Issues in Patient Education

Margaret Comerford Freda, RN, EdD, CHES Authors and Disclosures Posted: 05/25/2004; J Midwifery Womens Health. 2004;49(3) 2004 Elsevier Science, Inc.

Introduction Health education has always been a vital component of nursing and midwifery care.[1] Even though "productivity" has become the bottom line in most health care systems today, providers still work hard at finding the time to teach, no matter how overscheduled their days. But patient education is becoming more difficult to accomplish due to many factors outside our control. The influx of clients of varying cultures (speaking countless languages) into the health care system, the lack of time for patient education in managed care visits, the dearth of educational materials in languages other than English, and the lack of reimbursement for time spent on patient education all make the provision of this vital service more difficult to accomplish. In addition, providers might not have been afforded specific training in the provision of patient education and, therefore, might lack skills needed to perform this activity successfully. The literature also provides strong evidence that health education materials are rarely written at appropriate literacy levels, yet they continue to be produced in this manner. There are also issues to consider for the clients we serve. Paramount among these issues are the culture from which they come, and their ability to understand verbal or written instructions, whether or not they speak English, for lack of understanding of written patient education materials can occur in English-speaking clients as well as in clients who speak other languages. Clients are routinely asked to read informed consent forms and then sign them, thus agreeing to undergo tests or procedures they may or may not fully understand. A lack of "health literacy," a concept that denotes not only the clients' ability to read but also to comprehend and act on medical instructions, can influence health outcomes. Diminished health literacy is common among ethnic minorities, as has been shown by Schillinger et al.,[2] who found that reduced health literacy was correlated with negative health outcomes, such as poor glycemic control and more retinopathy of diabetes. This article describes some current issues in patient education practice, linking some of them to ethical dilemmas.

The Increasing Need For Cultural Competence in Patient Education

The multicultural milieu of the United States mandates that providers consider culture when delivering patient education, for it is clear that the culture of the client has a major influence on her health care behaviors and on her interest in learning more about her health. "Culture" has been defined as shared practices, beliefs, customs, and values of a particular group, passed down through generations. Culture provides a sense of belonging, a sense of identity, a feeling of cohesiveness, and a sense of connectedness to those who came before and will come after.[3] Although most citizens of any country share some common cultural or societal values (i.e., embracing the same form of government), the United States stands as a model of multiculturalism, encouraging peoples of multiple ethnic cultures to blend into one society while simultaneously maintaining their original culture. Providers practicing in the United States, therefore, have the great privilege of working with women from many diverse cultures. However, with that privilege comes the obligation to learn about the cultural values and mores of each group with whom they work, adapting their clinical care to accommodate these disparate health values. This is a difficult and challenging task.

When taking cultural competence into account, therefore, developing a patient teaching program for women from a different culture than that of the midwife can be fraught with difficulty. However, Sabogal[5] has offered suggestions for how to do this effectively: Take the time to become aware of your own cultural biases and prejudices, and examine yourself for generalizations you might use routinely about cultures other than your own. Confront those biases and learn more about the cultures about which you have generalized in the past. Investigate the core cultural values of any group for whom you provide care. Most cultures have several core values on which all other values are based (i.e., "fatalismo," a core value of many Hispanic cultures, teaches that little can be done to alter one's fate. This could have a detrimental effect on patient education if not confronted. Sabogal has shown that when "fatalismo" is embraced by clients, it is essential to provide clients with stories of other people who have been cured or treated successfully for the same problem if you hope that your patient education instructions will be followed). Although it is essential to have written patient education materials available to send home with your clients, literal translations of English to another language should not be attempted. Many concepts simply cannot be translated. Rather, it is better to find a native speaker of the target language (a certified translator is the ideal) and ask that person to write the educational materials based on the English version but composed wholly new in the target language. When teaching clients who speak a different language from the provider, it is always advisable to have a qualified translator in the room. When teaching about subjects that are difficult to explain or about a topic the group might find culturally disagreeable, the use of testimonials from people in the same cultural group who have experienced the same health problem have been found to be most effective. [5]

Principles of Patient Education

Several decades ago, Knowles[15] formulated what he called the "Adult Learning Principles" ( Table 2 ). They remain today essential knowledge for people who teach adults in health settings. These adult learning principles can help us to plan effective health education programs.

