What Should the Patient Be Taught?

The patient’s need for information depends on the disease process, the treatment plan, and the patient–provider relationship. When a patient is first diagnosed with a medical problem, education must start with explaining the pathophysiology in terms the patient will understand and describing what the prognosis might be. It is only when patients understand what has happened to them that they can move on to consider what to do about it.

The initiation of new medication therapy requires fairly extensive teaching. It is clearly not possible to provide all information that patients might need in a single teaching session. Instead, the health care provider should have a plan in mind for the things that need to be covered, and this needs to be shared with patients. Information also should be shared regarding perceptions, expectations, and options (Bastable, 2005; Lorig, 2000; Shapiro et al, 2006; Yetzer, Goetsch & St Paul, 2011) (Box 12-1).

Additional teaching will be required when therapy is changed, medication dosages or schedules are adjusted, or changes in a patient’s condition warrant additional modifications to therapy. Teaching then becomes individualized to what the patient requires and thus is packaged in quantities that the patient can handle. Each change offers an opportunity for a short educational session (Eisenmann, 2012; Canobbio, 2005).

The health care provider must be familiar with the legal issues involved in the situation. Patients have the right to obtain information about their diagnosis, treatment, and prognosis. Informed consent is a principle that is implicit in the process of prescribing a medication for a patient. The practitioner has a legal obligation to ensure that patients understand their condition, the treatment proposed, and the risks and benefits of the treatment recommendations. The law requires that the amount and type of information provided to the patient should be “reasonable.” It is up to the practitioner to determine what is reasonable for each patient to understand. The accepted standard of care ensures that practitioners are held legally responsible if they fail to advise a patient adequately. Notes in the patient record should summarize the topics covered.

Various studies have found discrepancies between the information that clinicians perceive as important and the information that patients desire (Moore, 2011; Safeer & Keenan, 2005; Safeer, Cooke, & Keenan, 2006; Schillinger et al, 2006; Shershneva et al, 2006). Rare or serious side effects are awkward to discuss. Some health care providers have been reluctant to volunteer in-depth discussion of these topics for fear of frightening patients, believing it may decrease their adherence with treatment (Baniasadi, 2011). However, Reyes-Ortiz and colleagues (2005) found that seizure patients wanted to receive specific information on potentially serious side effects associated with carbamazepine. Although this information made the patients perceive the drug as risky, no patient refused treatment, and no evidence of a negative reaction was observed after patients had been given extensive information. The authors concluded that patients who are given detailed information may be able to accurately recognize side effects, should they occur.

Although formal teaching is carefully planned, teaching in the clinical areas often occurs in response to a patient’s question and is implemented on the spur of the moment without adequate preparation, planning, or overall consideration of what the patient needs to know. Using scientific or professional jargon, providing too much technical detail, or being unnecessarily vague all hinder or destroy the teaching process. Although it is impossible to avoid answering impromptu questions (even if they take the provider by surprise), it is essential to have an overall written plan that will cover what will be taught, how it will be taught, and how the clinician will know when the patient has learned the material. Some hospitals and clinics schedule time for patient teaching, often for groups of patients with the same clinical diagnosis (Falvo, 2010; Safeer et al, 2006).

As was introduced earlier in the discussion of process, formalization of the teaching–learning experience begins with the writing of specific objectives. Objectives reflect the blend of patient and provider decisions regarding the treatment philosophy, the use of results from research, learner motivation and need to learn, continuity in learning, sequential arrangement of the behavior to be learned, and the priority of learning. Specifically, the objectives must describe new behaviors that will occur because of changes in patients’ thinking or understanding. The best objectives are precisely stated by describing the important conditions that surround performance and by specifying the criteria for acceptable performance. These are often based on national recommendations, clinical guidelines, or standard treatment goals for a particular disease or problem (Redman, 2006). Specific goals help to clarify for patients what they are to do (Falvo, 2010). For example, “Blood pressure will decrease to the diastolic reading of less than 95 mm Hg within 3 months” is specific, measurable, and based on national guidelines. As patients and providers craft objectives together, the provider has a chance to evaluate patients’ knowledge, understanding, and general motivation to change behavior.

How Will Patient Education Be Accomplished?

Both the content and the process of patient education are important factors for consideration when specific teaching–learning objectives are planned. Many patients are overwhelmed when they first learn that they have a new diagnosis. Fear and anxiety increase the confusion they often feel and interfere with their learning. Address these anxieties directly (“No, you don’t have cancer”).

To avoid increasing the stress that patients may feel, teaching should be conducted systematically when the learner is ready to learn. It should be provided in a timely manner, in a quiet and unhurried environment that gives patients a chance to ask questions. It is difficult to fulfill these criteria in today’s busy health care system. Educational research has suggested that people are able to remember three major things that they are taught in any one session (Wolf et al, 2007). And they generally remember those things in the order in which they are presented. Providers who accept these premises and develop a teaching plan consistent with them can set aside small periods of time to devote to teaching a few, very specific things. Review on subsequent visits to evaluate learning and retention of information. Then the provider can move on to the next phase of information sharing that has been identified. The patient’s family, caregivers, or loved ones might be included in the educational sessions as appropriate and in accordance with HIPAA privacy requirements.

In an effort to specifically improve medication adherence, the literature suggests a variety of strategies for providing patients with information about their medications (Barker et al, 2006; Ferguson & Pawlak, 2011; Jafri et al, 2007). These strategies include verbal instruction, verbal and written instruction, and/or audiovisual aids. Some CDs, DVDs, and websites on the Internet combine audiovisual and written information in an interactive process.

