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Part One Perspectives on Teaching and Learning 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 2 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 3

Chapter 1 Overview of Education in Health Care Susan B. Bastable

CHAPTER HIGHLIGHTS Historical Foundations for the Teaching Role of Barriers to Teaching and Obstacles to Nurses Learning Social, Economic, and Political Trends Affecting Factors Impacting the Ability to Teach Health Care Factors Impacting the Ability to Learn Purposes, Goals, and Benefits of Client and Staff Questions to Be Asked About Teaching Education and Learning The Education Process Defined State of the Evidence Role of the Nurse as Educator

KEY TERMS ❑ education process ❑ staff education ❑ teaching/instruction ❑ barriers to teaching ❑ learning ❑ obstacles to learning ❑ patient education

OBJECTIVES After completing this chapter, the reader will be able to 1. Discuss the evolution of 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 client and staff/student education. 4. Compare the education process to the nursing process.

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5. Define the terms education process, teaching, and learning. 6. Identify reasons why client and staff/student education is an important duty for professional 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.

Education in health care today—both patient the professional nurse’s role. Another purpose is education and nursing staff/student education— to offer a perspective on the current trends in is a topic of utmost interest to nurses in every health care that make the teaching of clients a setting in which they practice. Teaching is a highly visible and required function of nursing major aspect of the nurse’s professional role care delivery. Also addressed are the continuing (Carpenter & Bell, 2002). The current trends in education efforts required to ensure ongoing health care are making it essential that clients practice competencies of nursing personnel. be prepared to assume responsibility for self-care In addition, this chapter clarifies the broad management. Also, these trends make it imper- purposes, goals, and benefits of the teaching– ative that nurses in the workplace be account- learning process; focuses on the philosophy of able for the delivery of high-quality care. The the nurse–client partnership in teaching and focus is on outcomes that demonstrate the ex- learning; compares the education process to the tent to which patients and their significant oth- nursing process; identifies barriers to teaching ers have learned essential knowledge and skills and obstacles to learning; and highlights the for independent care, or that staff nurses and status of research in the field of patient educa- nursing students have acquired the up-to-date tion as well as staff and student education. The knowledge and skills needed to competently focus is on the overall role of the nurse in teach- and confidently render care to the consumer in ing and learning, no matter who the audience of a variety of settings. learners may be. Nurses must have a basic pre- The need for nurses to teach others and to requisite understanding of the principles and help others learn will continue to increase in the processes of teaching and learning to carry out healthcare environment (Carpenter & Bell, their professional practice responsibilities with 2002). With changes rapidly occurring in the efficiency and effectiveness. system of health care, nurses are finding them- selves in increasingly demanding, constantly fluctuating, and highly complex positions Historical Foundations for (Gillespie & McFetridge, 2006). Nurses in the the Teaching Role of Nurses role of educators must understand the forces, both historical and present day, that have influ- Patient education has long been considered a enced and continue to influence their responsi- major component of standard care given by bilities in practice. nurses. The role of the nurse as educator is One purpose of this chapter is to shed light deeply entrenched in the growth and develop- on the historical evolution of teaching as part of ment of the profession. Since the mid-1800s, 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 5

Historical Foundations for the Teaching Role of Nurses 5

when nursing was first acknowledged as a identified course content in nursing school cur- unique discipline, the responsibility for teach- ricula to prepare nurses to assume the role as ing has been recognized as an important role of teachers of others. Most recently, the NLN devel- nurses as caregivers. The focus of teaching oped the first certified nurse educator (CNE) efforts by nurses has not only been on the care of exam (National League for Nursing, 2006) to the sick and on promoting the health of the well raise “the visibility and status of the academic public, but also on educating other nurses for nurse educator role as an advanced professional professional practice. practice discipline with a defined practice set- Florence Nightingale, the founder of modern ting” (Klestzick, 2005, p. 1). nursing, was the ultimate educator. Not only So, too, the American Nurses Association did she develop the first school of nursing, but (ANA) has for years put forth statements on the she also devoted a large portion of her career to functions, standards, and qualifications for nurs- teaching nurses, physicians, and health officials ing practice, of which patient teaching is a key about the importance of proper conditions in element. In addition, the International Council hospitals and homes to improve the health of of Nurses (ICN) has long endorsed the nurse’s people. She also emphasized the importance of role as educator to be an essential component of teaching patients of the need for adequate nutri- nursing care delivery. tion, fresh air, exercise, and personal hygiene to Today, all state nurse practice acts (NPAs) improve their well-being. By the early 1900s, include teaching within the scope of nursing public health nurses in this country clearly practice responsibilities. Nurses, by legal man- understood the significance of the role of the date of the NPAs, are expected to provide nurse as teacher in preventing disease and in instruction to consumers to assist them to main- maintaining the health of society (Chachkes & tain optimal levels of wellness and manage ill- Christ, 1996). ness. Nursing career ladders often incorporate For decades, then, patient teaching has been teaching effectiveness as a measure of excellence recognized as an independent nursing function. in practice (Rifas, Morris, & Grady, 1994). By Nurses have always educated others—patients, teaching patients and families as well as health- families, and colleagues. It is from these roots care personnel, nurses can achieve the profes- that nurses have expanded their practice to sional goal of providing cost-effective, safe, and include the broader concepts of health and ill- high-quality care. ness (Glanville, 2000). In recognition of the importance of patient As early as 1918, the National League of education by nurses, the Joint Commission (JC), Nursing Education (NLNE) in the United States formerly the Joint Commission on Accredi- (now the National League for Nursing [NLN]) tation of Healthcare Organizations (JCAHO), observed the importance of health teaching as a established nursing standards for patient educa- function within the scope of nursing practice. tion as early as 1993. These standards, known as Two decades later, this organization recognized mandates, describe the type and level of care, nurses as agents for the promotion of health and treatment, and services that must be provided by the prevention of illness in all settings in which an agency or organization to receive accreditation. they practiced (National League of Nursing Required accreditation standards have provided Education, 1937). By 1950, the NLNE had the impetus for nursing service managers to put 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 6

