Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques

Educating Patients: Understanding Barriers, Learning Styles, and Teaching TechniquesLinda Beagley, MS, BSN, RN, CPANHealth care delivery and education has become a challenge for providers.Linda Beagley, Mcator, Swedish CovConflict of intereAddress correspnant Hospital, 51e-mail address: lbe� 2011 by Ame 1089-9472/$36.doi:10.1016/j.joJournal of PeriAnesthNurses and other professionals are challenged daily to assure that thepatient has the necessary information to make informed decisions.Patients and their families are given a multitude of information abouttheir health and commonly must make important decisions from thesefacts. Obstacles that prevent easy delivery of health care informationinclude literacy, culture, language, and physiological barriers. It is upto the nurse to assess and evaluate the patient’s learning needs and read-iness to learn because everyone learns differently. This article willexamine how each of these barriers impact care delivery along withteaching and learning strategies will be examined.Keywords: patient education, barriers, culture, literacy, perianesthesia nursing.� 2011 by American Society of PeriAnesthesia NursesEDUCATING PATIENTSHAS become a challenge for health care providers because the patientlength of stay has decreased and the need to delivercomplex information has increased. A new versionof the melting pot society requires special effortsby health care professionals to ensure that the pa-tient understands the information given to him orher. Barriers that inhibit patient education are liter- acy, language, culture, and physiological obstacles.Assessing and evaluating the learning needs ofthe patient are essential before planning and im-plementation of an educational plan. Presentinga well-formulated plan will increase the likelihoodof a successful recovery for the patient. In thisarticle, barriers will be dissected and strategiesexamined to determine what will best suit the edu- cational needs of the patient.S, BSN, RN, CPAN, is a PACU Clinical Edu-enant Hospital, Chicago, IL.st: None to report.ondence to Linda Beagley, Swedish Cove-40 N. California Ave, Chicago, IL 60625;agley@schosp.org.rican Society of PeriAnesthesia Nurses00pan.2011.06.002esia Nursing, Vol 26, No 5 (October), 2011: pp 331-337Adult LearningTo effectively educate patients, health care pro-viders must have an understanding of the princi-ples of adult learning. Malcolm Knowles, whobegan to study adult learners in the 1960s, isknown as the father of adult learning principles be-cause of his extensive writing on adult education. The term andragogy, the art and science of teach-ing adults, is synonymous with that of Knowles.He deduced that adults learn differently than chil-dren. His studies determined five assumptions onlearning: self-concept, experience, readiness tolearn, orientation to learning, and motivation tolearn.1 According to Knowles, as a person ma-tures, his self-concept moves from one of being a dependent personality towards one of beinga self-directed human being. Humans accumulatea growing reservoir of knowledge, followed bya readiness to learn, which increasingly is orientedtowards developmental tasks related to social roleswith immediate application of their new knowl-edge. Knowles’ final assumption reflects the moti-vation of learning as moving from external to internal.1,2 Table 1 compares and summarizesKnowles’ assumption regarding the adult (andra-gogy) and the child (pedagogy) learner.331 mailto:lbeagley@schosp.orghttp://dx.doi.org/10.1016/j.jopan.2011.06.002 Table 1. Assumptions Differences of Pedagogy and Andragogy1,2Assumptions Pedagogy AndragogySelf-concept Dependency Self-directedExperience Happens to learner Rich resourceReadiness Biologic and academic development Evolving social and life rolesOrientation to learning Logical; directed by teacher Life centered; task/problem centeredMotivation External approval of teacher Internal drive; life goals332 LINDA BEAGLEYLiteracy BarrierLiteracy is defined as ‘‘an individual’s ability toread, write and speak in English and computeand solve problems at levels of proficiency neces-sary to function on the job and in society, toachieve one’s goals, and to develop one’s knowl-edge and potential.’’3 Illiteracy does not discrimi- nate; it can be found in all populations, anda person’s grade level is not an accurate gaugefor reading ability.4 Having any level of illiteracycan cause a number of problems with activitiesof daily living, such as analyzing a transportationschedule, following directions, understanding rec-ipes, and completing job applications. Low liter-acy is described as those people who have the ability to read, write, and