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Patient and Family Education: A Multidisciplinary Responsibility Course

Author: Alene Burke RN, MSN
6 Contact Hours

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DESCRIPTION:

The purpose of this course is to give health care providers the knowledge and skills necessary to provide their patients and family members with appropriate and effective education. Virtually all healthcare providers play a role in patient and family education as they serve as a member of the multidisciplinary team.

The content of the class includes the cognitive, psychomotor and affective domains of learning; assessment of learning needs, planning educational activities, implementing education and evaluating the outcomes of education; motivational techniques as related to the age specific characteristics and needs of the learner; modifying the teaching plan to accommodate for personal, ethnical/cultural characteristics, age, and any cognitive, language, reading level, sensory, emotional and/or physical barriers to education.

OBJECTIVES:

1. Detail the importance of patient and family teaching as a critical part of patient care.
2. Differentiate among the cognitive, psychomotor and affective domains of learning.
3. Detail the purpose and components of the four phases of the teaching/learning process, that is, assessment, planning, implementation and evaluation
4. Describe ways to motivate the learner, some of which are related to the age specific characteristics and needs of the learner.
5. Modify the teaching plan to facilitate personal, ethnical/cultural characteristics, age, and any cognitive, language, reading level, sensory, emotional and physical barriers to education.
6. Accurately assess the educational needs of patients and family members.
7. Generate learning objectives that are specific, measurable, behavioral and consistent with the educational need, the domain, and the level of the domain, individual or group preferences, and the goal of the learning activity.
8. Implement an established teaching plan and modify it, as indicated, throughout the course of the instruction.
9. Evaluate the outcomes of education for individuals and groups, using a variety of data sources.

INTRODUCTION

Patient and family education is sadly overlooked as healthcare providers sometimes become overwhelmed with the day to day routines of their daily practice in the workplace. We often forget how important this part of care is. We often forget that patient and family education is as important as administering medications, insuring that the patient gets their ordered diagnostic tests and/or goes to physical therapy for their treatments.

This education should not be an incidental part of care or an aspect of total care that is addressed only upon the request of the patient or family member or when a problem arises. Patient and family education should be a consistent part of care.

Teachers in our schools and healthcare providers have always suspected that education was effective in terms of the provision of knowledge, however, now we are able to demonstrate that patient and family education makes a difference in the outcome of care. Making a positive change in the outcome of care is the ultimate goal of patient and family education.

Here are some examples of how patient education has impacted positively on the outcome of care, in terms of the client and their status.

• One interventional group of sedentary clients exercised 30 minutes more than a control group after only a few minutes of education by their physician. (Calfas, 1996).
   
• Patients with moderate to severe asthma had less asthmatic symptoms, fewer complaints about their asthma symptoms and increased physical activity after educational intervention, as reported by Wilson (1993).
   
• A meta analysis of 191 research studies indicated that pre-operative education provided to patients, undergoing both minor and major surgical procedures, resulted in decreased length of stay, fewer postoperative complications, better respiratory status and decreased anxiety (Devine, 1992).
   
• Another meta analysis, of 28 studies, suggests that mortality, exercise, diet and blood pressure significantly improve when the client is provided with education (Mullen, 1992).

External regulatory bodies, such as The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), has standards specifically related to patient family education for virtually all healthcare settings. Federal and state external regulatory bodies also require some aspects of patient education. It is apparent that these regulatory bodies are also convinced that patient and family education is a vital component of complete and comprehensive care. It is a multidisciplinary responsibility.

JCAHO and PATIENT EDUCATION

JCAHO, in its Comprehensive Accreditation Manual for Hospitals, emphasizes patient and family education in its Patient Care section. It is also integrated in other sections, such as Leadership.

JCAHO requires that the patient and family member, when appropriate, get effective and complete education, as based on their unique need, throughout the continuum of care regarding:

• all treatments;
• available alternatives;
• patient rights;
• pain management;
• discharge and discharge alternatives;
• medications;
• nutrition and diet;
• activities of daily living;
• restorative and rehabilitation care;
• self care;
• community resources.

In summary, the Joint Commission, in PC 6.10, states that "The patient receives education and training specific to the patient's needs and as appropriate to the care and services provided." (JCAHO, 2004).

The provision of quality care mandates that the multidisciplinary team provide the patient and family with:

• an accurate, timely and complete assessment of educational needs that reflects the individuals' preferences;
• education that is appropriate to identified need(s);
• education that is timely and effective;
• education that is consistent with the learners' personal preferences, learning styles and comprehension level;
• education that accommodates for the ethnical, cultural, and age specific needs of the individual;
• approaches that address and accommodate for any language barriers, cognitive, sensory, emotional, psychological and physical impairments;
• active multidisciplinary involvement in the assessment, implementation and evaluation of the education and training that they receive.

THE DOMAINS OF LEARNING

The domains of learning are the:

• cognitive domain
• psychomotor domain
• affective domain

The Cognitive Domain

The cognitive domain consists of knowledge and understanding. It is also called the thinking domain. This domain includes facts, figures and theories. Knowing about one's medications and their side effects is an example of a cognitive domain competency.

The cognitive domain has 6 levels or categories that can easily be remember with the mnemonic Killing Cats Almost Always Seems Mean (K-C-A-A-S-E). The six levels, arranged from the least complex to the most complex, include:

• Knowledge- is the lowest level of the cognitive domain. It involves the remembering or recall of previously learned material.
   
• Comprehension- involves some understanding and the grasping of the meaning of the material presented. The learner comprehends, translates and interprets the information that they have learned.
   
• Application- is described as the ability to apply or use the learned material in new situations. Application can involve the application of a rule, concept, theory, principle etc.
   
• Analysis- is the ability to break down material into smaller parts to see relationships among the parts and/or unifying principles or themes.
   
• Synthesis- is the ability to put parts together to create a new whole, new patterns or new structures.
   
• Evaluation- is the highest level of the cognitive domain. This level involves the ability to come to some value judgment about the material, as based on some criteria. This level contains elements of the other five, lower levels of the cognitive domain in addition to a conscious value judgment based on established criteria.

