained. Such a method for selecting the sample of community members would elimi- nate intentional selection of those individuals who were the most active program participants and who might therefore have a better health status than does the entire community. At the same time, the 10% random sample could unin- tentionally include only those individuals who did not participate in the health education pro- gram. Data collected from this sample of non- participants would be just as misleading as data collected from the first sample. A more repre- sentative sample for this evaluation should in- clude both participants and nonparticipants, ideally in the same proportions in the sample as in the community.

Preexisting data should be used as a source of evaluative data only if the purpose for which they were collected mirrors the purpose of the evaluation currently being considered, if oper- ational definitions are the same and if the same population of interest is the focus of both past and current evaluations. Data already in exis- tence generally are less expensive to obtain and available sooner than are original data.

How, When, and Where to Collect Data Methods for how data can be collected include the following:

■ Observation ■ Interview ■ Questionnaire or written examination ■ Record review ■ Secondary analysis of existing databases

Which method is selected depends, first, on the type of data being collected and, second, on the available resources. When possible, data should be collected using more than one method. Using multiple methods provides the evaluator, and consequently the primary audience, with

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evaluating. This second, and perhaps less bi- ased, input can strengthen the legitimacy and usefulness of the evaluation results.

Also, data can be collected by the learners themselves, by other colleagues within the de- partment or institution, or by someone from outside the institution. Fairchild’s (2012) de- scription of a mixed-methods evaluation of a service-learning academic–practice partner- ship with rural hospitals provides an example of data collection that included faculty serv- ing as coaches for students, students serving as educators– coleaders of project teams, and hos- pital staff and administrators who were primary recipients of support. Data collection included use of online surveys consisting of Likert-scaled items and open-ended questions asking for nar- rative comments regarding strengths and areas for improvement of the partnership.

The individuals who are chosen to carry out data collection become an extension of the evaluation instrument. If the data collected are to be reliable, unbiased, and accurate, the data collectors must likewise be unbiased and suffi- ciently expert at the task. Use of unbiased ex- pert data collectors is especially important for collecting observation and interview data be- cause these data in part depend on the subjec- tive interpretation by the data collector.

Also, data collectors can influence the in- formation that is obtained in other ways. For ex- ample, if staff nurses are asked to complete a job satisfaction survey and their head nurse is asked to collect the surveys for return to the evalua- tor, which problems might occur? Might some staff nurses be hesitant to provide negative scores on certain items, even though they hold one or more negative opinions? Likewise, physiologi- cal data can be altered, however unintentionally, by the data collector. For example, an outcome evaluation might be conducted to determine whether a series of biofeedback classes given to young executives can reduce stress as measured by pulse and blood pressure. How might some executives’ pulse and blood pressure results be affected by a data collector who is physically at- tractive or overtly acting rushed or frustrated?

process, content, outcome, and impact evalua- tions already conducted.

Where an evaluation is conducted can have a major effect on evaluation results. Those con- ducting an evaluation must be careful not to make the decision about where to collect data based on convenience for the data collector. For example, an appropriate setting for conducting a content evaluation may be in the classroom or skills laboratory where learners have just com- pleted class instruction or training. An outcome evaluation to determine whether training has improved the nurse’s ability to perform a skill with patients on the nursing unit, however, re- quires that data collection—in this case, observa- tion of the nurse’s performance—be conducted on the nursing unit.

As another example, an outcome evalua- tion to determine whether discharge teaching in the hospital enabled the patient to provide self-care at home requires that data collection, or observation of the patient’s performance, be conducted in the home. What if available resources are insufficient to allow for home visits by the evaluator? To answer this ques- tion, keep in mind that the focus of the eval- uation is on performance by the patient—not performance by the evaluator. Training a fam- ily member, a visiting nurse, or even the patient to observe and record patient performance at home is preferable to bringing the patient to a place of convenience for the evaluator.

Who Collects Data The educator conducting the class or activity being evaluated commonly collects evaluation data because of already being present and in- teracting with learners. Combining the role of evaluator with that of educator is an appropri- ate method for conducting a process evalua- tion because evaluative data are integral to the teaching–learning process. Inviting another ed- ucator or a patient representative to observe a class can provide additional data from the per- spective of someone who does not have to di- vide his or her attention between teaching and

Designing the Evaluation 617

35 years, primarily from an academic perspec- tive (Bahreini, Moattari, Shahamat, Dobarada- ran, & Ravanipour, 2013; Garrett, MacPhee, & Jackson, 2012; Hayes, 2007; Laux & Stoten, 2016). Although formal education of nursing students is not the focus of this text, other uses of portfo- lios are relevant to the role of the practice-based nurse as educator. Individual completion of a professional portfolio is a current requirement for recertification in some nursing specialties in the United States and for periodic registration in the United Kingdom (Morgan & Dyer, 2015).

Given the growing importance of a nurse’s portfolio documentation for career advancement, the nurse educator may find several colleagues asking for assistance in creating and maintain- ing a portfolio that provides a strong base of evaluative evidence demonstrating that nurse’s continuing professional development and con- sequent impact on practice (Chamblee, Dale, Drews, Spahis, & Hardin, 2015; Hespenheide, Cottingham, & Mueller, 2011; Oermann, 2002; Schneider, 2016). Perhaps the best suggestion the nurse educator might offer—and heed— is to clarify the focus of the portfolio as deter- mined by the requiring organization (in this case, the primary audience) as stated in that or- ganization’s criteria for portfolio completion. Is the focus more on process evaluation, on out- come evaluation, or on both? Specifically, is the nurse expected to demonstrate reflective prac- tice? If so, what does the organization accept as evidence of reflective practice?

One reason focus clarification is so challeng- ing is because there is no consistent description of how portfolios are to be used or what they are to contain. In its simplest form, a practice port- folio is composed of a collection of information and materials about one’s practice that have been gathered over time. The issue of whether this collection is intended to demonstrate previous learning or whether the process of collecting is itself a learning experience continues to fos- ter debate (Fitch, Peet, Reed, & Tolman, 2008).

Central to this issue is the notion of reflec- tive practice. First coined by Schön (1987), the term reflective practice still does not have

Use of trained data collectors from an ex- ternal agency is, in most cases, not a financially viable option. The potential for a data collector to bias data can be minimized using less expen- sive alternatives, however. First, the number of data collectors should be limited as much as pos- sible, because this step automatically decreases person-based variation. Also, individuals assist- ing with data collection should wear similar con- servative clothing and speak in a moderate tone. Because moderate tone, for example, may not be interpreted the same way by everyone, at least one practice session or dry run should be held with all data collectors prior to conducting the evaluation. In addition, data collection should be conducted by someone who has no vested interest in the results and who will be perceived as unbiased and nonthreatening by those per- sons providing the data. Furthermore, provid- ing interview scripts to be read verbatim by the interviewer can ensure that all patients or staff being interviewed are asked the same questions.

With the emphasis on continuous quality improvement (CQI) in healthcare organizations, nurses and other professionals are expected to become more knowledgeable about what data are needed and how to use measurement tech- niques to collect evidence in their work setting (The Joint Commission, 2017). In response to the demand for measurable evidence to support healthcare decision making, the field of data ana- lytics has grown exponentially. The enactment of the American Recovery and Reinvestment Act of 2009 and the introduction of incentives to pro- mote meaningful use of health information tech- nology and electronic health records (EHRs) has effectively provided nurse educators and other healthcare providers with a rich source of data that can be used to evaluate delivery of care and resulting patient outcomes (Centers for Medicare & Medicaid Services, 2017). Although some ben- efits of EHRs are yet to be realized, many facilities already have staff available to help nurse educa- tors extract data that are useful for evaluation.

Use of a portfolio as a method for evalu- ation of an individual’s learning over time has been documented in the literature for more than

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The initial step in instrument selection is to conduct a literature search for evaluations similar to the evaluation that is being planned. A helpful place to begin is with the same jour- nals listed earlier in this chapter. Instruments that have been used in more than one study should be given preference over an instrument developed for a single use. This is because in- struments used multiple times generally have been more thoroughly tested for reliability and validity. Once potential instruments have been identified, each instrument must be carefully critiqued to determine whether it is, in fact, ap- propriate for the evaluation planned.

First, the instrument must measure the per- formance being evaluated exactly as that perfor- mance has been operationally defined for the evaluation. For example, if satisfaction with a continuing education program is operationally defined to include a score of 80% or higher on five specific program components (such as ed- ucator responsiveness to questions, relevance of content, and so on), then the instrument se- lected to measure participant satisfaction with the program must include exactly those five components and must be able to be scored in percentages.

Second, an appropriate instrument should have documented evidence of its reliability and va- lidity with individuals who are as closely matched as possible with the people from whom data will be collected. For example, when evaluating the ability of older adult patients to complete activi- ties of daily living, one would not want to use an instrument developed for evaluating the ability of young orthopedic patients to complete rou- tine activities. Similarities in reading level and visual acuity also should exist if the instrument being evaluated is a questionnaire or scale that participants will complete themselves. In addi- tion, existing instruments being considered for selection must be affordable, must be feasible for use in the location planned for conducting data collection, and should require minimal training on the part of data collectors.

A cognitive test is the evaluation instru- ment most likely to require modification from

a commonly agreed-upon definition (Cotton, 2001; Epstein, 2008; Lavoie, Pepin, & Cossette, 2017; Morgan, 2009; Wainwright, Shepard, Har- man, & Stephens, 2010). Noveletsky (2007) of- fers one definition of reflective practice “as the process of exposing the contradictions in prac- tice . . . [when] the health professional must first come to understand what he or she defines as ideal practice” (p. 141). Lavoie et al. (2017) describe reflection as a process that helps the individual—in this case the new nurse graduate— “to understand the meaning of a problematic situation, which is the relationship between causes, actions, and consequences” (p. 52) so they might improve future observations and actions in similar situations. Schön (1987) de- scribes two key components of reflective practice as reflection-in-action and reflection-on-action. Reflection-in-action occurs when the nurse in- trospectively considers a practice activity while performing it so that change for improvement can be made at that moment. In contrast, re- flection-on-action occurs when the nurse in- trospectively analyzes a practice activity after its completion to gain insights for the future (Cotton, 2001). From an evaluation perspec- tive, these components are similar in meaning to formative and summative evaluation, indi- cating that reflective practice has more than one focus (Paschal, Jensen, & Mostrom, 2002).

Evaluation Instruments In the selection, revision, or construction of eval- uation instruments, nurse educators must con- sider some key points. Whenever possible, an evaluation should be conducted using existing instruments. This is because instrument devel- opment not only requires considerable exper- tise, time, and resources but also requires testing to be sure the instrument, whether it is in the form of a questionnaire or a type of equipment, demonstrates reliability and validity before it is used for collecting data. This testing can take several months to several years to determine the usefulness of the tool (Osborne, Elsworth, & Whitfield, 2007).

Designing the Evaluation 619

Barriers to Evaluation If evaluation is so important to healthcare edu- cation, why is evaluation often an afterthought or even overlooked entirely? The reasons given for not conducting evaluations are many and varied but rarely, if ever, are impossible to over- come. Barriers to evaluation must first be iden- tified and understood; then, the nurse educator must design and conduct the evaluation in a way that minimizes or eliminates as many identified barriers as possible.

Barriers to conducting an evaluation can be classified into three broad categories:

1. Lack of clarity 2. Lack of ability 3. Fear of punishment or loss of self-

esteem

Lack of Clarity If the focus for evaluation is unclear, unstated, or not well defined, then undertaking an eval- uation is difficult if its purpose or what will be done with the results is unknown. Often evalu- ations are attempted to determine the quality of an educational program or activity, yet quality is not defined beyond some vague sense of good- ness. What is “goodness” and from whose per- spective will it be determined? Who or what will demonstrate evidence of goodness? What will happen if goodness is or is not evident? Inabil- ity to answer these or similar questions creates a significant barrier to conducting an evaluation even the most seasoned evaluator.

Barriers in this category have the greatest po- tential for successful resolution because the best solution for lack of clarity is to provide clarity. Recall that evaluation focus includes five compo- nents: (1) audience, (2) purpose, (3) questions, (4) scope, and (5) resources. To overcome a po- tential lack of clarity, the nurse educator must identify all five components and make them available to those conducting the evaluation.

For example, clear identification of who constitutes the primary audience is very import- ant. This is because it is from the perspective of

an existing tool or development of an entirely new instrument. The primary reason for con- structing such a test is that it must be consistent with the content covered during the educational program or activity. The intent of a cognitive test is to be comprehensive and relevant and to fairly test the learner’s knowledge of content. Using a test blueprint is one of the most helpful meth- ods for ensuring comprehensiveness and rele- vance of test questions. A blueprint enables the evaluator to be certain that the test covers each area of instructional content and that content areas emphasized during instruction are simi- larly emphasized during testing.

Multiple questionnaires, scales, and other types of instruments exist to measure patient and healthcare provider characteristics, such as traits, perceptions, beliefs, attitudes, activity levels, conflicts, communication skills, and re- lationships. For example, many measurement tools are already available and have been tested for how well and how consistently they perform in collecting data related to patient education. Redman (2003) describes many of these useful evaluation instruments. Monsivais and Reynolds (2003) describe how to evaluate patient educa- tion materials using an instrument to measure effectiveness for patient teaching and learning. Also, a patient education materials assessment tool (PEMAT) is an instrument recently de- veloped to evaluate whether patients are able to understand and take action on information available in print and audiovisual formats that are used so frequently for patient education (Shoemaker, Wolf, & Brach, 2013).

One helpful step in instrument selection for evaluation of patient education is to review ma- terials used to provide that education. Did the educator use a step-by-step checklist to teach the patient how to flush a urinary catheter? That same checklist might be used to observe whether the patient remembers each step during return demonstration. A checklist for both teaching and evaluation almost guarantees that the nurse is measuring the performance being evaluated exactly as that performance was operationally defined prior to instruction and evaluation.

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a barrier to conducting an evaluation that can be difficult—though not impossible—to over- come. Lack of knowledge can be resolved or min- imized by enlisting the assistance of individuals with needed expertise through consultation or contract (if funds are available), through collab- oration, or indirectly through literature review.

For instance, a survey tool recently was de- veloped to evaluate the perceptions of pediat- ric nurses in carrying out their role as patient educators, but the self-designed instrument re- quired outside experts to determine if the sur- vey content was reliable and valid (Lahl, Modic, & Siedlecki, 2013). In another study, interviews with nurses revealed that they needed much more professional education on how to teach children and their families, including the use of multimethod evaluation techniques (Kelo, Martikainen, & Eriksson, 2013).

Lack of knowledge about evaluation tech- niques can be resolved by enlisting the assis- tance of individuals who have expertise and are willing to collaborate or provide consulta- tion services. Remember that patient care is a team activity. If a patient, for example, needs to learn how to use crutches correctly before being discharged, the nurse can appropriately request a physical therapist who is expert in evaluating the patient’s ability to use them safely.

Fear of Punishment or Loss of Self-Esteem Evaluation might be perceived as a judgment of someone’s value or personal worth. Both the learner and the teacher may fear that anything less than a perfect performance will result in criticism, punishment, or evidence that their mistakes will result in their being labeled as in- competent (Lahl et al., 2013). These fears form one of the greatest barriers to conducting an evaluation.

Unfortunately, these fears may not easily be overcome, especially for individuals who have had negative experiences with teaching and learning in the past. Consider, for exam- ple, traditional quality assurance monitoring,

the primary audience that terms such as “qual- ity” should be defined and operationalized. Al- though the results of the evaluation provide the information on which decisions will be made, the primary audience makes those decisions. Also, a clearly stated purpose is as important as knowing who the audience is because the pur- pose explains why the evaluation is being con- ducted. For example, if the purpose for teaching a patient about his medications is so that he can be independent in self-care at home, then the nurse must evaluate both the knowledge and physical ability of the patient to take his medi- cines correctly prior to discharge. Using teach- back can inform the nurse whether the patient understands what the medications are for, how frequently and in what dosage they should be taken, and what might be side effects that should prompt the patient to contact his primary care provider immediately. Filling the prescriptions in advance before discharge can allow the nurse to observe whether the patient is able to read the labels, open the containers, and take the medi- cations as directed (Visiting Nurse Associations of America, 2012).

Lack of Ability Inability to conduct education evaluations most often results from lack of knowledge, confidence, interest, or resources needed to carry out this process. Members of the primary audience are accountable for providing the necessary resources— personnel, equipment, time, facilities, and so on—to conduct the evaluation they are request- ing. Unless these individuals have some exper- tise in evaluation, they may not know what resources are necessary. The persons conduct- ing the evaluation, therefore, must accept re- sponsibility for knowing the resources that are necessary and for providing this information to the primary audience. The person asked or expected to conduct the evaluation may be as uncertain about necessary resources as the pri- mary audience is, however.

Lack of knowledge of which resources are necessary or lack of actual resources may create

Designing the Evaluation 621

many distractions are present in the immediate environment, making concentration on learn- ing all but impossible. And yet another reason may be psychosocial, such as embarrassment about carrying out this procedure. The educa- tor must attend to these teaching and learning factors for education to be successful.

A third step in overcoming the fear of be- ing evaluated on the outcomes of education is to point out achievements, if they exist, or to con- tinue to encourage effort if success at learning has not been achieved. For example, the nurse educator should praise the efforts of the learner honestly, focusing on the task at hand.

Communication of information about why an evaluation is being done is very important for those who are the subjects of an evaluation as much as for those who will conduct the eval- uation. If learners or educators know and un- derstand the focus of an evaluation, they may be less fearful than if such information is left to their imaginations.

Last, failure to provide and protect certain information about the learner may be uneth- ical or even illegal. People must be reassured that their privacy will be protected, otherwise they may be unwilling to be evaluated. For ex- ample, any evaluative data about an individual that can be identified with that specific person should be collected only with the individual’s informed consent. The ethical and legal im- portance of informed consent as a protection of human rights must be a central concern and responsibility of anyone involved in collecting data for evaluation purposes.

▸ Conducting the Evaluation

How smoothly an evaluation is implemented depends primarily on how carefully and thor- oughly that evaluation was planned and how carefully the instruments for data collection were selected or developed. However, these two factors alone do not always guarantee success.

where results are used to correct deficiencies often through punitive measures, such as losing the opportunity for promotion or losing respect from colleagues. As another example, many times an educator has interpreted learner dissatisfac- tion with a teaching style as learner dislike for the educator as a person. In addition, it is un- fortunate but not unusual for parents of pedi- atric patients to say, “If you don’t do it right, the doctor won’t let you go home . . . and we will be very disappointed in you.” And everyone prob- ably has experienced test anxiety as a learner at some point in their life.

The first step in overcoming this barrier is to realize that the potential for its existence may be close to 100%. Individuals whose perfor- mance or knowledge is being evaluated are not likely to state outright that evaluation represents a threat to them. Rather, they are far more likely to demonstrate self-protective behaviors or atti- tudes that can range from failing to participate in a teaching session or attend a class that has a posttest to providing socially desirable answers on a questionnaire or to responding with anx- iety or anger to evaluation questions. It is even possible that an individual may intentionally choose to fail an evaluation as a method for controlling the uncertainty of success.

The second step in overcoming the bar- rier of fear or threat in being evaluated is to remember that “the person is more important than the performance or the product” (Narrow, 1979, p. 185). If the purpose of an evaluation is to facilitate better learning, as in process evalu- ation, then the focus is on the process. For ex- ample, in teaching a patient how to perform urinary self-catheterization using the same clean technique as she will use at home, the ed- ucator carefully and thoroughly explains each step of the process, observing the patient’s re- sponses (e.g., level of attention or nonverbal reactions) during the explanation. When the patient tries to demonstrate the steps, how- ever, she is unable to begin. Why? One answer may be that the use of an auditory teaching style does not match the patient’s visual learn- ing style. Another possibility might be that too

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Including extra time while conducting an evaluation means leaving room for unexpected delays. Almost invariably, more time is needed than anticipated for evaluation planning, data collection, analysis of evaluation results, and re- porting the results that will be meaningful and useful to the primary audience.

Because delays not only will likely occur but also are likely to crop up at inconvenient times during the evaluation, keeping a sense of humor is vitally important. An evaluator with a sense of humor is more successful at main- taining a realistic perspective on the evaluation process as well as when reporting results that include negative findings. However, it is im- portant to acknowledge that an audience with a vested interest in positive evaluation results may blame the evaluator if results are less im- pressive than expected.

