An Approach to Teaching
Patients in the Hospital
R. Neal Axon, MD, MSCR
2012
Patient Misunderstandings
Are Common…
• Among Patients Discharged from the
Hospital…
– 41% able to state discharge diagnosis(es)
– 37% able to recount the purpose of all
medications
– 28% able to list all their medications
– 14% able to state common side effects of
meds
Makaryus AN.Mayo Clin Proc.2005.
How Adult Learners are
Different…
Malcolm S. Knowles. 1913-1997.
Learning Objectives
•
•
•
Knowledge:
– Summarize basic principles of adult learning as summarized, for example,
by Knowles.
– Describe basic methods of learner assessment in patient education.
Skill:
– Demonstrate techniques for reflective listening in patient assessment of
disease knowledge.
– Demonstrate the visual, auditory, kinesthetic (VAK) framework for
assessing learning preferences.
– Practice using "SOS" questions to assess for low health literacy.
– Practice assessing a patient's motivational stage of change for a given
health behavior.
Attitude:
– Acknowledge that proscriptive advice giving is not always a productive
means for stimulating behavior change.
– Pay attention to principles of learner assessment in preparing for patient
education.
A Common Approach to Patient
Education…
Step 1: Go teach the
patient.
A Better Approach to Patient Education
Step 5:
Evaluate
Learning
Process
Step 1: Assess
patient
knowledge,
learning styles,
and motivation
Step 2: Assess
barriers to
learning
Step 4: Go teach
the patient.
Step 3: Set
educational goals
with patient
Stromberg A. Eur. J. Heart Failure. 2005.
Step 1: Assessment
Disease-Specific Knowledge
• General Questions.
– “Why do you think you feel short of
breath?”
– “Tell me what heart failure means to you?”
– “What things do you need to do to take
care of your heart failure?”
Perceived Importance of CHF
Topics
Patients
Nurses
Rank
Topic
Rank
Topic
1.
Medications
1.
Signs/Symptoms
2.
Signs/Symptoms
2.
Medications
3.
General Information (i.e.
anatomy/physiology)
3.
Diet
4.
Risk Factors
4.
Risk Factors
5.
Prognosis
5.
General Information (i.e.
anatomy/physiology)
6.
Activity
6.
Activity
7.
Psychological (i.e. coping)
7.
Psychological (i.e. coping)
8.
Diet
8.
Prognosis
Wehby RN. Heart and Lung. 2005.
Step 1: Assessment
Learning Styles
Type of Learner
Characteristics
Sample Approaches to
use in teaching
Visual
Prefers pictures,
diagrams, other visuals
Use of copious visual
aids, process algorithms,
and trigger cards
Auditory
Prefers to learn via verbal Use oral descriptions,
instruction; visuals may
lectures, podcasts
distract learners
Kinesthetic
Prefers to learn via
movement and hands-on
activities
Use demonstrations,
simulations, role playing,
as well as discussion
groups, where possible
Eschelman KY. Prog Transplantation.2008.
Fleming ND. A Guide to Learning Styles.2008.
Step 1:
Assessment
Motivation to
Change
Paradis V. J. Cardiovascular Nursing.2010.
Step 2: Barriers
Health Literacy
• 3 General Questions:
1. “What was the highest grade you completed in
school?”
2. “How would you rate your ability to read?”
3. “How often do you need to have someone help
you when you read instructions, pamphlets, or
other written material from your doctor or
pharmacy?”
Assessing Health Literacy:
SOS Method
Stands for…
Question Topic
Cut Point
Odds Ratio
S
O
"Schooling"
Educational
attainment
Sub-Secondary (6th
grade or less)
1.89
"Opinion"
Patient self-rating
of reading ability
"Okay" or worse on a 5
point scale (Excellent or
very good, Good, Okay,
Poor, Terrible or very
poor)
3.37
S
"Support"
Help when
reading
Sometimes or worse on a 2.03
5 point scale (Never,
Rarely, Sometimes,
Often, Always)
Letter
Jeppesen KM, Ann Fam Med. 2009.
Additional Barriers to
Learning…
• Functional
–
–
–
Visual Impairment
Hearing Impairment
Decreased mobility
• Illness-Related
–
–
Pain
Fatigue
• Cognitive Impairment
–
–
Dementia
Delirium
• Depression
Stromberg.EurJCard.2005.
Step 3: Goal Setting
• Potential Statements:
– “What would you like to learn more about
with regards to your heart failure?”
– “It sounds like you understand a lot about
how heart failure works. How comfortable
are you with managing all the medicines?”
– “What are your goals before leaving the
hospital or after you get home?”
Step 4: Go Teach the Patient
• Begin with knowledge of patient’s understanding of
his/her disease, learning styles, and motivation
• Understand and adapt to barriers to learning
• Present material in multiple formats, over multiple
episodes, and in coordination with other care team
members
Teach Back
NEW CONCEPT: Health
information, advice,
instructions, or change
in management
Assess patient
comprehension /
Ask patient to
demonstrate
Explain new concept /
Demonstrate new skill
Clarify and tailor
explanation
Patient recalls and
comprehends /
Demonstrates skill mastery
Adherence /
Error reduction
Re-assess recall and
comprehension / Ask
patient to
demonstrate
Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90
References
•
•
•
•
•
•
•
•
Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge.
Mayo Clin Proc. Aug 2005;80(8):991-994.
Knowles MS, Holton EF, Swanson RA. The Adult Learner. 5th ed. Woburn, MA: Butterworth-Heinemann;
1998.
Wehby D, Brenner PS. Perceived learning needs of patients with heart failure. Heart Lung. Jan-Feb
1999;28(1):31-40.
Eshleman KY. Adapting teaching styles to accommodate learning preferences for effective hospital
development. Prog Transplant. Dec 2008;18(4):297-300.
Paradis V, Cossette S, Frasure-Smith N, Heppell S, Guertin MC. The efficacy of a motivational nursing
intervention based on the stages of change on self-care in heart failure patients. J Cardiovasc Nurs. MarApr 2010;25(2):130-141.
Jeppesen KM, Coyle JD, Miser WF. Screening questions to predict limited health literacy: a cross-sectional
study of patients with diabetes mellitus. Ann Fam Med. Jan-Feb 2009;7(1):24-31.
Stromberg A. The crucial role of patient education in heart failure. Eur J Heart Fail. Mar 16 2005;7(3):363369.
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients
who have low health literacy. Arch Intern Med. Jan 13 2003;163(1):83-90.
Additional Resources
• London, F. No Time to Teach: The
Essence of Patient and Family
Education. (2009). Atlanta, GA. Prichett
& Hull Associates.
• The Institute for Patient and Family
Centered Care (http://www.ipfcc.org/)