The Psychomotor Domain

The psychomotor domain consists of "hands on" skills. The psychomotor domain is referred to as the doing domain. Examples of psychomotor skills include taking a pulse or a blood pressure, walking with crutches, the self administration of insulin using a needle and syringe, and the use of a piece of equipment, like a defibrillator for example. This domain has 7 levels or categories, again, starting with the least complex and moving up to the most complex level of this domain are:

• Perception- which is the lowest level of the psychomotor domain, consists of the sensing of the task and its relevant cues. For example, when a patient hears an IVAC machine alarming, they are cued that this sound indicates some malfunctioning of the machine.
   
• Set- involves the physical capacity and mental willingness to act and to perform a particular action. For example, a person who has just learned to self administer insulin will willingly use a needle and syringe, normal saline, or water, and an orange to practice the proper technique.
   
• Guided Response- is the return demonstration of a skill after a demonstration. Guided response involves the imitation of the demonstrated skill. This response is generally not done with confidence, accuracy or in a proficient manner. The person may need additional time and practice in order to perform the learned skill in a more proficient manner. A person who, under the direct guidance of a nurse, injects insulin into his or her own abdomen for the first time is performing with a guided response.
   
• Mechanism- is a proficient, habitual performance of a skill with some degree of confidence. As the person continues to inject themselves with their own insulin for a period of time, they are performing at this level of the psychomotor domain.
   
• Complex Overt Response- is the smooth, accurate, quick performance of a complex skill with a somewhat coordinated and automatic pattern. Confidence and competence continue to grow as the person continues to perform the learned skill.
   
• Adaptation- occurs when an individual is so skilled that they can modify the psychomotor skill when problems or unusual circumstances arise. They have moved beyond an automatic routine without consideration for any need for modification. For example, if a person contaminates the needle (problem or unusual situation) while drawing up their insulin, they may be able to quickly replace the needle with a new one without discarding the entire dose.
   
• Origination- is the creation of brand-new patterns of movement that have been created by the individual in order to overcome a problem or to fit a particular situation. Origination is the highest of the psychomotor domain levels and perception is the lowest.

The Affective Domain

The affective domain consists of the development of attitudes, beliefs, values and opinions. It is often referred to as the feeling domain. Developing a commitment to lifestyle changes is an example of an affective domain competency. The affective domain has 5 levels or categories, again, beginning with the most basic and moving to the most complex and advanced:

• Receiving- is the lowest level of the affective domain. It involves simply a willingness to hear about a particular phenomena or stimulus. For example, a patient may be willing to listen to a short explanation about their responsibilities regarding health and wellness.
   
• Responding- is defined as the response or reaction to the particular phenomena or stimulus. Here, the person may react to the wellness responsibilities.
   
• Valuing- involves the attachment of some worth or value to the phenomena or stimulus. Now the person is able to see the worth and value in wellness.
   
• Organization- occurs when the individual is able to bring together different value systems, resolve conflicts among the different systems and begin to build their own internally consistent, harmonious value system. At this level, the person can integrate their family, cultural characteristics, their work life and wellness without conflict.
   
• Characterization by a Value or a Value Complex- occurs when the value system of the individual becomes highly consistent, pervasive and predictable over time. Now, the individual accepts responsibility for their own health and wellness in a consistent manner. They value wellness throughout the day in a predictable manner.

ADULT (Androgogy) and CHILDHOOD (Pedagogy) LEARNING

Learning can be categorized into two basic categories, that is, pedagogy, or childhood learning, and androgogy, adult learning. Elementary, middle schools and high schools use pedagogy. Adults should be taught using the principles of adult learning, or androgogy.

HOW PATIENTS AND FAMILY MEMBERS CAN BE MOTIVATED TO LEARN

Motivation is a critical part of the teaching-learning process. People will not learn unless they are motivated to do so. Below are some of the ways that patients and residents can be motivated to learn.

• Involve the learners in the entire teaching- learning process. Encourage the learner's input regarding ALL aspects of the needs assessment, learning plan, the teaching session and the evaluation of the outcome.
   
• Focus the teaching/learning on the immediate problems and concerns of the learner and family members.
   
• Explain how the learning can benefit the individual. Adults become motivated to learn when they realize that the learning can help solve a problem that they have.
   
• Emphasize how the learner can immediately apply the learning to their own life and situation.
   
• Encourage the learner to debate, share and exchange their knowledge, ideas and past experiences with the instructor and others.
   
• Make the learning a highly active and participative process.
   
• Relate the new knowledge to past knowledge and experience.
   
• Maintain an open, honest and highly respectful environment.

THE FOUR PHASES OF THE TEACHING/LEARNING PROCESS: ASSESSMENT- PLANNING- IMPLEMENTATION & EVALUATION

Healthcare professionals, not unlicensed assistive staff such as CNAs and technicians, are involved in the educational process in its entirety. CNAs and other unlicensed staff can reinforce teaching and impart information, but they are not qualified to assess educational needs, nor are they competent to plan and evaluate educational activities.

There are four phases of the teaching/learning process. These phases are:

• Assessment,
• Planning,
• Implementation and
• Evaluation

Assessment

The purpose of assessment is to determine:

• the learning needs of the patient and family members,
• their level of motivation,
• personal, ethnical, religious and cultural preferences as related to learning,
• age specific characteristics and needs that influence learning,
• any cognitive, language, reading level, sensory, emotional and physical barriers to learning, and
• whether or not the patient elects to have family members and/or significant others involved in the education.

The assessment of learning needs must be:

• an interdisciplinary process, similar to other patient assessments,
• complete,
• accurate,
• timely, and
• collaboratively agreed to by the learner.

Learning needs can be assessed in a number of direct and indirect ways for both individuals and groups.

Individual learning needs are assessed by determining what the individual already knows (cognitive) or what skill they can already perform (psychomotor) in a proficient manner. Once this baseline is established, through direct questioning or observation, and it is compared or contrasted to what the patient should know or be able to do, a gap in performance or knowledge is identified. This gap is the learning need. For example, if a patient, who is taking a tricyclic antidepressant, knows little or nothing about its food-drug interactions, there is a gap. There is a gap between what the person knows and what he should know.