Verbal education is often provided as one-on-one counseling, particularly when a patient’s condition is first diagnosed and when therapy is first being implemented. Verbal instruction provides content and then gives the patient a chance to ask questions. Patients with chronic diseases such as diabetes or hypertension, who have extensive needs for teaching, may come together in small groups for part of their educational experience. Group interaction and observation may actually enhance learning because the context for learning is enhanced.

Written information can be provided in the form of special labels for prescription bottles, patient package inserts, single-page materials developed by individual pharmacists or organizations, and booklets. The health care provider, the health care institution, and professional specialty organizations may prepare and disseminate written information. Regardless of the source, information should be provided to meet specific educational needs and should not be provided to the patient until the patient is ready to receive it.

Audiovisual programs may use CDs or videocassettes. The greater availability of these resources and the wider use of VCRs, DVDs, and CDs in the home have led to the development of lending libraries with information on common topics. Wider availability of personal computers has increased the use of CDs for teaching patients. Use of the Internet to collect information allows patients to select what they want and to download and print it for future reference (Teasdale & Shaikh, 2006).

Research attention is now focused on the use of computers (Gresty et al, 2007; Kuhl et al, 2006), both to assess and to meet the needs of patients. Research (Koivunen et al, 2007; Navarre et al, 2007) suggests that patients might actually be more comfortable disclosing personal information to a computer than to a human being, even though they know the information will be reviewed by a health care professional. Although many educators initially thought that computers would not be appropriate for audiences with poor literacy skills, research findings have revealed the opposite. Investigators have found that the use of an audio computer-assisted self-interview system may result in more candid reporting of certain health behaviors and may be acceptable to subjects with poor literacy skills (Beranova & Sykes, 2007; Mackenzie et al, 2007).

All teaching methods, with the possible exception of patient package inserts, have been shown to improve knowledge and enhance information retention (Lorig, 2000; Redman, 2006). A combination of verbal and written information, or the use of verbal counseling along with audiovisual aids, is generally superior to the use of traditional written material only. Most patients prefer a combination of written and verbal information, and studies have shown that this approach is most effective in improving knowledge (Redman, 2006). When other criteria (such as efficacy, volume, logistics, and cost) are used to evaluate the best strategy for providing patient education, the preferred method again is to provide information both in writing and verbally. This is especially important for new prescriptions (Davis et al, 2006; Redman, 2006). Providing only written information is usually insufficient for patient education.

Reduced Literacy as a Barrier to Patient Education

Functional health literacy is

the ability to read, understand, and act on health information. This includes such tasks as reading and comprehending prescription labels, interpreting appointment slips, completing health insurance forms, following instructions for diagnostic tests, and understanding other essential health-related materials required to adequately function as a patient.

(Andrus & Roth, 2002)

An individual may be able to read and understand general materials with familiar content at home or at work but may struggle when presented with medical material of the same complexity that contains unfamiliar vocabulary and concepts. This applies even to well-educated patients. Health literacy includes reading ability, numeracy skills (described as the ability to perform mathematical computations with numbers embedded in printed materials), and comprehension. Some authors suggest that numeracy, or quantitative literacy, may be the most important element of health literacy (Ferguson & Pawlak, 2011; Jackson, 2005; Scudder, 2006; U.S. Public Health Service, 2005). For example, this would include reading how many pills one should take and when they should be taken—a skill that is essential for adequate and safe medication administration.

Lack of adequate literacy skills is a major barrier to patients’ receiving proper health care. People with low reading levels have problems accessing the health care system, understanding recommended treatments and consent forms, and following the instructions of providers. Patients are routinely expected to read and understand labels on medicine containers, appointment slips, informed consent documents, and health education materials (Davis et al, 2006). Thus, patients with lower literacy often have poor health outcomes (Scudder, 2006). The number of years of school completed as reported by patients was four or five levels higher than their actual reading ability, as revealed on the Wide Range Achievement Test (WRAT), a word pronunciation and recognition test (Hironaka & Paasche-Orlow, 2006).

Many of the health educational materials that have been developed for patients by pharmaceutical companies, professional associations, and institutions are not suitable because a serious mismatch is noted between the level at which the patient can read and the level at which the materials are written. Approximately half of the population struggles with basic reading skills, and studies (Ferguson & Pawlak, 2011; Jackson, 2005) have found the following to be true:

One study (Rogers et al, 2006) of an indigent, uninsured, urban population documented average reading levels that were 4.6 grades below the last grade completed in school, with mean reading comprehension at the fifth grade level. Clearly, literacy problems are very prevalent and so critical that it is understandable that Healthy People 2010 devoted some of its health communication objectives to this issue (USDHHS, 2002).

Notwithstanding the desire of some providers to develop patient teaching materials, there is no lack of prewritten patient educational materials. Many materials are available for sale, although the investment required to purchase this information for all patients may become prohibitive. In fact, the problem lies not in finding patient education materials but in evaluating their quality, readability, and applicability, particularly because many of them are written at too high a level for patient understanding. Many patient education handouts, such as those available over the Internet, may be modified and customized to the individual patient. However, even a cursory evaluation of these materials reveals that most are written at a higher reading level than is essential for most patients. No commercially available handouts should be used for patients unless they have been carefully assessed for readability. Most will require revision to be acceptable, no matter how “pretty” they look or how much money was spent to prepare them. Information from drug companies must be carefully screened because they often consist of more advertisement than information. Keeping sentences short and choosing simple words make it much easier to develop reading materials at a simple and straightforward reading level (Redman, 2006).