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greater emphasis on unit-based clinical staff and to the role of the nurse as educator. These education activities for the improvement of nurs- recommendations for the practice of nursing ing care interventions to achieve expected client include the need to: outcomes (Joint Commission on Accreditation • Provide clinically competent and coordi- of Healthcare Organizations, 2001). Positive nated care to the public outcomes of patient care are to be achieved by • Involve patients and their families in the nurses through teaching activities that must be decision-making process regarding patient centered and family oriented. health interventions More recently, the JC has expanded its expec- • Provide clients with education and tations to include an interdisciplinary team ap- counseling on ethical issues proach in the provision of patient education as • Expand public access to effective care well as evidence that patients and their signifi- • Ensure cost-effective and appropriate cant others participate in care and decision mak- care for the consumer ing and understand what they have been taught. • Provide for prevention of illness and This requirement means that providers must promotion of healthy lifestyles for all consider the literacy level, educational back- Americans ground, language skills, and culture of every client during the education process (Cipriano, In 2006, the Institute for Healthcare Im- 2007; Davidhizar & Brownson, 1999; JCAHO, provement announced the 5 Million Lives cam- 2001). paign. The campaign’s objective is to reduce the In addition, the Patient’s Bill of Rights, first 15 million incidents of medical harm that occur developed in the 1970s by the American Hos- in U.S. hospitals each year. Such an ambitious pital Association, has been adopted by hospitals campaign has major implications for teaching nationwide. It establishes the guidelines to en- patients and their families as well as nursing sure that patients receive complete and current staff and students the ways they can improve information concerning their diagnosis, treat- care to reduce injuries, save lives, and decrease ment, and prognosis in terms they can reason- costs of health care (Berwick, 2006). ably be expected to understand. Another recent initiative was the formation of The Pew Health Professions Commission the Sullivan Alliance to recruit and educate staff (1995), influenced by the dramatic changes sur- nurses to deliver culturally competent care to the rounding health care, published a broad set of public they serve. Effective health care and health competencies it believed would mark the suc- education of our patients and their families cess of the health professions in the 21st century. depends on a sound scientific base and cultural Shortly thereafter, the commission (1998) re- awareness in an increasingly diverse society. This leased a fourth report as a follow-up on health organization’s goal is to increase the racial and cul- professional practice in the new millennium. tural mix of nursing faculty, students, and staff, Numerous recommendations specific to the who will be sensitive to the needs of clients of nursing profession have been proposed by the diverse backgrounds (Sullivan & Bristow, 2007). commission. More than one half of them pertain Accomplishing the goals and meeting the to the importance of patient and staff education expectations of these various organizations calls 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 7

Social, Economic, and Political Trends Affecting Health Care 7

for a redirection of education efforts. Since the Another very important role of the nurse as 1980s, the role of the nurse as educator has educator is serving as a clinical instructor for stu- undergone a paradigm shift, evolving from what dents in the practice setting. Many staff nurses once was a disease-oriented approach to a more function as clinical preceptors and mentors to prevention-oriented approach. In other words, ensure that nursing students meet their expected the focus is on teaching for the promotion and learning outcomes. However, evidence indicates maintenance of health. Education, once done as that nurses in the clinical and academic settings part of discharge plans at the end of hospital- feel inadequate as mentors and preceptors due to ization, has expanded to become part of a com- poor preparation for their role as teachers. This prehensive plan of care that occurs across the challenge of relating theory learned in the class- continuum of the healthcare delivery process room setting to the practice environment requires (Davidhizar & Brownson, 1999). nurses not only to be up to date with clinical skills As described by Grueninger (1995), this tran- and innovations in practice, but to possess the sition toward wellness has entailed a progression knowledge and skills of the principles of teaching “from disease-oriented patient education (DOPE) and learning. However, knowing the practice field to prevention-oriented patient education (POPE) is not the same thing as knowing how to teach the to ultimately become health-oriented patient edu- field. The role of the clinical educator is a dynamic cation (HOPE)” (p. 53). This new approach has one that requires the teacher to actively engage changed the role of the nurse from one of wise students to become competent and caring profes- healer to expert advisor/teacher to facilitator of sionals (Gillespie & McFetridge, 2006). change. Instead of the traditional aim of simply imparting information, the emphasis is now on empowering patients to use their potentials, abil- Social, Economic, and ities, and resources to the fullest (Glanville, 2000). Political Trends Affecting Also, the role of today’s educator is one of Health Care training the trainer—that is, preparing nursing staff through continuing education, in-service In addition to the professional and legal stan- programs, and staff development to maintain dards put forth by various organizations and and improve their clinical skills and teaching agencies, many social, economic, and political abilities. It is essential that professional nurses trends nationwide affecting the public’s health be prepared to effectively perform teaching ser- have led to increased attention to the role of vices that meet the needs of many individuals the nurse as teacher and to the importance of and groups in different circumstances across a client and staff education. The following are variety of practice settings. The key to the suc- some of the significant forces influencing nurs- cess of our profession is for nurses to teach other ing practice in particular and the healthcare sys- nurses. We are the primary educators of our fel- tem in general (Birchenall, 2000; Bodenheimer, low colleagues and other healthcare staff per- Lorig, Holman, & Grumbach, 2002; Cipriano, sonnel (Donner, Levonian, & Slutsky, 2005). In 2007; DeSilets, 1995; Glanville, 2000; U.S. De- addition, the demand for educators of nursing partment of Health and Human Services, 2000; students is at an all-time high. Zikmund-Fisher, Sarr, Fagerlin, & Ubel, 2006): 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 8