The patient should know about the medication's food-drug interactions as well as other things about it. The learning need is the lack of knowledge about tricyclic antidepressants. The goal of the teaching, therefore, would be to provide the patient with a thorough knowledge of tricyclic antidepressants. This patient had a gap between what they already knew and what they should know. The gap between what the person knows and what they should know (cognitive domain) is the learning need.

Likewise, if a physical therapist observes that a patient is not walking with crutches in a safe and proper manner, a learning need has been assessed. This person is demonstrating that there is a gap between what they can do and what they should do (psychomotor domain). A learning need has been identified.

Learning needs can also be indirectly assessed. For example, if a post operative patient returns to the emergency room 2 days after discharge with a wound infection, it is possible that the post operative teaching about wound care was not effective. The patient must know how to care for the wound at home in order to reduce the risk of infection. The visit to the emergency room may indicate that this self-care is not being done properly, as it should. A learning need relating to wound care is indirectly identified because this patient has returned to the hospital with a wound infection.

Similarly, learning needs for groups can also be assessed indirectly with the analysis of aggregated data. For example, if infection control data indicates a high rate of postoperative pneumonia or if performance improvement data over time reveals that the functional status of patients, after suffering a stroke (CVA), does not meet or exceed the national or local benchmark, there is a problem. A gap exists between what should be and what actually is. Further exploration may reveal that postoperative patients need more or more effective coughing and deep breathing instruction and that CVA patients and/or family members have a learning need relating to exercise.

Learning Need = What Should Be Known Minus What is Actually Known Or What Should Be Done Minus What is Actually Done

Assessment Techniques:

• Observation
• Patient & Family Interview
• Survey
• Focus Group Research
• Data Generated With The Following and Other Activities:
  • Quality Assurance
  • Quality Control
  • Performance Improvement
  • Root Cause Analysis
  • Customer Satisfaction Surveys
  • Other Questionnaires
  • Infection Control Data
  • Peer Reviews
  • Utilization Review
  • Length of Stay Statistics
  • Unanticipated Returns to the Hospital After Discharge
  • Unanticipated Doctor Visits After Discharge

Other than identifying learning needs, the following should also be assessed:

• Is the learner motivated to learn? How can their level of motivation be increased? Will the child be motivated to learn with a game or a prize? Will the adolescent be motivated to learn with peer group learning? Will the adult be motivated to learn after being informed that knowledge has help millions of diabetics to gain control over diabetes?
   
• What personal beliefs and preferences does the patient have? Does the patient prefer to learn with reading material, a videotape or one-to-one with the healthcare teacher? Does the child believe that they can perform an aspect of self-care?
   
• What cultural, religious and ethnical preferences exist that require a modification of a teaching plan? How can the patient's ethnical preference for a high carbohydrate diet be incorporated in the dietary teaching plan? How can religious fasting be addressed?
   
• What age related characteristics and needs must be incorporated into the teaching plan? How will the school age child's need to be industrious affect and be affected by the learning? In what way can the young child's need to manipulate objects in order to learn be incorporated into the teaching episode?
   
• What cognitive, language, reading level, sensory, emotional and physical barriers to learning exist? Is a family member able to learn how to provide basic care for an elderly spouse with severe dementia? Is there a foreign language interpreter available to assist with the teaching of those who do not speak or comprehend the English language? Are the educational reading materials at a grade level that can be comprehended by the nine year old? Are large print materials available to those with a visual impairment? Does the patient have a lack of fine motor coordination? How can a physical impairment, such as a lack of fine motor coordination, be overcome as the patient learns how to draw up insulin for self-injection?

Planning

The purpose of planning is to ensure that the patient and family teaching is:

• Appropriate and specific to the identified learning needs of the patient and family members,
• Able to be evaluated in terms of effectiveness,
• Consistent with the domain of knowledge, the level of the domain, the individual or group preferences, learning styles, cultural, ethnical, religious and age related needs, and
• Modified according to any assessed and identified barriers to learning (cognitive, language, reading level, sensory, emotional and physical).

The planning of patient and family education must be:

• an interdisciplinary process, similar to other patient care planning,
• complete,
• accurate,
• timely, and
• collaboratively agreed to and participated in by the learner.

Planning consists of:

• Generating learning objectives
• Deciding on a teaching strategy
• Determining the length or duration of the teaching session or episode
• Deciding upon and preparing for the use of learning resources, such as a medical model, a video tape, reading material etc.
• Logistics, such as time of day and physical location determinations
• Consideration of the need for modifications based on need, preferences and potential barriers

Learning Objectives

Learning objectives guide the teaching process and enable us to evaluate the outcomes and effectiveness of the teaching.

Learning objectives must be:

• Specific
• Measurable and behavioral
• Learner, not teacher oriented
• Consistent with the assessed need
• Congruent with the domain and level of knowledge

Specific Learning Objectives: List the basic food groups.	Non Specific Learning Objectives: Discuss food.
Measurable/ Behavioral Learning Objective: Demonstrate coughing and deep breathing	Non Measurable & Non Behavioral: Understand how to cough and deep breathe
Learner Oriented Learning Objective: The learner will be able to describe the food-drug interactions of tricyclic antidepressants.	Teacher Oriented Learning Objective: The social worker will instruct the patient about community resources.
Objective That is Consistent With The Domain: The learner will be able to demonstrate proper wound care.	Objective That is NOT Consistent With The Domain: The learner will be able to describe proper wound care.
Objective That is Consistent With The Level of the Domain: Categorize (synthesis) the degree of risk associated with multiple & complex risk factor relationships (synthesis)	Objective That is NOT Consistent With The Level of the Domain: List (knowledge) the degree of risk associated with multiple & complex risk factor relationships (synthesis)

The best way to write learning objectives is to begin the list of learning objectives with the statement, "At the conclusion of the teaching, the learner will be able to:" and then start the statement with a measurable verb that is consistent with the domain and domain level.