understand informationonly at the seventh grade reading level. Accordingto the US Department of Health and Human Ser-vices (DHHS),3 demographics does play a role inliteracy; certain groups demographically havea higher prevalence of low literacy. Table 2 out-lines this population.Low literacy and low health literacy are related butnot interchangeable. Health literacy is defined inHealthy People 2010 as ‘‘the degree to which indi-viduals have the capacity to obtain, process, andunderstand basic health information and servicesneeded to make appropriate health decisions.’’5Low health literacy is content specific. An individ-Table 2. Demographics of Low Literacy3Fewer years of educationLower cognitive abilityElderlySome racial or ethnic groups from the South orNortheastFemaleIncarcerationLow income statusual may be able to read and write in certain con-texts but struggle to comprehend the unfamiliarvocabulary and concepts found in health-relatedmaterials or instructions.5 According to the US Department of Education, which conducts a na-tionwide survey of adult Americans to evaluate lit-eracy skills,5 an estimated nearly one half ofAmericans (90 million) have difficulty understand-ing and acting on health information. These stud-ies have linked low health literacy with delayeddiagnosis, poor disease management skills, andhigher health care costs. These same individuals demonstrate a limited understanding of their dis-ease processes resulting in worse health care out-comes.6 Unnecessary health care costs rangingfrom $106 to $238 billion are attributed to limitedhealth literacy.7Factors associated with health literacy are depen-dent on the skills, preferences, and expectations of health information providers. At times, healthcare professionals may be oblivious to the effectof limited health literacy on patients and the healthcare system. In one study7 of 240 health care pro-viders and students, researchers found fewer than12% of participants were aware of their degree oflimited health literacy. Twenty-five percent werefound to have a common misconception that health literacy could be determined by race, eth-nicity, culture, age, or socioeconomic status.7 Toheighten matters, responders inaccurately be-lieved that patients with a higher level of educationwere not at risk for having limited health literacy(7.4%). In health care, nurses comprise the largestgroup of providers and are responsible for ensur-ing patient education. The researchers recom- mend health literacy education for nurses duringthe education process.Cutilli8 completed a systematic review of the liter-ature for the purpose of analyzing and evaluatingthe research on health literacy and the elderly.  EDUCATING PATIENTS 333Age becomes an important demographic markerwith an inverse relationship to health literacy.Cutilli found that as the patient’s age increases,the health literacy level decreases. This is animportant element because of the aging popula- tion in the United States and the projected trendof aging. By 2030, it is estimated that 20% of thepopulation will be 65 years and older.9 TheFederal Interagency Forum on Aging9 reports olderAmericans are proportionately more likely to havebelow basic health literacy than other age groups.Thirty-nine percent of people aged 75 years orolder have below average health literacy skills compared to 23% of people aged 65 to 74 yearsand 13% of people aged 50 to 64 years.Language and Culture BarrierThe United States has been known as a melting potof diversity over the last 100 plus years. Somechanges, however, have occurred from those early years. Ethnicities are found in large urban neigh-borhoods, as well as the suburbs and rural areasof the country. The diversity now existing acrossthe country has presented many challenges forhealth care providers. In 2001, DHHS publishednational standards on culturally and linguisticallyappropriate services. These DHHS standards10 re-quired health care institutions to demonstrate cul- tural competency while caring for patients ina manner responsive to their beliefs, interpersonalstyles, attitudes, language, and behaviors of the in-dividual and required that care be provided ina manner that demonstrates respect for individualdignity, personal preference, and cultural differ-ences.Health care providers must be knowledgeable ofcultural competencies. Nurses should have aware-ness of biases and prejudices by examining gener-alizations they might use routinely about culturesother than their own. Any biases must be con-fronted. A commitment to learn more about thecultures that have been generalized in the pastmust be made.11 Second, core cultural values need to be examined and understood about thevarying populations that frequent the