1. Adults learn best when there is a perceived need. If an adult does not understand why she needs to be taught about a subject, little learning will occur. Therefore, we must be sure that our clients understand the underlying health problem we are trying to prevent or the illness we are trying to cure before we begin teaching. 2. Teaching of adults should progress from the known to the unknown. Always assess what the clients know about a topic before beginning a teaching session. Don't reteach the things they already understand, but use that extra time to teach more about the topic. 3. Teaching of adults should progress from the simpler concepts to more complex topics. When teaching about triple screening, for instance, start by asking if the client knows about Down syndrome or about spina bifida. Explain what those entities are before going on to a discussion of how to screen for those health problems and what the triple screen might show and what choices the client would be asked to make on receiving the results of the screening test. 4. Adults learn best using active participation. Classroom-type didactic lecturing is not usually interactive and should be avoided when teaching clients. Teaching sessions

about a topic in which the client is frequently asked to restate what has been discussed will inspire far more learning than a passive lecture in which the client is expected to learn simply because someone spoke to them. 5. Adults require opportunities to practice new skills. Anytime a new manual skill is required (e.g., learning how to draw up and inject insulin or learning how to detect uterine contractions), it is essential that time be spent watching the client practice these skills, giving return demonstrations of manual abilities. 6. Adults need the behavior reinforced. Teaching about health topics needs reinforcement continually. If syringe skills have been taught, be sure to ask the client to show you their technique on subsequent visits. 7. Immediate feedback and correction of misconceptions increases learning. Always ask the client to restate what you have taught. Also ask them what they have heard about this topic from their friends or relatives. It could be that the "old wives tales" they have heard from family and friends will be retained as "true," whereas our formal teaching is extinguished within several days.

Methods of Teaching
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has mandated that client and family education be a part of comprehensive care since 1993.[16] Although they have developed many standards for the provision and coordination of health education efforts, JCAHO does not suggest methods of delivering that education. Should patient education be done on a one-to-one basis, or is it better to teach in groups? Perhaps the newest methods of teaching, such as computer-aided instruction, should be used, or maybe we should be instructing our clients to use the Internet to get their information. One-to-one education is a commonly used methodology for patient education in which one provider teaches the client in an office, clinic, or hospital visit. One-to-one teaching is especially appropriate when sensitive or private topics need to be discussed, but it is not cost-effective, for it is the most time-consuming method for the provider.[17] When pregnancy-related topics must be taught often, to many women, more cost-effective methods, such as group classes, should be considered. Group teaching of clients costs less than one-to-one teaching and is very effective.[18,19]Additional advantages include group support from other group members, questions asked by group members that might not have been considered by each individual client, and the modeling of behaviors and skills by the teacher and by the group members. Group teaching is best done for general topics of interest to most clients. One innovative group methodology is Centering Pregnancy, a process of group prenatal care that combines patient education and prenatal care.[20] In group teaching, videotapes or similar technology (CDs, DVDs, etc.) are often used. Teaching clients by using videotapes as a methodology has been studied many times and has been found to be an effective way to teach, providing the tape is appropriate for the audience, is short (11 minutes or less), and delivers appropriate information.[21,22] Use of videos is an especially appropriate methodology for low literacy populations.[21,24]Videotaped education is more effective when followed by facilitation by a health care provider who can clarify information and answer questions than when used as a stand-alone method of teaching.[25] Another form of teaching using videotapes has proliferated in times of nursing shortages and economic downturns: "passive" videotaped education using videotapes running in waiting rooms. This has been studied and found to be ineffective in teaching the women most in need of quality patient education: primiparas, minority low-income women, and pregnant women under the age of 20.[21] Computers can be used to teach clients in many ways. Computer-aided instruction (CAI) can be made available at clinics or offices, or clients can be directed to rent or purchase CAI programs

to learn at home. One major limitation of CAI is that the material is rarely tailored to the specific needs of the individual client. Unfortunately, published descriptions of CAI programs have rarely included evaluative research.[26] Another important use of computers for patient education is through the use of the Internet. This type of patient education has been studied several times, although not specifically for women's health or perinatal health. Leaffer and Gonda[27] found that clients taught how to use the Internet to retrieve health information were still using it 90 days later, and 66% of them were taking the information they found on the Internet to their health care providers when they had a scheduled visit. More than 50% reported that using the Internet made them feel more satisfied with their treatments, because they felt more knowledgeable. Baker et al.[28] surveyed 4,764 individuals, finding that 40% of the respondents had used the Internet for information or advice about health or health care during the past year, and 67% reported that using the Internet or e-mail improved their understanding of symptoms, conditions, or treatments. The authors concluded that the Internet is an important tool with the potential to improve information dissemination and perhaps to improve health care delivery and outcomes. This form of health education is clearly one midwives need to keep abreast of, for it seems that clients will continue to use it and bring such information to their visits. When helping our clients to use the Internet more effectively to gain health information, we need to teach them that information on the Internet is not monitored by any regulatory body, and so they need to be careful in choosing health Web sites to use.[29]

