NURS2101 UOWG Alternative Rhythms in Patient Education Paper

NURS2101 UOWG Alternative Rhythms in Patient Education Paper

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414 Concept 43 Patient Education Barbara Carranti Education empowers. Patient education is no exception. Effective patient education allows patients and their families the opportunity to control their own health, reduce risk for illness, improve longevity, and enhance overall wellness. Specifically, the goals of patient education are to learn and adapt by forming connections and associations that will facilitate changes in behavior, resulting in enhanced health and well-being or improved treatment of illness.1 Lamiani and Furey note that the emphasis of patient education frequently focuses on the disease as opposed to the patient, and they stress the importance of incorporating exploration of the patient’s illness experience into the educational plan to ensure high-quality care.2 The importance of patient education is supported by Healthy People 2020. This science-based program, in existence for more than 30 years, has used evidence to establish objectives to improve the health of Americans. Patient education is the key to achievement of the overarching goals of Healthy People, specifically increasing the quality and years of healthy life and eliminating health disparities.3 Definition For the purposes of this concept presentation, patient education is defined as “a process of assisting people to learn health-related behaviors so that they can incorporate these behaviors into everyday life.”4,p11 This is a purposeful process whereby the patient is learning health-related information to support healthy lifestyle or behavior change. A similar term, patient teaching, is used interchangeably. The role of the nurse in patient education is to assist the patient in forming goals; assess patient need, motivation, and ability; plan educational interventions to achieve goals; and evaluate patient outcomes toward goal attainment. In short, nurses empower patients. This empowerment is accomplished by providing information to enhance wellness, reducing the risk for illness, and encouraging autonomy by enhancing self-care skills while maintaining a patient-centered approach. Scope As a concept, patient education can include provision of information in a wide range of formats and can be described from two perspectives: the delivery approach and educational domains. The process varies depending on multiple variables, including the intended outcome and the characteristics of the learner. For example, is the educational intervention intended to teach the patient a skill or impart knowledge related to a known health problem, increase the probability of successful treatment, prepare for discharge, or to promote a healthy lifestyle and enhance wellbeing? Thoughtful consideration of intended outcomes will enhance the patient’s learning by matching an approach to intended goals. The nurse must ask, “What change in the patient is the desired outcome of this activity?” The type of education offered will require that the nurse match the approach, method, and evaluation to this desired outcome.5 Educational Approaches Patient educational approaches can range from formal educational programming such as group lecture settings to informal, individualized one-on-one teaching and to self-directed learning by the patient that is facilitated by the nurse.1 Formal patient education courses or classes are useful to address needs common to a group of patients or as individual teaching sessions. Formal courses are often taught using a curriculum/course plan with standardized content. In contrast, informal teaching often occurs in one-on-one sessions with the patient and/or family. Informal sessions may be planned or spontaneous, but they do not follow a specified formalized plan. An informal approach represents a large portion of patient education done by nurses. In fact, the majority of critical education occurs with each patient encounter when medications, diet, or treatment is explained or simply when answering questions about the patient’s issues or concerns. Individual or self-directed education results when a patient or family obtains and/or completes an educational activity independent from the nurse or other health care providers. With the influence of consumerism and the availability of information, a great deal of education can occur through self-directed learning employing written material or media (e.g., Internet and video) designed to assist the patient with information about health topics, a particular disease, treatments, or a specific skill (Figure 43-1).1 FIGURE 43-1 Scope of Patient Education Concept Because of the increasing dependence on technology in all aspects of life, the use of Internet resources for patient education cannot be ignored. A majority of adults in America use the Internet to find information on many aspects of life, including health, healthy lifestyles, and treatment options.5 This use of technology expands the role of the nurse in patient education to include teaching on evaluation of 415Internet sources. Patients should be encouraged to search for information sources that list authors and their credentials and contact information. The source of information should also be listed, and any photographs, charts, graphs, or other graphics should contain helpful understandable information. Any links associated with the site