institution.Cultures have several core values on which allother values are based.12 This foundation is a start-ing point for health care providers in understand-ing different cultures.A challenging aspect is the ability to communicateeffectively to the patient whose native language isnot English. Thoroughly assessing the patient’scomprehension and the need for a translator is vi-tal. Every attempt must be made to provide a qual- ified translator whether the translator is physicallypresent or available via a telephone translationline. Family members as translators may not beable to translate important terms needed in obtain-ing informed consent or education. Furthermore,caregivers must provide written education mate-rials for the patient to take home. Many conceptsare not easily translated, and it is imperative to have a fluent translator translate the writtenword into the targeted language.11An estimated 40 different languages are spoken bythe patients who use the services at one Midwestcommunity hospital. Managing multiple languagesand cultures has proven to be a challenge. The hos-pital intranet offers resources for many of the cul- tures including common practices, values, andbeliefs. Another unique attribute for this hospitalis the diverse nursing population. In the surgicalarena, every effort is made to pair similar culture/language of the patient to the health care provider.This luxury of a diverse nursing population is notcommon for many facilities, creating a need torely on telephone language lines or hospital- employed interpreters.Madeleine Leininger’s theory of cultural care diver-sity and universality defines culture as a guidewhereby the individual’s thinking, aswell as his de-cisions and actions, is patterned and usually passedon from one generation to another.12 A personuses culture as a framework in viewing the world, including health and the need for health care. Be-cause patients can feel a sense of losing control,they have a tendency to hold onto family beliefswhen they become ill. Successful teaching plansare congruent with patient and family values.4Nursing care that incorporates cultural valuesand practices can be positively related to patientsatisfaction, and patient compliance to treatment will be greater. Conflict will result if nursing careis in discord with the patient’s belief systems.Knowing one’s patient is important for delivery ofcare. A recent Swahili refugee was admitted tohave a cholecystectomy. She had been treatedwith tribal medicine, which resulted in several  334 LINDA BEAGLEYhealed burn scars on her abdomen. Arousing fromanesthesia, the patient relayed through her inter-preter that she wanted to see what was removedduring surgery. The nurse tried to explain thatthe patient’s gallbladder had been removed and sent to pathology. The patient continued to insistthat she needed to see the gallbladder. For this pa-tient, it was imperative to visualize the gallbladderto confirm that she was healed from her illness.The nurse recognized the needs of the patient,contacted the surgeon, and between the two ofthem, they were able to have the patient see hergallbladder through pictures taken during surgery.Another example of the importance of culturalawareness is demonstrated in the story below.The diabetic educator consults with patientswho have gestational diabetes frequently in theclinic. A Muslim patient and her husband werescheduled for education. In this patient’s culture,the educator was not permitted to address the patient directly and was to speak only to thehusband. To acknowledge the patient’s culturalbeliefs, the educator instructed the husband,who then instructed the patient in her presence.The educator used several different teaching tech-niques to quantify that the patient could safely ad-minister insulin to herself.In the American culture, the patient is the key deci-sionmaker in health care.13 Thepatientmay consultwith other family members, but ultimately, the pa-tient makes the final decision.14 Traditionally, Amer-ican families have been defined as having a mother,father, and child/children. Familial hierarchy can bedifferent for some cultures. How is the ‘‘family’’ de-fined for this patient? Is it the immediate nuclear family or the family that may include extended fam-ilymembers, close friends, or neighbors? Identifyingwho is thehealth care decisionmaker for thepatientis important.4,13 For some cultures, the decisionmaker is the head of the household or the entireextended family. All key players must be involvedin any decisions because they will either reinforceor block health care behaviors.The nurse must be aware of both verbal and non-verbal communication behaviors. There are vastdifferences in culturally