▸ Analyzing and Interpreting Data Collected

The purposes for conducting data analysis are twofold: (1) to organize data so that they can provide meaningful information and (2) to pro- vide answers to evaluation questions. The terms data and information are not the same. Data, a mass of numbers or a mass of comments, do not become information until it has been orga- nized into coherent tables, graphs, or categories that are relevant to the purpose for conducting the evaluation.

Basic decisions about how data will be ana- lyzed are dictated by the nature of the data and by the questions used to focus the evaluation. As described earlier, data can be either quanti- tative or qualitative. Data also can be described as either continuous or discrete. Age and level of anxiety are examples of continuous data; gender and diagnosis are examples of discrete data. Fi- nally, data can be differentiated by level of mea- surement. All qualitative data are at the nominal

To minimize the effects of unexpected events that can occur when carrying out an evalua- tion, the following three methods are likely to add to a successful achievement of the process:

1. Conduct a pilot test first. 2. Include extra time to complete all

the evaluation steps. 3. Keep a sense of humor throughout

the experience.

Conducting a pilot test or trial run of the evaluation involves trying out the data collec- tion methods, instruments, and plan for data analysis with a few individuals who are the same as or very similar to those who will be included in the full evaluation. If the nurse ed- ucator plans to use any newly developed in- struments for the evaluation, a pilot test must be conducted to assess the reliability, validity, interpretability, and feasibility of those new in- struments. Also, a pilot test should be carried out prior to implementing a full evaluation that is expected to be expensive or time consuming to conduct or on which major decisions will be based. Process evaluation generally is not pilot tested unless a new instrument will be used for data collection, but pilot testing should be con- sidered prior to conducting outcome, impact, or program evaluations.

Fields et al. (2016) conducted a pilot study for 1 year to test feasibility and acceptability of a multidisciplinary team education program to help patients with gout to manage their dis- ease. Education included a nurse-taught curric- ulum, monthly phone calls from pharmacists, and patient knowledge exams at baseline, 6, and 12 months. The curriculum was developed by a rheumatologist and a social worker. Both patients and providers completed evaluations of the program. Among 45 patients who were enrolled in the study, 42 remained enrolled at 6 months and 40 at 12 months. After 1 year, 84.6% of patients rated the education as use- ful in understanding and managing their gout, 81% evaluated the education from nurses as helpful, and 50% evaluated the calls from phar- macists also as helpful.

Analyzing and Interpreting Data Collected 623

once ruled by traditional experimental quantita- tive methods. The method used should be con- sistent with the purpose for the evaluation, that is to provide information that the primary audi- ence can use for decision making. Descriptive content analysis of qualitative data can be used to add meaning to numerical results from quan- titative analysis. For example, an average score of 3.5 on a Likert scale of 1 = strongly disagree to 5 = strongly agree can be interpreted to mean that the majority of the students or patients re- sponding to a survey positively viewed their educational program. Results of content anal- ysis of comments provide narrative details that enrich the meaning of the quantitative results.

The first step in analyzing quantitative data consists of organizing and summarizing the data using statistics, such as frequencies and percent- ages that describe the sample or population from which the data were collected. A description of learners in a sample and from a larger popula- tion, for example, might include such informa- tion as presented in TABLE 14-2.

The next step in analyzing quantitative data is to select the statistical procedures ap- propriate for the type of data collected to an- swer the questions asked during the planning phase of the evaluation. Again, nurse educators

level of measurement, meaning they are de- scribed in terms of categories such as health fo- cused versus illness focused. Quantitative data, in contrast, can be at the nominal, ordinal, in- terval, or ratio level of measurement. The level of measurement of the data determines which statistics can be used to analyze those data. A useful suggestion for deciding how data will be analyzed is to enlist the assistance of someone with experience in data analysis.

Analysis of data should be consistent with the type of data collected. In other words, all data analysis must be rigorous, but not all data analysis needs to include use of inferential sta- tistics. For example, qualitative data, such as ver- bal comments obtained during interviews and written comments obtained from open-ended questionnaires, are summarized, or themed, into categories of similar comments. Each category or theme is qualitatively described by directly quoting one or more comments that are typi- cal of that category. These categories then may be quantitatively described using descriptive statistics such as total counts and percentages.

As noted earlier in this chapter, different qualitative methods for analyzing data continue to emerge as they gain traction and are recog- nized as legitimate in a scientific environment

TABLE 14-2 Participants in a Breastfeeding Teaching Session Compared to All Women Eligible for the Teaching Session During the Same Time Frame

Demographic Characteristics Teaching Session Participants1 All Eligible Women2

Group Averages

Age 27.5 years 25.5 years

Length of time employed 3.5 years 7.5 years

Years of post-high school education 2.0 years 2.0 years

1 n = 50 2 n = 98

624 Chapter 14 Evaluation in Healthcare Education

the primary audience. The report of evaluation results, therefore, must be consistent with that purpose. One rule of thumb: Always begin an evaluation report with an executive summary or an abstract that is no longer than one page. No matter who the audience members are, their time is important to them and they want something succinct to read.

A second rule of thumb is to present eval- uation results in a format and language that the audience can understand and use without ad- ditional interpretation. This statement means that in the body of the report, important infor- mation should be written using nontechnical terms. For example, graphs and charts gener- ally are easier to understand than are tables of numbers. If a secondary audience of technical experts also will receive the report of evalua- tion results, it should include an appendix con- taining the more detailed or technically specific information.

A third rule of thumb is that the evaluator should make every effort to present results in person as well as in writing. A direct presenta- tion, which should include specific recommen- dations for how the evaluation results might be used, provides an opportunity for the evaluator to answer questions and to assess whether the report meets the needs of the audience. Giving specific recommendations may increase the likelihood that the results of evaluation actu- ally will be used.

Stick to the Evaluation Purpose Evaluators should keep the main body of an evaluation report focused on information that fulfills the purpose for conducting the evalua- tion. The main aspects of how the evaluation was conducted and answers to questions asked also should be provided.

Use Data as Intended Evaluators should maintain consistency with actual data when reporting and interpreting

are encouraged to enlist the assistance of an ex- pert statistician to assist with data analysis and interpretation.

▸ Reporting Evaluation Results

Results of an evaluation must be reported if the evaluation is to be of any use. Such a statement seems obvious, but many times an evaluation is carried out, yet its results are never made pub- lic. Often people participate in an evaluation but never receive feedback or see the final re- port. How many times have nurses conducted an evaluation without sharing their findings? Al- most all health professionals, if they are honest, would have to answer that they have been guilty of this on more than one occasion.

Reasons for not reporting evaluation re- sults are diverse and numerous. The follow- ing are four major reasons why evaluation data never make the trip from the spreadsheet to the customer:

1. Ignorance of who should receive the results

2. Belief that the results are not impor- tant or will not be used

3. Lack of ability to translate findings into language useful in producing a final report

4. Fear that results will be misused

The following guidelines can significantly increase the likelihood that results of the eval- uation will be reported to the appropriate indi- viduals or groups, in a timely manner, and in usable form:

■ Be audience focused. ■ Stick to the evaluation purpose. ■ Use data as intended.

Be Audience Focused The purpose for conducting an evaluation is to provide information for decision making by

Reporting Evaluation Results 625

“evidence-based practice” first appeared in the literature), no relevant articles were found. Con- sidering that this search was limited to only those articles published in one database and in English, the findings are impressive. Clearly, a body of evidence related to evaluation exists and continues to grow.

One reason why a body of literature on eval- uation has come into being is that journal re- view boards have accepted evaluation projects and internal evidence generated by such proj- ects as important for publication. Many of the articles providing evidence on evaluation of pa- tient and staff development education are not research articles—that is, articles providing ex- ternal evidence resulting from studies conducted to provide generalizable results. Practice-based evidence from such projects should be consid- ered carefully because patients in one setting may not respond in the same manner as would patients in another setting.

As discussed earlier in this chapter, how- ever, practice-based evidence is gaining in legiti- macy as increased rigor is being used to plan and conduct evaluations. Ammerman et al. (2014) argue for the important role of practice-based research to provide the rigorous evidence es- sential for meeting the challenges of the 2001 Institute of Medicine report to improve the pub- lic’s health. Losby and colleagues (2015) de- scribe the Enhanced Evaluability Assessment approach to public health program evaluation that includes preevaluation appraisal of a pro- gram’s capacity and readiness for evaluation, evaluation of program effectiveness, and eval- uation of dissemination of practice-based evi- dence generated by the program.

A notable shift over the past decade has been the increase in the number of evaluations conducted as evaluation research. Conduct- ing impact and program evaluations as re- search projects might be expected, given that these types of evaluation are already resource intensive and the increased rigor associated with research strengthens confidence in their

findings. A question not asked cannot be an- swered, and data not collected cannot be in- terpreted. For instance, if evaluators did not measure or observe a teacher’s performance, they should not draw conclusions about the adequacy of that performance. Similarly, if the only measures of patient performance were those conducted in the hospital, the evalua- tors must not interpret successful inpatient performance as successful performance by the patient at home or at work.

These examples might make what seem like obvious points, but conceptual leaps from the data collected to the conclusions drawn from those data are an all-too-common occurrence. One suggestion that decreases the opportunity to overinterpret data is to include evaluation re- sults and interpretation of those results in sep- arate sections of the report.

A discussion of any limitations of the eval- uation is an important part of the evaluation report. For example, if several patients were un- able to complete a questionnaire because they could not understand it or because they were too fatigued, the report should say so. Know- ing that evaluation results do not include data from patients below a certain educational level or physical status can help the audience realize that they cannot make decisions about those patients based on the evaluation. Discussion of limitations also provides useful information for what not to do the next time a similar eval- uation is conducted.

▸ State of the Evidence A recent search of the Cumulative Index to Nurs- ing and Allied Health Literature (CINAHL) da- tabase using the keywords “evaluation,” “patient education,” and “nursing” identified 1,962 arti- cles. When first conducted in 2007, this same search identified only 254 articles. When the time frame was changed to include only ar- ticles published prior to 1992 (the year when

626 Chapter 14 Evaluation in Healthcare Education

Review Questions 1. How is the term evaluation defined? 2. How does the process of evaluation differ

from the process of assessment? 3. How is evidence-based practice (EBP)

related to evaluation? 4. How does internal evidence differ from

external evidence? 5. What is the first and most important step

in planning any evaluation? 6. What are the five basic components

included in determining the focus of an evaluation?

7. How does formative evaluation differ from summative evaluation, and what is another name for each of these two types of evaluation?

8. What are the five basic types (levels) of eval- uation, in order from simple to com plex, as identified in Abruzzese’s RSA evalua- tion model?

9. What is the purpose of each type (level) of evaluation as described by Abruzzese in her RSA evaluation model?

10. Which data collection methods can be used in conducting an evaluation of educational interventions?

11. What are the three major barriers to conducting an evaluation?

12. When and why should a pilot test be conducted prior to implementing a full evaluation?

13. What are three guidelines to follow in reporting the results of an evaluation?

627Review Questions

Ammerman, A., Smith, T. W., & Calancie, L. (2014). Practice- based evidence in public health: Improving reach, relevance, and results. Annual Reviews in Public Health, 35, 47–63. doi:10.1146/annurev-publhealth-032013-182458

Bahreini, M., Moattari, M., Shahamat, S., Dobaradaran, S., & Ravanipour, M. (2013). Improvement of Iranian nurses’ competence through professional portfolio: A quasi-experimental study, Nursing and Health Sciences, 15, 51–57. doi:10.1111/j.1442-2018.2012.00733.x

Balas, M. C., Burke, W. J., Gannon, D., Cohen, M. Z., Colburn, L., Bevil, C., . . . Vasilevskis, E. E. (2013). Implementing the ABCDE bundle into everyday care: Opportuni- ties, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium (PAD) guidelines. Critical Care Medicine, 41(9 Suppl. 1), S116–S127. doi: 10.1097/CCM.0b013e3182a17064

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You next meet with Eric, the certified diabetes educator at your hospital, and he reminds you that all nurses are mandated to annually review the patient and family education program for patients with type 2 diabetes and complete the cognitive posttest.

1. Which type of evaluation is being conducted every year when the nurses review the program and complete the cognitive test?

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seems often an afterthought or is even overlooked entirely by the educator?

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Appendix A Tests to Measure Readability, Comprehension, and Health Literacy and Tools to Assess Instructional Materials

▸ How to Use the Flesch–Kincaid Scale

1. To test a whole piece of writing, take 3 to 5 100-word samples of an article or 25 to 30 100-word samples of a book. For short pieces, test the entire selection. Do not pick good or typical samples but rather choose every third paragraph or every other page. In a 100-word sample, find the sentence that ends nearest to the 100-word mark; that may be, for example, at the 94th or the 109th word. Start each sample at the begin- ning of a paragraph, but do not use an introductory paragraph as part of the sample. Count contractions and hyphenated words as one word; count numbers and letters separated by space as words.

2. Figure the average sentence length (SL) by counting the number of words and dividing by the number of sentences. In counting sentences, follow units of thought marked off by periods, colons, semicolons,

question marks, or exclamation points.

3. Determine word length (WL) by counting the number of syllables in each word in the sample as they are normally read aloud (i.e., two sylla- bles for $ [“dollars”] and four sylla- bles for 1918 [“nineteen-eighteen”]. It helps to read silently aloud while counting. Divide the syllables by the number of words in the sample and multiply by 100.

4. Determine the average WL by mul- tiplying it by 0.846 and the average SL by multiplying it by 1.015. Then apply the formula:

RE = 206.835 – 0.846 (WL) – 1.015 (SL)

where RE is the reading ease score, after WL and SL have been sub- tracted from 206.835 (Flesch, 1948; Spadero, 1983; Spadero, Robinson, & Smith, 1980).

The reading ease score ranges from zero (practically unreadable) to 100 (very easy for any literate person) with interpretations in be- tween (TABLE A-1).

633

▸ How to Use the Fog Formula

1. Count 100 words in succession (W). If the selection is long, choose several samples of 100 words from the text and average the results.

2. Count the number of complete sen- tences (S). If the 100th word falls past the midpoint of a sentence, include this sentence in the count.

3. Divide the words (W) by the number of sentences (S).

4. Count the number of words hav- ing three or more syllables (A), but do not count verbs ending in -ed or -es that make a word have a third syllable; do not count cap- italized words, and do not count

combinations of simple words, such as butterfly.

5. Apply the formula:

GL = (W/S + A) × 0.4

In other words, to find the GL (grade level), divide the number of words (W) by the number of complete sentences (S) in the sample 100-word passage, add the number of words having three or more syllables (A), and multiply the result by a constant of 0.4 (Gunning, 1968; Spadero, 1983; Spadero et al., 1980).

▸ How to Use the Fry Readability Graph

1. Select three 100-word sample passages from near the beginning, middle, and

TABLE A-1 Reading Ease Scores

Ease Score 100 Words Length Difficulty Level Grade Level

0–30 192 or more 29 or more Very difficult College grad

30–50 167 25 Difficult College

50–60 155 21 Fairly difficult 10–12

60–70 147 17 Standard 8–9

70–80 139 14 Fairly easy 7

80–90 131 11 Easy 6

90–100 123 or less 8 or less Very easy 5

Data from Flesch, R. (1948). A new readability yardstick. Journal of Applied Psychology, 32(3), 221–233; Spadero, D. C. (1983). Assessing readability of patient information materials. Pediatric Nursing, 9(4), 274–278.

634 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

level of the material. The following is an example.

Number of Syllables

Number of Sentences

First 100 words

153 6.3

Second 100 words

161 5.9

Third 100 words

139 5.2

Average count 5

453 43 5 151 17.4 4 3 5 5.8

In the example (Fry 1968, 1977), the aver- age number of syllables is 151, and the average number of sentences is 5.8. When plotted on the graph (FIGURE A-1), the point falls within the ap- proximate grade level of 9, which shows the ma- terials to be at the ninth-grade readability level. If the point when plotted falls in the gray area, grade-level scores are invalid (Fry, 1968, 1977; Spadero et al., 1980).

▸ How to Use the SMOG Formula

Passages Longer Than 30 Sentences

1. Count 10 consecutive sentences near the beginning, 10 consecutive sen- tences from the middle, and 10 con- secutive sentences from the end of the selection to be assessed. A sentence

end of a book, article, pamphlet, or brochure. Skip all proper nouns as part of the 100-word count. Fewer than three samples and passages of less than 30 sentences can be used, but the user should be aware that there is necessarily a sacrifice in both reliability and validity.

2. Count the total number of sentences in each 100-word sample (estimating to the nearest 10th of a sentence for partial sentences).

3. Average the sentence counts of the three sample passages.

4. Count the total number of syllables in each 100-word sample. Count one syllable per vowel sound; for example, cat has one syllable, blackbird has two, and continental has four. Caution: Do not be fooled by word size (e.g., polio [three syllables], through [one syllable]). Endings such as -y, -ed, -el, or -le usually make a syllable (e.g., ready [two syllables], bottle [two syllables]). Graph users sometimes have trouble determining syllables. The clue is to believe what you hear (speech sounds), not what you see (e.g., wanted is a two-syllable word, but stopped is a one-syllable word). Count proper nouns, numerals, and initials or acronyms as words. A word is a symbol or group of symbols bounded by a blank space on either side. Thus, 1945, &, and IRS are all words. Each symbol should receive a syllable count of one (i.e., the date 1945 is one word with five syllables, and the acronym IRS is one word with three syllables).

5. Average the total number of syllables for the three samples.

6. Plot on the graph the average sentence count and the average word count to determine the appropriate grade

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 635

FIGURE A-1 Fry readability graph. Courtesy of Edward Fry, Rutgers University Reading Center, New Brunswick, NJ.

is any independent unit of thought punctuated by a period, question mark, or exclamation point. If a sen- tence has a colon or semicolon, con- sider each part as a separate sentence.

2. From the 30 randomly selected sen- tences, count the words containing three or more syllables (polysyllabic), including repetitions. Abbreviated words should be read aloud to deter- mine their syllable count (e.g., Sept. = September = three syllables). Letters or numerals in a string beginning or ending with a space or punctuation mark should be counted if, when read aloud in context, at least three

syllables can be distinguished. Do not count words ending in -ed or -es if the ending makes the word have a third syllable. Hyphenated words are counted as one word. Proper nouns should be counted.

3. Approximate the reading grade level from the SMOG conversion table (TABLE A-2), or calculate the reading grade level by estimating the nearest perfect square root of the number of words with three or more syllables and then adding a constant of 3 to the square root. For example, if the total number of polysyllabic words was 53, the nearest perfect square would

636 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

TABLE A-2 SMOG Conversion Table

Word Count Grade Level

0–2 4

3–6 5

7–12 6

13–20 7

21–30 8

31–42 9

43–56 10

57–72 11

73–90 12

91–110 13

111–132 14

133–156 15

157–182 16

183–210 17

211–240 18

Developed by Harold C. McGraw, Office of Educational Research, Baltimore County Public Schools, Towson, MD. In U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. (2004). Making health communication programs work: A planner’s guide. Retrieved from http://www.cancer.gov/publications/health -communication/pink-book.pdf.

set of 10 sentences taken from one of the many pamphlets designed and distributed by the Na- tional Cancer Institute. In Figure A-2, there are 20 words with three or more syllables. Note that the word United is not counted as a three-sylla- ble word because only the -ed ending makes it polysyllabic (see rule 2). For this passage of 10 sentences, the conversion number is 3 using the conversion table (TABLE A-3) for samples with fewer than 30 sentences. That is, 20 multisyllabic words × 3 (conversion number) = 60, which falls at the 11th-grade level on Table A-2 as per the rules in the next section for passages shorter than 30 sentences.

Passages Shorter Than 30 Sentences

1. Count the number of sentences in the material and the number of words containing three or more syllables.

2. In the left-hand column of Table A-3, locate the number of sentences. Then in the column opposite, locate the conversion number.

3. Multiply the word count found in step 1 by the conversion number. Locate this number in Table A-2 to obtain the corresponding grade level.

Example: If the material is 25 sentences long and 15 words of three or more syllables were counted in this material, the conversion number in Table A-3 for 25 sentences is 1.2. Multiply the word count of 15 by 1.2 to get 18. For the word count of 18, the grade level in Table A-2 is 7. Therefore, the material is at a seventh-grade reading level.

▸ The Cloze Test How to Construct a Cloze Test Instead of using packaged cloze tests available from commercial sources, it is suggested that

be 49. The square root of 49 would be 7. By adding a constant of 3, the reading level would be 10th grade.