should be functional, active links. It is also important that patients be taught to search for government (.gov), educational (.edu), and nonprofit (.org) sites because they are considered to be the most credible sources of information. Finally, sites chosen for use in gathering information should clearly identify how consumers can contact a site administrator and should be secure sites.6 For this discussion of approaches to patient education to be complete, the educated and motivated consumer should be considered. Many patients will be active consumers of health information and use self-directed approaches to education. Patients may present the nurse with articles, computer printouts, and other materials gathered in an attempt to learn about health promotion, symptoms, diagnoses, and treatments. These materials can be incorporated into the nurse’s assessment of the patient and the educational plan. The tendency to pursue learning opportunities addresses motivation and presents the nurse with an opportunity to ask the patient to discuss what has been learned. This also gives the nurse the opportunity to teach the patient evaluative skills, looking at sources and content of the material for credibility and reliability.7 Learning Domains Patient education can also be conceptualized from the perspective of learning domains—in other words, in terms of the type of learning a patient will need. The three main domains are cognitive, psychomotor, and affective (Figure 43-2).1 Education intended to increase a patient’s knowledge of a subject, for example, is cognitive in nature, and using methods such as written material, lecture, and discussion is appropriate. Skill teaching or psychomotor teaching requires that the patient have opportunities to touch and manipulate equipment and practice skills. A patient who must learn to change a dressing over a wound is an example. Education that is intended to change attitudes, such as viewing the lifestyle modifications associated with the treatment of coronary artery disease as a positive change rather than a burden, is known as the affective domain in education.5 FIGURE 43-2 Learning Domains To illustrate this, consider an example of a patient with a new diagnosis of a degenerative neurologic disorder that will require the patient to self-catheterize. The nurse will need to teach the patient the complex psychomotor skill of self-catheterization, and the teaching will be successful when the patient is able to competently demonstrate this skill. Part of this teaching will include physiological information designed to enhance the patient’s understanding of the necessity of this procedure (cognitive learning) as well as assistance with lifestyle alterations and coping to help the patient to adapt and continue to live fully (affective domain).1 Attributes and Criteria For patient education to occur, there must be an identified need for learning. Although this need may be identified by the nurse, learning will not occur without readiness on the part of the learner. Ultimately, it is patient motivation that determines when, how, and if patient education will occur.1 In addition to an identified need, the following are other major attributes of patient education: 1. Planning is involved. 2. The outcomes are goal oriented. 3. The patient is motivated to learn. Like any other teaching-learning process, patient education requires that the teacher (nurse) know the intended audience and plan appropriately. This is a process that must be in place even in the most routine patient encounters. There must also be a goal, which is usually a change in behavior or attitude of some sort. The learners (patient and/or significant other) not only should be identified as the target of the teaching plan but also should be motivated by the outcome of the behavioral or attitudinal change. The nurse then develops the plan and evaluation to be consistent with the patient needs. The nurse must determine the overall appropriateness of patient education. This requires asking, “Is the timing right, are the involved parties ready, and are the goals clear?” Only after these answers are determined can true education of the patient occur. Theoretical Links The goal of all patient education is to produce change. It is helpful to examine theories of behavior and learning in addition to nursing theory to understand patient need and motivation to change. Theories of Health Behavior The health belief model was developed by Rosenstock in the mid-20th century to help explain individual decisions to use health screening opportunities. It has been adapted many times to explain compliance and behavior as they relate to health.8 According to the health belief model, individual perceptions of susceptibility to and severity of disease are the primary motivators for making attempts to change health behavior. These motivators are modified by demographic, social, psychological, and structural variables that may heighten or dampen motivation. The primary motivation of patient perception then allows the patient to be open to cues to act, which of course leads to patient education opportunities.8 For example, a patient who is aware that her risk for breast cancer is high because of genetics may be likely to participate in some form of education about risk for the disease. This education can enhance the patient’s knowledge level to produce lifestyle changes that reduce risk. Simply stated, the health belief model states that