defined communicationbehaviors. Before discussion of personal informa-tion, it is important to understand cultural prac-tices related to nonverbal communication duringconversation, communication practices related tothe opposite gender, and cultural practices of so-cial conversation.4 Gender-specific topics couldbe taboo for some cultures. For some, direct eyecontact is a sign of disrespect. Be aware of cultures in which disagreement is perceived as impolite-ness. The patient may be agreeing with what thehealth provider is saying purely out of civilityrather than out of agreement.13,15Physical and Environmental BarriersPhysiological factors play a role in how the patient isable toprocess health information. As a person ages,visual clarity and auditory acuity will decrease, mak-ing it difficult for the person to receive information.Many times, a patient may refuse to wear correctivedevices. Altered mental capacity because of patho- logic disease processes, such as Alzheimer disease,or pharmacologic interventions, such as medica-tions, can create a barrier for effective teaching.Increased agingmay causedecline in cognitive capa-bilities in processing information, memory, andcomprehending abstractions.16 As the adult ages,the ability to reason and process information occursat a slower rate and reaction or response time in- creases significantly after the age 65. Managingmultiple messages simultaneously is harder to do.Short-term memory loss and the quantity of newinformation may limit the length of the teachingsession and amount of information given. Thecapacity to draw conclusions from inferencedecreases in the older adult. Vague terms of‘‘adequate,’’ ‘‘several times a day,’’ and ‘‘often’’ can have multiple meanings. Directions should be spe-cific to time and order with quantities defined.Physical conditions can limit mobility and the pa-tient’s ability to sit and be receptive to learning.Many times, patients seek out health care be-cause of pain or not feeling well. Uncontrolledpain will block the patient’s ability to receive in- formation. Anticipation, anxiety, and fear are allcontributing factors in diminishing reception ofknowledge. In the perianesthesia area, pain andanxiety are obstacles that must be identifiedand controlled for the patient to comprehendinformation.Because of busy schedules, environmental barriers are challenging at times. Poor lighting, noise levels,and room temperatures can inhibit the learning  Table 3. Learning Styles With Teaching StrategiesLearn Styles Teaching StrategiesVisual Visual materialHandouts—easy to readVariety of technology—computers,overhead, video, TV, InternetAuditory Rephrase key pointsVary speed, volume, and pitchWrite down key pointsPositioned to hear the message clearlyUse multimedia—tapes, musicKinesthetic Frequent breaks to move aroundLearner writes own notesProvide tactile activitiesProduct samplesEDUCATING PATIENTS 335process. These barriers are difficult to control be-cause of capped thermostats and controlled light-ing. Noise levels are under careful considerationbecause of the complaints of patients who havenot been able to rest because of noise while hospi- talized. Hospitals have responded by institutingquiet times during the day. Physical space for thehealth care professional to share informationwith the patient that is private, quiet, and withminimal distractions can be at a premium,although necessary for effective learning. Lastly,time to devote to adequate teaching is a large bar-rier in today’s health care environment. Profes- sionals are asked to do more with less, includingtime. Patients’ length of stay has shortened be-cause of many factors, giving the nurse less timewith the patient to accomplish important teachingelements.Learning StylesBesides understanding barriers that impact the re-ception of education, the nurse must be aware ofhow an individual learns. Learning patterns are de-veloped as a child and the ‘‘learner’’ discovers whatworks best for his or her individual learning style. Assessment of the patient is essential for effectiveteaching, which may require more than one learn-ing style for comprehension. Learning patterns in-clude visual, auditory, and kinesthetic.17 A visuallearner prefers to see what he or she is learning.Pictures and images help the learner understandideas and information better than an explanation.The auditory learner needs to hear the message or instructions being given. This type of learnerwants to be talked through a process rather thanreading about it first. The kinesthetic learnerdoes not like lecture or discussion, preferring themovement of the skill or task. Demonstrationand return demonstration works best with kines-thetic learners.17,18Once the learning style