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• The federal government has published • Healthcare professionals are increasingly Healthy People 2010: Understanding and concerned about malpractice claims and Improving Health, a document that put disciplinary action for incompetence. forth national health goals and objec- Continuing education, either by legisla- tives for the future. These goals and tive mandate or as a requirement of the objectives include the development of employing institution, has come to the effective health education programs to forefront in response to the challenge of assist individuals to recognize and ensuring the competency of practition- change risk behaviors, to adopt or main- ers. It is a means to transmit new tain healthy practices, and to make knowledge and skills as well as to rein- appropriate use of available services for force or refresh previously acquired health care. Achieving these national knowledge and abilities for the continu- priorities would dramatically cut the ing growth of staff. costs of health care, prevent the prema- • Nurses continue to define their profes- ture onset of disease and disability, and sional role, body of knowledge, scope of help all Americans lead healthier and practice, and expertise, with client educa- more productive lives. Nurses, as the tion as central to the practice of nursing. largest group of health professionals, • Consumers are demanding increased play an important role in making a real knowledge and skills about how to care difference by teaching clients to attain for themselves and how to prevent dis- and maintain healthy lifestyles. ease. As people are becoming more • The growth of managed care has resulted aware of their needs and desire a greater in shifts in reimbursement for healthcare understanding of treatments and goals, services. Greater emphasis has been the demand for health information is placed on outcome measures, many of expected to intensify. The quest for con- which can be achieved primarily sumer rights and responsibilities, which through the health education of clients. began in the 1990s, continues into the • Health providers are recognizing the 21st century. economic and social values of reaching • Demographic trends, particularly the out to communities, schools, and work- aging of the population, are requiring places to provide education for disease an emphasis to be placed on self-reliance prevention and health promotion. and maintenance of a healthy status over • Politicians and healthcare administrators an extended lifespan. As the percentage alike recognize the importance of health of the U.S. population over 65 years education to accomplish the economic climbs dramatically in the next 20 to 30 goal of reducing the high costs of health years, the healthcare needs of the baby services. Political emphasis is on pro- boom generation of the post–World ductivity, competitiveness in the mar- War II era will become greater as mem- ketplace, and cost-containment measures bers deal with degenerative illnesses and to restrain health service expenses. other effects of the aging process. 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 9

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• Among the major causes of morbidity supported by research, that client edu- and mortality are those diseases now cation improves compliance and, hence, recognized as being lifestyle related health and well-being. Better under- and preventable through educational standing by clients and their families of intervention. In addition, millions of the recommended treatment plans can incidents of medical harm occur every lead to increased cooperation, decision year in U.S. hospitals, making it making, satisfaction, and independence imperative that clients, nursing staff, with therapeutic regimens. Health edu- and nursing students be educated cation will enable patients to indepen- about preventive measures that will dently solve problems encountered reduce these incidents (Berwick, outside the protected care environments 2006). of hospitals, thereby increasing their • The increase in chronic and incurable independence. conditions requires that individuals and • An increasing number of self-help families become informed participants groups exist to support clients in meet- to manage their own illnesses. Patient ing their physical and psychosocial teaching can facilitate an individual’s needs. The success of these support adaptive responses to illness. groups and behavioral change programs • Advanced technology is increasing the depends on the nurse’s role as teacher complexity of care and treatment in and advocate. home and community-based settings. More rapid hospital discharge and more Nurses recognize the need to develop their procedures done on an outpatient basis expertise in teaching to keep pace with the are forcing patients to be more self- demands of patient and staff education. As they reliant in managing their own health. continue to define their role, body of knowl- Patient education is necessary to assist edge, scope of practice, and professional exper- them to independently follow through tise, nurses realize more than ever before that with self-management activities. their role as educator is central to the practice of • Healthcare providers are becoming nursing and should be captured to even a greater increasingly aware that client health lit- extent as part of their professional domain. eracy is an essential skill if health out- Nurses are in a key position to carry out health comes are to be improved nationwide. education. They are the healthcare providers Nurses must attend to the education who have the most continuous contact with needs of their clients to be sure that clients, are usually the most accessible source of they adequately understand the infor- information for the consumer, and are the most mation required for independence in highly trusted of all health professionals. In self-care activities to promote, maintain, Gallup polls taken since 1999, nurses continue and restore their health. to be ranked No. 1 in honesty and ethics among • There is a belief on the part of nurses 45 occupations (Mason, 2001; McCafferty, 2002; and other healthcare providers, which is Saad, 2006). 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 10