for an individual to change behavior related to health and wellness, there first must be a belief that illness can be avoided and that taking a particular action 416can reduce risk. Furthermore, the individual must believe that he or she is capable of making the needed change. Nola Pender’s health promotion model (HPM), developed in 1987 and revised in the late 1990s, is “an attempt to depict the multidimensional nature of persons interacting with their interpersonal and physical environment as they pursue health.”9,p44 The HPM is based on the health belief model that was expanded by Pender to include factors that can influence the patient’s motivation to change behavior, such as previous experience with behavior changes to address the problem, and the patient’s perception of success in these attempts. This model also expands the view of patient motivation by including social supports and competing priorities as factors to consider. Pender’s model is focused on achieving optimum wellness rather than avoiding disease, which Rosenstock’s original model stressed as the primary motivator for changing behaviors. Pender points out, for example, that consideration of the patient’s prior experience with attempting to change health behaviors is a key factor for the nurse when planning strategy, including educational strategy. An obese patient with comorbidities of coronary artery disease and type 2 diabetes will likely be told to lose weight to avoid serious complications. The HPM dictates that part of the nursing assessment would be to ask the patient about prior attempts at weight reduction and perceived success of these efforts. The patient response to these inquiries will assist the nurse in development of educational interventions to address patient need. Pender also emphasizes that how the patient views the benefits and barriers to behavior change as well as the patient’s own perception of ability to succeed will impact the nurse’s plan for education.9 Nursing Theory There are many theories that can be used as a basis for formulating patient education plans. Dorothea Orem’s self-care deficit theory is based on optimizing the patient’s ability to assume responsibility for his or her own care and that motivation is based on the anticipation of resuming this responsibility. Orem defines self-care as a regulatory function that is “a deliberate action to supply or ensure the supply of necessary materials needed for continued life, growth, development and maintenance of human integrity.”10,p134 Orem addresses the role of family and others in the patient’s social support system as assuming the responsibility of the patient’s care when the patient is unable. Utilization of Orem’s theory can assist the nurse to determine if teaching materials are consistent with factors discovered during the assessment process so that selection can move the patient toward meeting self-care demands.11 Context to Nursing and Health Care Education of patients is integral to professional nursing practice; this fact is illustrated in multiple documents, including the American Nurses Association’s Nursing: Scope and Standards of Practice,12 each state’s Nurse Practice Act, the Institute of Medicine’s Future of Nursing report,13 and the Quality and Safety Education in Nursing competencies.14 Nursing practice has been defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of patients, families, communities, and populations.”12,p1 These positive patient outcomes are often achieved through education. Numerous agencies require that patients and families be provided with information required to make decisions about health care and treatment of illness.15 Modifications in health care in terms of delivery style and financer expectations have also changed the role of the patient in participating in his or her own care. This new level of patient engagement in health care requires that patient education be a priority for the registered nurse in the provision of patient care.16 Consumerism has also made more individuals want to take control of their own health and wellness and is promoting more individuals to seek health education opportunities in many venues. Patient education, however, is a cornerstone of nursing practice and is one of the ways in which members of care teams collaborate to achieve quality patient care outcomes. Quality patient education requires appropriate assessment, planning, implementation, and evaluation of this often-complex process. The educational process and the nursing process are essentially the same4 and include learner assessment, planning, implementation, evaluation, and documentation. Each of these steps is discussed in detail. Learner Assessment Learner assessment begins with a comprehensive assessment of the patient’s learning needs. This may include a formalized written assessment, may be incorporated as part of the health assessment interview, or certainly may be a stated need from the patient. The assessment should include patient resources (education level, literacy level, social support, and financial resources), educational resources, and nursing resources. Assessment data should be used to develop a teaching plan that is appropriate for the patient but also one that will meet the desired goal. To fully individualize the educational plan for a patient, the nurse will consider the age, stage of development, and motivation to change behavior. Psychosocial Development Educational interventions must