is established, the nurseadapts the teaching materials to the preferredstyle. For the visual learner, the nurse will havema-terials for the patient to read or watch. The infor-mation should be well organized, interesting,appealing, and easy to read. With today’s advance-ment of technology, there are many choices to of-fer the visual learner, including computers, live video feeds, close circuit television, photography,and the Internet.For the auditory learner, the nurse should rephraseimportant points and questions in several differentways to communicate the intended message. Vary-ing the speed, volume, and pitch helps create aninteresting aural texture. An environment where the patient and family can hear the message is im-portant while encouraging the patient to write keyelements. A quiet space, preferably with the abilityto close the door along with minimal distractions,assists the teacher to maximum the learning for anauditory learner. To assist the auditory learner, in-corporate multimedia of sounds, music, or speech.Kinesthetic learners prefer frequent breaks so thatthey can move around. The nurse should encour-age the patient to take notes while providing tacti-cal and hands-on activities. Providing sampleswill allow the kinesthetic learner to practicewhat he or she is learning, verifying comprehen-sion through return demonstration. Table 3 sum-maries learning styles with teaching strategies.In the perianesthesia arena, more than one type ofteaching strategy may be necessary to successfullydeliver the message and establish comprehension.For example, the follow-up telephone call was indi-cating negative outcomes for several patients whowere to remove their urinary catheter at home. Thepatient teaching before going home for this patient population had become labor intensive, yet urinarycatheters were still being removed without deflat-ing the catheter balloon, causing harm to thepatient and unhappy surgeons. Brainstorming,  336 LINDA BEAGLEYa group of nurses looked to see how those in theunit could improve the education process and out-comes. The result was to continue to demonstrateto the patient and significant other how to deflatethe balloon and remove the catheter. A return dem- onstration was verified by both the patient and thefamily member, each practicing using the syringeand inserting it into the catheter port (without re-moving the catheter). The department also devel-oped a step-by-step handout with pictures for thepatient to take home. All three learning styleswere instituted to ensure a positive change of nolonger having patients remove the urinary device with the balloon intact.Teaching MethodologiesTeaching methodologies are multiple, and not all will work in the perianesthesia setting. The mostcommonmethod is lecture, inwhich the presentergives information to the learner and learning is pas-sive. Discussion allows for participation and forthe ability of the learner to ask and answer ques-tions and share feelings. Demonstration is a usefultechnique using both psychomotor and socialskills of the learner. In health care, demonstration with return demonstration is commonly usedwhen a new technique or skill is to be learned bythe patient. An example of demonstration was theurinary catheter instructions and patient demon-stration previously mentioned.Another common method of teaching is the use ofprinted instructions. Printed health care informa- tion should avoid technical language: use shortsimple sentences and write at a level that most pa-tients will understand.4 The recommendation forwritten instructions is that they be at the fifthgrade level. Avoidance of glossy paper and smallfonts also assists the learner.The Internet can be a friend or foe when obtaining health care information. Hospitals are setting upWeb sites for patients to obtain information. Inone pre-surgical testing department, the nursegives the scheduled surgical patient a Web sitewhere he or she can learn more about anesthesiabefore coming to the hospital. Health care profes- sionals also need to establish that the patient is ob-taining reliable information on the Internet andsteer the patient to government and academic sitesthat are proven to be more trustworthy.19 Inpa-tients can watch health-related stations on theirtelevisions.11 On the obstetric unit, patients canaccess the television to learn about a variety of is-sues related to the mother and care of the new baby. The disadvantage of watching a televisionstation or already-taped segment is the inabilityto ask and have questions answered immediately.The nurse must be diligent in following up withthe patient to answer questions and reinforce theteachings from the video.ConclusionFor effective delivery of health information