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Purposes, Goals, and Because many health needs and problems are handled at home, there truly does exist a need to Benefits of Client and Staff educate people on how to care for themselves— Education both to get well and to stay well. Illness is a nat- ural life process, but so is mankind’s ability to The purpose of patient education is to increase learn. Along with the ability to learn comes a the competence and confidence of clients for natural curiosity that allows people to view new self-management. The goal is to increase the and difficult situations as challenges rather than responsibility and independence of clients for as defeats. As Orr (1990) observed, “Illness can self-care. This can be achieved by supporting become an educational opportunity . . . a ‘teach- patients through the transition from being able moment’ when ill health suddenly encour- invalids to being self-sustaining in managing ages [patients] to take a more active role in their their own care; from being dependent recipients care” (p. 47). This observation remains relevant to being involved participants in the care today. process; and from being passive listeners to Numerous studies have documented the fact active learners. An interactive, partnership edu- that informed clients are more likely to comply cation approach provides clients the opportunity with medical treatment plans, find innovative to explore and expand their self-care abilities ways to cope with illness, and are less likely to (Cipriano, 2007). experience complications. Overall, clients are The single most important action of nurses more satisfied with care when they receive ade- as caregivers is to prepare clients for self-care. quate information about how to manage for If they cannot independently maintain or im- themselves. One of the most frequently cited prove their health status when on their own, we complaints by patients in litigation cases is that have failed to help them reach their potential they were not adequately informed (Reising, (Glanville, 2000). The benefits of client educa- 2007). tion are many. Effective teaching by the nurse Just as the need exists for teaching clients to has demonstrated the potential to: help them become participants and informed consumers to achieve independence in self-care, • Increase consumer satisfaction the need also exists for staff nurses to be exposed • Improve quality of life to up-to-date information with the ultimate • Ensure continuity of care goal of enhancing their practice. The purpose of • Decrease client anxiety staff and student education is to increase the • Effectively reduce the complications of competence and confidence of nurses to function illness and the incidence of disease independently in providing care to the con- • Promote adherence to treatment plans sumer. The goal of our education efforts is to • Maximize independence in the perfor- improve the quality of care delivered by nurses. mance of activities of daily living Nurses play a key role in improving the nation’s • Energize and empower consumers to health, and they recognize the importance of become actively involved in the plan- lifelong learning to keep their knowledge and ning of their care skills current (DeSilets, 1995). 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 11

The Education Process Defined 11

In turn, the benefits to nurses in their role as basis for nursing practice rather than an intu- educators include increased job satisfaction itive one. The education process, like the nurs- when they recognize that their teaching actions ing process, consists of the basic elements of have the potential to forge therapeutic relation- assessment, planning, implementation, and eval- ships with clients, enhanced patient–nurse uation. The two are different in that the nursing autonomy, increased accountability in practice, process focuses on the planning and implemen- and the opportunity to create change that really tation of care based on the assessment and diag- makes a difference in the lives of others. nosis of the physical and psychosocial needs of Our primary aims, then, as educators should the patient. The education process, on the other be to nourish clients, mentor staff, and serve as hand, focuses on the planning and implemen- teachers and clinical preceptors for nursing stu- tation of teaching based on an assessment and dents. We must value our role in educating oth- prioritization of the client’s learning needs, ers and make it a priority for our clients, our readiness to learn, and learning styles (Carpenter fellow colleagues, and the future members of our & Bell, 2002). The outcomes of the nursing profession. process are achieved when the physical and psy- chosocial needs of the client are met. The out- comes of the education process are achieved The Education Process when changes in knowledge, attitudes, and Defined skills occur. Both processes are ongoing, with assessment and evaluation perpetually redirect- The education process is a systematic, sequential, ing the planning and implementation phases of logical, scientifically based, planned course of the processes. If mutually agreed-on outcomes action consisting of two major interdependent in either process are not achieved, as determined operations, teaching and learning. This process by evaluation, then the nursing process or the forms a continuous cycle that also involves two education process can and should begin again interdependent players, the teacher and the through reassessment, replanning, and reimple- learner. Together, they jointly perform teaching mentation (Figure 1–1). and learning activities, the outcome of which It should be noted that the actual act of teach- leads to mutually desired behavior changes. ing or instruction is merely one component of the These changes foster growth in the learner and, education process. Teaching and instruction, it should be acknowledged, growth in the terms often used interchangeably with one teacher as well. Thus, the education process is a another, are deliberate interventions that involve framework for a participatory, shared approach sharing information and experiences to meet to teaching and learning (Carpenter & Bell, intended learner outcomes in the cognitive, 2002). affective, and psychomotor domains according The education process has always been com- to an education plan. Teaching and instruction, pared to the nursing process—rightly so, be- both one and the same, are often formal, struc- cause the steps of each process run parallel to one tured, organized activities prepared days in another, although they have different goals and advance, but they can be performed informally objectives. Both processes provide a rational on the spur of the moment during conversations 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 12

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Figure 1–1 Education process parallels nursing process.