attend to the patient’s achievement of developmental tasks. Erikson’s theory of development is based on an eight-stage process in which each stage requires the achievement of a particular task. Completion of each stage forms the foundation of the next stage.17 An understanding of Erikson’s theory of development assists the nurse in patient education by understanding approaches necessary to accomplish the goal. For example, the educational approach taken by the nurse in teaching a patient how to use a metered dose inhaler for delivery of steroids will be different for a school-age child than for a middle-aged adult. Using play-type activities to teach the procedure and identifying a celebrity or other role model who may need a similar treatment will appeal to the school-age patient. The middle-aged adult is more concerned with fitting this treatment into his or her normal life patterns. Finally, it is critical for the nurse to incorporate the patient’s own culture to make the teaching process meaningful. Pedagogy Versus Androgogy An appropriate next step to follow when utilizing Erikson’s theory of development is to ensure that the type of educational method used is appropriate to the individual stage of development. Pedagogy is the methodology used to assist children to learn, or the strategies of traditional teaching. Androgogy conversely describes adult learning.5 This implies that the strategies used with great success for teaching children in classrooms may not translate to successful outcomes for the nurse teaching adults. The nurse should attend to the developmental level of the individual and tailor learning activities to account for these differences. In general, learning in the adult is focused on an immediate need to address a personal issue or to solve a problem. The nurse is viewed as one who can facilitate that goal rather than simply impart knowledge. All learning activity should be directed toward meeting the learning goals of the adult patient. It is also important to note that most 417adults enter any learning situation with a rich history of experiences that can be, and should be, drawn on by the nurse to enhance present learning.1 Adults tend to learn best when there is a perceived need to learn the information (internal motivation) and the information perceived is pertinent to address an immediate problem or need, when learning is self-directed using learner-centered strategies with application, and when learning draws on the past experiences of the learner. The nurse further enhances learning in the role of a facilitator and by providing timely feedback. Hierarchy of Needs Maslow’s hierarchy of needs theory is based on a simple premise that for higher level needs to be addressed, lower level needs must be met. Maslow, a humanist, concluded that if environmental conditions are appropriate to meet basic needs, then individuals will be able to learn and self- actualize.18 This is an important concept in all types of teaching and is clear in all levels of education. A school-age child has limited ability to concentrate if the child is hungry. A college student has limited ability to concentrate and learn after an all-night study session. Of course, this extends to patients as well. For example, inadequate oxygenation, safety deficits, and food, water, and elimination needs must be addressed before the patient can adequately learn. A patient who needs to learn a complex skill must have the needs of pain management and comfort met before he or she attempts to meet learning needs. The motivation for patient education may also be linked to survival, representing a much more basic level of need. For example, a patient learning to self-administer insulin for the first time may feel a great sense of accomplishment at mastering this complex task, but the ability to self-administer this drug is truly a matter of survival for the diabetic patient. Generational Differences Generational differences are also a consideration when approaching patient education. Much has been reported about differences in the learning styles between generations, relating not only to the age of the patient but also to the era in which the individual was raised, as well as the social and political experiences of a group.19 Educational approaches may need to differ for those born before 1946; members of this age group usually are self-motivated and do not seek feedback for their performance. On the other hand, members of Generation Y are dependent on technology and desire immediate feedback.20 This generational factor, perhaps more than any other, will dictate how the nurse approaches patient education. Literacy Level The ability to read and understand the written word is, of course, critical if the educational process is to include any written material. Based on the 2003 National Assessment of Adult Literacy, 43% of adults in the United States had literacy skills at the basic or below basic level.21 It is also important to consider the patient’s ability to understand and interpret health-related information and instructions—the individual’s level of health literacy.4 Although assessment of literacy levels can be very difficult in adult patients because of the stigma and shame often associated with limited reading ability, patients may give cues to limited literacy, such as avoiding reading materials provided (the patient may state “I forgot my glasses”) or demonstrating repeated inability to follow written instructions. If