FIGURE A-2 is an example of how to count all the words containing three or more syllables in a

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 637

TABLE A-3 SMOG Conversion for Samples with Fewer Than 30 Sentences

Number of Sentences in Sample Material Conversion Number

29 1.03

28 1.07

27 1.1

26 1.15

25 1.2

24 1.25

23 1.3

22 1.36

21 1.43

FIGURE A-2 Example of counting words with three or more syllables. Reproduced from National Cancer Institute of the National Institutes of Health, Public Health Service, U.S. Department of Health and Human Services. (1987). Mastectomy: A treatment for breast cancer [Brochure] (p. 1). Washington, DC: Author.

638 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

Number of Sentences in Sample Material Conversion Number

20 1.5

19 1.58

18 1.67

17 1.76

16 1.87

15 2.0

14 2.14

13 2.3

12 2.5

11 2.7

10 3

educators devise their own tests so that the re- sultant scores will indicate a client’s comprehen- sion of their own instructions. Problem words or sentences within these printed education ma- terials can be revised accordingly to make them more understandable.

1. Select a prose passage (one without reference to figures, tables, charts, or pictures) from printed educational materials currently in use, such as pamphlets, brochures, manuals, or instruction sheets. Be sure the material is typical of what is normally given to patients but has not been previously

read by them. The chosen passage should include whole paragraphs so that readers benefit from complete units of thought.

2. Leave the first and last sentences intact, and delete every fifth word from the other sentences, for a total of about 50 word deletions. Do not delete proper nouns, but delete the word following the proper noun. Replace all deleted words with a line or blank space, all of equal length.

3. Ask the reader to fill in the blanks with the exact word replacements.

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 639

percentage of correct responses. For example, if the passage has 50 blanks and the patient correctly filled in 25 blanks (10 were incorrect responses and 15 spaces were left blank), divide 25 by 50, and the percentage score would be 50%.

5. A score of 60% or higher indicates the patient is fully capable of under- standing the material. A score of 40% to 60% indicates the patient needs supplemental instruction. A score less than 40% indicates that the material as written is too difficult for the patient to understand and is not suitable to be used for teaching (Doak et al., 1996).

The following are the words that were deleted from the sample cloze test in FIGURE A-3.

1. it 2. heart 3. kidney 4. cases 5. causes 6. chemistry 7. a 8. have 9. high

10. remain 11. been 12. risk 13. heart 14. cause 15. a 16. blood 17. to 18. the 19. work 20. muscle 21. pump 22. your 23. from 24. it 25. all 26. supplying 27. oxygen 28. its

Preparing Participants for the Cloze Test Because the cloze procedure is a test of learners’ ability to understand what they have read, nurse educators should be honest about the purpose of the test. For example, they might state that it is important for patients to understand what they are to do when on their own after discharge, so the educator wants to be sure they understand the written instructions they will need to fol- low. Doak, Doak, and Root (1996) suggest that the following guidelines should be used in pre- paring participants for the cloze test:

1. Encourage the participants to read through the entire test passage before attempting to fill in the blanks.

2. Tell them that only one word should be written in each blank.

3. Let them know that it is okay to guess but that they should try to fill in every blank as accurately as possible.

4. Reassure them that spelling errors are okay if the word they have put in the blank can be recognized.

5. Explain to them that this exercise is not a timed test. (If readers struggle to complete the test, tell them not to worry, that it is not necessary for them to fill in all the blanks, and set the test aside to go on to something else less frustrating or less threatening).

How to Score a Cloze Test 1. Count as correct only those words

that exactly replace the deleted words (synonyms are not to be counted as a correct answer).

2. Inappropriate word endings such as -s, -ed, -er, and -ing should be counted as incorrect.

3. The raw score is the number of exact word replacements.

4. Divide the raw score by the total num- ber of blank spaces to determine the

640 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

FIGURE A-3 Sample cloze test. Please note that the information from this booklet is not current and is used for illustrative purposes only. Modified from American Heart Association. (1983). An older person’s guide to cardiovascular health. Dallas, TX: Author.

29. to 30. your 31. through 32. the 33. oxygen 34. begins 35. by 36. the 37. vessels 38. pumping 39. creates 40. pressure 41. moment 42. or

43. are 44. you 45. arteries 46. constrict 47. even 48. blood 49. your 50. then 51. return 52. relax

Note: The words are listed in missing order. Hyphenated words are counted as one word; words in parentheses are counted as a word.

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 641

limiting each paragraph to a single message or action.

14. Keep the density of words low (do not exceed 30–40 characters per line).

15. Provide adequate white space for margins and between lines and paragraphs (use double spacing).

16. Justify left margins and keep right margins unjustified.

17. Use arrows or numbers that give di- rection and organization to layouts.

18. Select large print (minimum of 12- to 14-point font) and simple style type (serif ); avoid italics, all CAPITAL LETTERS, and fancy lettering.

19. Rely on bold print or underlining to emphasize key points or words.

20. Attract attention with consistent use of appealing colors to highlight and organize topics.

21. Use a simple, short title that clearly indicates the subject being presented.

22. Keep the length of the document short; avoid including details and extraneous information.

23. Avoid glossy paper to reduce glare; rely on bold primary colors (not pas- tels) and black print on white paper for an older audience.

24. Use simple, realistic illustrations that convey the intended message; never superimpose typed words on a background design.

25. Include a summary at the end to review key points of information.

26. Put the grade reading level (RL) on the back of the tool for future reference.

27. Determine readability, comprehen- sion, and reading skills by applying at least two formulas or tests.

Readability formulas: (1) SMOG, (2) Fog, and (3) Fry. Comprehension tests: (1) Cloze pro- cedure, and (2) listening test. Reading skills tests: (1) WRAT, (2) REALM, and (3) TOFHLA.

▸ Guidelines for Writing and Evaluating Printed Education Materials

To reduce reading level and increase reading ease, do the following:

1. Write in conversational style with an active voice in the present tense using the second person pronoun you or your.

2. Use short, simple vocabulary of one- or two-syllable words; avoid multi- syllabic words.

3. Spell out words rather than using ab- breviations or acronyms, unless they are familiar to the reader or defined.

4. Organize information into chunks or series of numbered and bulleted lists; use statistics sparingly. A question-and-answer format is an interactive approach to presenting single units of information.

5. Keep sentences short (20 words max- imum); avoid complex grammatical sentence structures that contain colons, semicolons, commas, and dashes.

6. Focus on familiar terms; avoid techni- cal jargon and medical terminology; define or spell out difficult words phonetically; include a glossary if medicalese is necessary.

7. Use words consistently (repetition) throughout text; avoid synonyms.

8. Use exact terms; avoid value-judgment words with many interpretations.

9. Put the most important information first by prioritizing the need to know.

10. Use advance organizers to cue the reader about the topic being presented.

11. Limit the use of connective words that lengthen and make sentences more complex.

12. Make the first sentence of a paragraph the topic sentence.

13. Reduce concept density by includ- ing only one idea per sentence and

642 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

average time needed to complete all six questions is about 3 minutes. However, if a patient is still struggling with the first or second question after 2 or 3 minutes, the likelihood is that the patient has limited literacy and you can stop the assessment.

Ask the questions in sequence. Continue even if the patient gets the first few questions wrong. However, if question 5 is answered incorrectly, do not ask question 6.

You can stop asking questions if a patient gets the first four correct. With four correct responses, the patient almost certainly has adequate literacy.

Do not prompt patients who are unable to answer a question. Prompting may jeopardize the accuracy of the test. Just say, “Well, then, let’s go on to the next question.”

Do not show the score sheet to patients. If they ask to see it, tell them that “I can’t show it to you because it contains the answers, and showing you the answers spoils the whole point of asking you the questions.”

Do not tell patients if they have answered correctly or incorrectly. If patients ask, say something like: “I can’t show you the answers until you are finished, but for now you are doing fine. Now let’s go on to the next question.”

5. Score by giving 1 point for each correct answer (maximum 6 points). See Exhibit A-1B. Score of 0–1 suggests high likelihood (50% or more) of limited literacy. Score of 2–3 indicates the possibility of limited literacy. Score of 4–6 almost always indicates adequate literacy. Record the NVS score in the patient’s medical record, preferably near other vital sign measures.

▸ Newest Vital Sign How to Use the Newest Vital Sign1

1. When to administer the Newest Vital Sign and who should ad- minister it. A nurse (or other trained clinic staff ) is the preferred administrator of the Newest Vital Sign. Administer this test when the patient’s other vital signs are being taken.

2. Ask the patient to participate. The following example is a useful way to explain to the patient the purpose of this exercise: We are asking our patients to help us learn how well patients can understand the medical information that doctors give them. Would you be willing to help us by looking at some health information and then answering a few questions about that information? Your answers will help our doctors learn how to provide medical information in ways that patients will understand. It will take only about 3 minutes.

3. Hand the nutrition label to the patient. The patient can and should retain the nutrition label (see EXHIBIT A-1A) throughout administration of the Newest Vital Sign. The patient can refer to the label as often as desired.

4. Start asking the six questions (see EXHIBIT A-1B), one by one, giving the patient as much time as needed to refer to the nutrition label to answer the questions. Do NOT provide the patient with the answers.

There is no maximum time al- lowed to answer the questions. The

1Copyright © 2002–2013 Pfizer Inc. All rights reserved. Reproduced from Pfizer. (2016). Implementation guide for the Newest Vital Sign. http://www.pfizerhealthliteracy.com/asset/pdf /NVS_Eng/files/nvs_flipbook_english_final.pdf.

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 643

EXHIBIT A-1A Nutrition Label on Ice Cream Container

Nutrition Facts

Serving Size ½ cup

Servings per container 4

Amount per serving

Calories 250 Fat Cal 120

%DV

Total Fat 13g 20%

Sat Fat 9g 40%

Cholesterol 28mg 12%

Sodium 55mg 2%

Total Carbohydrate 30g 12%

Dietary Fiber 2g

Sugars 23g

Protein 4g 8%

*Percentage Daily Values (DV) are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs. Ingredients: Cream, Skim Milk, Liquid Sugar, Water, Egg Yolks, Brown Sugar, Milkfat, Peanut Oil, Sugar, Butter, Salt, Carrageenan, Vanilla Extract.

Copyright © 2002–2013 Pfizer Inc. All rights reserved. Pfizer. (2016). Implementation guide for the Newest Vital Sign. Retrieved from http://www.pfizer.com /files/health/2016_nvs_flipbook_english_final.pdf

644 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

EXHIBIT A-1B Score Sheet for the Newest Vital Sign Questions and Answers

Questions and Answers

READ TO SUBJECT: This information is on the back of a container of a pint of ice cream (see food label).

ANSWER CORRECT?

Yes No

1. If you eat the entire container, how many calories will you eat? Answer: 1,000 is the only correct answer.

2. If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? Answer: Any of the following is correct: 1 cup (or any amount up to 1 cup), half the container. Note: If patient answers “two servings,” ask “How much ice cream would that be if you were to measure it into a bowl?”

3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? Answer: 33 is the only correct answer.

4. If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Answer: 10% is the only correct answer.

READ TO SUBJECT: Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings.

5. Is it safe for you to eat this ice cream? Answer: No

6. (Ask only if the patient responds “no” to question 5.) Why not? Answer: Because it has peanut oil.

Number of correct answers:

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 645

EXHIBIT A-2 e-Health Literacy Scale (eHeals Tool)

I would like to ask you for your opinion and about your experience using the Internet for health information. For each statement, tell me which response best reflects your opinion and experience right now.

1. How useful do you feel the Internet is in helping you in making decisions about your health? 1. Not useful at all 2. Not useful 3. Unsure 4. Useful 5. Very useful

2. How important is it for you to be able to access health resources on the Internet? 1. Not important at all 2. Not important 3. Unsure 4. Important 5. Very important

3. I know what health resources are available on the Internet. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

4. I know where to find helpful health resources on the Internet. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

5. I know how to find helpful health resources on the Internet. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

6. I know how to use the Internet to answer my questions about health. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

7. I know how to use the health information I find on the Internet to help me. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

646 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

8. I have the skills I need to evaluate the health resources I find on the Internet. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

9. I can tell high-quality health resources from low-quality health resources on the Internet. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

10. I feel confident in using information from the Internet to make health decisions. 1. Strongly Disagree 2. Disagree 3. Undecided 4. Agree 5. Strongly Agree

Thank you! *Note: Questions #1 and #2 are recommended as supplementary items for use with the eHEALS to understand consumer’s interest in using eHealth in general. These items are not a formal part of the eHealth Literacy Scale, which comprises questions #3–10.

EXHIBIT A-3 SAM Scoring Sheet

2 points for superior rating

1 point for adequate rating

0 points for not suitable rating

N/A if the factor does not apply to this material

(continues)

Reproduced from Norman, C. D., & Skinner, H. A. (2006). eHEALS: The eHealth Literacy Scale. Journal of Medical Internet Research, 8(4), e27. doi:10.2196 /jmir.8.4.e27. Creative Commons license available at http://www.creativecommons.org/licenses/by/2.0/.

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 647

Factor to Be Rated Score Comments

1. Content

(a) Purpose is evident ———— ————————————

(b) Content about behaviors ———— ————————————

(d) Summary or review included ———— ————————————

2. Literacy Demand

(a) Reading grade level ———— ————————————

(b) Writing style, active voice ———— ————————————

(d) Context is given first ———— ————————————

(e) Learning aids via “road signs” ———— ————————————

3. Graphics

(a) Cover graphic shows purpose ———— ————————————

(b) Type of graphics ———— ————————————

(d) Lists, tables, etc. explained ———— ————————————

(e) Captions used for graphics ———— ————————————

4. Layout and Typography

(a) Layout factors ———— ————————————

(b) Typography ———— ————————————

EXHIBIT A-3 SAM Scoring Sheet (continued)

648 Appendix A Tests to Measure Readability, Comprehension, and Health Literacy

5. Learning Stimulation, Motivation

(a) Interaction used ———— ————————————

(b) Behaviors are modeled and specific ———— ————————————

6. Cultural Appropriateness

(a) Match in logic, language, experience ———— ————————————

(b) Cultural image and examples ———— ————————————

Total SAM score: ____________

Total possible score: _____________, Percent score: ___________%

References American Heart Association (1983). An older person’s guide

to cardiovascular health. Dallas, TX: Author. Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching

patients with low literacy skills (2nd ed.). Philadelphia, PA: Lippincott.

Flesch, R. (1948). A new readability yardstick. Journal of Applied Psychology, 32(3), 221–233.

Fry, E. (1968). A readability formula that saves time. Journal of Reading, 11, 513–516, 555–579.

Fry, E. (1977). Fry’s readability graph: Clarifications, validity, and extension to level 17. Journal of Reading, 21, 242–252.

Gunning, R. (1968). The Fog index after 20 years. Journal of Business Communications, 6, 3–13.

National Cancer Institute of the National Institutes of Health, Public Health Service, U.S. Department of Health and Human Services. (1987). Mastectomy: A treatment for breast cancer [Brochure] (p. 1). Washington, DC: Author.

Norman, C. D., & Skinner, H. A. (2006). eHEALS: The eHealth Literacy Scale. Journal of Medical Internet Research, 8, e27. doi:10.2196/jmir.8.4.e27

Pfizer. (2016). Implementation guide for the Newest Vital Sign. Retrieved from http://www.pfizer.com/files /health/2016_nvs_flipbook_english_final.pdf

Spadero, D. C. (1983). Assessing readability of patient information materials. Pediatric Nursing, 9(4), 274–278.

Spadero, D. C., Robinson, L. A., & Smith, L. T. (1980). Assessing readability of patient information materials. American Journal of Hospital Pharmacy, 37, 215–221.

U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. (2004). Making health communication programs work: A planner’s guide. Retrieved from http://www.cancer.gov/publications /health-communication/pink-book.pdf

Reproduced from Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia, PA: Lippincott. Reprinted with permission from Cecilia Doak.

Appendix A Tests to Measure Readability, Comprehension, and Health Literacy 649

▸ Assistive Technology AbleData 103 W. Broad Street, Suite 400 Falls Church, VA 22046 800-227-0216 E-mail: [email protected] http://www.abledata.com

Alliance for Technology Access 1119 Old Humboldt Rd. Jackson, TN 38305 E-mail: [email protected] http://www.ataccess.org https://www.facebook.com/ATAccess/

▸ Augmentations and Alternative Communication

American Speech–Language–Hearing Association (ASHA)

2200 Research Blvd Rockville, MD 20850 Members: 800-498-2071 Nonmembers: 800-638-8255 http://www.asha.org

International Society for Augmentative and Alternative Communication (ISAAC)

312 Dolomite Drive, Suite 216 Toronto, ON M3J 2N2 Canada +1-905-850-6848 http://www.isaac-online.org

▸ Blindness American Diabetes Association 2451 Crystal Drive, Suite 900 Arlington, VA 22202 800-342-2383 http://www.diabetes.org

American Foundation for the Blind 2 Penn Plaza, Suite 1102 New York, NY 10121 800-232-5463 http://www.afb.org

Library of Congress 101 Independence Avenue, SE Washington, DC 20540 202-707-5000 http://www.loc.gov Administers a free program of Braille and audio materials.

Appendix B Resources and Organizations for People with Disabilities

651

Registry of Interpreters for the Deaf, Inc. 333 Commerce Street Alexandria, VA 22314 703-838-0030 http://www.rid.org Provides information on interpreting and interpreters; referral to local agencies and state chapters of the Registry of Interpret- ers for the Deaf for assistance in locating interpreters.

▸ Developmental Disabilities

Eunice Kennedy Shriver National Institute of Child Health and Human Development

PO Box 3006 Rockville, MD 20847 800-370-2943 TTY: 888-320-6942 E-mail: NICHDInformationResourceCenter@

mail.nih.gov http://www.nichd.nih.gov

▸ Disability Services Americans with Disabilities Act (ADA) U.S. Department of Justice 950 Pennsylvania Avenue, NW Civil Rights Division Disability Rights Section–NYA Washington, DC 20530 202-307-0663 (voice) 800-514-0301 (voice) 800-514-0383 (TTY) http://www.ada.gov

Autism Speaks 1 East 33rd Street, 4th Floor New York, NY 10016 212-252-8584 888-288-4762 http://www.autismspeaks.org

National Braille Press 88 St. Stephen Street Boston, MA 02115 617-266-6160 888-965-8965 E-mail: [email protected] http://www.nbp.org

National Library Service for the Blind and Physically Handicapped

1291 Taylor Street NW Washington, DC 20542 202-707-5100 888-657-7323 E-mail: [email protected] http://www.loc.gov/nls/

▸ Deafness Gallaudet University 800 Florida Avenue, NE Washington, DC 20002-3695 202-651-5000 http://www.gallaudet.edu

Helen Keller National Center 141 Middle Neck Road Sands Point, NY 11050 516-944-8900 E-mail: [email protected] http://www.hknc.org

National Institute on Deafness and Other Communication Disorders

31 Center Drive, MSC 2320 Bethesda, MD 20892-2320 301-496-4000 800-241-1044 E-mail: [email protected] http://www.nidcd.nih.gov

652 Appendix B Resources and Organizations for People with Disabilities

▸ Learning Disabilities A.D.D. Warehouse 300 NW 70th Avenue, Suite 102 Plantation, FL 33317 954-792-8100 800-233-9273 http://www.addwarehouse.com/shopsite_sc

/store/html/index.html

Attention Deficit Disorder Association PO Box 103 Denver, PA, 17517 800-939-1019 http://www.add.org

Learning Disabilities Association of America

4156 Library Road Pittsburgh, PA 15234 412-341-1515 http://ldaamerica.org

▸ Mental Health Mental Health America 500 Montgomery Street, Suite 820 Alexandria, VA 22314 703-684-7722 800-969-6642 800-433-5959 (TTY) http://www.mentalhealthamerica.net

National Institute of Mental Health (NIMH)

Science Writing, Press & Dissemination Branch

6001 Executive Boulevard Room 8184, MSC 9663 Bethesda, MD 20892-9663 301-443-4513 866-615-6464 TTY: 301-443-8431 TTY toll-free: 866-415-8051 E-mail: [email protected] http://www.nimh.nih.gov

National Council on Disability 1331 F Street NW Suite 850 Washington, DC 20004 202-272-2004 (voice) 206-272-2074 (TTY) http://www.ncd.gov

▸ Head Injury Brain Injury Association of America 1608 Spring Hill Road, Suite 110 Vienna, VA 22182 800-444-6443 703-761-0750 http://www.biausa.org

▸ Healthcare-Related Federal Agencies

Centers for Disease Control and Prevention (CDC)

1600 Clifton Road Atlanta, GA 30333 404-639-3311 800-232-4636 800-232-6348 (TTY) http://www.cdc.gov

National Center for Medical Rehabilitation Research

800-370-2943 http://www.nichd.nih.gov/about/org/ncmrr

/Pages/overview.aspx

National Institute on Disability, Independent Liv- ing, and Rehabilitation Research (NIDILRR)

Administration for Community Living U.S. Department of Health and Human Services 330 C Street SW, Room 1304 Washington, DC 20201 202-795-7398 http://www.acl.gov/about-acl/about-national

- institute-disability-independent-living -and-rehabilitation-research

653Appendix B Resources and Organizations for People with Disabilities

Myasthenia Gravis Foundation of America 355 Lexington Avenue, 15th Floor New York, NY 10017 800-541-5454 E-mail: [email protected] http://www.myasthenia.org

Parkinson’s Disease Foundation, Inc. 1359 Broadway, Suite 1509 New York, NY 10018 800-457-6676 212-923-4700 800-4PD-INFO E-mail: [email protected] http://www.pdf.org

▸ Stroke National Aphasia Association PO Box 87 Scarsdale, NY 10583 800-922-4622 E-mail: [email protected] http://www.aphasia.org

National Institute of Neurological Disorders and Stroke (NINDS)

PO Box 5801 Bethesda, MD 20824 301-496-5751 800-352-9424 http://www.ninds.nih.gov

National Stroke Association 9707 E. Easter Lane, Suite B Centennial, CO 80112-3747 800-STROKES (787-6537) 303-649-9299 E-mail: [email protected] http://www.stroke.org

▸ Neuromuscular Disorders

ALS Association National Office 1275 K Street NW, Suite 250 Washington, DC 20005 800-782-4747 202-407-8580 http://www.alsa.org

Epilepsy Foundation 8301 Professional Place East, Suite 200 Landover, MD 20785-2353 301-459-3700 800-332-1000 http://www.epilepsyfoundation.org

MS Helpline, Program Services Assistance 888-MSFOCUS E-mail: [email protected] https://msfocus.org/Get-Help/MSF

-Programs-Grants/Emergency -Assistance-Program

Multiple Sclerosis Foundation 6520 North Andrews Avenue Fort Lauderdale, FL 33309-2132 800-225-6495 954-776-6805 E-mail: [email protected] https://msfocus.org

Muscular Dystrophy Association—USA National Headquarters 222 S. Riverside Plaza, Suite 1500 Chicago, IL 60606 800-572-1717 E-mail: [email protected] http://www.mda.org

654 Appendix B Resources and Organizations for People with Disabilities

4MAT system A learning style model based on Kolb’s model combined with right–left brain research.