Nursing Process Education Process

Appraise physical and psychosocial ASSESSMENT Ascertain learning needs, needs readiness to learn, and learning styles

Develop teaching plan based on mutually predetermined Develop care plan based on mutual PLANNING behavioral outcomes to meet goal setting to meet individual needs individual needs

Perform the act of teaching using specific instructional methods and Carry out nursing care interventions IMPLEMENTATION tools using standard procedures

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

or incidental encounters with the learner. iors in a learner who is receptive, motivated, and Whether formal or informal, planned well in adequately informed (Duffy, 1998). advance or spontaneous, teaching and instruc- Learning is defined as a change in behavior tion are nevertheless deliberate and conscious (knowledge, attitudes, and/or skills) that can be acts with the objective of producing learning observed or measured and that occur at any time (Carpenter & Bell, 2002). or in any place as a result of exposure to envi- The fact that teaching and instruction are ronmental stimuli. Learning is an action by intentional does not necessarily mean that they which knowledge, skills, and attitudes are con- have to be lengthy and complex tasks, but it sciously or unconsciously acquired such that does mean that they comprise conscious actions behavior is altered in some way (see Chapter 3). on the part of the teacher in responding to an The success of the nurse educator’s endeavors at individual’s need to learn. The cues that some- teaching is measured not by how much content one has a need to learn can be communicated in has been imparted, but rather by how much the the form of a verbal request, a question, a puz- person has learned (Musinski, 1999). zled or confused look, a blank stare, or a gesture Specifically, patient education is a process of of defeat or frustration. In the broadest sense, assisting people to learn health-related behav- then, teaching is a highly versatile strategy that iors that can be incorporated into everyday life can be applied in preventing, promoting, main- with the goal of optimal health and indepen- taining, or modifying a wide variety of behav- dence in self-care. Staff education, by contrast, 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 13

Role of the Nurse as Educator 13

is the process of influencing the behavior of Legal and accreditation mandates as well as nurses by producing changes in their knowl- professional nursing standards of practice have edge, attitudes, and skills to help nurses main- made the educator role of the nurse an integral tain and improve their competencies for the part of high-quality care to be delivered by all delivery of quality care to the consumer. Both registered nurses licensed in the United States, patient and staff education involve forging a regardless of their level of nursing school prepa- relationship between the learner and the edu- ration. Given this fact, it is imperative to exam- cator so that the learner’s information needs ine the present teaching role expectations of (cognitive, affective, and psychomotor) can be nurses, irrespective of their preparatory back- met through the process of education (see ground. The role of educator is not primarily to Chapter 10). teach, but to promote learning and provide for A useful paradigm to assist nurses to orga- an environment conducive to learning—to cre- nize and carry out the education process is the ate the teachable moment rather than just wait- ASSURE model (Rega, 1993). The acronym ing for it to happen (Wagner & Ash, 1998). stands for: Also, the role of the nurse as teacher of patients and families, nursing staff, and students cer- • Analyze the learner tainly should stem from a partnership philoso- • State the objectives phy. A learner cannot be made to learn, but an • Select the instructional methods and effective approach in educating others is to materials actively involve learners in the education process • Use the instructional methods and (Bodenheimer et al., 2002). materials Although by license all nurses are expected • Require learner performance to teach, few have ever had formal preparation • Evaluate the teaching plan and revise as in the principles of teaching and learning necessary (Donner et al., 2005). As you will see in this textbook, there is much knowledge and there are skills to be acquired to carry out the role as Role of the Nurse as educator with efficiency and effectiveness. Educator Although all nurses are able to function as givers of information, they need to acquire the For many years, organizations governing and skills of being a facilitator of the learning influencing nurses in practice have identified process (Musinski, 1999). Consider the follow- teaching as an essential responsibility of all reg- ing questions posed: istered nurses in caring for both well and ill clients. For nurses to fulfill the role of educator, • Is every nurse adequately prepared to no matter whether their audience consists of assess for learning needs, readiness to patients, family members, nursing students, learn, and learning styles? nursing staff, or other agency personnel, they • Can every nurse determine whether must have a solid foundation in the principles of information given is received and teaching and learning. understood? 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 14

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• Are all nurses capable of taking appro- planning, link learners to learning resources, and priate action to revise the approach to encourage learner initiative (Knowles et al., educating the client if the information 1998; Mangena & Chabeli, 2005). provided is not comprehended? Instead of the teacher teaching, the new edu- • Do nurses realize the need to transition cational paradigm focuses on the learner learn- their role of educator from being a con- ing. That is, the teacher becomes the guide on tent transmitter to being a process man- the side, assisting the learner in his or her effort ager, from controlling the learner to to determine objectives and goals for learning, releasing the learner, and from being a with both parties being active partners in deci- teacher to becoming a facilitator sion making throughout the learning process. (Musinski, 1999)? To increase comprehension, recall, and applica- tion of information, clients must be actively A growing body of evidence suggests that involved in the learning experience (Kessels, effective education and learner participation 2003; London, 1995). Glanville (2000) describes go hand in hand. The nurse should act as a this move toward assisting learners to use their facilitator, creating an environment conducive own abilities and resources as “a pivotal transfer to learning that motivates individuals to want of power” (p. 58). to learn and makes it possible for them to Certainly patient education requires a col- learn (Musinski, 1999). The assessment of laborative effort among healthcare team mem- learning needs, the designing of a teaching bers, all of whom play more or less important plan, the implementation of instructional roles in teaching. However, physicians are first methods and materials, and the evaluation of and foremost prepared “to treat, not to teach” teaching and learning should include partici- (Gilroth, 1990, p. 30). Nurses, on the other pation by both the educator and the learner. hand, are prepared to provide a holistic ap- Thus, the emphasis should be on the facilita- proach to care delivery. The teaching role is a tion of learning from a nondirective rather unique part of our professional domain. Be- than a didactic teaching approach (Knowles, cause consumers have always respected and Holton, & Swanson, 1998; Musinski, 1999; trusted nurses to be their advocates, nurses are Mangena & Chabeli, 2005; Donner et al., in an ideal position to clarify confusing infor- 2005). mation and make sense out of nonsense. No longer should teachers see themselves as Amidst a fragmented healthcare delivery sys- simply transmitters of content. Indeed, the role tem involving many providers, the nurse serves of the educator has shifted from the traditional as coordinator of care. By ensuring consistency position of being the giver of information to of information, nurses can support clients in that of a process designer and coordinator. This their efforts to achieve the goal of optimal role alteration from the traditional teacher- health (Donovan & Ward, 2001). They also can centered to the learner-centered approach is a assist their colleagues in gaining knowledge paradigm shift that requires skill in needs assess- and skills necessary for the delivery of profes- ment as well as the ability to involve learners in sional nursing care. 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 15

