An Approach to Teaching Patients in the Hospital R. Neal Axon, MD, MSCR Medical University of South Carolina July 31,2012

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.

Key Messages Adult learners are different Assess patient's disease specific knowledge, learning style and motivation to change Assess barriers:  health literacy using SOS Method Set goals with the patient Teach the patient - Teach Back Method

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.

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 4: Go teach the patient. Step 2: Assess barriers to learning 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 Rank Topic 1. Medications 2. Signs/Symptoms 3. General Information (i.e. anatomy/physiology) 4. Risk Factors 5. Prognosis 6. Activity 7. Psychological (i.e. coping) 8. Diet Nurses Rank Topic 1. Signs/Symptoms 2. Medications 3. Diet 4. Risk Factors 5. General Information (i.e. anatomy/physiology) 6. Activity 7. Psychological (i.e. coping) 8. Prognosis This slide depicts the perceived order of importance of different heart failure learning topics as rated by HF patients and nurses. Not surprisingly, they don’t match up perfectly. In general, patients were more interested in learning about medications, general information on HF, and prognosis than nurses perceived. 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 instruction; visuals may distract learners Use oral descriptions, lectures, podcasts 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: “What was the highest grade you completed in school?” “How would you rate your ability to read?” “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 Letter Stands for… Question Topic Cut Point Odds Ratio S "Schooling" Educational attainment Sub-Secondary (6th grade or less) 1.89 O "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 "Support" Help when reading Sometimes or worse on a 5 point scale (Never, Rarely, Sometimes, Often, Always) 2.03 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 Re-assess recall and comprehension / Ask patient to demonstrate Adherence / Error reduction 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. Mar-Apr 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):363-369. 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/)