A abstract conceptualization A term used by Kolb as one of two ways of processing information; known as the thinking mode. accommodator One of the four learning style types according to Kolb’s theory, combining the learning modes of concrete experience and active experimentation. acculturation An individual’s adaptation to the cus- toms, values, beliefs, and behaviors of a new coun- try or culture. active experimentation A term used by Kolb as one of two ways of processing information; known as the doing mode. adherence Commitment or attachment to health- promoting regimens. affective domain One of three domains in the tax- onomy of behavioral objectives; deals with attitudes, values, and beliefs. ageism Prejudice against the older adult that per- petuates the negative stereotyping of aging as a pe- riod of decline. aids See instructional materials (tools). analogue A type of model that uses analogy to com- pare an object to something else. The model performs like the real object, although its actual appearance may differ. For example, a dialysis machine and the description of a pump explain how the kidneys and heart work respectively. andragogy The art and science of helping adults learn; a term coined by Knowles to describe his the- ory of adult learning.

animistic thinking The tendency of preschoolers to endow inanimate objects with life and consciousness; the belief that objects possess human characteristics. anomic aphasia The difficulty finding the right noun or verb to convey thoughts. Individuals affected with this disorder retain an understanding of what is being said to them, and they are able to speak in full sentences. Circumlocution, or speaking in a round- about way, is an attempt to fill in the gaps of speech by talking around an issue or taking a new approach to describe the word that cannot be remembered. Asperger syndrome A pervasive developmen- tal disability at the high end of the autism spectrum that is characterized by impaired communication, impaired social interaction, and repetitive or restric- tive patterns of thought and behavior. assessment The process of systematically collect- ing data to determine the relative magnitude, impor- tance, or value of needs, problems, and strengths of the learner to decide a direction for action. assimilation The willingness of a person emigrat- ing to a new culture to gradually adopt and incor- porate the characteristics of the prevailing culture. assimilator One of the four learning style types, according to Kolb’s theory, combining the learn- ing modes of abstract conceptualization and reflec- tive observation. assistive technologies Technological tools (comput- ers and communication devices) available for people with disabilities that provide access to education, em- ployment, recreation, and communication opportuni- ties that allow them to live as independently as possible. association learning See respondent conditioning. asynchronous A message that can be sent via the computer at the convenience of the sender, with the message then being read when the receiver is online and ready to read it; messages that can be sent and responded to any time, day or night.

Glossary

655

rather than content oriented and learner centered rather than teacher centered. behaviorist learning One of the five major learn- ing theories. According to behaviorists, the focus for learning is mainly on what is directly observable, and learning is viewed as the product of the stimu- lus conditions (S) and the responses (R) that follow. It is sometimes termed the S-R model of learning. beneficence The principle of doing good. blended learning A more recently used term in ed- ucation that combines e-learning technology with the more traditional instructor-led methodology, such as lecture or demonstration. blogs One of the newest forms of online commu- nication, also known as web logs or web diaries; an increasingly popular mechanism for individuals to share information and/or experiences about a given topic that include images, media objects, and links allowing for public responses. bodily-kinesthetic intelligence A term used by Gardner to describe children who learn by process- ing knowledge through bodily sensations. brain preference indicator (BPI) A learning style instrument used to determine hemispheric domi- nance in Sperry’s model of right-brain/left-brain and whole-brain thinking.

C case studies An approach that offers learners the opportunity to become thoroughly acquainted with a client situation before discussing client needs and identifying health-related problems; leads to the de- velopment of analytical and problem-solving skills, exploration of complex issues, and application of new knowledge and skills. causal thinking The ability of school-aged children to understand cause and effect through logic, con- crete thinking, and inductive and deductive reasoning. causality The ability to grasp a cause-and-effect relationship between two paired, successive events, which is an elementary concept that begins to de- velop during toddlerhood. characteristics of the learner One of the three major variables that refers to the learner’s perceptual abilities, reading ability, self-direction, and learning

attention-deficit/hyperactivity disorder (ADHD) A disorder of children and adults with prominent at- tentional difficulties as demonstrated by inattention and impulsivity that are signs of developmentally in- appropriate behavior. attribution theory Describes the cause-and-effect relationships and explanations that individuals for- mulate to account for their own and others’ behavior and the way in which the world operates. audio learning resources Instructional tools whose chief characteristic is exploitation of the learners’ sense of hearing as a mechanism for teaching. Audiotapes and recorders are examples. audiovisual materials (tools) Nonprint instruc- tional media that can influence all three domains of learning and stimulate the senses of hearing and/or sight to help convey the message to the learner. This category includes five major types: projected, audio, video, telecommunications, and computer formats. auditory processing disorder An umbrella term used to describe a condition that results in the inabil- ity of the central nervous system to efficiently pro- cess or interpret sound impulses. augmentative and alternative communication Devices, such as computers, that allow people who are unable to speak or whose speech is difficult to understand to be able to communicate with others, which has added a whole new dimension and qual- ity to their lives. augmented feedback An opinion or conveyance of a message through oral or body language by the teacher to the learner about how well he or she per- formed a psychomotor skill. autonomy The right of self-determination. avoidance conditioning A type of negative reinforce- ment whereby an unpleasant stimulus is anticipated rather than directly applied and the person receiving the reinforcement avoids doing something he or she does not want to do when faced with a fearful event.

B barriers to teaching Those factors that impede the nurse’s ability to deliver educational services. behavioral (learning) objectives Intended out- comes of the education process that are action oriented

656 Glossary

within a cognitive framework to adequately consider someone’s affect as an aspect of conceptual change. cognitive learning One of the five major learning theories. According to a cognitive theorist’s perspec- tive, individuals change as a result of the way they perceive, process, interpret, and organize information based on what is already known; the reorganization of information leads to new insights and understanding. cognitive load Refers to the total amount of men- tal effort being used in working memory. Failure to pace the amount of information provided can over- whelm the learner. cognitive map See cognitive plan. cognitive plan An overall understanding of a skill to be learned. compliance Submission or yielding to predeter- mined goals through regimens prescribed or estab- lished by others. comprehension The degree to which individuals understand what they have read or heard; the ability to grasp the meaning of a verbal or nonverbal message. computer-assisted instruction (CAI) An individ- ualized instructional method of self-study using the technology of the computer to deliver an educational activity. The interactive capability of CAI holds enor- mous potential for reinforcing learning, primarily in the cognitive domain, and its efficacy is dependent on programmatic software, hardware, and the learner’s familiarity with and motivation to use this technology. computer literacy The ability to use the necessary computer hardware and software to meet the needs for information. concept mapping A contemporary nursing edu- cational strategy that can be used to promote moti- vation by enabling the learner to integrate previous learning with newly acquired knowledge through dia- grammatic mapping, which facilitates the acquisition of complex knowledge with visual links. concordance A consultative process that is charac- terized by mutual respect for the client’s and the pro- fessional’s beliefs and that allows for negotiation to take place about the best course of action for the client. concrete experience A term used by Kolb to describe a dimension of perceiving; known as the feeling mode. concrete operations period As defined by Piaget, this is the third stage in the cognitive development of children in middle to late childhood (ages 6 to

style, which must be considered when making appro- priate choices of instructional materials. characteristics of the medium One of the three major variables that refers to the form through which information will be communicated, which must be considered when making appropriate choices of instructional materials. characteristics of the task One of the three ma- jor variables defined by the behavioral objectives in the cognitive, affective, and psychomotor domains of learning, which must be considered when mak- ing appropriate choices of instructional materials. chronic illness A disease or disability that is per- manent and can never be completely cured. It con- stitutes the number one medical malady of people in this country and affects the physical, psychosocial, economic, and spiritual aspects of an individual’s life. cisgender Denoting or relating to a person whose sense of personal identity with respect to gender cor- responds with their birth sex. classical conditioning See respondent conditioning. cloze test A standardized test to measure compre- hension of written materials (particularly recom- mended for health education literature) based on systematically deleting every fifth word from a por- tion of a text and having the reader fill in the blanks. code of ethics An articulation of professional val- ues and moral obligations with regard to the nurse– patient relationship and in support of the mission of the nursing profession. cognitive development A cognitive perspective on learning that focuses on the qualitative changes in per- ceiving, thinking, and reasoning as individuals grow and mature based on how external events are conceptualized, organized, and represented within each person’s mental framework or schema. The process of acquiring more complex and adaptive ways of thinking as an individual grows from infancy to adulthood according to Piaget’s four stages of cognitive maturation: sensorimotor, pre- operational, concrete operations, and formal operations. cognitive domain One of three domains in the tax- onomy of behavioral objectives; deals with aspects of behavior focusing on the way in which someone thinks in acquiring facts, concepts, principles, and other abstract ideas. cognitive-emotional perspective A cognitive the- ory recognizing that emotions must be considered

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cost recovery Monies realized when revenues gen- erated are equal to or greater than expenditures. cost savings Monies realized through decreased use of expensive services, shortened lengths of stay, or fewer complications resulting from preventive ser- vices or patient education. crystallized intelligence The intellectual ability de- veloped over a lifetime, which includes such elements as vocabulary, general information, understanding of social interactions, arithmetic reasoning, and capac- ity to evaluate experiences, all of which tend to in- crease over time as a person ages. cuing Using prompts and reminders to get a learner to perform routine tasks by focusing on an appropri- ate combination of time and situation. cultural assessment An organized, systematic ap- praisal of beliefs, values, and practices of an individ- ual or group to determine client needs as a basis for planning nursing care interventions. cultural awareness The process of becoming sen- sitive to diversity within other cultural groups by ex- amining one’s biases and prejudices toward others of another culture or ethnic background. cultural competence The ability to demonstrate knowledge and understanding of another person’s culture and accept and respect cultural differences by adapting interventions to be congruent with that specific culture when delivering care. cultural distress An emerging paradigm that describes patient reactions to care when nurses do not attend to a person’s cultural needs. cultural diversity Interacting with others who represent different cultures from one’s own culture. cultural encounter The process of exposing one- self in nursing practice to cross-cultural interactions with clients of diverse cultural backgrounds. cultural knowledge The process of acquiring an educational foundation about various cultural worldviews. cultural literacy The ability of knowing how to communicate with someone from another culture without having to explain undertones, voice intona- tions, and message contexts during a conversation. cultural relativism The values and behaviors every human group assigns to its conventions, which arise out of its own historical background and can be ac- curately interpreted and understood only in the light of that group’s cultural worldview.

11 years) who are capable of logical thought pro- cesses and the ability to reason but are still incapa- ble of abstract thinking. confidentiality A binding social contract or cov- enant; a professional obligation to respect privi- leged information between the health professional and the client. conservation The ability to recognize that the prop- erties of an object stay the same even though its ap- pearance and position may change, which is a concept mastered during middle to late childhood. constructivism See social constructivism. consumer informatics A discipline that analyzes consumers’ needs for information, studies and im- plements methods of making information accessible to consumers, and models and integrates consumer preferences into medical information systems. Also referred to as consumer health informatics. content evaluation A systematic assessment tak- ing place immediately after the learning experience to determine the degree to which learners have ac- quired the knowledge or skills taught during a teach- ing–learning session. contextual interference effects Factors that make the initial performance of a motor task more diffi- cult but in actuality make learning more effective. contracting A popular, relatively recent means of fa- cilitating learning through informal or formal agree- ments that delineate and promote learning objectives. converger One of the four learning style types according to Kolb’s theory, combining the learn- ing modes of abstract conceptualization and active experimentation. cooperative learning A highly structured form of group work that focuses on problem solving that leads to deep learning and critical thinking; a methodology of choice for transmitting foundational knowledge. cost benefit Money well spent. Cost of services (e.g., education) ensures return of satisfied clients and sta- bility of the economic base of a healthcare facility. cost–benefit analysis The relationship between cost and outcomes that can be expressed in monetary terms. cost–benefit ratio Relationship (expressed as a ra- tio) of program costs to economic benefits gained by the healthcare institution. cost-effectiveness analysis The efficiency of an educational offering when an actual monetary value cannot be assigned to a program.

658 Glossary

desirable needs Learning needs of the client that are not life dependent but related to well-being and can be met by the overall ability of nursing staff to provide high-quality care. determinants of learning Factors related to learn- ing needs, readiness to learn, and learning styles. developmental disability A disorder that mani- fests itself during the developmental period when a child demonstrates subaverage general intellectual functioning with concurrent deficits in adaptive be- haviors. Sometimes referred to as mental retardation or developmental delay. developmental stages Milestones marking changes in the physical, cognitive, and psychosocial growth of an individual over time from infancy to old age. dialectical thinking The ability to search for com- plex and changing understandings to find a variety of solutions to any given situation (to see the bigger pic- ture), which is characteristic of middle-aged adults. digital divide The gap between those individuals who can access and use information technology re- sources and those who cannot or do not. digital natives Referring to the children and young adults of today who have had lifetime exposure to dig- ital technology that has shaped their way of thinking and processing information. direct costs Tangible, predictable costs associated with expenditures for personnel, equipment, and other resources. disability Inability to perform some key life func- tions; often used interchangeably with the term func- tional limitation. discovery learning A teaching method that pres- ents learners with challenging, yet achievable problems and encourages them to discover their own solutions. discrimination learning The ability to differentiate, with more and varied practice, among similar stimuli. displays Type of demonstration materials, frequently regarded as static, which may be permanently installed or portable. Included in this category are whiteboards, flip charts, and posters. distance education A flexible telecommunications method of instruction using video or computer tech- nology to transmit live, online, or taped messages di- rectly between the instructor and the learner, who are separated from one another by time and/or location. distance learning Techniques as varied as online courses, correspondence courses, independent study

cultural skill The process of learning how to con- duct an accurate cultural assessment. culturally competent model of care A model for conducting a thorough and sensitive cultural assessment that includes the four components of cultural awareness, cultural knowledge, cultural skill, and cultural encounter. culture A complex concept that is an integral part of each person’s life; it includes knowledge, beliefs, values, morals, customs, traditions, and habits ac- quired by the members of a society. cybersecurity The effectiveness of the technol- ogies, processes, and practices designed to protect computer systems from unauthorized use or harm. cycle of poverty See poverty cycle.

D decision aids Includes printed materials, videos, and interactive web-based tutorials that provide cli- ents with information about specific health issues, particular diagnoses, treatment risks and benefits, and questionnaires to determine whether they need more information for decision making. defense mechanisms Mechanisms that are em- ployed to protect the self when an individual’s ego is threatened; short-term use is a way of coming to grips with reality, but long-term reliance allows in- dividuals to avoid reality and may act as a barrier to learning and transfer. delivery system The physical form of instructional materials, including durable equipment used to pres- ent these materials, such as film and projectors, au- diotapes and tape players, and computer programs and computers. demonstration An instructional method by which the learner is shown by the teacher how to perform a particular psychomotor skill. demonstration materials Tools that stimulate the senses by combining sight with touch, smell, and some- times even taste with the advantage of helping to teach cognitive and psychomotor skill development. Major forms of media in this category include many types of nonprint media, such as models, real equipment, di- agrams, charts, posters, displays, photographs, and drawings. deontological The ethical notion of the Golden Rule promulgated by the 16th-century philosopher Kant.

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consists of two interdependent operations, teaching and learning, which form a continuous cycle to in- clude assessment of the learner, establishment of a teaching plan, implementation of teaching methods and tools, and evaluation of the learner, teacher, and education program. educational contracting See learning contract. educational objectives See instructional objectives. edutainment Computer games as educational soft- ware that are disguised in a game format. egocentric causation Children in the early child- hood period attribute the cause of illness to the con- sequences of their own transgressions. egocentricism A characteristic belief of the young child carried through to adolescence that everyone is focusing on them and their activities. e-health literacy The ability to seek, find, under- stand, and appraise health information from elec- tronic sources and apply the knowledge gained to addressing or solving a health problem. e-learning An abbreviation for electronic learn- ing, which professional development and training organizations have capitalized on by using the power of computer technology to provide learning solu- tions for workforce training; it involves the use of technology-based tools and processes to provide for customized learning anytime or anywhere. embedded figures test (EFT) A test designed to measure how a person’s perception of the environ- ment (field independence/ field dependence) is in- fluenced by the context in which it appears. emoticons Symbols commonly used to represent emotions, such as a :) (smiley face) or ;) (winking), by people who are sending e-mail messages. emotional intelligence The ability to manage emo- tions, motivate oneself, read the emotions of others, and work effectively in interpersonal relationships. emotional readiness A state of psychological will- ingness to learn, which is dependent on such factors as anxiety level, support system, motivation, risk-tak- ing behavior, frame of mind, and psychosocial devel- opmental stage. escape conditioning An individual’s response that causes an unpleasant or uncomfortable stimu- lation to cease. ethical A term that refers to the external value system and standards of behavior of healthcare professionals.

course, and videoconferencing to deliver educational programs to students studying at a distance. distributed practice Learning information over successive periods of time, which is much more ef- fective for remembering facts and forging memories than massed practice or cramming, which does not allow for long-term recall of information. diverger One of the four learning style types accord- ing to Kolb’s theory, combining the learning modes of concrete experience and reflective observation. domains of learning Cognitive, psychomotor, and affective are the three domains in which learning occurs. Dunn and Dunn learning style inventory A self-reporting instrument that is used in the iden- tification of how individuals prefer to function, learn, concentrate, and perform in learning activities. duty Comes from the Greek word deon and is an ethical belief system that stresses the importance of professionals following the rules and standards of practice, such as the delivery of good quality care and the demonstration of respect for others, truth telling, honesty, and respect for life. dysarthria Difficulty with voluntary muscle control of speech because of damage to the central or periph- eral nervous system that controls muscles essential to speaking and swallowing. Types of dysarthria in- clude flaccid, spastic, ataxic, hypokinetic, and mixed. Persons with degenerative neurologic diseases often suffer with this disorder. dyscalculia A severe learning disability that im- pairs those parts of the brain involved in mathemat- ical processing. dyslexia A neurodevelopmental learning disorder that is characterized by slow and inaccurate word recognition; affects approximately 10–15% of the U.S. population.