Barriers to Teaching and Obstacles to Learning 15

Barriers to Teaching and carry out their educator role effectively. Early discharge from inpatient and out- Obstacles to Learning patient settings often results in nurses and clients having fleeting contact with It has been said by many educators that adult one another. In addition, the schedules learning takes place not by the teacher’s initi- and responsibilities of nurses are very ating and motivating the learning process, but demanding. Finding time to allocate to rather by the teacher’s removing or reducing teaching is very challenging in light of obstacles to learning and enhancing the process other work demands and expectations. after it has begun. The educator should not In one survey by the Joint Commission, limit learning to the information that is in- 28% of the nurses claimed that they tended but should clearly make possible the were not able to provide patients and potential for informal, unintended learning that their families with the necessary instruc- can occur each and every day with each and tion because of lack of time during their every teacher–learner encounter (Carpenter & shifts at work (Stolberg, 2002). Nurses Bell, 2002). must know how to adopt an abbreviated, Unfortunately, nurses must confront many efficient, and effective approach to client barriers in carrying out their responsibilities and staff education by first adequately for educating others. Also, learners face a vari- assessing the learner and then by using ety of potential obstacles that can interfere appropriate instructional methods and with their learning. For the purposes of this instructional tools at their disposal. textbook, barriers to teaching are defined as those Discharge planning plays an ever more factors that impede the nurse’s ability to de- important role in ensuring continuity of liver educational services. Obstacles to learning care across settings. are defined as those factors that negatively 2. Many nurses and other healthcare per- affect the ability of the learner to pay attention sonnel admit that they do not feel com- to and process information. petent or confident with their teaching skills. As stated previously, although Factors Impacting the Ability to nurses are expected to teach, few have Teach ever taken a specific course on the prin- ciples of teaching and learning. The The following include the major barriers inter- concepts of patient education are usually fering with the ability of nurses to carry out integrated throughout nursing curricula their roles as educators (Carpenter & Bell, 2002; rather than being offered as a specific Casey, 1995; Chachkes & Christ, 1996; Duffy, course of study. As early as 1965, Pohl 1998; Glanville, 2000; Honan, Krsnak, Petersen, found that one third of 1,500 nurses, & Torkelson, 1988): when questioned, reported that they 1. Lack of time to teach is cited by nurses had no preparation for the teaching they as the greatest barrier to being able to were doing, while only one fifth felt 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 16

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they had adequate preparation. Almost interfere with the adoption of innova- 30 years later, Kruger (1991) surveyed tive and time-saving teaching strategies 1,230 nurses in staff, administrative, and techniques. and education positions regarding their 5. The environment in the various settings perceptions of the extent of nurses’ where nurses are expected to teach is not responsibility for and level of achieve- always conducive to carrying out the ment of patient education. Although all teaching–learning process. Lack of space, three groups strongly believed that lack of privacy, noise, and frequent inter- client and staff education is a primary ferences due to client treatment sched- responsibility of nurses, the vast major- ules and staff work demands are just ity of them rated their ability to per- some of the factors that negatively affect form educator role activities as the nurse’s ability to concentrate and to unsatisfactory. Few additional studies effectively interact with learners. have been forthcoming on the nurses’ 6. An absence of third-party reimbursement perceptions of their educator role to support patient education relegates (Trocino, Byers, & Peach, 1997). Today, teaching and learning to less than high- the role of the nurse as educator still priority status. Nursing services within needs to be strengthened in undergrad- healthcare facilities are subsumed under uate nursing education, but fortunately hospital room costs and, therefore, are an upswing in interest and attention to not specifically reimbursed by insurance the educator role has been gaining sig- payers. In fact, patient education in some nificant momentum in graduate nursing settings, such as home care, often cannot programs across the country. be incorporated as a legitimate aspect of 3. Personal characteristics of the nurse routine nursing care delivery unless educator play an important role in specifically ordered by a physician. determining the outcome of a teaching– 7. Some nurses and physicians question learning interaction. Motivation to whether patient education is effective as teach and skill in teaching are prime a means to improve health outcomes. factors in determining the success of any They view patients as impediments to educational endeavor (see Chapter 11). teaching when patients do not display an 4. Until recently, low priority was often interest in changing behavior, when they assigned to patient and staff education demonstrate an unwillingness to learn, by administration and supervisory per- or when their ability to learn is in ques- sonnel. With the strong emphasis on tion. Concerns about coercion and viola- Joint Commission mandates, the level tion of free choice, based on the belief of attention paid to the educational that patients have a right to choose and needs of consumers as well as healthcare that they cannot be forced to comply, personnel has changed significantly. explain why some professionals feel frus- However, budget allocations for educa- trated in their efforts to teach. Unless all tional programs remain tight and can healthcare members buy into the utility 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 17