there is a suspicion that the patient may not be able to read written material or that the information is written at a level that the patient cannot understand, the nurse must use alternate methods of instruction to ensure patient understanding. Although beyond the scope of this text, several methods exist for the nurse to quickly evaluate written material for readability for those with limited reading skills. Barriers There are a number of barriers to learning that must be considered as part of learner assessment. The lack of available social support systems, which may impair the patient’s motivation to learn or ability to participate in classes or programs, is one common barrier. Lack of support may also limit the patient’s ability to practice new skills. Additional patient-related barriers include cultural differences, lack of financial resources or time, and frequent interruptions. It may be within the patient’s or the nurse’s ability to control or remove these barriers to enhance patient learning and outcomes. Barriers on the part of the nurse to participate in patient education include lack of time and multiple competing demands. The teaching role of the professional nurse is often not prioritized because of issues with staffing, payment, and perception of effectiveness of educational efforts. Furthermore, the nurse’s professional motivation and confidence in education skills may pose a barrier to patient education. Again, assessing the nurse’s attitudes can assist in identification of these professional barriers and development of interventions to overcome them.1 Planning Planning is the determination of what methods will be used to meet the educational need. This includes deciding if the outcome is a cognitive (knowledge) change, a psychomotor (performance of a skill) change, or an affective (feeling or attitude) change. Determining the type of outcome dictates the approach as well as the goal. For example, a patient diagnosed with type 1 diabetes may need to learn about the overall pathophysiology of the disease so that he or she can appreciate the physical and lifestyle impact. However, the patient also needs to develop practical psychomotor skills (e.g., injection and testing) to cope with this disease. The nurse must plan not only to describe what diabetes is but also to demonstrate blood glucose testing and selfinjection of insulin, allowing for practice and re-demonstration from the patient and perhaps significant others as well. The teaching methodology used should match the domain of learning. Implementation of Educational Plan Implementation or carrying out the plan is an area in which flexibility is key. The nurse will need to determine the length of educational sessions, content to be covered, and methodology for teaching. These plans may be influenced by numerous unpredictable factors, such as patient condition and competing priorities. The nurse must adjust the teaching session to accommodate the priorities of the patient. Evaluation Evaluation of learning outcomes should be consistent with the domain of learning as well. Psychomotor skills, for example, require that the patient be able to do something, such as perform a skill. Using a survey or other measurement tool to evaluate a skill will not adequately measure this outcome. Surveys and questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Because the goal of patient education is behavior change, the evaluation of the process may need to be conducted over time and be dependent on multiple sources of data. Returning to the example of teaching a patient diagnosed with type 1 diabetes, the nurse will likely include cognitive information about disease pathology to appropriately manage the condition. This patient will probably need to master the psychomotor skill of blood glucose monitoring and insulin injection. The nurse will also be concerned 418with the affective dimension of the diagnosis of chronic disease. Evaluation of all of these dimensions will require that the nurse observe the skills for level of mastery, discuss the “why” of diet and exercise with the patient on multiple occasions, evaluate the impact of the patient’s daily decisions on disease management, and use repeated assessment of the patient’s acceptance of the condition to fully evaluate behavior change. No discussion of patient education would be complete without consideration of patient adherence. There are many factors that block patient adherence, such as lack of understanding, literacy, financial problems, lack of environmental or interpersonal support, previous experiences with treatment or self-management, and motivation.3 These issues should be included in the assessment process and addressed in the educational plan for the patient in an attempt to enhance compliance. Documentation To ensure consistency in care, documentation of patient education is included in the patient record. This documentation should be comprehensive and include not only a description of the information that the patient was taught but also an assessment of the patient’s motivation, ability to learn (any physical or cognitive issues that may inhibit the process), developmental level, and resources (personal and financial, if appropriate). A detailed plan should be included in the documentation so that other professionals can reinforce the process if education is to be continued across care settings. This should include goals and progress toward them. Finally, the