E education An overall umbrella term used to de- scribe the process, including the components of teaching and instruction, of producing observable or measurable behavioral changes (in knowledge, atti- tudes, and/or skills) in the learner through planned educational activities. education process A systematic, sequential, planned course of action that parallels the nursing process and

660 Glossary

external evidence Evidence derived from research that is generalizable beyond a specific study setting or sample. external locus of control An individual’s motiva- tion to learn comes from outside oneself, attributing success or failure of an action to luck, the nature of the task, or the efforts of someone else. extraversion-introversion (E-I) Terms used to describe behavior that reflects an orientation to either the outside world of people or to the inner world of concepts and ideas; one of four dichoto- mous preference dimensions in the Myers–Briggs type indicator. extrinsic (augmented or enhanced) feedback A response provided by the teacher through the sharing of opinion or the conveying of a message via body language about how well a learner has performed; often used in relation to psychomotor skill performance.

F field dependence One of two styles of learning in the cognitive domain identified by Witkin in which a person’s perception of the environment is immersed in and influenced by the surrounding field. field independence One of two styles of learning in the cognitive domain identified by Witkin in which a person’s perception of the environment is separate from the surrounding field. fixed costs Predictable and controllable expenses that remain stable over time. Flesch–Kincaid scale An objective, statistical mea- surement tool for readability of written materials be- tween fifth grade and college level, based on a count of the two basic language elements of average sen- tence length in words of selected samples and of av- erage word length measured as syllables per 100 words of sample. fluid intelligence The intellectual capacity to per- ceive relationships, to reason, and to perform abstract thinking, which declines over time as degenerative changes occur with aging. Fog Index A formula appropriate for use in deter- mining readability of materials from fourth grade to college level based on average sentence length and

ethical dilemma A specific type of moral conflict in which two or more ethical principles apply but sup- port mutually inconsistent courses of action. ethics Guiding principles of human behavior. ethnic group A community or population of peo- ple, also referred to as a subculture, that has experi- ences and shares a common cultural background or descent different from those of the dominant culture. ethnicity A dynamic and complex concept referring to how members of a group perceive themselves and how, in turn, they are perceived by others in relation to the population subgroup’s common heritage of cus- toms, characteristics, language, and history. ethnocentrism The belief that one’s own culture is superior and all other cultures are less sophisticated. ethnomedical A cultural orientation delineating the nature and consequences of illness problems and disease interventions rather than adhering to the bio- medical orientation of defining diseases and illness interventions. In this context, the concept of illness incorporates the relationship of humans with their universe, bridging culture with a sensitivity toward the daily practices inherent within specific ethnic groups. evaluation A systematic and continuous process by which the significance of something is judged; the process of collecting and using information to de- termine what has been accomplished and how well it has been accomplished to guide decision making. evaluation research Scientific inquiry applied to a specific program or activity to determine processes, outcomes, and/or their relationship. evidence-based practice (EBP) The conscientious use of current best evidence in making decisions about client care; most EBP models gather evidence from systematic reviews of clinically relevant, randomized controlled trials upon which to base practice deci- sions, especially about treatment. experiential readiness A state of willingness to learn based on such factors as an individual’s past experiences with learning, cultural background, pre- vious coping mechanisms, locus of control, orienta- tion, and level of aspiration. expressive aphasia An absence or impairment of the ability to communicate through speech or writ- ing caused by a dysfunction in Broca’s area of the brain, which is the center of the cortex that controls motor abilities.

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from pursuing their own interests and achieving their potentials. gender-fair language Language used to reduce gender stereotyping and social discrimination. gender gap The behavioral and biological differ- ences between males and females. gender-related cognitive abilities A comparison among the sexes as to how males and females act, re- act, and perform in situations affecting every sphere of life resulting from genetic and environmental in- fluences on behavior. gender-related personality behaviors The ob- served differences among the sexes in personality and affective behaviors that are thought to be largely determined by culture but to some extent are a result of interaction between environment and heredity. geragogy The art and science of teaching the older adult. gestalt perspective The oldest of psychological the- ories, which emphasizes the importance of percep- tion in learning from a cognitive perspective, with a focus on the configuration or organization of a pat- tern of stimuli rather than of discrete stimuli. It re- flects the maxim that “the whole is greater than the sum of the parts.” global aphasia The most severe form of aphasia that produces deficits in both the ability to speak and the ability to understand language as well as dif- ficulty with reading and writing as a result of exten- sive damage to the left side of the brain. goal A desirable outcome to be achieved by the learner at the end of the teaching–learning process; goals are global and more future oriented and long term in nature than the specific, short-term objectives that lead step by step to the final achievement of a goal. group discussion A commonly employed method of instruction whereby a group of learners (ideally 3 to 20 people) gathers together to exchange information, feel- ings, and opinions with one another and the teacher; the activity is learner centered and subject centered.

H habilitation All activities and interactions that en- able individuals with a disability to develop new abil- ities to achieve their maximum potential.

the percentage of multisyllabic words in a 100-word passage. formal operations period As defined by Piaget, this is the fourth and final stage of cognitive devel- opment in which adolescents (ages 12 to 19 years) and adults are capable of abstract thought, internal- ization of ideas, complex logical reasoning, and un- derstanding causality. formative evaluation It is a systematic and con- tinuous assessment of success of the teaching pro- cess made during the implementation of materials, methods, and activities to control, ensure, or improve the quality of performance in delivery of an educa- tional program. Also referred to as process evaluation. Fourth Industrial Revolution An era characterized by a fusion of technologies that are blurring the lines between the physical, digital, and biological spheres. Fry readability graph A measurement tool for testing the readability of materials (especially books, pamphlets, and brochures) at the level of first grade through college by using a graph to plot the number of syllables of words and the number of sentences in three 100-word samples. functional illiteracy The lack of fundamental ed- ucation skills needed by adults to read, write, or comprehend information to function effectively in today’s society; the inability to read well enough to understand and interpret written information for use as intended. functional magnetic resonance imaging (fMRI) A type of advanced technology that has revolution- ized the field of neuroscience by making colorful im- ages of the brain on computer monitors to determine the possible areas of nerve activity involved in the pro- cesses of thinking, emotions, and recall.

G gaming An instructional method requiring the learner to participate in a competitive activity (which may or may not reflect reality) with preset rules. Gardner’s eight types of intelligence A theory that describes the styles of learning in children. gender bias A preconceived notion about the abil- ities of women and men that prevents individuals

662 Glossary

ideology Thoughts, attitudes, and beliefs that re- flect the social needs and desires of an individual or ethnocultural group. illiterate The total inability of an adult to read, write, or comprehend information or whose reading and writing skills are at or below the fourth-grade level. illusionary representations A category of instruc- tional materials that depict two-dimensional realism. Examples are photographs, drawings, and audiotapes, which depend on imagination to fill in the gaps and offer the learner experiences that simulate reality. iloralacy The inability to understand simple oral language. imaginary audience A type of social thinking that explains the pervasive self-consciousness of adoles- cents who may feel embarrassed because they believe everyone is looking at them, which has considerable influence over their behavior. impact evaluation The process of assessing out- comes or effects of an educational activity that extend beyond the activity itself to address organizational and/or societal effects. indirect costs Costs that may be fixed but are not necessarily directly related to an educational activity (e.g., heating, electricity, housekeeping). informatics See consumer informatics. Information Age An era in which sweeping advances in computer and information technology transformed the economic, social, and cultural life of society. information literacy The ability to access, evaluate, organize, and use information from a variety of sources. information processing A cognitive perspec- tive that emphasizes thinking processes: includes thought, reasoning, the way information is encoun- tered and stored, memory functioning, and infor- mation retrieval. input disabilities A general category of learning disability that refers to the process of receiving and recording information in the brain, which includes visual, auditory, perceptual, and integrative process- ing. Examples are dyslexia and short- and long-term memory disorders. instruction The communicating of information about a specific skill in the cognitive, affective, or psychomotor domain with the objective of producing learning; often used interchangeably with teaching.

health belief model A framework or paradigm used to explain or predict health behavior composed of the interaction between individual perceptions, modify- ing factors, and likelihood of action. health literacy How well an individual can read, interpret, and comprehend health information for maintaining an optimal level of wellness. health promotion model A framework that de- scribes the interaction of health-promoting factors in- cluding cognitive perceptual factors, modifying factors, and likelihood of participation in health-promoting behaviors. healthcare-related setting One of three classifications of instructional settings, in which healthcare-related services are offered as a complementary function of a quasihealth agency. Some examples are American Heart Association, American Cancer Society, Muscular Dys- trophy Association, and Leukemia Society of America. healthcare setting One of three classifications of instructional settings, in which the delivery of health care is the primary or sole function of an institution, organization, or agency. Examples: hospitals, visit- ing nurse associations, public health departments, outpatient clinics, physician offices, health main- tenance organizations, extended-care facilities, and nurse-managed centers. hearing impairment A complete loss or a reduc- tion in sensitivity to sounds by persons who are deaf or hard of hearing. hidden costs Costs that cannot be predicted or ac- counted for until after the fact. hierarchy of needs Theory of human motivation based on integrated wholeness of the individual and levels of satisfaction of basic human needs orga- nized by potency. humanistic learning One of the five major learn- ing theories, which views learning as being facilitated by curiosity, needs, a positive self-concept, and open situations where freedom of choice and individuality are promoted and respected.

I identity-first language The practice of placing the disability-related word first when describing a per- son with a disability.

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J judging-perceiving (J-P) Terms used to describe behavior that reflects the way a person comes to a conclusion about something or becomes aware of something; one of four dichotomous preference di- mensions in the Myers–Briggs type indicator. justice The equal distribution of benefits and burdens.

K knowledge deficit A gap in what a learner needs or wants to know; this category of nursing diagno- sis can include learning needs in the cognitive, affec- tive, and psychomotor domains. knowledge readiness A state of willingness to learn dependent on such factors as the learner’s pres- ent knowledge base, the level of learning capability, and the preferred style of learning. Kolb’s learning style inventory An experiential learning model that includes four modes of learning reflecting the dimensions of perception and processing.

L LAD (Literacy Assessment for Diabetes) A reading skills test to measure word recognition in adult patients with diabetes. This standardized test, modeled after the REALM test, consists of lists of common words used when teaching self-care man- agement of diabetes. learner characteristics See characteristics of the learner. learning A conscious or unconscious permanent change in behavior as a result of a lifelong, dynamic process by which individuals acquire new knowledge, skills, and/or attitudes that can be measured and can occur at any time or in any place through exposure to environmental stimuli. learning contract A mutually agreed-on specific plan of action between the learner and the educator clearly defining the specific behavioral objectives and predetermined goal to be achieved as a result of in- struction. Also referred to as an educational contract.

instructional materials (tools) The resources or vehicles used to help communicate information, which include both print and nonprint media, to aid teach- ing and learning by stimulating the various senses, such as vision and hearing. These are intended to supplement, not replace, actual teaching. Synony- mous terms are educational aids and audiovisual materials. instructional objectives Intended outcomes of the education process that are in reference to an aspect of a program or a total program of study that are con- tent oriented and teacher centered. Also referred to as educational objectives. instructional setting A situation or area in which health teaching takes place as classified on what re- lationship health education has to the primary func- tion of an organization, agency, or institution in which the teaching occurs. instructional strategy See teaching strategy. intellectual disability A condition that originates before the age of 18 and results in impaired reason- ing, learning, problem solving, and adaptive behavior. internal evidence Evidence that is not generated from research but is appropriate for use when, for example, it is derived from a systematically con- ducted evaluation. internal locus of control Individuals are motivated from within to learn, attributing success or failure to their own ability or effort. Internet A huge global computer network, of which the World Wide Web is a component, established to allow transfer (exchange) of information from one computer to another; it provides a diverse range of services used to deliver information to large num- bers of people and to enable people to communicate with one another, such as via e-mail, real-time chat, or electronic discussion groups. interpersonal intelligence A term used by Gard- ner to describe children who learn best in groups. intrapersonal intelligence A term used by Gard- ner to describe children who learn well with inde- pendent, self-paced instruction. intrinsic (inherent) feedback A response that is generated within the self, giving learners a sense of or a feel for how they have performed; often used in relation to a psychomotor skill performance.

664 Glossary

LISTSERV An automated mailing list software pro- gram that copies messages and distributes them to all subscribers. literacy The ability of adults to read, understand, and interpret information written at the eighth-grade level or higher. An umbrella term used to describe so- cially required and expected reading and writing abil- ities; the relative ability of persons to use printed and written material commonly encountered in daily life. literate The ability to write and to read, understand, and interpret information written at the eighth-grade level or higher. locus of control The location of control of behav- iors as either self-directed or directed by others. Per- sons with internal or external locus of control differ particularly in the degree of responsibility taken for their own actions. logical-mathematical intelligence A term used by Gardner to describe children who are strong in explor- ing patterns, categories, and relationships of objects. low literacy The ability of adults to read, write, and comprehend information between the fifth- and the eighth-grade level of difficulty. Also referred to as marginally literate or marginally illiterate.

M m-learning Mobile learning; a new strategy that takes advantage of the many wireless, portable, and handheld devices, such as MP3 players, that can ac- cess course materials, search the Web, listen to lec- tures, and record experiences and assignments. malpractice Failure to exercise an accepted degree of professional skill or knowledge by one rendering professional services that results in injury, loss, or damage to the recipient of those services. mandatory needs Requisites to be learned for sur- vival or situations where the learner’s life or safety is threatened. marginally literate A term to describe a person with low literacy skills; also known as marginally illiterate. massed practice Learning information all at once, which is much less effective for remembering facts than learning information over successive periods of time; similar to cramming.

learning curve A record of an individual’s improve- ment in psychomotor skill development made by mea- suring his or her ability at different stages during a specified time period, which includes six stages: neg- ligible progress, increasing gains, decreasing gains, plateau, renewed gains, and approach to limit. Also referred to as the experience curve. learning disability (LD) A generic term that refers to a heterogeneous group of disorders manifested by significant difficulties with learning. Inattention and impulsivity are signs indicating developmentally in- appropriate behavior. learning needs Gaps in knowledge that exist between a desired level of performance and the actual level of performance; what the learner needs or wants to know. learning styles The manner by which (how) indi- viduals perceive and then process information. Cer- tain characteristics of style are biological in origin, whereas others are sociologically developed as a re- sult of environmental influences. learning theory A coherent framework and set of integrated constructs and principles that describe, explain, or predict how people learn. lecture The oldest, most commonly used, and most traditional instructional method by which the teacher verbally transmits information in a highly structured format directly to a group of learners. left-brain thinking The left hemisphere of the brain is vocal and analytical, which is used for verbalization and reality-based, logical thinking according to Sperry. legal rights and duties Rules governing behavior or conduct that are enforceable by law under threat of punishment or penalty, such as a fine, imprison- ment, or both. legally blind A person’s vision is 20/200 or less in the better eye with correction or visual field limits in both eyes are within 20 degrees diameter. linguistic intelligence A term used by Gardner to describe children who have highly developed audi- tory skills and think in words. listening test A standardized test to measure com- prehension using a selected passage from instruc- tional material written at approximately the fifth-grade level that is read aloud at a normal rate to deter- mine what a person understands and remembers when listening.

Glossary 665

flexible, client-centered approach that is supportive, empathetic, and goal directed. motor learning A set of processes associated with practice or experience leading to relatively perma- nent changes in the capability for movement. motor performance Acquisition of a motor skill but not necessarily retention of that skill. multimedia learning The use of two or more types of learning modes (e.g., audio, visual, or animation) that can be accessed via a computer to engage the learner in the content. musical intelligence A term used by Gardner to describe children who are talented in playing musical instruments, singing, dancing, and keeping rhythm and who often learn best with music playing in the background. Myers–Briggs type indicator (MBTI) A self-report inventory that uses forced-choice questions and word pairs to measure four dichotomous dimensions of behavior.

N needs assessment The process of determining through data collection what a person, group, orga- nization, or community must learn or wants to learn to provide appropriate education programs to meet the required or desired needs of the learners. negligence Doing or nondoing of an act, pursu- ant to a duty, that a reasonable person in the same circumstances would or would not do; the acting or the nonacting is the proximate cause of injury to an- other person or property. neuropsychology The scientific study of psycho- logical behavior based on neurological assessments of the brain and central nervous system. nonadherence Failure of the patient to follow treat- ment recommendations that are mutually agreed upon. noncompliance Nonsubmission or resistance of the individual to follow a prescribed, predetermined regimen. nonhealthcare setting One of three classifica- tions of instructional settings in which health care is an incidental or supportive function of an organiza- tion, such as a business, industry, and school system.

media characteristics See characteristics of the medium. medicalese The vocabulary of medicine. mental imaging See mental practice. mental practice Imagining or visualizing a skill without body movement that can have positive ef- fects on the performance of the skill. Motor skill ac- quisition is enhanced when mental practice is used together with physical practice. metacognition A person’s understanding of his/ her way of learning. A concept related to cognitive learning theory. mnemonic devices Memory tricks and techniques to help a person improve their ability to remember something. Such devices can be in the form of a song, rhyme, acronym, image, or phrase. mobile technology Electronic equipment such as smartphones, media players, electronic readers, cloud-based digital assistants, and other computer-driven devices that can be used in different places. models Three-dimensional instructional tools that al- low the learner to immediately apply knowledge and psychomotor skills by observing, examining, manipu- lating, handling, assembling, and disassembling objects while the teacher provides feedback. Replicas, analogues, and symbols are all types of models that enhance in- struction by means that range from concrete to abstract. moral values A term that refers to an internal value system, a certain moral fabric, that is expressed ex- ternally in ethical behaviors of healthcare profes- sionals; often used interchangeably with the terms morality and morals. motivation A psychological force that moves a person to take action in the direction of meeting a need or goal, evidenced by willingness or readiness to act. motivational axioms Premises on which an under- standing of motivation is based, such as a state of op- timal anxiety, learner readiness, realistic goal setting, learner satisfaction/success, and uncertainty-reducing or uncertainty-maintaining dialogue. motivational incentives Factors that influence mo- tivation in the direction of the desired goal. motivational interviewing (MI) A method of stag- ing readiness to change for the purpose of promoting desired health behaviors, which is an individualized,

666 Glossary

teacher delivers individual verbal instruction of learn- ing activities in a format designed specifically to meet the needs of a particular learner. operant conditioning Conditioning that focuses on the behavior of an organism as a result of a posi- tive or negative reinforcer (stimulus or event) applied after a response that strengthens the probability that the response will be performed again; nonreinforce- ment and punishment decrease the likelihood that a response will continue to be performed. oral literacy The ability to comprehend the spo- ken word. outcome The result of actions that may be intended or unintended; synonymous with stated goals. outcome evaluation See summative evaluation. output disabilities A general category of learning disability that refers to orally responding and per- forming physical tasks, which include language and motor disorders.

P pacing The speed at which information is pre- sented to a learner. patient education A process of assisting consumers of health care to learn how to incorporate health-related behaviors (knowledge, skills, and/or attitudes) into everyday life with the purpose of achieving the goal of optimal health. Pavlovian conditioning See respondent conditioning. pedagogy The art and science of helping chil- dren to learn. people-first language The practice of putting the person first before the disability in writing and speaking to describe what a person has, not what a person is (e.g., a person with diabetes, not a dia- betic person). personal fable A type of social thinking that leads adolescents to believe that they are invulnerable or invincible, which can result in them engaging in risk-taking behavior. physical readiness A state of willingness to learn that is dependent on such factors as measures of phys- ical ability, complexity of task, health status, gender, and environmental effects.

nonmaleficence The notion of doing no harm. nonprint instructional materials The full range of audio and visual instructional materials, includ- ing demonstrations and displays. numeracy The ability to read and interpret numbers. nurse–client negotiations model A model devel- oped for cultural assessment and planning for care of culturally diverse people that recognizes discrepancies existing between notions of the nurse and client about health, illness, and treatments. This model is used to bridge the gap between the scientific perspectives of the nurse and the cultural perspectives of the client. nurse practice acts Legal provisions of each state defining nursing and the standards of nursing prac- tice, including patient teaching as a professional re- sponsibility to protect the public from incompetent practitioners. nursing process A model for nursing practice us- ing the problem-solving approach, which includes the phases of assessment, nursing diagnosis, plan- ning, implementation, and evaluation of patient care that parallels the educational process.