Barriers to Teaching and Obstacles to Learning 17

of patient education (that is, they believe amount of information a client is it can lead to significant behavioral expected to learn can discourage and changes and increased compliance to frustrate the learner, impeding the abil- therapeutic regimens), then some profes- ity and willingness to learn. sionals may continue to feel absolved 2. The stress of acute and chronic illness, from their responsibility to provide ade- anxiety, and sensory deficits in patients quate and appropriate patient education. are just a few problems that can dimin- 8. The type of documentation system used ish learner motivation and interfere by healthcare agencies has an effect on with the process of learning. However, the quality and quantity of patient it must be pointed out that illness alone teaching. Both formal and informal seldom acts as an impediment to learn- teaching are often done (Carpenter & ing. Rather, illness is often the impetus Bell, 2002) but not written down for patients to attend to learning, make because of insufficient time, inattention contact with the healthcare professional, to detail, and inadequate forms on and take positive action to improve which to record the extent of teaching their health status. activities. Many of the forms used for 3. Low literacy and functional health illiter- documentation of teaching are designed acy has been found to be a significant fac- to simply check off the areas addressed tor in the ability of clients to make use of rather than allow for elaboration of what the written and verbal instructions given was actually accomplished. In addition, to them by providers. Almost half of the most nurses do not recognize the scope American people read and comprehend at and depth of teaching that they perform or below the eighth-grade level and an on a daily basis. Communication among even higher percentage suffer from health healthcare providers regarding what has illiteracy (see Chapter 7). been taught needs to be coordinated and 4. The negative influence of the hospital appropriately delegated so that teaching environment itself, resulting in loss of can proceed in a timely, smooth, orga- control, lack of privacy, and social isola- nized, and thorough fashion. tion, can interfere with a patient’s active role in health decision making and involvement in the teaching–learning Factors Impacting the Ability to process. Learn 5. Personal characteristics of the learner have major effects on the degree to The following are some of the major obstacles which behavioral outcomes are achieved. interfering with a learner’s ability to attend to Readiness to learn, motivation and com- and process information (Glanville, 2000; pliance, developmental-stage character- Weiss, 2003): istics, and learning styles are some of 1. Lack of time to learn due to rapid the prime factors influencing the success patient discharge from care and the of educational endeavors. 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 18

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6. The extent of behavioral changes • What are the ethical, legal, and eco- needed, both in number and in com- nomic issues involved in patient and plexity, can overwhelm learners and staff education? dissuade them from attending to and • Which theories and principles support accomplishing learning objectives and the education process, and how can they goals. be applied to change the behaviors of 7. Lack of support and lack of ongoing learners? positive reinforcement from the nurse • What assessment methods and tools can and significant others serve to block the be used to determine learning needs, potential for learning. readiness to learn, and learning styles? 8. Denial of learning needs, resentment of • Which learner attributes negatively and authority, and lack of willingness to positively affect an individual’s ability take responsibility (locus of control) are and willingness to learn? some psychological obstacles to accom- • What can be done about the inequities plishing behavioral change. (in quantity and quality) in the delivery 9. The inconvenience, complexity, inacces- of education services? sibility, fragmentation, and dehuman- • Which elements need to be taken into ization of the healthcare system often account when developing and imple- result in frustration and abandonment menting teaching plans? of efforts by the learner to participate in • Which instructional methods and mate- and comply with the goals and objec- rials are available to support teaching tives for learning. efforts? • Under which conditions should certain teaching methods and materials be used? Questions to be Asked • How can teaching be tailored to meet About Teaching and the needs of specific populations of learners? Learning • What common mistakes are made when To maximize the effectiveness of client and staff/ teaching others? student education by the nurse, it is necessary to • How can teaching and learning be best examine the elements of the education process evaluated? and the role of the nurse as educator. Many ques- tions arise related to the principles of teaching State of the Evidence and learning. The following are some of the important questions that the chapters in this The literature on patient and staff education is textbook address: extensive from both a research- and nonresearch- based perspective. The nonresearch literature on • How can members of the healthcare patient education is prescriptive in nature and team work together more effectively to tends to give anecdotal tips on how to take indi- coordinate educational efforts? vidualized approaches to teaching and learning. 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 19