Verbs for Each Domain and Level

COGNITIVE DOMAIN
Knowledge	Define Describe Identify Label List Name Select State	Comprehension	Distinguish Explain Infer Summarize Predict Interpret Estimate
Application	Modify Relate Produce Apply	Analysis	Break Down Analyze Differentiate Discriminate Outline Subdivide Separate
Synthesis	Compile Categorize Design Generate Organize Revise Reconstruct	Evaluation	Conclude Contrast Criticize Contrast Support Appraise
PSYCHOMOTOR DOMAIN
Perception	Choose Detect Isolate Select Relates	Set	Move Proceed Respond Demonstrate Desire to...
Guided Response	Perform Calibrate Use Apply Self Inject Assemble	Mechanism   Same as Guided Response:	Perform Calibrate Use Apply Self Inject Assemble
Complex Overt Response   Same as Guided Response:	Perform Calibrate Use Apply Self Inject Assemble	Adaptation	Alter Change Adjust Modify Adapt Reorganize Revise Vary Procedure for...
Origination	Create Originate Arrange Combine Design
AFFECTIVE DOMAIN
Receiving	Ask Reply	Responding	Assist Comply Present Recite
Valuing	Explain Demonstrate a Belief in... Show a Commitment to... Show a Concern for...	Organization	Synthesize Accept Personal Responsibility For... Accepts Personally Integrate
Characterization   By A Value	Consistently Demonstrate Influence Others to... Always Practice...

Teaching Strategies

Teaching strategies, also referred to as teaching methodologies, must also be consistent with the identified learning need, the learning objectives, the domain and level of the domain that you wish to address.

For example, each learning need should be addressed with a separate learning objective and a correlate teaching methodology when the multidisciplinary team has assessed multiple learning needs. If a patient with chronic pain has the need to learn about the use and application of a TENS machine and some nonpharmaceutical pain management techniques and the patient's family has to overcome their unwillingness to accept the patient's desires to not have any life sustaining measures, the following domains, levels, objectives and teaching strategies are appropriate:

ASSESSED NEED	DOMAIN
TENS Machine Use	Psychomotor
Pain Interventions	Cognitive
Acceptance of Other's Wishes	Affective
	DOMAIN LEVEL
TENS Machine Use	Mechanism (Psychomotor)
Pain Interventions	Comprehension (Cognitive)
Acceptance of Other's Wishes	Valuing (Affective)
	LEARNING OBJECTIVE
TENS Machine Use	The learner will apply the TENS unit according to the manufacturer's instructions.
Pain Interventions	The learner will be able to relate how non-pharmacological interventions effectively reduce pain.
Acceptance of Other's Wishes	The family member will internalize a belief in the self-determination rights of others.
	TEACHING STRATEGY
TENS Machine Use	Demonstration and Return Demonstration
Pain Interventions	Discussion, Reading Material or Video
Acceptance of Other's Wishes	Role Playing

Teaching Strategies Appropriate for Each Domain
COGNITIVE	Lecture Discussion Seminar Workshop Reading Material Video Tape Audio Tape Computer Assisted Instruction Case Study or Scenario Critical Incident Discussion Games Self Learning Independent Study Posters or Pictures Peer Group Learning	PSYCHOMOTOR	Live Demonstration Video Tape Demonstration Step by Step Pictures That Show The Procedure
		AFFECTIVE	Role Playing Value Clarification Exercises Other Exercises & Activities That Foster Self Examination and Change
Learning Resources Appropriate for Each Domain
COGNITIVE	Pamphlets & Books Other Reading Material Pictures & Posters Video and Audio Tapes Overhead Transparencies	PSYCHOMOTOR	Medical Models Actual Equipment Pamphlets, Books, and Pictures Showing the Skill Being Done Video Tapes
AFFECTIVE	Props to Foster Attitude, Value or Belief Change (A day in a wheelchair to promote empathy for the physically challenged)

The Duration or Length of the Teaching Session

Accurately planning the duration of a teaching session is somewhat of a challenge to even the most experienced educators because a number of variables impact upon the amount of time that is needed to effectively facilitate learning. Generally speaking, however, there are some principles that should be considered when planning the duration of the teaching/learning interaction:

• Children, the cognitively impaired and those with serious illness and pain have a short attention span. Teaching/learning sessions for these patients and family members should be brief and modified, as based on the individual's need.
   
• Learning is best accomplished with short sessions over time, when time permits. For example, a cognitive need, such as the need to learn about discharge instructions, is best accomplished with a brief session about the medications the patient will take when discharged and another session, on the following day, that teaches the patient about the community resources that could be of benefit to the patient. A psychomotor need is best met with short sessions for each step of the procedure or process with ample time in between sessions so the patient can practice, practice and practice without the stress of another's presence, particularly when the learner is affected with a physical or functional impairment.
   
• Short-term memory decreases as a function of the natural aging process. Repetition and hence, more time, may be necessary for the aging patient and/or family member(s).
   
• Heterogeneous (mixed groups of varying knowledge) and large groups tend to require more time than homogeneous (similar group members in terms of knowledge) or smaller groups.

Healthcare providers must:

• Permit ample time for questions (cognitive domain) and return demonstration (psychomotor domain) and "trying on" new behaviors (affective domain). How long will it take to move the learner from an intolerance of other cultures to the point that diversity and differences are celebrated and sought after?
   
• Effectively move the learner or learners from the known and familiar to the unknown and non-familiar (the learning objective). How long will it take to move the learner from their previously held cognitive knowledge about diabetes to how a modification of the eating habits and preferences of a diabetic Irishman who loves potatoes can promote diabetes control and their personal health?
   
• Effectively move the learner or learners from the simple to the complex? How long will it take to move the learner from understanding what diabetes is to how diet, exercise and stress all affect blood glucose?
   
• Effectively move the learner or learners from the non-threatening to the more threatening? How long will it take to move the learner from knowledge about the need for blood glucose monitoring to actually performing a finger stick on themselves?

Logistics : Time of Day and Location

The multidisciplinary team must also plan to conduct the teaching at the best time of day and the best location. Both time of day and location or environment impact upon the effectiveness of the teaching. All humans have a natural 24-hour circadian rhythm. Some people are "owls" and others are "larks". Owls do not perform or learn well in the early daytime hours. Larks do not perform or learn well in the latter part of the day. Health care providers should assess the patient and family preference for time of day for teaching and education.