O OARS A mnemonic to describe specific strategies in motivational interviewing (Open-ended ques- tioning, Affirmation of the positives, Reflective lis- tening, and Summaries of the interaction) that can be used by the nurse to build motivation to change in patients in the early phases of treatment and con- tinuing throughout treatment. object permanence Toward the end of the second year of life, the stage in which a child realizes that ob- jects and events exist even when they cannot be seen, heard, or touched. objective A specific, single, unidimensional behavior that is short term in nature, which should be achiev- able after one teaching session or within a matter of a few days following a series of teaching sessions. obstacles to learning Those factors that negatively affect the ability of the learner to attend to and pro- cess information. one-to-one instruction A common instructional method for exchange of information whereby the

Glossary 667

preoperational period As defined by Piaget, this is the second key milestone in the cognitive develop- ment of children when in the early childhood stage (3–5 years) they are acquiring language skills and gaining experience but thinking is precausal, ani- mistic, egocentric, and intuitive, with only a vague understanding of relationships and multiple classi- fications of objects. presentation The form in which the message (con- tent) is put forth, occurring along a continuum from real objects to symbols. primary characteristics of culture Factors that influence an individual’s identification with an eth- nic group and that cause the individual to share a group’s worldview, such as nationality, race, color, gender, age, and religious affiliation. printed education materials (PEMs) As the most common type of teaching tools, these include hand- outs, leaflets, books, pamphlets, brochures, and instruction sheets, which may be purchased or in- structor developed. process evaluation See formative evaluation. Prochaska’s change model See stages of change model. productivity environmental preference survey (PEPS) The assessment tool used in the adult ver- sion of the Dunn and Dunn learning style inventory. program evaluation A systematic assessment to de- termine the extent to which all activities for an entire department or program over a specified time period have accomplished the goals originally established. programmed instruction A type of self-study tool, usually printed or computerized, that takes the learner through the learning task step by step. projected learning resources Audiovisual instruc- tional formats that depend primarily on the learners’ sense of sight as the means through which messages are received. These resources require equipment to project images, usually in a darkened room, and in- clude movies, PowerPoint slides, overhead transpar- encies, and others. propositional reasoning The ability to think ab- stractly and use complex logical reasoning, which be- gins in the adolescent stage of development. protection motivation theory A linear motiva- tional theory that explains behavioral change in terms of threat and coping appraisal, which leads to intent and ultimately to action.

plasticity The ability of the brain to change with learning and experience. pooled ignorance Lack of knowledge or informa- tion about issues or problems during a group discus- sion session, whereby clients cannot adequately learn from one another if they do not possess a basic, accu- rate understanding of a subject to draw on for pur- poses of discourse. positron emission tomography (PET) A type of technology that has revolutionized the field of neu- roscience by making images of the brain to detect which possible areas of the brain are used for think- ing, feeling, and remembering. possible needs Nice-to-know information that is not essential at a given point in time or in situations in which learning is not directly related to daily activities. postformal operations period The ability to learn during middle adulthood that goes beyond Piaget’s last stage of cognitive development (formal opera- tions) to include searching for complex and chang- ing understandings to find a variety of solutions to any given situation or problem; to be able to see the bigger picture. poverty cycle A process whereby parents who are of low income and educational level produce chil- dren of low income and educational attainment, who grow up and repeat the process with their own chil- dren; a situation in which generation after generation are born into poverty owing to many factors, such as poor health care, limited resources, family stress, and low-paying jobs. Also known as the cycle of poverty or the poverty circle. practice acts Documents that define a profession, describe that profession’s scope of practice, pro- vide guidelines for state professional boards regard- ing entry into a profession via licensure, and outline disciplinary actions that protect the public from un- qualified practitioners. practice-based evidence Evidence derived from practice rather than from research, such as the re- sults of a systematically conducted evaluation, cli- ents’ responses to care delivered based on clinical expertise, or a systematically conducted quality im- provement project. precausal thinking Unawareness by children in early childhood (3 to 5 years of age) of causation by invisible and mechanical forces.

668 Glossary

participate in the learning process; preparedness or willingness to learn. reading The process of transforming letters into words and being able to pronounce them correctly; also known as word recognition. READS A mnemonic to help the nurse remember the five general principles of motivational interviewing (roll with resistance, express empathy, avoid argumen- tation, develop discrepancy, and support self-efficacy. realia The most concrete form of stimuli that can be used to deliver information. Example: a real per- son or a model being used to demonstrate a proce- dure such as breast self-examination. REALM (rapid estimate of adult literacy in medicine) A reading skills test to measure a client’s ability to read medical and health-related vocabulary. receptive aphasia An absence or impairment of the ability to comprehend what is read or heard be- cause of a dysfunction in Wernicke’s area of the brain, which controls sensory abilities. Although hearing is unimpaired, the person is unable to understand the significance of the spoken word and is unable to com- municate verbally. reflection-in-action Occurs when the nurse in- trospectively considers a practice activity while per- forming it so that change for improvement can be made at that moment. reflection-on-action Occurs when the nurse intro- spectively analyzes a practice activity after its com- pletion so as to gain insights for the future. reflective observation A term used by Kolb to describe a dimension of perceiving; known as the watching mode. reflective practice A notion of evaluation that in- cludes reflection-in-action (formative evaluation) and reflection-on-action (summative evaluation). rehabilitation The relearning of previous skills, which often requires an adjustment to altered func- tional abilities and altered lifestyle. religiosity An individual’s adherence to beliefs and ritualistic practices associated with religious institutions. repetition A technique that strengthens learning by aiding in retention of new or difficult material through reinforcement of important points. replica A facsimile constructed to scale that resem- bles the features or substance of the original object. It may be examined or manipulated by the learner

psychodynamic learning One of the five major learning theories. Largely a theory of motivation stress- ing emotions rather than cognition and responses, this perspective emphasizes the importance of con- scious and unconscious forces derived from earlier childhood experiences and conflicts that guide and change behavior. psychomotor domain One of three domains in the taxonomy of behavioral objectives, which is con- cerned with the physical activities of the body, such as coordination, reaction time, and muscular control, related to the acquisition of a skill or task. psychosocial development The process of psycho- logical and social adjustment as an individual grows from infancy to adulthood according to Erikson’s eight stages of the psychological and social maturation of humans: trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus in- feriority, identity versus role confusion, intimacy ver- sus isolation, generativity versus self-absorption and stagnation, and ego integrity versus despair. Purnell model for cultural competence A popular organizing framework for understanding the complex phenomenon of culture and ethnicity that provides a comprehensive, systematic, and concise approach to assist healthcare providers in delivering holistic, culturally competent, and therapeutic interventions.

R reachable moment A unique opportunity de- scribed by Beddoe when nurses provide emotional support to clients; the time when a nurse truly con- nects with clients by directly meeting them on mutual terms without the nurse being inhibited by prejudice or bias, setting the stage for the teachable moment. readability The level of reading difficulty at which printed teaching tools are written. A measure of those elements in a text of printed material that influence with what degree of success a group of readers will be able to read and understand the information; the ease—or, conversely, the difficulty—with which a person can understand or comprehend the style of writing of a selected printed passage. readiness to learn The time when the learner is receptive to learning and is willing and able to

Glossary 669

secondary characteristics of culture Factors that influence an individual’s identification with an ethnic group and that cause the individual to share a group’s worldview, such as socioeconomic status, physical characteristics, educational status, occupa- tional status, and place of residence. selective attention The process of recognizing and selecting appropriate or inappropriate stimuli. self-efficacy theory A framework that describes the belief that an individual is able to accomplish a specific behavior. self-instruction A method of instruction used by a teacher to provide or design teaching materials and activities that guide the learner in independently achieving the objectives of learning. self-regulation The process of monitoring one’s own cognitive processes, emotions, and surround- ings to achieve goals. seminars An educational format that consists of one or more sessions in which a group of learners, facili- tated by an educator, actively participates in discuss- ing questions and issues that emerge from assigned readings on a topic of practical relevance. sensing-intuition (S-N) Describes how individ- uals perceive the world, either directly through the five senses or indirectly by way of the unconscious; one of four dichotomous preference dimensions in the Myers–Briggs type indicator. sensorimotor period As defined by Piaget, this is the first key milestone in the cognitive development of children in the age group of infancy to toddlerhood when learning is enhanced through movement and manipulation of objects in the environment via visual, auditory, tactile, olfactory, taste, and motor stimulation. sensory disabilities A category of physical disabil- ities that commonly includes, in particular, hearing and visual impairments but also can involve partial or total loss of tactile, olfactory, and/or gustatory senses. settings for teaching Any place where nurse educa- tors engage in teaching for disease prevention, health promotion, and health maintenance and rehabilitation. silent epidemic A term used to describe the liter- acy problem in the United States; also known as the silent barrier or silent disability. simulation A method of instruction whereby an artificial or hypothetical experience that engages the learner in an activity reflecting real-life conditions,

to get an idea of how something works. Example: re- suscitation dolls. resistance What people oppose talking about or learning, which is an indicator of underlying emo- tional difficulties that must be dealt with for them to move ahead emotionally and behaviorally. respondeat superior A legal term referring to the master–servant rule: “let the master respond and answer.” respondent conditioning Emphasizes the impor- tance of stimulus conditions and the associations formed in the learning process, whereby, without thought or awareness, learning takes place when a newly conditioned stimulus becomes associated with a conditioned response; also termed classical or Pav- lovian conditioning. return demonstration An instructional method by which the learner attempts to perform a psychomotor skill, with cues or prompting as needed from the teacher. revenue generation Income realized over and above costs; also called profit. right-brain thinking The right hemisphere of the brain is emotional, visual-spatial, and nonverbal, in which thinking is intuitive, subjective, relational, ho- listic, and time free, according to Sperry. role model The use of self as a role model, often overlooked as an instructional method, whereby the learner acquires new behaviors and social roles by identification with the role model. role play A method of instruction by which learn- ers participate in an unrehearsed dramatization, act- ing out an assigned part of a character as they think the character in reality would act.

S SAM (suitability assessment of materials) An evaluation instrument designed to measure the ap- propriateness of print materials, illustrations, and video- and audiotaped instructions for a given cli- ent population. scaffolding An incremental approach to sequenc- ing discrete steps of a procedure by slowing down the pace of performance, exaggerating some of the steps, or breaking lengthy procedures into a series of shorter steps.

670 Glossary

spirituality A belief in a higher power, a sacred force that exists in all things. spontaneous recovery A response that appears to be extinguished but reappears at any time (even years later), especially when stimulus conditions are similar to those in the initial learning experience. staff education A process of assisting nursing staff personnel to acquire knowledge, skills, or attitudes in nursing practice to maintain or improve their ability to deliver high-quality care to the consumer. stages of change model A model developed by Prochaska that explains the phenomenon of health behaviors of the learner, particularly applied to ad- dictive and problem behaviors; it includes six distinct stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. stereotype threat A negative impression associated with an individual’s status that triggers physiological and psychological behaviors in patients as well as in providers and may contribute to healthcare disparities. stereotyping An oversimplified conception, opinion, or belief about some aspect of an individual or group. stimulus generalization The tendency of initial learning experiences to be easily applied to other similar stimuli. subculture An ethnocultural group of people who have experiences different from those of the dominant culture. subobjective A specific statement of a short-term behavior that is written to reflect an aspect of the main objective leading to the achievement of the primary objective. suitability assessment of materials See SAM. summative evaluation Systematic assessment of the degree to which individuals have learned or ob- jectives have been met as a result of education in- tervention. Also referred to as outcome evaluation. syllogistic reasoning The ability to consider two premises and draw a logical conclusion from them, which is a cognitive skill developed in middle to late childhood. symbol A type of model that conveys a message to the learner using abstract constructs, such as words and numbers, that stand for the real thing. Cartoons, graphs, and printed materials are examples of sym- bolic forms of a message. symbolic representations Numbers and words; sym- bols written and spoken to convey ideas or represent

but without the risk-taking consequences of an ac- tual situation, is created. situated cognition A theory that describes know- ing as inseparable from doing. Knowledge cannot be separated from the context and is situated in activ- ity related to social, cultural, and physical contexts. Learning is measured by an individual’s effective per- formance across situations instead of just in terms of conceptual knowledge acquired. The way individuals interact with their environment broadens and trans- forms their thinking. situational poverty Circumstances whereby pov- erty leads to poor health or poor health traps a per- son in poverty. Poverty is considered both a cause and a consequence of poor health. skill inoculation The opportunity for repeated prac- tice of a behavioral task. SMOG formula A relatively easy-to-use, popular, valid test of readability based on a set number of sentences and polysyllabic words in printed mate- rial from grade four to college level. social cognition An increasingly popular perspective within cognitive theory that highlights the influence of social factors on perception, thought, motivation, and behaviors. social constructivism An increasingly popular per- spective within cognitive theory proposing that in- dividuals formulate or construct their own versions of reality and that learning and human development are richly colored by the social and cultural context in which people find themselves. social learning One of five major learning theories, this theory is a mixture of behaviorist, cognitive, and psychodynamic influences; much of learning is a so- cial process that occurs by observation and watching other people’s behavior to see what happens to them. Role modeling is a central concept of this theory, with cognitive or psychodynamic aspects of internal pro- cessing and motivation sometimes considered in the learning process. social media Online communication tools, such as blogs, wikis, Twitter, and Facebook. socioeconomic status (SES) Variation in health status, health behavior, or learning abilities among individuals of different social and economic levels. spatial intelligence A term used by Gardner to describe children who learn by images and pictures.

Glossary 671

resources of the learning experience to achieve spe- cific behavioral objectives. teaching plan Overall blueprint or outline for in- struction, clearly defining the relationship between the essential components of behavioral objectives, instructional content, teaching methods and tools, time frame for teaching, and methods of evaluation that fit together in a logical pattern of flow to achieve a predetermined goal. teaching strategy An overall plan of action for in- struction that anticipates barriers and resources of the learning experience to achieve specific behav- ioral objectives. team-based learning Uses a structured combina- tion of preclass preparation, individual and group readiness assurance tests, and application exercises. telecommunications Technological devices for the deaf (TDD). teleological The ethical notion purported by Mill that, given the alternatives, choices should be made that result in the greatest good for the greatest num- ber of people. telepractice The provision of nursing, medical, and other types of technology-facilitated healthcare ser- vices to clients at a distance. theory of planned behavior (TPB) A new learn- ing theory model developed by Ajzen that added a third element (the concept of perceived behavioral control) to his original theory of reasoned action. theory of reasoned action (TRA) A framework that is concerned with predicting and understanding of human behavior within a social context. therapeutic alliance model An interpersonal pro- vider–client model that addresses the continuum of compliance, adherence, and collaboration in thera- peutic relationships. therapeutic relationship A principle of human- istic theory that emphasizes the healing nature of a relationship between health professionals and their clients. thinking-feeling (T-F) An approach used by individ- uals to arrive at judgments through impersonal, log- ical, subjective, or empathetic processes; one of four dichotomous preference dimensions in the Myers– Briggs type inventory. TOFHLA (Test of Functional Health Literacy in Adults) A relatively new instrument for measur- ing patients’ literacy level by using actual hospital

objects, which are the most common form of commu- nication and yet the most abstract types of messages. systematic desensitization A technique based on respondent conditioning that is used by psycholo- gists to reduce fear or anxiety by unlearning or ex- tinguishing it through teaching relaxation techniques or introducing a fear-producing stimulus at a non- threatening level.

T tailored instruction Personalizing the message so that the content, structure, and image fit an individ- ual client’s learning needs. task characteristics See characteristics of the task. taxonomic hierarchy See taxonomy. taxonomy A form of hierarchical classification of cognitive, affective, and psychomotor domains of be- haviors according to their degree or level of complexity. teach back approach A way of assessing how well and how much the patient and/or their family mem- bers understood the information given to them; ask- ing patients to explain in their own words what they have been taught to determine if there are any gaps in their interpretation and remembering of informa- tion provided; repeating back to the nurse or other healthcare provider the essential points that have been taught is a way to be sure that the content has been learned; also known as tell back or show me. teachable moment As defined by Havighurst, that point in time when the learner is most receptive to a teaching situation; it can occur at any time that a pa- tient, family member, staff member, or nursing stu- dent has a question or needs information. teaching One component of the educational process; a deliberate, intentional act of communicating infor- mation to the learner in response to identified learn- ing needs, with the objective of producing learning to achieve desired behavioral outcomes. Also com- monly referred to as instruction. teaching method The way information is taught that brings the learner into contact with what is to be learned; a technique or approach used by the teacher to communicate and share information with the learner. Examples include lecture, group discus- sion, and one-to-one instruction. It is an overall plan of action for instruction that anticipates barriers and

672 Glossary

VARK learning style A model that describes four categories or preferences—visual, aural, read/ write, and kinesthetic—that reflect learning style experiences. veracity Truth telling; honesty. vicarious reinforcement A concept from social learning theory that involves determining whether role models are perceived as rewarded or punished for their behavior. visual impairment A reduction or complete loss of vision resulting from infection, accident, poison- ing, aging, or congenital degeneration of the eye(s).

W webcasts Live broadcasts over the Internet that per- mit audio and/or video to be transmitted to partici- pants in multiple locations. webinars Web conferencing with usually two com- ponents: a computer-based display, such as a Power- Point presentation, and a live discussion that allows for interaction via telephone or computer. whole-brain thinking When learners are able to use both brain hemispheres in developing their thought processes; a duality of thinking. wiki A new form of online communication. Unlike blogs, wikis are more social in their construction in that multiple users come together to collaboratively write the content of a collection of webpages that us- ers can add to, edit, and remove content. Wikipedia is one of the best-known wikis. worldview The way individuals or groups of people look at the universe to form values and beliefs about their lives and the world around them. World Wide Web A computer network of infor- mation servers around the world that are connected to the Internet; a technology-based educational re- source that was created as a virtual space for the dis- play of information. WRAT (Wide Range Achievement Test) A word recognition screening test used to assess a person’s ability to recognize and pronounce a list of words out of context as a criterion for measuring comprehen- sion of written materials. The level I test is designed for children ages 5–12 years; level II is intended to test persons over 12 years of age.

materials, such as prescription labels, appointment slips, and informed consent documents, to determine their reading and numeracy skills. tools See instructional materials. total program evaluation Within the framework of the Roberta Straessle Abruzzese (RSA) model, the purpose is to determine the extent to which all activities for an entire department or program over a specified period of time meet or exceed the goals originally established. transcultural Making comparisons for similarities and differences between cultures. transcultural nursing A formal area of study and practice comparing and analyzing different cul- tures and subcultures with respect to cultural care, health practices, and illness beliefs with the goal of using these insights to provide culture-specific and culture-universal care to diverse groups of people. transfer of learning The effects of learning one skill on the subsequent performance of another related skill; includes self-transfer, near transfer, and far transfer. transference A process in which individuals proj- ect their feelings, conflicts, and reactions, especially those developed during childhood, onto authority figures and others in their lives. triad communication A technique of involving a third person, such as a family member, significant other, or caregiver, in the communication pattern of the nurse and the client to serve as a listener and learner in the teaching situation that assists the cli- ent in understanding content, encouraging family or caregiver involvement and support, and enhancing client compliance with treatment regimens.

U unlearning Extinguishing a previously learned re- sponse. For the older adult, learning a new way of doing things is often more difficult because it upsets established habits and contradicts existing beliefs (cog- nitive schemas) that they have embraced for years.

V variable costs Not predictable, volume-related expenses.