patient response to the educational plan and adjustments to accommodate changes in patient condition or other factors should be included to ensure consistent, successful patient education outcomes. Interrelated Concepts Patient education as a concept is central to the role of the nurse in the delivery of quality patient care (Figure 43-3). The professional roles and attributes of Collaboration and Communication are essential in the development, planning, and delivery of patient education, whereas the nurse’s role as an educator is central to his or her Professional Identity. The nurse works not only with the patient but also with teams of providers in determining care needs, and quality patient education is one of the results of this skilled collaborative effort. To accomplish this, the nurse’s knowledge of Technology and Informatics along with the ability to teach patients and families the use of health care technology are critical when transitioning care from the acute care facility into the home. The result of current changes in health care requires the nurse to engage Leadership skills not only to assist patients and families but also to prepare the consumer for this evolution of health care. FIGURE 43-3 Patient Education and Interrelated Concepts Professional nursing concepts are represented in blue; health care recipient concepts are represented in red. The role of the nurse in Health Promotion, an area in which nurses generally take the lead, is also a critical professional dimension that is related to patient education. The nurse’s knowledge and skill in recognizing opportunities to improve wellness, health, and function through lifestyle modification are used in all patient encounters and are a critical professional role in the education of patients. Patient education incorporates the patient’s attributes and resources. The nurse approaches each patient encounter as an opportunity to educate. This involves a determination of the patient’s developmental level (Development) as well as an analysis of the dynamics of relationships (Family Dynamics) to assist in determination of supports and stressors. The patient’s cultural background (Culture) and prior experiences with Adherence to prescribed regimens are also concepts that have a direct relationship to patient education and in fact form the foundation of the assessment and planning process. Clinical Exemplars Examples of patient education exist in many formats for a broad range of topics, intended for use in a variety of ways. Box 43-1 represents some of the most common examples. Grouped by the primary focus as well as how the teaching/learning may be accomplished, Box 43-1 also highlights the numerous types, venues, and media types that can be considered in patient education. Box 43-1 Exemplars of Patient Education Illness Related Formal Patient Education Programming • Cancer support groups Cardiac Education Exemplar • Cardiac education • Coumadin classes Diabetes Education Exemplar • Diabetes education Preoperative teaching Exemplar • Group preoperative teaching • Ostomy support group Informal Patient–Nurse Encounters Discharge teaching Exemplar • Discharge teaching • Disease-specific diet teaching • High-tech home care teaching • Medication teaching • Symptom control • Targeted written materials • Wound care Self-Directed Patient Education Activities • Common literature (e.g., magazines, journals, newspapers) • Instructional videos specific to condition or treatment Internet Resources Exemplar • Internet resources (e.g., American Cancer Society, American Heart Association) • Self-help books (e.g., diet plans, herbal remedies, alternative and complementary treatment, coping with addiction) Health Promotion Formal Patient Education Programming • Childbirth classes Childbirth education Exemplar Alternative Therapy Exemplar • Complementary and alternative therapy • Drug abuse avoidance • Elder care classes • Parenting classes • Risk reduction activities Smoking Cessation Programs Exemplar • Smoking cessation programs • Strength/endurance building • Weight reduction classes • Wellness education programs Informal Patient–Nurse Encounters • Advanced care planning • Age-specific screening needs • Breast-feeding • Counseling Genetic screening Exemplar • Genetic screening • Health counseling • Immunization teaching • Preventing sexually transmitted diseases Self-Directed Patient Education Activities • Common literature (e.g., magazines, journals, newspapers) • Exercise videos (e.g., aerobics, yoga, Pilates) • Instructional videos specific to health-related topic • Internet resources (e.g., WebMD, Real Age) • Self-help books (e.g., diet plans, herbal remedies, alternative and complementary treatment, coping with addiction) • Television (e.g., health-related programming, FIT TV) 419 Featured Exemplars Although a discussion of all the exemplars presented in Box 43-1 is beyond the scope of this concept presentation, brief descriptions of a few of the most common and important exemplars are presented next. Refer to other resources for detailed information about these and any of the other exemplars. Diabetes Education Diabetes patient education is aimed at increasing the patient’s ability to self-manage this endocrine disorder. Diabetes education programs can take many forms, including group classes and one-to-one teaching. Typical topics included in diabetes education programs are the physiological alterations present in this disease, diet and medication