In addition to circadian rhythms, there are other time of day and day of week considerations, such as:

• Geriatric patients and family members may be visually impaired to a degree that impedes their driving after darkness falls. An evening class or teaching session during the evening hours, therefore, is not appropriate.
   
• A wellness class for families may be best conducted on a Saturday during the daytime hours, based on the fact that most families have 2 working parents.

Modifying the Teaching Plan According to Age Specific Characteristics and Needs

As with most continuums, it is not always clear and exact where one category or classification ends and the next one begins. The same holds true for the age groups along the continuum of life. Age group characteristics and needs can serve as guidelines, however. They guide us with the most often found characteristics and needs within the parameters of a certain age group even though the beginning and the end of each group is not firmly concrete.

Additionally, characteristics and needs within age groups can vary from individual to individual. An older adult may demonstrate the needs and characteristics of the middle age adult and vice versa. Age specific characteristics are not considered hard and fast rules that stereotype people by their age, but instead reliable guidelines that should be considered when providing care to clients of all different ages.

Traditionally accepted age categories for the adult include the young adult, the middle aged adult and the older adult with only minor variations, as found in the literature. However, one researcher and writer Gail Sheehy (1995), has noted a shifting of traditionally accepted age group characteristics and needs as children, according to Sheehy, are growing up faster and adults are taking longer to grow old. As a result of these findings and beliefs, Sheehy has redefined the traditional adult age groups as Provisional Adulthood (18-30), First Adulthood (30-45) and Second Adulthood (after the age of 45). However, for the purpose of this course, we will use the traditionally accepted age groups and parameters.

AGE GROUP	AGE IN YEARS
Infant	Birth to one year
Toddler	One to three years
Preschool child	Three to five years
School age child	Five to twelve years
Adolescent	Twelve to eighteen years
Young Adult	Eighteen to forty four years
Middle Age Adult	Forty five to 65 years
Old Adult	Over 65

Jean Piaget, a developmental psychologist, is considered to be the leader in the area of how humans develop, from birth until age twelve, in terms of their cognitive or learning abilities. His level of expertise in this area is similar to the level of respect and expertise that Eric Erickson receives in the area of developmental tasks.

Piaget developed his theory about the stages of cognitive development after hundreds of hours directly observing and recording his observations of children of all age groups. His research suggests and supports the fact that children are able to process information and learn according to their age. Cognitive development, according to Jean Piaget, is nearly complete or totally complete by the time the individual reaches the age of fifteen when the child is able to think in an abstract manner. Piaget's stages of cognitive development are sensorimotor, pre-operations, concrete operations and formal operations (Schuster & Ashburn, 1993).

Cognitive Development

Sensorimotor. During the sensorimotor stage, the infant learns and explores the world with actual, physical manipulation of things in their environment. There are six substages in the sensorimotor stage. Pre-Operations. During the preoperational stage, the young child is not yet able to use abstract thinking or perform concrete operations like adding and subtracting using marbles or other concrete objects. Concrete Operations. During the stage of concrete operations the child is able to count and do some basic mathematic processes. They are not yet able to use abstract thinking, but they are able to add simple numbers using marbles or other concrete objects without a thorough understanding of exactly what the numbers represent and what the meaning of addition is. The number five, for example means that there are five concrete objects which the child is able to hold and manipulate concretely. Formal Operations. During the stage of formal operations the child has fully developed, complex, logical abstract thought and is able to manipulate abstract concepts.

From the moment infants are born and until approximately 2 years of age, young children learn how to separate themselves from the environment around themselves. They begin to manipulate concrete objects and to understand some of the meaning behind symbols.

During the Preoperational Stage, which begins at about the age of 2, young toddlers and preschool children begin to use and develop language and vocabulary. With these basic tools they become better able to converse with others and to communicate their needs and desires. They learn to count and begin to understand the concepts underlying the symbolic nature of numbers. They test and try things using rudimentary skills such as trial and error. They learn best by the discovery method and trial and error experimentation. They ask a tremendous number of questions. They are thirsty for knowledge. Some of their most frequently asked questions start with the word "why". "Why is the sky blue?", "Why do boats float in the tub?", "Why do I have to go to bed?" They are truly inquisitive and highly curious. Young children also begin to be able to draw conclusions, particularly when they are given materials and aids such as concrete objects to manipulate and use, during this stage.

Young preschool children also think about the results of their actions as they manipulate concrete objects. "If I put 2 blocks on top of 1 block, the 2 on the top will probably fall." After this thought the young child will then attempt to place and balance the 2 blocks on only 1 and, through the process of discovery they will be able to come to the conclusion that placing 2 blocks on only block will result in the tumbling of the top 2. Later, through the process of trial and error, the pre-operational child will be able to build a pyramid of blocks that is stable and able to stand.

After this stage, at about age 7, children move into the Concrete Operations Stage. During the Concrete Operations Stage the young school age child begins to perform complex mental operations and logical reasoning. Cognitive development then continues until it has reached its fullest development, typically between the ages of 12 and 15. This final cognitive development occurs during the Abstraction Stage. During this time the adolescent learns to think in a highly abstract way. They no longer require concrete items to manipulate for learning and thought. At this point, Piaget believes that children have completed the development of their cognitive processes (Schuster & Ashburn, 1993).

Summary of Cognitive Development

Age	Stage	Features
Up to 2 years	Sensorimotor thought	6 substages Physical manipulation of objects
2 to 7 years	Preoperational symbolic functioning	Language development
7 to 11 years	Concrete operations	Logical reasoning Can solve concrete problems
11 to 15 years	Formal operations	Fully developed, complex, logical abstract thought Manipulation of abstract concepts

Age related characteristics and needs have implications on how we plan and implement patient/family education.