Glossary 673

4MAT system, 154–156 instrument to measure, 156 McCarthy’s 4MAT system, 155f Type 1/Imaginative, 154 Type 2/Analytical, 154 Type 3/Common sense, 155 Type 4/Dynamic, 155

A AAC. See augmentative and

alternative communication AACN. See American Association of

Colleges of Nursing Abruzzese’s evaluation model. See

Roberta Straessle Abruzzese abstract conceptualization

(AC mode), 152 abstractness vs. concreteness

(AC–CE), 154 AC mode. See abstract

conceptualization ACA. See Affordable Care Act AC–CE. See abstractness vs.

concreteness accommodator learning mode,

152–153 acculturation, 331t achievement orientation, 324 ACME. See audience–channel–

message–evaluation ACOR. See Association of Cancer

Online Resources, Inc. action, 241 action vs. reflection (AE–RO), 157 active experimentation

(AE mode), 152 ADA. See Americans with

Disabilities Act ADHD. See attention-deficit/

hyperactivity disorder

adherence of learner, 221–225 Adobe Flash, 534 adolescence (12–19 years of age),

188–192 adult client population literacy,

257–306 assessment, clues to look for,

274–275 cloze procedure, 285 comprehension, 264 computerized readability

software programs, 284 cultural diversity, 272 definition of terms, 262–266 easy-to-read written materials, 297 e-health, 266 eHealth Literacy Scale

(eHEALS), 288 ethical, financial, and legal

concerns, 277–279 Flesch–Kincaid scale, 283 Fog, 283 Fog index, 283 fry readability graph,

extended, 283 general reading skills, tests to

measure, 286–289 health literacy skills of clients,

tests to measure, 286–289 illiteracy impact on motivation

and compliance, 275–277 informatics, 266 landmark initiatives, 261t listening test, 285–286 Literacy Assessment for Diabetes

(LAD), 288 literacy levels test, measurement

tools, 281–282 literacy problems, trends

associated with, 269–270 literacy relative to computer

instruction, 265–266

literacy relative to oral instruction, 265

low-literacy materials for clients, sources of, 281t

myths, stereotypes, and assumptions, 272–274

Newest Vital Sign (NVS), 288 online resources, 268t printed education materials

comprehension, tests to measure, 284–286

readability, 279–281 simplifying, 289–297

Rapid Estimate of Adult Literacy in Medicine (REALM), 286–287

readability of PEMs, formulas to measure, 282–284

Flesch, 283 readability, 264 reading, 264 scope and incidence of the

problem, 266–269 Simplified Measure of

Gobbledygook (SMOG), 283 state of the evidence, 301–304 strategies to address NAP

goals, 302t Suitability Assessment of

Materials (SAM), 288–289

teaching strategies, 297–300 Test of Functional Health

Literacy in Adults (TOFHLA), 287

those at risk, 270–272 Wide Range Achievement Test

(WRAT), 286 writing effective PEMs,

guidelines, 292–296 adult learning, cognitive learning

theory about, 82

Index Note: Page numbers followed by “f” and “t” indicate figures and tables, respectively.

675

prioritizing needs, 124 desirable, 125t mandatory, 125t possible, 125t

taking time-management issues into account, 126

assimilation, 331t assimilator learning mode,

152–153 assistive technologies, 409–411 association learning, 73 Association of Cancer Online

Resources, Inc. (ACOR), 577 ASSURE model, 15 asynchronous, 569 attention, relevance, confidence,

and satisfaction (ARCS) model, 230

attentional phase of Bandura’s model, 85

attention-deficit/hyperactivity disorder (ADHD), 393–397

manifesting forms, 395 combined/other, 395 hyperactive/impulsive, 395 inattentive, 395

attribution theory, 83 audience response system

(ARS), 461 audience–channel–message–

evaluation (ACME), 602 audio learning resources, 528–531

advantages, 529 disadvantages, 529

audiovisual materials, 523–537. See also computer learning resources

audio learning resources, 528–531 compact discs and digital sound

players, 528–529 overhead transparencies, 526–527 projected learning resources,

525–527 Microsoft PowerPoint, 525

radio and podcasts, 529 telecommunications learning

resources, 531–533 video learning resources,

529–531 auditory learners, 147 auditory processing disorder (APD),

391–392 augmentative and alternative

communication (AAC), 405

andragogy, 192 process elements of andragogy, 193t

animistic thinking, 181 anomic aphasia, 404 anterior commissure, 320t anxiety level, 134–135 APD. See auditory processing

disorder aphasia, 404–406

anomic aphasia, 404 expressive aphasia, 404 global aphasia, 404 receptive aphasia, 404

ARCS. See attention, relevance, confidence, and satisfaction

ARS. See audience response system Asian/Pacific islander culture,

346–347 ASL. See American Sign Language Asperger syndrome, 398–399 assessing learning needs, 122–127

assessing the demands of the organization, 126

assessment choosing the right setting, 123 collecting data about the

learner, 123 collecting data from the

learner, 124 determining availability of

educational resources, 125 evaluation vs., 598–600 identifying learner, 123 involving members of

healthcare team, 124 of the learner, 121–122 methods for, 127–131

checklists, 128 documentation, 129–130 focus groups, 128 informal conversations, 127 observations, 129 questionnaires, 128–129 structured interviews, 127–128 tests, 129

of nursing staff, 130–131 chart audits, 130 formal and informal

requests, 130 gap analysis, 130–131 quality assurance reports, 130 rules and regulations, 130 self-assessment, 130 written job descriptions, 130

AE mode. See active experimentation

AE–RO. See action vs. reflection affective domain, 433f, 436t

levels of, 437–438 characterization level, 438 organization level, 437–438 receiving level, 437 responding level, 437 valuing level, 437

teaching in, 438–439 extrapersonal level, 438 interpersonal level, 438 intrapersonal level, 438

Affordable Care Act (ACA), 11, 20 ageism, 200 Agency for Healthcare Research and

Quality (AHRQ), 267 aggression, 323 AHA. See American Hospital

Association AHRQ. See Agency for Healthcare

Research and Quality AMA. See American Medical

Association American Association of Colleges of

Nursing (AACN), 19 American Hospital Association

(AHA), 6, 42 American Indian/Alaska native

culture, 350–353 belief on death, 352 children in, 351 common characteristics, 351 family values, 351 religion and health in, 351 sharing among, 352 teaching strategies, 352–353

American Medical Association (AMA), 41, 267

American Medical Informatics Association (AMIA), 553

American Nurses Association (ANA), 9, 41

American Sign Language (ASL), 379

Americans with Disabilities Act (ADA), 373, 583

AMIA. See American Medical Informatics Association

amygdala, 320t ANA. See American Nurses

Association analogue, 518

676 Index

case studies, 467 causal thinking, 184 causality concept, 178 cautioning, 246 CE mode. See concrete experience Centers for Medicare and Medicaid

Services (CMS), 19, 42 central auditory processing disorder

(CAPD), 391 Certified Language

International, 336 Certified Nurse Educator (CNE), 9 characteristics of the learner, 508 characteristics of the medium, 508 characteristics of the task, 508 chats, 579–581 checklists, 128 chronic illness, 407–408. See also

disabilities, learners with educating, 369–413 family’s role in, 408–409 models and definitions, 372–374 nurse educators, roles and

responsibilities of, 375–376

chronic obstructive pulmonary disease (COPD), 541

CINAHL. See Cumulative Index to Nursing and Allied Health Literature

CIPP. See context, input, process, product

circumlocution, 404 classical conditioning, 73 clinical education specialists

(CESs), 47 clinical nurse specialists (CNSs), 47 clinical practice guidelines

(CPGs), 603 clinical simulations, 480 closed-circuit TV, 532 cloze procedure, 285, 637–640 CMS. See Centers for Medicare and

Medicaid Services CNE. See Certified Nurse Educator COBRA. See Consolidated Omnibus

Budget Reconciliation Act Code of Ethics, 41, 43 cognitive abilities, 319–323

general intelligence, 319–322 personality traits, 323–324

cognitive ability, 139 cognitive development, 81 cognitive dissonance theory, 231

spontaneous recovery, 75 stimulus generalization, 75 systematic desensitization, 74

beneficence, 47 Betty Neuman’s Systems Model

Theory, 15 biomedical theory, 222 Black/African American culture,

342–350 inequality among, 343 low educational attainment, 343 poverty in, 343 religiosity, 344 spirituality, 344 teaching strategies, 345–346

blended learning, 524 blindness, 383 blogs, 568–569

American Life Project, 568 Pew Internet, 568

BMIs. See body mass indexes bodily-kinesthetic intelligence, 157 body mass indexes (BMIs), 240 BPI. See brain preference indicator brain hemispheres, 321t brain preference indicator

(BPI), 142 brain size, 321t brain structure, differences in,

320t–321t amygdala, 320t anterior commissure, 320t brain hemispheres, 321t brain size, 321t corpus callosum, 320t hippocampus, 321t prefrontal cortex, 320t temporal lobe, 320t

brain-based learning, 95 Bruce Whitehall’s Game Evaluation

Sheet, 478

C cable TV, 532 CAHPS. See Consumer Assessment

of Healthcare Providers and Systems

CAPD. See central auditory processing disorder

cardiopulmonary resuscitation (CPR), 139

augmented feedback, 104, 443 autism spectrum disorder,

398–399 automated mailing groups, 577 autonomy, 42–43 avoidance conditioning, 76

B Bandura, Albert, 85–86, 229–231,

238–239 barriers to teaching, 21–26, 22f behavioral objectives and teaching

plans, 423–455. See also affective domain; cognitive domain; psychomotor domain

characteristics of goals and objectives, 426–427

domain hierarchies, 433f educational objectives, 426 importance of using, 427–428 instructional objectives, 426 learning contracts use,

448–449 learning curve, 449–453 learning objectives, 426 postcircumcision care, 447t taxonomy according to learning

domains, 432–444 teaching plan development,

444–448 types of objectives, 426 writing, 428–431

common mistakes in, 431–432 condition, 429 criterion, 429 four-part method of objective

writing, 429t performance, 429 performance words with many

or few interpretations, 430–431

SMART objectives, 432t behavioral objectives, 426 behavioral/social learning

theory, 222 behaviorist learning theory, 73–78

discrimination learning, 75 operant conditioning, 75 respondent conditioning,

73, 74f

Index 677

cost recovery, 60 cost savings, 60 cost-benefit analysis, 61–62 cost-benefit ratio, 60 cost-effectiveness analysis,

61–62 Council on Scientific Affairs of

the American Medical Association, 263

CPGs. See clinical practice guidelines

CPR. See cardiopulmonary resuscitation

CPT. See Common Procedural Terminology

CQI. See continuous quality improvement

CR. See conditioned response Cronbach’s learning curve,

450–451, 451f crystallized intelligence, 201 CS. See conditioned stimulus cuing, principles of, 300, 439 cultural assessment, 330–337 cultural attributes of the learner,

315–358. See also subcultural ethnic groups

diversity care, preparing nurses for, 353–354

general assessment, 335–336 interpreters use, 336–337 Purnell’s definition of terms, 331t state of the evidence, 356–357 teaching interventions,

335–336 cultural awareness, 331t cultural characteristics, 330

culturally unique individual, 333t negotiation, 334 primary, 332 secondary, 332

cultural competence, 331t cultural distress, 354 cultural diversity, 331t cultural relativism, 331t culturally sensitive care delivery,

assessment models for, 330–337

culture, 331t Cumulative Index to Nursing and

Allied Health Literature (CINAHL), 140, 626

cybersecurity, 553 cycle of poverty. See poverty cycle

computer learning resources, 533–537

Adobe Flash, 534 flash-based online resources, 534 QuickTime format, 534

computer literacy, 561 computer simulations, 480 computer-assisted instruction

(CAI), 485 computer-based technologies, 551 computerized readability software

programs, 284 concept mapping, 230 concordance, 243 concrete experience (CE mode), 152 concrete operations, 184 conditioned response (CR), 73 conditioned stimulus (CS), 73 conductive hearing loss, 377 confidentiality, 39, 45–46

anonymous and, 45 Confucianism, 347

ancestor worship, 347 man in harmony with the

universe, 347 patterns of authority, 347

consensual regimen, 224 conservation, 184 Consolidated Omnibus Budget

Reconciliation Act (COBRA), 48

Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, 18

consumer informatics, 553 contemplation, 241 content, 508–509

evaluation, 604–605 principles, 290

context, input, process, product (CIPP) model, 603

contextual interference concept, 102–103

continuous quality improvement (CQI), 618

contracting, 247, 471 contracting converger learning

mode, 152–153 contractor, nurse as, 247 cooperative learning, 465–467 COPD. See chronic obstructive

pulmonary disease corpus callosum, 320t cost benefit, 60

cognitive domain, 433–437 levels of, 434–435

analysis level, 434 application level, 434 comprehension level, 434 evaluation level, 435 knowledge level, 434 synthesis level, 435

teaching in, 435–437 cognitive evaluation theory, 230 cognitive learning theory, 78–84

adult learning and, 82 benefit of, 84 cognitive load, 81 ‘Cold’ cognitive models, 83 criticisms of, 83 emotions in, 84

emotional intelligence (EI), 84 empathy and the moral

emotions, 84 memory storage and

retrieval, 84 self-regulation, 84

gestalt perspective, 79 information processing, 79, 80f mnemonic devices, 81 proponents of, 82

cognitive load, 81 cognitive map, 99 cognitive plan, 99 cognitive-emotional perspective, 83 Coleman–Liau Index, 284 commercially prepared materials,

510–511 Common Procedural Terminology

(CPT) codes, 23 communication disorders, 403–407

aphasia, 404–406 dysarthria, 406–407

communication models, 222 compact discs, 528–529 compliance of learner, 221–225

illiteracy impact on, 275–277 perspectives, 222

behavioral/social learning theory, 222

biomedical theory, 222 communication models, 222 rational belief theory, 222 self-regulatory systems, 222

comprehension, 264 Computer Age, 552 computer instruction, literacy

relative to, 265–266

678 Index

developmental stages of childhood, 172–192

adolescence (12–19 years of age), 188–192

cognitive development, 188–190

long-term learning, 191–192 physical development,

188–190 propositional reasoning, 188 psychosocial development,

188–190 short-term learning, 191 teaching strategies, 190–192

cognitive development, 172–179 early childhood (3–5 years of

age), 180–183 animistic thinking, 181 cognitive development,

181–182 egocentric causation, 182 long-term learning, 183 physical development,

181–182 precausal thinking, 181 preoperational period, 181 psychosocial development,

181–182 short-term learning, 183 teaching strategies, 182–183

infancy (first 12 months of life), 172–180

middle and late childhood (6–11 years of age), 183–188

cognitive development, 183–185

long-term learning, 187–188 physical development,

183–185 psychosocial development,

183–185 short-term learning, 187 syllogistic reasoning, 184 teaching strategies, 185–188

physical development, 172–179 psychosocial development,

172–179 stage-appropriate teaching

strategies, 173t–177t adolescence, 175t early childhood, 173t infancy–toddlerhood, 173t middle and late childhood, 174t

autism spectrum disorder, 398–399

intellectual disabilities, 397–398

developmental stages of adulthood, 192–210

activity-oriented learners, 194 goal-oriented learners, 194 Knowles’s framework, 192 learning-oriented learners, 194 middle-aged adulthood (41–64

years of age), 197–199 cognitive development,

197–198 dialectical thinking, 198 generativity vs. self-absorption

and stagnation, 198 physical development,

197–198 psychosocial development,

197–198 teaching strategies, 198–199

older adulthood (65 years of age and older), 199–210

adequacy of personal resources, 203

cognitive development, 200–203

cognitive needs, 207–209 coping mechanisms, 203 gerontological teaching–

learning model for nursing, 209f

independence, 203 meaning of life, 203 myths associated, 204 physical development,

200–203 physical needs, 205–207 problems overcome using

computers, 207t psychosocial development,

200–203 social acceptability, 203 teaching strategies, 203–210

young adulthood (20–40 years of age), 195–197

cognitive development, 195 emerging adulthood, 195 formal operations stage, 195 intimacy vs. isolation, 195 physical development, 195 psychosocial development, 195 teaching strategies, 195–197

D decision aids, 43 defense mechanisms, 88 delivery system, 508 Delphi technique, 131 demonstration, 147, 473–476

advantages, 475t limitations, 475t

demonstration materials, 517–523 advantage, 519 analogue, 518 disadvantages, 519 displays, 519–520 models, 517–519 posters, 520–523 symbol, 519

deontological, type of ethical belief system, 39

dependence, 171 design, 146 desirable needs, 125 determinants of learning, 119–163

assessing learning needs, 122–127. See also individual entry

assessment of the learner, 121–122

educator’s role in learning, 121 learning style models and

instruments, interpretation of, 159–161

general guidelines, 160–161 needs of the learner, 120 preferred learning styles, 121 state of readiness to learn, 121,

131–139. See also readiness to learn

state of the evidence, 161–162 developmental characteristics,

171–172 dependence, 171 family in patient education,

210–212 independence, 171 interdependence, 171 maturity continuum, 171 state of the evidence, 212–213 teachable moment, 172

developmental disabilities, 393–399 Asperger syndrome, 398–399 attention-deficit/hyperactivity

disorder, 394–397

Index 679

mid-1800s through the turn of the 20th century, 5

mid-1960s, 6 mid-1990s, 7 nursing education

transformation, 17 patient and nursing staff/student

education, 12–13 patient engagement, 17–19 quality and safety education in

nursing, 19–20 questions to be asked, 26 state of the evidence, 26–28

education process, 13–15 defined, 13–15 instruction, 14 learning, 15 parallels nursing process, 14 staff education, 15 teaching, 14

educational contracting, 247 educational objectives, 426 educational process, 35–64

ethical, legal, and economic foundations of, 35–64

differentiated view, 38–40 economic factors, 57–58 evolution of, 40–42 financial terminology, 58–60 issues of human rights, 38

program planning and implementation, 60–61

cost-benefit and cost- effectiveness analysis, 61–62

state of the evidence, 62–63 educator agreement with model

conceptualizations, 245 educator’s role in learning, 121 edutainment, 477 ego defense mechanisms, 88 ego integrity vs. despair, 201 egocentric causation, 182 egocentrism, 189 eHEALS. See eHealth Literacy Scale e-Health Code of Ethics, 554, 555t eHealth Literacy Scale (eHEALS), 288 e-health literacy, 266 EHRs. See electronic health records EI. See emotional intelligence E–I. See Extraversion–Introversion e-learning, 584 electronic discussion groups, 575–576 electronic health records (EHRs), 618

distance learning, 464 distributed practice, 101, 435 diverger learning mode, 152 diversity care, preparing nurses for,

353–354 documentation, 129–130

informed consent, factors affecting, 56

legal and financial implications of, 53–57

domain hierarchies, 433f affective domain, 433f, 436t cognitive domain, 433f thinking domain, 433

DOPE. See disease-oriented patient education

Dorothy Orem’s Self-Care Theory, 15 dual coding, 160 Dunn and Dunn learning styles,

145–148, 145f emotional elements, 145, 146 environmental elements, 145–146 instrument to measure, 148 physical elements, 145, 147–148 psychological elements, 145 sociological patterns, 145,

146–147 duty concept, 46 DVDs, 530 dysarthria, 406–407 dyscalculia, 392–393 dyslexia, 390–391

E early childhood (3–5 years of age),

180–183 easterner learning style, 154 EBP. See evidence-based practice economic factors in healthcare

education, 57–58 justice and duty revisited, 57–58

education in health care, 3–29. See also nurse contemporary role as educator

21st century, 8 after World War II, 5 barriers to teaching and learning,

21–26 gender issues, 27 historical foundations, 5–9 Institute of Medicine Report, 20–21

developmental stages of childhood (continued)

middle-aged adulthood, 175t older adulthood, 175t young adulthood, 175t

teaching strategies, 179–180 long-term learning, 180 short-term learning, 180

toddlerhood (1–2 years of age), 172–180

developmental stages of the learner, 169–215

normative age-graded influences, 171

normative history-graded influences, 171

normative life events, 171 Diabetes Knowledge Test, 129 dialectical thinking, 198 Digital Age, 552 digital divide, 581 digital immigrants, 524 digital natives, 524 digital sound players, 528–529 digital video files, 530 direct costs, 58–59 disabilities (social) model, 372 disabilities, learners with, 369–413.