and ed-ucation, the nurse must be aware of the barriers that can impede the patient’s ability and readinessto learn. Awareness of the potential barriers of lit-eracy, culture, language, and physiological factorswill help the nurse determine what tools he orshe may need to assist in the delivery of informa-tion. Awareness of one’s biases and prejudicesand overcoming them will assist in the educationprocess. The nurse assesses the patient’s under- standing by looking at both verbal and nonverbalcues that the patient is displaying. Using morethan one way of delivering the message will pro-mote the patient’s learning. A family member pres-ent during key moments will assist and help thepatient to remember the information. The astutenurse will be more successful in overcoming bar-riers if she or he is aware of patient’s needs and areas where additional assistance is needed.References1. Knowles M. Andragogy: An emerging technology for adultlearning. The Modern Practice of Adult Education. New York,NY: Association Press; 1970:37-55.2. Smith MK. Malcolm Knowles, informal adult education,self-direction and andragogy, the encyclopedia of informaleducation. Available at: www.infed.org/thinkers/et-knowl.htm.Accessed May 9, 2011.3. U.S. Department of Health and Human Services. Literacyand health outcomes. Available at: www.ahrq.gov. AccessedNovember 11, 2008. http://www.infed.org/thinkers/et-knowl.htmhttp://www.ahrq.gov EDUCATING PATIENTS 3374. Chang M, Kelly AE. Patient education: Addressing culturaldiversity and health literacy. Urol Nurs. 2007;5:411-417.5. National Network of Libraries of Medicine. Health literacy.Available at: http://nnlm.gov/outreach/consumer/hlthlit.html#A1. Accessed August 25, 2011.6. Schwartzber J, Cowett A, VanGeest J, Wolf M. Communica-tion techniques for patientswith low health literacy: A survey ofphysicians, nurses, and pharmacists. Am J Health Behav. 2007;1:96-104.7. Jukkala A, Deupree J, Graham S. Knowledge of limitedhealth literacy at an academic health center. J Contin EducNurs. 2009;7:298-302.8. Cutilli C. Health literacy in geriatric patients: An integra-tive review of the literature. Orthop Nurs. 2007;1:43-48.9. Federal Interagency Forum on Aging-Related Statistics.Older Americans 2008: Key indicators of well-being. Availableat: www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/OA_2008.pdf. Accessed May 9, 2011.10. U.S. Department of Health and Human Services. 2001National Standards for Culturally and Linguistically AppropriateServices in Health Care. Available at: http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. Accessed April 11, 2010.11. Comerford-Freda M. Issues in patient education. J Mid-wifery Womens Health. 2004;49:203-209.12. McFarlandM. Culture care theory of diversity and univer-sality. In: Marriner-Tomey, Raile-Alligood, eds. Nursing Theo-rists and Their Work, 6th ed. St. Louis, MO: Mosby; 2006:472.13. Singleton K, Krause E. Understanding cultural and lin-guistic barriers to health literacy. Online J Issues Nurs. 2009;14(3).14. Galanti G. Applying cultural competence to peri-anesthesia nursing. J Perianesth Nurs. 2006;2:97-102.15. Loxton M. Patient education: The nurse as source of ac-tionable information. Topics in Advanced Practice NursingeJournal. 2003;3(2).16. Speros C. More than words: Promoting health literacy inolder adults. Online J Issues Nurs. 2009;14(3).17. Russell S. An overview of adult learning processes. UrolNurs. 2006;26:349-352.18. Clark DR. Visual, auditory and kinesthetic learning styles(VAK). Available at: http://nwlink.com/�donclark/hrd/styles/ vakt.html. Accessed May 9, 2011.19. Bergeron B. Online patient-education options. GeneralMedicine. 2004;6:54. http://nnlm.gov/outreach/consumer/hlthlit.html#A1http://nnlm.gov/outreach/consumer/hlthlit.html#A1http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/OA_2008.pdfhttp://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/OA_2008.pdfhttp://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdfhttp://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdfhttp://nwlink.com/%7Edonclark/hrd/styles/vakt.htmlhttp://nwlink.com/%7Edonclark/hrd/styles/vakt.htmlhttp://nwlink.com/%7Edonclark/hrd/styles/vakt.htmlEducating Patients: Understanding Barriers, Learning Styles, and Teaching TechniquesAdult LearningLiteracy BarrierLanguage and Culture BarrierPhysical and Environmental BarriersLearning StylesTeaching MethodologiesConclusionReferencesThe post Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques appeared first on Infinite Essays. “Looking for a Similar Assignment? writersThe post Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques first appeared on nursing writers.  “Is this question part of your assignment? We Can Help!”