Patient Education for the Purpose of Informed Consent

Patient education is often directed toward assisting clients to make a decision about signing an informed consent document. The health care professional who has done the teaching is affirming that the client understands enough about the ramifications of her diagnosis, procedure, or test to make an informed decision.[43] There has been a plethora of research done over the past two decades, which clearly demonstrates that clients rarely comprehend or recall even a small amount of what they have been taught in anticipation of informed consent.[44-48] PaascheOrlow et al.[49] have recently shown that even informed consent documents provided by institutional review boards exceed suggested readability standards. It is disturbing that some research has found that only 18% of clients offered an informed consent document even read it before signing.[50] In a study about whether pregnant women who were taught about maternal serum alpha feto-protein testing understood enough to fulfill the criteria for informed consent, it was found that although 80% of the women agreed to have the screening test, 38% of those women could not describe the purpose of the test, and 72% of the women thought that a negative test meant that their baby would be healthy in all respects.[51] Similar misconceptions were also found in other studies of this same subject.[46,47] The evidence is clear in the literature, but the health care community has as yet done nothing in an organized fashion to improve the teaching of clients from whom we request informed consent. Although we might decry the findings that clients understand little before signing informed consent documents, in fact there is no agreement in the literature or in the legal community about how much clients actually need to understand about the topics that require informed consent.[51,52] This, of course, means that providers have no standards to guide them for how much comprehension is acceptable. Therefore, it is incumbent on those of us who teach our clients and then request informed consent to evaluate what our clients really understand and fully document our impressions.

Conclusion
Patient education is an essential component of the care provided by nurses and midwives. Although finding the time to teach our clients can be difficult, we remain committed to teaching. This article has presented some of the issues apparent for patient education in the early 21st century and suggested some possible solutions. To provide the most comprehensive education to their clients, providers need to consider the importance of cultural competence, the need for additional training in how to provide effective patient education, the importance of using appropriate written materials at readability levels of sixth to eighth grade, and the ethical issues regarding how much our clients really understand before we assume they can sign "informed consent" documents. This entire area of patient education deserves additional research by dedicated clinicians.[23] 1. What is the main theme of the article? The main theme of this article is about the different issues arising from patient education nowadays in the clinical setting, especially in the hospital. It is emphasized in this article that patient education is an essential component of health care than is given primarily by us nurses. These issues pertaining to the effectiveness of client education are reflected on the negative patient health outcomes and poor understanding of the informed consent and the procedures they underwent. But along with these issues are also suggestions, ways and tips to provide adequate and effective approach to patient education, and that is by considering their culture, the use of therapeutic communication, and the use of different teaching methods with integrated technology and computer use. 2. What is the implication of the article in nursing and client education? This article implies that patient education must be a priority in the clinical setting because it is a mediator for effective patient health outcomes. It emphasizes that to provide the most comprehensive education to the clients, providers need to consider the importance of cultural competence, the need for additional training in how to provide effective patient education, the importance of using appropriate written materials at readability levels, and the ethical issues regarding how much our clients really understand before we assume they can sign "informed consent" documents. 3. How do you plan to apply the findings and implication of the article chosen? We can apply the implications of this article to our practice by following the different methods of teaching as cited here, such as the need to consider one-on-one or group teachings, and the use of modern technology to heighten up the teaching process through the use of videos, presentations, and the internet. We can also apply the tips to consider the cultural competence of our clients and how to apply it in our teachings, such as being aware of our own cultural prejudices and biases and discarding them, and to investigate on the culture of our clients for us to learn how to adjust our teaching methods. We could also apply the Adult Learning Principles for us to be guided on the proper course of effectively teaching an adult client. We should also emphasize the need to discuss properly the informed consent that they are about to give, and let the patient understand the procedure he or she will be going through, not just making the patient sign it. 4. Cite your references. http://www.medscape.com/viewarticle/478283