An infant is cognitively unable to learn health related information and obviously unable to even ask a question, therefore, the obvious focus of the teaching will certainly be the caregiver(s), usually the parent(s). Teaching about the care and condition of the infant should be, therefore, planned with consideration for the physical, cognitive and sensory characteristics of the learner, that is, the caregiver(s). If the caregiver is an elderly grandmother, the teaching must be modified according to the age related characteristics and needs typically found in the older adult age group and as appropriate to this particular grandmother.

Toddlers, on the other hand, have an ability to learn some things when the material is presented in an age appropriate manner. Teaching the toddler should consist of short, concrete explanations at their level of understanding since they have a short attention span and are concrete thinkers. Very often dolls, puppets, pictures and stories are useful teaching aides for the toddler.

Motivation is a pre-requisite to learning. As we attempt to motivate our patients for a learning activity, our choice of technique should also be appropriate to the age of the client. For example, a school age child who enjoys reading will be motivated to learn about their upcoming surgery if they were provided with an attractive, colorful and interesting book that is written at the appropriate reading level.

An adolescent, on the other hand, may be motivated in a group learning activity with peers of a similar age, particularly if they have a common illness or health care concern.

A young and middle aged adult will be motivated to learn if we are able to facilitate their understanding of how the management of their disease or their post operative care, for example, will enable them to return to work, something that is developmentally characteristic of these age groups.

The need for effective communication while teaching also necessitates variation according to some of the guidelines provided to us with scientifically based age specific characteristics and needs. Some communication techniques that are most effective for each of the age groups include:

• Infant - soothing touch, being held and lullabies
• Toddler - simple concrete terms and short discussions
• Pre-School Child - simple terms and moderately brief discussions
• School Age Child - encouragement of questions and more detailed explanations, as based on level of understanding and cognition
• Adolescent and Adults - encourage questions and communicate at a level understandable to the receiver of the message

Summary of Age Specific Learning Characteristics

INFANT

• Limited ability to communicate needs
• Differentiates primary caregiver from others
• Unable to recognize dangers
• Begins to learn by imitation
• Begins to manipulate and move objects
• Begins to follow simple commands
• Towards the end of the year may speak a few words and mimic sounds

Patient Education Implications

• All teaching is directed to the primary caregivers
• Emphasis on preventative care, immunizations, nutrition, bonding and safety
• Allow caregiver time to ask questions and return demonstrate procedures
• Encourage caregiver to participate in care to decrease the infant's separation anxiety
• Provide emotional support to the family
• Provide tactile stimulation and motor skill development with age appropriate and safe toys of large size and without small pieces

TODDLER

• Preoperational
• Better able to verbally communicate needs
• Develops vocabulary
• Begins symbolic functions
• Differentiates familiar people from others
• Still unable to recognize dangers
• Short attention span
• Learns through exploration, discovery & imitation
• Seeks positive reinforcement & approval of caregiver
• Follows simple commands, understands concrete explanations
• Develops knowledge and skills with toys and storybooks, etc.
• Magical thinking
• Concept of Time is immediate and now

Patient Education Implications

• Most teaching is directed to the primary caregivers
• Emphasis continues remain on preventative care, immunizations, nutrition, parenting and safety
• Toddlers benefit from simple, short and concrete explanations and instruction, as consistent with their vocabulary
• The use of puppets, dolls, picture books and storybooks can facilitate learning and decrease of anxiety
• Allow caregiver time to ask questions and return demonstrate procedures
• Encourage caregiver to participate in care to decrease separation anxiety
• Provide emotional support to the family and the toddler
• Facilitate motor skill development with age appropriate and safe toys of large size and without small pieces

PRE-SCHOOL CHILDREN

• Pre-Operational
• Speech more intelligible. They speak using 4-6 word sentences
• Increases vocabulary by about 1,000 words
• Begins logical reasoning and abstract thought
• Learns right from wrong
• Learns name, address and phone number
• Differentiates familiar people from others
• Remains somewhat egocentric and unable to recognize dangers
• Attention span increases
• Learns from and tells stories
• Also learns through play and doing
• Imagination increases
• Learns through exploration, discovery & seeking answers to questions- The "Why Phase"

Patient Education Implications

• A sense of independence and control can be enhanced with increasingly more detailed information, as level of cognition increases
• Pre- School child is capable of some simple, uncomplicated self-care and ADLs
• Caregiver education remains important
• Emphasis continues on preventative care, immunizations, nutrition, parenting and safety
• The use of puppets, dolls and storybooks can remain useful educational resources
• Allow caregivers and the child time to ask questions and return demonstrate procedures
• Provide emotional support to the family and the child, particularly in addressing their fears of mutilation and pain

SCHOOL AGE CHILDREN

• Pre- operational in early school age years and then moves to operational, logical thought
• Learns a large variety of subjects through school teachers
• Logic and deductive reasoning replace concrete, literal and specific thinking
• May be reluctant to ask questions
• Able to articulate discomforts to some degree
• Begins to move from attention to the present and understand the meaning of the past and the future
• Increasing understanding of death and its finality
• Has a limited understanding of anatomy, bodily functions and illnesses

Patient Education Implications

• A sense of greater control independence can be enhanced with increasingly more detailed information, as level of cognition increases
• Age appropriate reading material at appropriate grade level and videotapes can be used
• Provide opportunities for decision-making and self-care
• Encourage questions and verbalization of feelings
• Group teaching sessions with peers are enjoyed

ADOLESCENTS

• Fully developed cognitive ability by the age of 15- Greater ability to abstract, think deductively and analyze
• Forms one's own opinion
• Develops creative skills
• Able to understand hypothetical situations and thought
• Beginnings of occupational identity and learning, " I want to be ..."
• May be reluctant to admit that they do not understand something
• Still has a somewhat limited understanding of body structures and functions

Patient Education Implications

• A sense of greater control independence can be enhanced with increasingly more detailed information
• Provide opportunities for decision-making and self-care
• Encourage questions and verbalization of feelings
• Group teaching sessions with peers are enjoyed

YOUNG ADULT

• Forms one's own opinions
• Life experiences add to learning
• Makes own decisions

Patient Education Implications

• Include significant other in education, as appropriate
• Provide opportunities for decision-making and self-care
• Allow the person to verbalize fears and concerns
• Emphasis is on the importance of regular physicals and health care screenings