management, monitoring of blood glucose, and risk reduction. Also critical to address in a comprehensive education plan is the psychosocial impact of this condition. If patients are unable to self-manage, family members and other support people can be educated to assist in the care.22 Genetic Screening (Testing) Education Although nurses are an excellent source of general information regarding genetic testing and screening, it is important to advise patients to consult with a genetics counselor if they are considering genetic testing. This professional can provide the most accurate information about cost, confidentiality of results, and the risks and benefits of testing. General information that can be provided to patients involves the information that can be gleaned from genetic testing as it relates to risk of developing a particular disease and passing that risk on to offspring.22 Internet Resources Many patients have the ability to actively research symptoms, diagnoses, and treatment options through use of the Internet. Although often an excellent resource, the nurse remains an active partner in the education of the patient and family by answering questions, reviewing material and websites for accuracy, and assisting the patient and family to locate high-quality health information. It is also important to note that use of Internet resources requires access to a computer or mobile device and some comfort with technology.22 Complementary and Alternative Therapy Inquiry into the use of complementary and alternative therapies should be part of a complete health assessment. This information is incorporated into a teaching plan for the patient. Teaching should include information about the specific type of complementary or alternative therapy (e.g., herbal supplements and meditation, acupuncture, or chiropractic intervention) and how these therapies may relate to more conventional treatments. For example, patients using herbal remedies should be instructed about the storage and use of these remedies and any potential medication or food interactions and also about potential complications of use in the perioperative period.22 Smoking Cessation Programs Smoking cessation programs are designed to assist smokers to stop their use of cigarettes and other forms of tobacco. These programs provide education on the dangers and risks of tobacco use, but they are more focused on methods of stopping habitual use. Interventions may vary depending on the type or sponsor of the smoking cessation program, but they may include nicotine replacement, behavior modification, counseling, support, and relapse prevention. Education plans may also include non-nicotine drugs that may assist the patient to quit, such as some antidepressant medications.22 420 Cardiac Education Information covered in cardiac education can include medication and treatment options as well as risk reduction. The following are all important topics to include in prevention programs as well as post-diagnosis education programs: alterations in lifestyle such as diet modification, weight loss, and control of diabetes; interpretation of common laboratory values (lipid profile); and sleep patterns and stress reduction. Concerns related to return to work, sexual activity, and exercise should be included in a comprehensive education plan. This information can be covered in group classes, which offer the benefit of support of others, or one-to-one teaching.22 Case Study Source: Fuse/ Thinkstock Case Presentation Mr. Jacobs is a 55-year-old college-educated male recently diagnosed with colon cancer. He is scheduled for surgery with formation of a colostomy. Prior to meeting the patient, the nurse reviews the health record and notes that Mr. Jacobs is able to read English, has family support, and is currently not working. Mr. Jacobs’ wife works in retail. Mr. Jacobs is very health conscious, and his goals are to return to “normal” life. The nurse notes a comment made by Mr. Jacobs that “a colostomy is the one thing I said I would never live with.” Based on the information gathered, the nurse develops a teaching plan for Mr. Jacobs. The plan includes the provision of written material about colon cancer, anatomy and physiology of the gastrointestinal tract, and alterations presented by having a stoma. Options for care of the stoma are also provided in writing. A second visit to demonstrate how the ostomy appliance is fitted, emptied, and changed is planned. A manikin abdomen will be used to demonstrate and practice stoma care with the patient. Mr. Jacobs is in the developmental stage of generativity versus stagnation.12 When planning for his learning needs, the nurse uses multiple sources of information to teach Mr. Jacobs according to his level of education but also attends to the fact that psychomotor learning is required. To evaluate the outcome of the educational intervention conducted, the nurse follows-up with Mr. Jacobs to determine his competency (both actual and perceived) in performing the necessary skills of care and Mr. Jacobs’ emotional and attitudinal changes related to the ostomy and his illness. Plans are changed and adjusted according to Mr. Jacobs’ progress toward his goals, incorporating family members while Mr. Jacobs becomes ready for this step. Case Analysis In this case, the nurse attended carefully to assessment before beginning the educational process. Because the patient was well educated, the nurse could rely on multiple forms of