1. بسم الله الرحمن الرحیم

2. Patient Education

3. Educational Domains Cognitive: Psychomotor: Affective:
information area (teaching joint protection principles to patient with Rheumatoid Arthritis
Psychomotor:
deal with motor skills; using crutches
Affective:
deals with attitude and feelings;

4. How Adult Learners are Different…
Malcolm S. Knowles

5. Step 1: Assessment Learning Styles
Type of Learner
Characteristics
Sample Approaches to use in teaching
Visual
Prefers pictures, diagrams, other visuals
Use of numerous 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.

6. Tools for Educating Pt’s, Pt’s Families & Caregivers
Verbal Instructions:
need to be at patient’s level of comprehension
Written Instructions:
need to be clear, and concise
Demonstration:
go slow, break skill into parts as needed
Other: video, patient group, three dimensional models etc.

7. Assessing Effectiveness of Teaching Strategies
Have patient repeat instructions back to you to verify they know what you want them to do and how to do it
Have patient demonstrate

8. Principles of Learning Pt’s Learn when:
They feel actively involved in the process
There is respect and trust between them and the doctor
They are working on something that meets their needs
Doctor is supportive and non-judgmental; patients need to be able to express their own ideas, beliefs, concerns

9. Principles of Learning Pt’s Learn when:
Adequate time to practice, must be able to make mistakes and go at their own pace
Opportunity for self-assessment. Let them reflect on what they might have done wrong or forgotten, give them time to process, provide a supportive environment

10. Teaching a Skill
Ensure patient understands why this skill is important to them – how it will effect their ability to function and relate it to their goals
Explain the skill to them
Demonstrate skill
Break skill into parts, demonstrate parts, have patient demonstrate parts
Practice

11. Patient Compliance with Exercise Programs
Patient must choose to perform (Values)
Know when/how often to perform & what to perform
Have the psychomotor skills to perform
Remain motivated to follow through

12. Effective Communication Skills

13. Effective Communication Skills
Effective communication skills for HCWs
Ask questions and listen (use open-ended questions)
Make interaction with the patient a positive experience
Speak clearly and simply
Encourage patient to ask questions
Ask checking questions to determine understanding

14. Ask Questions and Listen
To understand the patient’s medical history
To understand the patient’s current knowledge about disease
Identify and help to solve any problems the patient may have with treatment
Use open-ended questions

15. Ask Questions and Listen: Open-Ended Questions
Cannot be answered with “yes” or “no”
Usually start with:
What?
Why?
Who?
When?
How?
Explain or describe to me…..

16. Close-Ended vs. Open-Ended
Do you know anything about TB?
What do you know about TB?
Do you live alone?
Who else do you live with?

17. Make Interaction with the Patients a Positive Experience
Demonstrate a caring, respectful attitude
actions
words
body language
tone of voice
eye contact
Praise and encourage patient
Motivate the patient to continue treatment
Be non-judgmental if patients’ views or lifestyles differ from your own
Address patient by name and respect patient’s time.
When meeting patient say “I am glad to see you” or “You are doing the right thing by coming for treatment every day”

18. Speak Clearly and Simply (1)
Use simple non-medical terms
Use words that are familiar to the patient
Use appropriate language level and visual cues
Repeat important information
Image source: WHO

19. Speak Clearly and Simply (2)
Example:
Diffcult to understand
“This drug, isoniazid is a bactericidal agent that is highly active against Mycobacterium tuberculosis”
Simple to understand
“This isoniazid pill will help fight TB and help you get better”

20. Encourage Patient to Ask Questions
Ask patients “Do you have any questions”
Praise patients for asking questions
“I am glad that you asked that question…”
“Good question…”
Answer all questions thoughtfully and carefully

21. Ask Checking Questions
Ask patient questions
to understand the patient’s current knowledge about disease
to ensure that the patient knows exactly what to do next
Ensure that the patient understands and remembers important messages about TB and treatment
Ensure that the patient knows exactly what to do next

22. An Approach to Teaching Patients in the Hospital

23. 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.

24. A Common Approach to Patient Education…
Step 1: Go teach the patient.

25. 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

26. 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?”

27. 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

28. Step 1: Assessment Motivation to Change
Paradis V. J. Cardiovascular Nursing.2010.

29. 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?”

30. 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

31. Additional Barriers to Learning…
Functional
Visual Impairment
Hearing Impairment
Decreased mobility
Illness-Related
Pain
Fatigue
Cognitive Impairment
Dementia
Delirium
Depression
Stromberg.EurJCard.2005.

32. 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?”

33. 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

34. 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

35. References
Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. Aug 2005;80(8):
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):
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):
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 ;7(3):
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 ;163(1):83-90.

36. 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 (