MIDDLE AGED ADULT

• Forms one's own opinion
• Life experiences add to learning
• Makes own decisions

Patient Education Implications

• Include significant other in education, as indicated
• Provide opportunities for decision-making and self-care
• Allow the person to verbalize fears and concerns
• Emphasis is on the importance of regular physicals and health care screenings

OLDER ADULT

• Diminished short term memory and learning abilities
• Limited ability to communicate

Patient Education Implications

• Limited ability to understand
• Include significant other in education and decision making, as necessary
• Allow the person to verbalize fears and concerns
• Present material in a slow and understandable manner in short sessions
• Avoid distractions
• Possible visual and auditory impairments
• Possible physical impairments that affect functional ability to use medical equipment and perform self-care
• Use large print materials for the visually impaired
• Use simple pictures or drawings for the cognitively impaired
• Provide brief teaching sessions

Modifying the Teaching Plan According to Individual Learning Styles and Preferences

Some people learn best by listening, some by watching, some by reading and some by doing. Likewise, many learners prefer a videotape presentation, others dislike watching television and viewing videotapes. Some like to read, others do not. Many benefit from and enjoy learning on the internet. Others are "computer phobic".

Whenever possible, these individual learning styles and preferences should be accommodated for. For example, if the assessment reveals that a patient or family member has a preference for a live one-to-one discussion about the role that stress has on blood glucose levels, these preferences must be accommodated for. This patient should have a one-to-one discussion, not a videotape or group class with other diabetic patients.

Modifying the Teaching Plan According to Cultural, Language and Ethnical Background

Languages throughout the world make it possible for human beings to derive meaning from an abstract symbol, referred to as a word. Words abstractly transmit a message. The popular saying "A picture is worth a thousand words" reflects the close relationship between art and language. Communicating with and teaching those who speak a language unlike our own is challenging indeed. However, these barriers can be overcome to a great extent with some relatively simple techniques.

Effective Teaching Strategies When Language is a Potential Barrier

• Speak slowly.
   
• Clarify the perceived meaning of what you have said with the learner.
   
• Re-clarify as often as necessary until the learner understands precisely what you are saying.
   
• Clarify the meaning of questions and comments from the learner whenever necessary
   
• Attempt to master some essential foreign language phrases, particularly those that can facilitate more effective teaching with the groups of patients with which you frequently interact. For example, if your facility has a large population of Spanish speaking patients, health care providers will certainly want to learn how to ask their customers, "Tell me what you know about diabetes?", "Show me how to use this?", and "What would you like to know?" in the customer's primary language.
   
• Bridge the gap by using pictures, diagrams and graphics whenever possible during communication. They are understandable to most.

Elicit the support of a translator whenever necessary. JCAHO and other regulatory bodies require translators within healthcare facilities. Some facilities have chosen translation services, such as those offered by companies such as AT & T.

Culture also affects teaching and communication. Communication patterns and even vocabulary and terminology within a particular culture are very specific to the group. It separates the members of the group, or culture, from those who do not belong to the culture because these patterns are not understandable to those outside the culture, something not conducive to effective patient and family teaching when the goal is to transmit thoughts to those outside of the health care culture.

Culture and ethnicity are often viewed as identical concepts, however, in terms of communication this is sometimes, but not always the case. For example, health care professionals, engineers, chefs, librarians, nurses, pharmacists and doctors in America all have their own culture.

Every culture, however, whether ethnically associated or not, has a unique vocabulary. Those outside of the particular culture find the vocabulary, slang and terminology totally foreign and unintelligible. For example, a health care professional may tell a patient that they must be "NPO" after midnight instead of being interculturally competent and telling the patient that they can have nothing to eat or drink after midnight. For more information about the cultural diversity around the globe, check the Web of Culture website at http://www.webofculture.com/home/analysis.html.

Effective Patient/Family Education Through Intercultural Competency

• Become culturally competent. Learn as much as possible about the cultures, norms and gestures of others.
   
• Modify your terminology and behavior according to what is understandable and acceptable to those receiving your message.

Overcoming Barriers to Learning:

Physical, Cognitive, Sensory and Psychological/Emotional Barriers

Overcoming Physical Barriers

Some examples of how potential and actual physical barriers to patient teaching can be overcome include:

• Patient and family members not physically able to get to a class require either assistance from staff to get them there or they should have one to one teaching in their room.
   
• Children without fine motor coordination are not able to help nurses change their surgical dressing without the provision of a considerable amount of time and physical assistance.
   
• Older adults, as well as younger clients, with a functional disability may require an assistive device or the assistance of the teacher to perform a psychomotor skill. They may also require more time to practice the skill in order to compensate for the disability.
   
• Encourage the participation of family members and significant others in the teaching/learning activities as well as in the care of the patient, as appropriate.

Overcoming Cognitive Barriers

Some examples of how cognitive barriers to patient teaching can be overcome include:

• Provide brief teaching sessions.
• Speak slowly.
• Use simple, understandable explanations.
• Promote clarification and re-clarification.
• Repetition facilitates learning.
• Use assistive devices. For example, a monthly or weekly pill container is a helpful way for the cognitively impaired to remember to take their medications.

Overcoming Sensory Barriers

Ways to accommodate for sensory impairments include:

• Braille reading materials are necessary for the blind.
• Speak loudly enough for the auditory impaired.
• Provide large print materials for the visually impaired.
• Use appropriate assistive devices to facilitate psychomotor skill for the visually impaired. For example, a syringe magnifier and an auditory blood glucose monitor greatly assist some diabetic patients to draw up their insulin and monitor their blood glucose levels.
• Encourage the participation of family members and significant others in the teaching/learning activities as well as in the care of the patient, as appropriate.

Overcoming Emotional/Psychological Barriers

Some examples of how emotional and psychological barriers to patient teaching can be overcome are as follows:

• Establish trust.
• Maintain an open, trusting environment.
• Reinforce learning with positive feedback.
• Mild anxiety promotes learning. Severe anxiety prohibits learning. Alleviate anxiety prior to learning and when teaching an anxiety provoking piece of knowledge or skill, move from the least threatening aspect to the most threatening aspects, slowly and according to the patient's responses.
• Encourage the participation of family members and significant others in the teaching/learning activities as well as in the care of the patient, as appropriate.