education, including written materials. The nurse used hands-on practice to incorporate psychomotor skill. By asking about goals and listening to Mr. Jacobs’ as he discussed his feelings about living with an ostomy before initiating the educational plan, the nurse gathers valuable information about perceptions and attitudes. With this information, the nurse is able to incorporate strategies for addressing the affective domain that will be most effective. Including the family members before the patient is ready may hamper education efforts by limiting trust in the nurse–patient relationship. The patient’s desire to return to his normal life indicates to the nurse that this patient, in Erickson’s stage of generativity versus stagnation, wants to resume a productive life as soon as possible, lending to motivation to learn. This could have been further enhanced by incorporating frank discussions about the impact on Mr. Jacobs’ sexuality into the teaching plan. Failing to attend to the patient during assessment would have resulted in failure of the patient’s educational experience. For example, if the nurse assumed that the patient would want his wife included from the beginning and arranged the educational sessions with Mrs. Jacobs rather than the patient alone, the nurse would have limited the patient’s ability to express his own needs in the educational encounter. References 1. Bastable SB, Gramet P, Jacobs K, et al. Health professional as educator: Principles of teaching and learning. Jones & Bartlett: Boston; 2011. 2. Lamiani G, Furey A. 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Lewis SL, Dirksen SR, Heirkemper MM, et al. Medical–surgical nursing: Assessment and management of clinical problems. ed 9. Mosby: St Louis; 2014. Major Ingredients of Caring knowledge refers to knowing about something, to hav- ing information about it. I may know something in- directly without actually experiencing it, and I may experience it without knowing it directly. Caring, then, includes explicit and implicit knowledge, knowing that and knowing how, and di- rect and indirect knowledge, all related in various ways to helping the other grow. One important rea- son, perhaps, for our failure to realize how much knowing there is in caring is our habit sometimes of restricting knowledge arbitrarily to what can be ver- balized. We do not consider implicit knowledge, knowing how, and direct knowledge as ways of know- ing. Restricting the meaning of knowledge in this way is as arbitrary as assuming that only words can be communicated and restricting the meaning of com- munication to what can be put into words. pen 5 Alternating Rhythms As a teacher I try to explain some idea to a stu- dent, look to see whether I have succeeded, and if I have not, try again in some other way. Or as a writer I try to put a thought into words, read it over to see 21 On Caring whether I have succeeded, and if I have not, try again in some other way. In both cases I act with certain expectations, undergo or suffer the results of my ac- tions, and then link up these two phases and see whether what I expected was in fact achieved. I can- not care by sheer habit; I must be able to learn from my past. I see what my actions amount to, whether I have helped or not, and, in the light of the results, maintain or modify my behavior so that I can better help the other. But “doing” is to be understood broadly and not only in the active sense, as though I were always acting on the other. It may involve doing “nothing.” In caring for a person, for instance, there are times when I do not inject myself into the situa- tion, I do not take a stand one way or the other, I do “nothing.” And when I undergo this “inactivity,” I see what resulted from it and may change my behavior accordingly. Consider a different sort of rhythm that is also important in caring, the rhythm of moving back and forth between a narrower and a wider framework. There are times in caring for a child when I examine an act as a relatively isolated episode, without relating it carefully to what went before and what will follow, and other times when I look at the particular act in its wider connections within a larger framework and can discern trends, long-term effects, and tendencies. It is 22 Major Ingredients of Caring one thing, for example, to examine an act of insecurity as a relatively isolated event; it is another matter to consider it as the expression of a general pattern of insecurity. Or, in working out an idea, there are times when I attend to a detail in relative isolation, and times when I view the detail in connection with other ideas or with the projected essay or book as a whole. To see the way a chapter fits into a projected book may change my idea of what the book is to be, or it may change my idea of what the chapter ought to be. And clearly, the chapter we view in relative isolation at one time may, at another time, itself provide a wider con- text for examining some page. 6 Patience Patience is an important ingredient in caring: I enable the other to grow in its own time and in its own way. (The growth of a significant idea can no more be forced than the growth of a flower or a child.) By being patient I give time and thereby enable the other to find itself in its own time. The impatient man, on the other hand, not only does not give time, but he often takes time away from the other. If we know that someone 23
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