Patient Education
Patient education is an important component of care. An increasing number of cancer patients are undergoing multiple treatment modalities, and they need knowledge and skills to cope with them. It is estimated that more than 30% of Americans will be faced with a diagnosis of cancer, presenting a challenge to health care providers in terms of sheer numbers.
Recent changes in health care and the health care system have also underscored the importance of patient education. Among these changes are the emphasis on health promotion, patients’ rights, and cost containment (with the resulting move toward home health care). Standards by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) mandate that hospitals operationalize policies to ensure “the right of the patient, in collaboration with his/her physician, to make decisions involving his/her health care… and the right of the patient to the information necessary to enable him/her to make treatment decisions that reflect his/her wishes” (JCAHO, 1998). This expanded role can give the patient a sense of control and build self-esteem. Because of the emphasis on cost containment, lengths of stay have been shortened, reducing the amount of time available for patient education. The rapid growth of technology and the availablity of medical devices for the administration of various conventional chemotherapeutic drugs and immunological agents have shifted clinical care to the outpatient and home settings. Patients and caregivers need to be taught about equipment such as venous access devices and ambulatory infusion pumps, to name just a few. This expectation for
more active participation puts added demands and reponsibilities on the patient and his or her family.
more active participation puts added demands and reponsibilities on the patient and his or her family.
The major areas of education that a cancer patient needs are treatment options, side effects of the treatment modalities, management of side effects, coping mechanisms and support systems, treatment devices, self-care activities, and management at home. Patients who are educated in these areas are more likely to cooperate with the treatment regimen, suffer fewer side effects, and experience less anxiety and stress (Adams, 1992).
All of these areas involve the three domains of learning: cognitive, affective, and psychomotor. The cognitive domain comprises behaviors that deal with the recall or recognition of knowledge and the development of intellectual skills, such as being able to identify the common side effects of a chemotherapeutic agent. Affective learning relates to the patient’s attitudes, feelings, and coping mechanisms, such as being able to deal with the side effects of anticancer agents and the changes in appearance and lifestyle. The psychomotor domain relates to behaviors that affect the performance of skills, such as caring for a venous access device or troubleshooting a problem with an ambulatory infusion pump.
The Dot.com: The Role of the Internet in Patient EducationThe Internet has revolutionized patient education. With the growing number of computers at home, at work, in the community, and in schools, the Internet provides a steady and convenient way to obtain information. Some patients may seek medical information online because they do not receive it from their health care provider. However, there is growing concern over the quality of the information available on the Internet, and patients may need help evaluating the information they find. The nurse should ask the patient specific questions about what information he or she is seeking online. Does that information match what was already given? What needs reinforcement? How can the online information add to the patient’s understanding of the treatment plan? The nurse can play a pivotal role in providing education and helping patients evaluate the information they find on their own.
Nursing Process in Patient EducationPatient education requires time, energy, and resources. The nursing process—assessment, planning, implementation, evaluation, and documentation—is a useful framework for the patient education process, whether the nurse is teaching one patient or is designing a patient education program for an entire hospital.
ASSESSMENT AND PLANNING
A complete assessment is crucial to successful patient education. It should include the multidimensional aspects of the learner (physiologic, social, psychological, cultural, environmental, and spiritual dimensions), because these variables can enhance or limit learning. Patient responses during the initial assessment are good indicators as to what type of teaching the patient will need. Because of economic constraints and shorter hospital stays, the nurse should start patient education on admission or during the first office encounter.
After making an initial assessment of the patient’s learning needs, the nurse must clarify and validate these with the patient. Glaring differences often exist between what the educator perceives the learner needs and what the learner believes he or she needs.
Timing is important. The least appropriate time to engage the patient in a learning activity is at the time of diagnosis. The patient’s anxiety level is exceedingly high, and this can cloud comprehension. The educator should not present a barrage of information that the patient cannot process; rather, this time is better spent listening to the patient’s fears and uncertainties. Education can be delayed until the patient’s cognitive and emotional comprehension is better.
Ongoing assessments should also be done during subsequent visits or hospital admissions, and by telephone calls when the patient is discharged.
The teaching process is a partnership between the patient and the nurse, but usually a caregiver (a family member or significant other) is also involved and should not be overlooked. Many family members faced with the caregiver role experience high levels of stress and feel overwhelmed. They
suffer from loss of sleep and often get sick or injured themselves; they may even reach a breaking point as a result of the heavy demands. They too can benefit from a carefully designed education program.
suffer from loss of sleep and often get sick or injured themselves; they may even reach a breaking point as a result of the heavy demands. They too can benefit from a carefully designed education program.
IMPLEMENTATION
Nurses can choose from a wide variety of media to deliver the right information in the right way. Whatever the method, it should be appropriate, accurate, and accessible to the user. The nurse must match the method to the patient and should use creative flair in getting the message across, especially when there is limited time for patient education. Because patients are going home more quickly, it is best to combine different methods so that patients can learn in an interesting environment, which will enhance the learning process.
Printed Materials
The most common form of educational intervention is the use of printed materials. Health care workers depend greatly on printed materials to impart valuable information to patients, especially when inpatient stays are shorter and patients are expected to care for themselves at home.
Research has suggested that written materials combined with other teaching methods produce more positive outcomes than when used alone. There is an abundant supply of excellent printed materials dealing with cancer-related topics. Most can be obtained at minimal or no cost from the American Cancer Society and the National Cancer Institute. APPENDIX A lists the major publications available from the National Cancer Institute in English and Spanish. Pharmaceutical and biomedical companies are also rich sources of written materials, as are health care organizations, private foundations, and community outreach programs.
In hospitals, patient education materials are developed and tailored to specific patient needs to supplement what is available from outside sources. Helpful strategies in preparing appropriate written materials are:
Know the target audience; keep them in mind when preparing the materials.
Focus on “need-to-know” information.
Break complex information into small chunks.
Because verbal instructions are more understandable,
supplement printed materials with simple audiovisual materials. Use examples.
Pretest the materials on a sample audience before final publication to assess the relevancy and appropriateness of the content. Edit as needed.
APPENDIX B shows samples of written fact cards and instructional materials developed for patients. These typical handouts provide a ready, easy, and consistent method of presenting the necessary information. When patients go home, these handouts can be read at a later time.
The Readability and Literacy Issue: Can Patients Understand Patient Education Materials
Readability and literacy levels are important considerations when preparing patient education materials: written materials can benefit patients only if the patients understand what they read. One study showed that approximately 20% of American adults read at or below the fourth-grade level (Meade et al., 1992). Another study (Cooley et al., 1995) found that a patient’s reported grade level does not accurately denote his or her actual reading ability. That study recommended screening a patient’s reading ability initially so that appropriate patient education materials can be given. Literacy can be determined by using the Wide-Range Achievement Test to assess grade level and the Cloze Method to determine reading comprehension. The grade level should be indicated on printed materials so the nurse can select appropriate publications.
Two scales are widely used to assess the readability of materials: the FRY scale and the SMOG scale. The former is considered a better tool for readability, but the latter is more commonly used because it requires less time and is easier to use (Doak et al., 1985). To calculate the SMOG reading grade level:
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