IMPLEMENTATION

The establishment of an environment conducive to learning and modifying the established teaching plan, as indicated with formative evaluation are critical components of the implementation phase of the teaching/learning process.

An Environment Conducive to Learning

The environment in which the teaching takes place should be environmentally comfortable in terms of heating and cooling as well as seating. It should be well lit and transmit a feeling of mutuality. A classroom style environment with rows of chairs and desks and a podium is not ideal for most adult learning situations.

In addition to the physical aspects of the environment, there are also a multitude of non-physical attributes in the environment that affect the effectiveness of the education provided. For example, an open, accepting, respectful, trusting environment, that encourages feedback and questions from the learners and where all can freely express their feelings and thoughts and where all are listened to in a respectful and open manner, foster learning and the achievement of learning objectives.

EVALUATION

Formative Evaluation

Formative evaluation is defined as the continuous assessment of how effective the learning is during the time that the learning activity is being implemented. The purpose of formative evaluation is to allow for the modification of an established teaching plan if, during the course of the learning activity, it does not appear that the outcomes are being successfully achieved. For example, if the teaching plan consisted of a videotape about the proper diet after a heart attack and the learner is not able to capture the concepts surrounding cholesterol and fats, it may be necessary to alter the plan and have, instead, a brief discussion about cholesterol which is then followed with the discussion of some printed material on cholesterol. On the next day, you may then want to proceed with the discussion of dietary fat.

If the formative evaluation is not satisfactory, you may want to consider whether or not:

• The learning objectives were realistic
• The learner is committed to the learning objectives
• The teaching methodology is appropriate to the content, the individual's learning style and preference, etc
• Any previously unassessed barriers to learning exist
• The time allocation is adequate
• The reading material is at the appropriate grade level of reading
• The environment is conducive to learning
• Other factors are impeding learning

Summative Evaluation

Summative evaluation allows us to determine if the education provided has achieved the established learning objectives for the individual or group and if the learning activity has successfully closed the gap between what should be and what actually is.

When learning objectives are achieved the education has been effective. When one or more learning objectives have not been achieved, the education has not been effective and, therefore, the teacher must return to the assessment phase of the process to validate the accuracy of needs, then to the planning phase to determine whether or not this phase is educationally sound and make any necessary modifications needed to achieve desired outcomes during future re-teaching sessions.

Evaluation is more than a "smile-ometer" that consists of a survey that asks how the learner felt about the room, the teacher and their satisfaction with the educational activity.

Evaluation consists of comparing the outcome knowledge or skill to the established learning objective. Does the outcome skill or knowledge match the learning objective? If it does, the teaching has been effective. If, however, the outcome skill or knowledge after the educational activity does NOT match the pre-established learning objective, the activity has not been effective and the entire process must be repeated.

Be aware of the fact that learning is not always permanent. It is important for health care providers to periodically assess the patient to determine if the knowledge or skill has been retained over time. Learning reinforcement is necessary when the knowledge or skill has not been retained.

Summative Evaluation Immediately After The Learning

Immediate evaluation strategies that are appropriate for each of the domains include:

Cognitive:

• Oral questioning
• Written tests
• Puzzles like a crossword puzzle
• A jeopardy type game

Psychomotor:

• Return demonstration

Affective:

• Changed belief, attitude or value

Outcome Evaluation: Long Term Summative Evaluation and Aggregated Evaluation Of Learning Activities Over Time

• Has the patient, family member or the group retained the learning over time?
• Did the patient call the physician when they experienced a suspected adverse drug reaction?
• Have the number of times a bi-polar patient needs hospitalization decreased after individualized teaching about medications and the need to consistently take medications?
• Have the number of pediatric patients receiving immunizations increased?
• Has the education been effective in decreasing lengths of stay for CVA patients?
• Has the education decreased the rate of postoperative pneumonia within the facility?
• Has the patient/family teaching decreased the number and frequency of unexpected returns to the emergency room or the primary physician?
• Have the number of hyperglycemia or hypoglycemic episodes decreased for diabetic patients in the community after the diabetes class?
• Have community, group and individual educational endeavors increased customer satisfaction scores?

The answers to these questions reflect the true purpose of education- a change in behavior. A change in behavior should be measurable for both individuals and groups. These changes in behavior are the true outcomes of education.

Furthermore, when a patient teaching plan has been successful, it is advisable to accept and adopt it as the standard for the entire facility in order to insure that there is no variation in process and that successful outcomes can be maintained and predictable throughout the organization. For example, if the cardiovascular disease class for elderly patients has a correlation to decreased cholesterol levels among the participants of the class, this class should be replicated without variation to perpetuate this success with other learners.

SUMMARY

Patient/family education is a critically important aspect of care. Most health care providers who have direct contact with patients participate in some or all aspects of the process. These team members must have the knowledge and skill necessary to assess, plan, implement and evaluate patient and family education.

REFERENCES

Calfas KJ, et al. (1996). "A controlled trial of physician counseling to promote the adoption of physical activity." Preventive Medicine (25:225-233).

Devine EC. (1992) "Effects of psychoeducational care for adult surgical patients: A meta-analysis of 191 studies." Patient Education and Counseling (19:129-142).

Joint Commission on Accreditation of Healthcare Organizations. (2004). Comprehensive Accreditation Manual for Hospitals.

Mullen PD et al. (1992). "A meta-analysis of controlled trials of cardiac patient education." Patient Education and Counseling (19:143-162).

Schuster C and Ashburn S. (1992). The Process for Human Development: A Holistic Life Span Approach. Boston: Lippincott.

Sheehy Gail. (1995). New Passages: Mapping Your Life Across Time. BallantineBooks.

Wilson SR, et al.(1993). "A controlled trial of two forms of self-management education for adults with asthma." American Journal of Medicine (94: 6) (564-576).

Copyright © Alene Burke 2002.

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