State of the Evidence 19

A computer literature search, for example, different learners and in different situations reveals literally thousands of nursing and allied must be further explored (Kessels, 2003). Given health articles and books on teaching and learn- the significant incidence of low-literacy rates ing that are available from the general to the among patients and their family members, specific. much more investigation needs to be done on However, many research-based studies are the impact of printed versus audiovisual mate- being conducted on teaching specific population rials as well as written versus verbal instruction groups about a variety of topics, but only on learner comprehension (Weiss, 2003). recently has attention been focused on how to Gender issues, the influence of socioeconom- most effectively teach those with long-term ics on learning, and the strategies of teaching chronic illnesses. Much more research must be cultural groups and special populations need conducted on the benefits of patient education further exploration as well. Unfortunately, pri- as it relates to the potential for increasing the mary sources of information from nursing liter- quality of life, leading a disability-free life, ature on the issues of gender and socioeconomic decreasing the costs of health care, and manag- attributes of the learner are scanty, to say the ing independently at home through anticipatory least, and the findings from interdisciplinary teaching approaches. Studies from acute-care research on the influence of gender on learning settings tend to focus on preparing a patient for remain inconclusive. a procedure, with emphasis on the benefits of Nevertheless, nurses are expected to teach information to alleviate anxiety and promote diverse populations with complex needs and a psychological coping. Evidence does suggest range of abilities in both traditional settings and that patients cope much more effectively when nontraditional, unstructured settings. For more taught exactly what to expect (Donovan & than 30 years, nurse researchers have been study- Ward, 2001; Duffy, 1998; Mason, 2001). ing how best to teach patients, but much more More research is definitely needed on the research is required (Mason, 2001). Also, few benefits of teaching methods and instructional studies have examined nurses’ perceptions about tools using the new technologies of computer- their role as educators in the practice setting assisted instruction, online and other distance (Trocino et al., 1997). We need to establish a learning modalities, cable television, and Inter- stronger theoretical basis for intervening with net access to health information for both patient clients throughout “all phases of the learning con- and staff education. These new approaches to tinuum, from information acquisition to behav- information require a role change of the educa- ioral change” (Donovan & Ward, 2001, p. 211). tor from one of teacher to resource facilitator as Also, emphasis needs to be given to research in well as a shift in the role of the learner from nursing education to ensure that the nursing being passive to an active recipient. The rapid workforce is prepared for “a challenging and advances in technology for teaching and learn- uncertain future” in health care (Stevens & ing also will require a better understanding of Valiga, 1999, p. 278). generational orientations and experiences of the In addition, further investigation should be learner (Billings & Kowalski, 2004). Also, the undertaken to document the cost effectiveness of effectiveness of videotapes and audiotapes with educational efforts in reducing hospital stays, 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 20

20 Chapter 1: Overview of Education in Health Care

decreasing readmissions, improving the personal in how patients and families cope with their ill- quality of life, and minimizing complications of nesses, how the public benefits from education illness and therapies. Furthermore, given the directed at prevention of disease and promotion number of variables that can potentially inter- of health, and how staff and student nurses gain fere with the teaching–learning process, addi- competency and confidence in practice through tional studies must be conducted to examine the education activities that are directed at contin- effects of environmental stimuli, the factors uous, lifelong learning. Many challenges and involved in readiness to learn, and the influences opportunities are ahead for nurse educators in of learning styles on learner motivation, com- the delivery of health care as this nation moves pliance, comprehension, and the ability to apply forward in the 21st century. knowledge and skills once they are acquired. The teaching role is becoming even more One particular void is the lack of information in important and more visible as nurses respond to the research database on how to assess motiva- the social, economic, and political trends tion. The author of Chapter 6 proposes param- impacting on health care today. The foremost eters to assess motivation but notes the paucity challenge for nurses is to be able to demonstrate, of information specifically addressing this issue. through research and action, that definite links Although it was almost 20 years ago that exist between education and positive behavioral Oberst (1989) delineated the major issues in outcomes of the learner. In this era of cost con- patient education studies related to the evaluation tainment, government regulations, and health- of the existing research base and the design of care reform, the benefits of client, staff, and future studies, the following four broad problem student education must be made clear to the categories she identified remain pertinent today: public, to healthcare employers, to healthcare providers, and to payers of healthcare benefits. 1. Selection and measurement of appropri- To be effective and efficient, nurses must be ate dependent variables (educational willing and able to work collaboratively with outcomes) other members of the healthcare team to provide 2. Design and control of independent vari- consistently high-quality education to the audi- ables (educational interventions) ences they serve. 3. Control of mediating and intervening The responsibility and accountability of nurses variables for the delivery of care to the consumer can be 4. Development and refinement of the accomplished, in part, through education based theoretical basis for education on solid principles of teaching and learning. The key to effective education of our audiences of Summary learners is the nurse’s understanding of and ongo- ing commitment to the role of educator. Nurses are considered information brokers— educators who can make a significant difference 46436_CH01_001-024.qxd 11/19/07 11:09 AM Page 21

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REVIEW QUESTIONS 1. How far back in history has teaching been a part of the professional nurse’s role? 2. Which nursing organization was the first to recognize health teaching as an important function within the scope of nursing practice? 3. What legal mandate universally includes teaching as a responsibility of nurses? 4. How have the ANA, NLN, ICN, AHA, JC, and PEW Commission influenced the role and responsibilities of the nurse as educator? 5. What current social, economic, and political trends make it imperative that clients and nursing staff be adequately educated? 6. What are the similarities and differences between the education process and the nurs- ing process? 7. What are three major barriers to teaching and three major obstacles to learning? 8. What common factor serves as both a barrier to education and as an obstacle to learning? 9. What is the current status of research- and non-research-based evidence pertaining to education?

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