See also communication disorders; developmental disabilities; learning disabilities

disability-sensitive language, 375 educating, 369–413 identity-first language, 374 language of disabilities, 374–375 models and definitions,

372–374 nurse educators, roles and

responsibilities of, 375–376 people-first language, 374 types of disabilities, 376–377. See

also sensory disabilities; visual impairments

mental disabilities, 376–377 physical disabilities, 376

disability, 373–374 disability-sensitive language, 375 discovery learning, 103 discrimination learning, 75 disease-oriented patient education

(DOPE), 8 displays, 519–520 distance education, 585–587

680 Index

research, 612 reporting evaluation results,

625–626 be audience focused, 625 Enhanced Evaluability

Assessment, 626 stick to the evaluation

purpose, 625 use data as intended, 625–626

Roberta Straessle Abruzzese (RSA) evaluation model, 601, 601f

teach-back method, 605 test–retest analysis, 605 types of data to collect, 614–615

from whom, 615–616 how, 616–617 Likert-scaled items, 617 open-ended questions, 617 operational definition, 614 patient compliance, 614 qualitative data, 615 quantitative data, 615 reflection-in-action, 619 reflection-on-action, 619 what, 615–616 when, 616–617 where, 616–617 who, 617–619

evaluator, nurse as, 248 evidence-based practice (EBP),

597–598 Excelsior College, 586 experiential readiness, 137–138

cultural background, 138 language, 138 level of aspiration, 137 locus of control, 138 past coping mechanisms, 137–138

expressive aphasia, 404 external evidence, 598 external locus of control, 138 externals, 224 extraversion, 151 Extraversion–Introversion (E–I), 149 extrinsic feedback, 104

F Facebook, 570 facilitator of change, nurse as, 247 family in patient education, 210–212

veracity, 43–45 voluntariness, 44

ethical principles, the law, and practice standards linkages, 54t

ethics, 39 ethics of education in classroom and

practice settings, 49–52 ethical decision making, 51 patient–provider relationship,

50–52 student–teacher relationship, 49

ethnic group, 331t ethnocentrism, 331t ethnomedical, 350 evaluation, 596 evaluation in healthcare education,

595–627. See also total program evaluation

analyzing and interpreting data collected, 623–625

assessment vs., 598–600 barriers to evaluation, 620–622

fear of punishment or loss of self-esteem, 621–622

lack of clarity, 620–621 clinical practice guidelines

(CPGs), 603 conducting, 622–623 content evaluation, 604–605 context, input, process, product

(CIPP) model, 603 designing the evaluation, 611–622

design structure, 611–614 evaluation vs. research,

611–614 quasiexperimental designs, 613

evaluation models, 600–601 evaluation research, 612 evidence-based practice (EBP),

597–598 external evidence, 598 focus of evaluation, 599–600 impact evaluation, 607–608 instruments, 619–620

cognitive test, 619 multiple questionnaires, 620 scales, 620

internal evidence, 598 outcome (summative) evaluation,

605–607 PICO question, 606 practice-based evidence, 597–598 process (formative) evaluation,

602–604

electronic medical record (EMR), 55, 289

e-mail/texting, 572–575 face-to-face communication

vs., 574 emoticons, 580 Emergency Medical Treatment

and Active Labor Act (EMTALA), 48

emotional adjustment, 323–324 emotional elements, 145–146

motivation, 146 persistence, 146 responsibility, 146 structure, 146

emotional intelligence (EI), 84 emotional readiness, 134–137

anxiety level, 134–135 developmental stage, 137 fear, 135 frame of mind, 136–137 motivation, 136 risk-taking behavior, 136 support system, 135–136 teachable moment, 137

empathy and moral emotions, 84 EMR. See electronic medical record EMTALA. See Emergency Medical

Treatment and Active Labor Act

enhanced feedback, 104 environmental elements, 145–146

design, 146 light, 146 sound, 145 temperature, 146

Erikson’s nine stages of psychosocial development, 179t

escape conditioning, 76 ethical, 39 ethical concerns, in adult client

population literacy, 277–279

ethical dilemmas, 39 ethical principles application to

patient education, 38, 42–48 autonomy, 42–43 beneficence, 47 competence, 44 comprehension, 44 confidentiality, 45–46 disclosure of information, 44 justice, 47–48 nonmaleficence, 46–47

Index 681

gerontological teaching–learning model for nursing, 209f

gestalt perspective, 79 global aphasia, 404 goals, 426 Golden Rule, 39 Got Transition Model, 396 group discussion, 464–469

advantages, 470t cooperative learning, 465–467 limitations, 470t team-based learning, 465

Group Embedded Figures Test (GEFT), 144

H habilitation, 375 HBDI. See Herrmann Brain

Dominance Instrument HBM. See health belief model HCFA. See Health Care Financing

Administration health behaviors of learner,

219–249 health belief model (HBM),

235–237 interacting components, 235

as preventative health behavior predictor, 236f

individual perceptions, 235 likelihood of action, 235 modifying factors, 235

health care, 10–12 economic trends affecting, 10–12 political trends affecting, 10–12 social trends affecting, 10–12

Health Care Financing Administration (HCFA), 42

health education, 6 Health Information Technology

for Economic and Clinical Health Act (HITECH), 55

Health Insurance Portability and Accountability Act (HIPAA), 45, 276, 337, 575

health literacy, 263 health maintenance organization

(HMO), 42 Health Poverty Action, 329 health promotion model (HPM),

237–238, 238f

Fourth Industrial Revolution, 550 frame of mind, 136–137 fry readability graph, 634–635

extended, 283 functional illiteracy, 263 functional magnetic resonance

imaging (fMRI), 318

G gaming, 476–479

advantages, 479t game suitability checklist, 478t limitations of, 479t

gap analysis, 130–131 Gardner’s eight types of intelligence,

156–158 bodily-kinesthetic

intelligence, 157 child’s style of learning, 158 instrument to measure, 158 interpersonal intelligence, 157 intrapersonal, 157 linguistic intelligence, 157 logical-mathematical

intelligence, 157 musical intelligence, 157 naturalistic intelligence, 157 spatial intelligence, 157

GEFT. See Group Embedded Figures Test

gender, 134 attributes of the learner, 315–358 bias, 324 characteristics, 317–327. See also

cognitive ability gap, 324 gender-fair language, 355 gender-related cognitive

abilities, 319 general intelligence, 319–322

brain structure, differences in, 320t–321t

mathematical ability, 322 problem solving, 322 school achievement, 322–323 spatial ability, 322 verbal ability, 322

identity, 325–327 related personality

behaviors, 323 geragogy, 200

feedback, 104–106 extrinsic (augmented or

enhanced) feedback, 104 intrinsic (inherent) feedback, 104

feeling, 151 field-independent/field-dependent

perception, 143–145 characteristics of, 143t field-dependent learners, 143 field-independent learners, 143 instrument to measure, 144–145

financial concerns, in adult client population literacy, 277–279

financial terminology, 58–60 cost benefit, 60 cost recovery, 60 cost savings, 60 direct costs, 58–59 fixed costs, 59 hidden costs, 59 indirect costs, 59–60 revenue generation, 60 variable costs, 59

fixed costs, 59 Flash-based online resources, 534 Flesch–Kincaid scale, 283, 633–634 fluid intelligence, 201

changes due to decrease in, 201 altered time perception, 201 decreased short-term

memory, 201 increased test anxiety, 201 persistence of stimulus

(afterimage), 201 slower processing and reaction

time, 201 Flynn effect, 321 fMRI. See functional magnetic

resonance imaging focus groups, 128 focus of evaluation, determining,

599–600 audience, 599 content evaluation, 600 outcome evaluation, 600 purpose, 599–600 questions, 599, 600 resources, 599–600 scope, 599–600

Fog formula, 283, 634 Fog index, 283 formal operations, 188, 197 formative evaluation, 602–604

682 Index

major components and variables, 237

revised, 237 health status, 133–134 healthcare setting, 496 healthcare-related setting, 496–497 health-oriented patient education

(HOPE), 8 hearing impairments, 377–383

conductive hearing loss, 377 lipreading, 380–381 mixed hearing loss, 378 people-first language use, 378 sensorineural hearing loss, 377 sign language, 379–380 sound augmentation, 381–382 telecommunications, 382–383 verbalization by the client, 381 written materials, 381

Herrmann Brain Dominance Instrument (HBDI), 142

hidden costs, 59 hierarchy of needs, 91, 225 HIPAA. See Health Insurance

Portability and Accountability Act

hippocampus, 321t Hispanic/Latino culture, 338–342 HITECH. See Health Information

Technology for Economic and Clinical Health Act

HMO. See health maintenance organization

hope and faith vs. despair, 213 HOPE. See health-oriented patient

education hospital CAHPS (HCAHPS), 19 HPM. See health promotion model humanistic learning theory, 90–93

central purpose of, 92 feelings and emotions, 92 hierarchy of needs, 91 Maslow’s hierarchy of needs, 91f modification in, 93 weaknesses, 93

I identity vs. role confusion, 189 identity-first language, 374 ideology, 331t IEP. See individualized education plan

IHCAs. See interactive health communication applications

illiteracy impact on motivation and compliance, 275–277

illiterate, 262 illusionary representations, 509 imaginary audience, 189 Independence, 171 indirect costs, 59–60 individualized education plan

(IEP), 396 Individuals with Disabilities

Education Act, 394 industry vs. inferiority, 185 infancy (first 12 months of life),

172–180 informal conversations, 127 informatics. See consumer

informatics Information Age, 552 information literacy, 560–561 Information processing, 79, 80f informed consent, factors affecting,

39, 56 demands on providers, 56 patient autonomy, 56 patient comprehension, 56 patient use of disclosed

information, 56 physicians meeting minimum

demands, 56 inherent feedback, 104 Institute of Medicine Report, 20–21 institutional review board for

the protection of human subjects (IRBPHS), 40

instruction, 14 instructional materials, 505–543,

633–649 choosing variables, 507–508 comprehension, 633–649 evaluating instructional

materials, 537–539 patient education materials

assessment tool, 538t general principles, 507 health literacy and tools to assess,

633–649 learner, medium, and task

(LMAT), 508 learner, characteristics of, 507

major components of, 508–510 content, 508–509

delivery system, 508 illusionary representations, 509 presentation, 509–510 realia, 509 symbolic representations,

509–510 medium, characteristics of, 507 readability, 633–649 task, characteristics of, 507 types of, 510–537. See also

audiovisual materials; demonstration materials; written materials

instructional objectives, 426 instructional setting, 496–497 intellectual disabilities, 397–398 interactive health communication

applications (IHCAs), 485 interdependence, 171 internal evidence, 598 internal locus of control, 138 internals, 224 Internet, 485, 551, 557, 572–581

automated mailing groups, 577 electronic discussion groups,

575–576 e-mail/texting, 572–575 LISTSERV, 576 mailing lists, 576–579 online chats, 579–581 online support groups,

577–578 interpersonal intelligence, 157 interpreters use, 336–337 intrapersonal intelligence, 157 intrinsic feedback, 104, 443 introversion, 151 intuition, 151 IOM. See Institute of Medicine

Report IRBPHS. See institutional review

board for the protection of human subjects

J JCAHO. See Joint Commission on

Accreditation of Healthcare Organizations

Jean Watson’s Theory of Human Caring, 15

Joint Commission, The (TJC), 7

Index 683

learning style theories, models, and instruments, 140–159

4MAT system Dunn and Dunn learning styles,

145–148, 145f examples of hemisphere

functions, 142t field-independent/field-

dependent perception, 143–145

Gardner’s eight types of intelligence, 156–158

Jung and Myers–Briggs typology, 148–152, 149f

Kolb’s experiential learning model, 152–154, 153f

occurrence of learning, 10 right-brain/left-brain and whole

brain thinking, 141–142 VARK learning styles, 158–159 state of the evidence, 108–109

learning styles, 139–140 application to healthcare practice,

69–110 common principles, 106–108 comparison of, 95–98, 96t–97t construction and testing of, 71 determining learning styles, 140 experiences influencing, 107–108 learning becoming permanent, 108

learning theories, 69–110. See also behaviorist, cognitive, social learning, psychodynamic, humanistic, motor learning; neuropsychology and learning

lecture, 461–464 advantages, 464f analogies use, 462 body, 463 conclusion, 463–464 examples use, 462 introduction, 462–463 key terms use, 462 limitations, 464t opening and summary

statements, 462 visual backups use, 462

legal concerns, in adult client population literacy, 277–279

legal rights and duties, 39 legality of patient education and

information, 52–53

converger, 152–153 diverger, 152

learning styles, 154 easterner, 154 northerner, 154 southerner, 154 westerner, 154

reflective observation (RO mode), 152

L LAD. See Literacy Assessment for

Diabetes language of disabilities, 374–375 language, information, and

design (LID) method, 290 LEARN model, 336 learner readiness, 227 learner, medium, and task

(LMAT), 508 learning, 15

ability, factors affecting, 24–26 definition, 70

learning contracts, 448–449 components of, 449

content, 449 evaluation, 449 performance expectations, 449 time frame, 449

learning curve, 449–453 stages, 451–452

approach to limit, 452 decreasing gains, 451 increasing gains, 451 negligible progress, 451 plateau, 451 renewed gains, 451

use, 448–449 learning disabilities, 387–393. See

also disabilities, learners with; dyslexia

auditory processing disorder (APD), 391–392

dyscalculia, 392–393 misconceptions and realities

about, 389t statistics on, 388

learning needs, 122 learning objectives, 426 Learning Style Inventory

(LSI), 154

Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 7, 53, 278

judging, 151 Judging–Perceiving (J–P), 150

Jung and Myers–Briggs typology, 148–152

Extraversion–Introversion (E–I), 149

instrument to measure, 150–152 Judging–Perceiving (J–P), 150 Myers–Briggs dichotomous

dimensions or preferences, 149f

Myers–Briggs types, 149f Sensing–Intuition (S–N), 149 Thinking–Feeling (T–F), 150

justice, 39, 47–48 duty revisited and, 57–58

K Kant, Immanuel, 38–39 KAS. See Kim Alliance Scale KAS-R. See Kim Alliance Scale

Refined Kim Alliance Scale (KAS), 243 Kim Alliance Scale Refined

(KAS-R), 243–244 kinesthetic learners, 147 knowledge readiness, 138–139

cognitive ability, 139 learning

and reading disabilities, 139 styles, 139

present knowledge base, 138–139

Knowles, Malcolm, 192, 196, 212 Kolb’s experiential learning model,

152–154 abstract conceptualization

(AC mode), 152 active experimentation

(AE mode), 152 concrete experience

(CE mode), 152 instrument to measure, 154 Kolb’s learning style

inventory, 153f learning modes, 152

accommodator, 152–153 assimilator, 152–153

684 Index

OARS, 231 READS, 232

personal attributes, 226 principles, 290 relationship systems,

226–227 motivational axioms, 227–228

learner readiness, 227 learner satisfaction/success, 228 realistic goals, 227–228 state of optimal anxiety, 227 uncertainty reduction or

maintenance, 228 motivational interviewing (MI),

231–234 motor learning, 98–106

feedback variables in, 106t motor performance, 99 practice variables in, 106t stages of, 99–100

associative stage, 100 autonomous stage, 100 cognitive stage, 99

variables, 100 contextual interference effects,

102–103 discovery learning, 103 distributed practice, 101 feedback, 104–106 massed practice, 101 practice, 101–104 prepractice, 100–101

motor performance, 99 multimedia learning, 524 Multiple Intelligences

Developmental Assessment Scales (MIDAS), 158

multiple questionnaires, 620 musical intelligence, 157 mutual contracting, 224 Myers–Briggs dichotomous

dimensions or preferences, 149f

Myers–Briggs Type Indicator (MBTI), 150

N NAAL. See National Assessment of

Adult Literacy NALS. See National Adult Literacy

Survey

maturity continuum, 171 MBTI. See Myers–Briggs Type

Indicator medical model, 372 medicalese, 263 memory disorders, 403 memory storage and retrieval, 84 mental illness, 399–400 mental imaging, 443 mental practice, 103, 443 metacognition, 78 MI. See motivational interviewing Microsoft PowerPoint, 525 MIDAS. See Multiple Intelligences

Developmental Assessment Scales

middle and late childhood (6–11 years of age), 183–188

middle-aged adulthood (41–64 years of age), 197–199

Mill, John Stuart, 38 mixed hearing loss, 378 mnemonic devices, 81 mobile technology, 552 model simulations, 480 models and theories, 235–244 models for health education, 244–246.

See also individual entries educator agreement with model

conceptualizations, 245 functional utility of models,

245–246 integration of models, 246 similarities and dissimilarities of,

244–246 moral model, 372 moral values, 39 motivation, 136, 146, 225–235

assessment of, 228–229 comprehensive parameters

for, 229t multitheory-based

parameters, 229 nonverbal cues, 229 subjective self-reports, 229

definition, 225 environmental influences, 226 illiteracy impact on, 275–277 motivational factors, 225–227 motivational incentives, 225 motivational strategies, 230–234

beliefs, 231 cognitive evaluation theory, 230 concept mapping, 230

lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ), 325–327

LGBTQ. See lesbian, gay, bisexual, transgender, and queer/ questioning

LID. See language, information, and design

Life Cycle Completed, The, 202 light, 146 Likert-scaled items, 617 linguistic intelligence, 157 lipreading, 380–381 listening test, 285–286 LISTSERV, 576 Literacy Assessment for Diabetes

(LAD), 288 literacy, 262

levels test, measurement tools, 281–282

relative to computer instruction, 265–266

relative to oral instruction, 265 literate, 262 locus of control (LOC), 138, 224–225

chance external, 224 doctors external, 224 external, 138

others, 224 internal, 138, 224

logical-mathematical intelligence, 157 long-term learning, 180, 183 long-term services and supports

(LTSS), 211 low literacy, 262 low-literacy materials for clients,

sources of, 281t LSI. See Learning Style Inventory LTSS. See long-term services and

supports

M mailing lists, 576–579 maintenance, 241 malpractice, 46 mandatory needs, 125 marginally illiterate, 262 marginally literate, 262 Maslow’s hierarchy of needs, 91f massed practice, 101, 435 mathematical ability, 322

Index 685

operational definition, 614 oral instruction, literacy relative

to, 265 Organization for Economic

Cooperation and Development (OECD), 267

organizational factors, 290 organizer, nurse as, 247–248 OSHA. See Occupational Safety and

Health Administration OTSES. See Online Technologies

Self-Efficacy Scale outcome (summative) evaluation,

605–607 overhead transparencies, 526–527

P pacing, 495 past coping mechanisms, 137–138 patient and nursing staff/student

education, 12–13 patient compliance, 614 patient education, 5–9. See also

education in health care patient education materials

assessment tool (PEMAT), 538t, 620

patient engagement, 17–19 Patient Learning Needs Scale, 128 Patient Protection and Affordable

Care Act of 2010, 263 Patient Self-Determination Act

(PSDA), 43 Patient’s Bill of Rights, 6, 53 patient–provider relationship,

50–52 blurring of, 51

Patricia Benner’s Novice to Expert Theory, 16

Pavlovian conditioning, 73 PBS. See Public Broadcasting

Service PDF. See Portable Document

Format PDPP. See planning, development,

process, and product pedagogy, 172 PEMAT. See Patient Education

Materials Assessment Tool PEMs. See printed education

materials

facilitator of change, 247 organizer, 247–248

nursing education transformation, 17 future of nursing, 20–21 quality and safety education in,

19–20 Nursing Alliance for Quality Care

(NAQC), 18 advocacy, 18 consumer-centered health care,

18 leadership, 18 performance measurement and

public reporting, 18 nursing process vs. education

process, 13–15, 14f NVS. See Newest Vital Sign

O OARS, 231

affirming the positives involves, 231

open-ended questions, 231 reflective listening, 233 summarizing, 233

object permanence, 178 objectives, 426 obstacles to learning, 21–26, 25f Occupational Safety and

Health Administration (OSHA), 497

OECD. See Organization for Economic Cooperation and Development

older adulthood (65 years of age and older), 199–210

one-to-one instruction, 469–473 action stage, 471 advantages, 473t contemplation stage, 471 limitations, 473t maintenance stage, 471 precontemplation stage, 470 preparation stage, 471

online chats, 579–581 online support groups, 577–578 Online Technologies Self-Efficacy

Scale (OTSES), 144 online technologies, 12 operant conditioning, 75–77

NAQC. See Nursing Alliance for Quality Care

National Adult Literacy Survey (NALS), 259

National Assessment of Adult Literacy (NAAL), 267

National Council Licensure Examination (NCLEX), 123

National Institute on Deafness and Other Communication Disorders (NIDCD), 377

National League for Nursing (NLN), 9 National League of Nursing

Education (NLNE), 5 naturalistic intelligence, 157 NCLEX. See National Council

Licensure Examination needs assessment, 123–127 negligence, 46 neuropsychology and learning,

93–95 New York State Nurse Practice Act, 44 Newest Vital Sign (NVS), 288,

643–649 NIDCD. See National Institute

on Deafness and Other Communication Disorders

Nightingale, Florence, 9 NLN. See National League for

Nursing NLNE. See National League of

Nursing Education nonadherence, 222–223 noncompliance, 222–223

health risk and, 223 patience issues and, 223

nonhealthcare setting, 497 nonmaleficence, 39, 46–47 nonprint instructional materials,

517–537 nonverbal cues, 229 Northerner learning style, 154 numeracy, 262 nurse–client negotiations model, 333 nurse contemporary role as

educator, 15–21 Betty Neuman’s Systems Model

Theory, 15 Dorothy Orem’s Self-Care

Theory, 15 nurse practice acts (NPAs), 9 nurse role as educator, 247–248

contractor, 247 evaluator, 248

686 Index

problem solving, 322 process (formative) evaluation,

602–604 Prochaska’s change model, 240.