Chapter One

Patient Education: Empowering Patients and Families (Part 2)

You can find the first half of this chapter in our Spring 2005 archive.

Chapter Objectives

When you finish this chapter, you will be able to:

1. Define patient education and state the goals of patient education
2. Identify the nurse's role in patient education
3. Discuss JCAHO Patient and Family Education standards
4. Explain the value of interdisciplinary collaboration in patient teaching
5. Describe three theories that provide a basis for effective patient teaching
6. Recognize ways to help patients achieve compliance

How theories can help improve patient teaching

Theories that explain behavior change serve as guidelines for teaching. Theories that can be applied to patient teaching come from the disciplines of sociology, psychology, adult education, communication, and organizational development. Some of the most relevant theories for patient and family teaching are the Health Belief Model, self-efficacy theory, and locus of control theory. Stress, coping, and social support theories are other theories that are relevant for patient teaching.

The Health Belief Model helps explain why individual patients may accept or reject preventive health practices or adopt health behaviors. This theory proposes that people will respond best to messages about health promotion or disease prevention when an individual believes that:

• He or she is at risk of developing a specific condition
• The risk is serious and the consequences of developing the condition are undesirable
• The risk will be reduced by a specific behavior change
• Barriers to the behavior change can be overcome and managed

The first condition in the Health Belief Model is perceived threat. If the person does not see a health behavior as dangerous, there is no stimulus for change. There are two types of perceived threat- susceptibility and severity. Susceptibility refers to how much risk a person believes he is at; severity refers to how serious the consequences might be. To effectively change health behaviors, the individual must usually sense both susceptibility and severity. This is one reason why many people become motivated to change behavior after they have been diagnosed with cancer, heart disease, or diabetes.

Patients must also have the expectation that the new behavior will be beneficial; they must feel that barriers to change don't outweigh the benefits and that they can realistically accomplish the needed behavior change. Knowing what aspect of the Health Belief Model patients accept or reject can help you design appropriate interventions. For example, if a patient is aware of a risk, but feels the behavior change is overwhelming or unachievable, you can focus your teaching efforts to helping the patient overcome the perceived barriers.

Self-efficacy refers to the extent a person has confidence in his or her abilities. Because self-efficacy is based on feelings of self-confidence and control, it is a good predictor of motivation and behavior. Research shows that healthcare professionals can have an impact on self-efficacy by using teaching techniques such as skills mastery and modeling. Skills mastery is a teaching technique in which skills are broken down into small, manageable tasks that are likely to be done successfully.

Modeling helps increase self-efficacy by exposing the patient to someone else with a similar problem who can model positive behavior change. Recognizing and rewarding the patient for accomplishing tasks is important to help build the esteem that is the basis of self-efficacy. Recognition is particularly important for patients with a limited education or who have low literacy skills.

Locus of control theory describes the extent to which people believe they are in control of their own choices. This theory proposes that people who believe they are in charge of their own health status( internal locus of control) are more likely to make necessary changes that those who believe their health is in the hands of others or decided by fate (external locus of control). You can assist patients with external locus of control by helping them consider the abilities they have to control health events, by helping them improve their decision making skills, and encouraging them to use social support systems.

Helping patients achieve compliance

Health care professionals consider patients “compliant" when they follow treatment recommendations for health care management. We describe patients as “noncompliant" when they ignore instructions or don't follow them correctly. The nursing diagnosis on noncompliance is defined as “behavior of a person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed upon by the person (and/or family) and health care professionals."

The extent to which patients comply with health care teaching and instructions is a major issue in health care today. Most studies show that a large percentage of patients are noncompliant and that health care professionals significantly underestimate how common noncompliance is. Concern about compliance with health teaching has a long history - even Hippocrates is reported to have complained about patients being noncompliant.

Noncompliance negatively affects the patient's health status, the health of a community, the motivation and job satisfaction of nurses and other health care professionals, and the country's health care system. Significant financial resources are wasted when medications are not taken correctly, when medical equipment is misused, when patients are re-admitted for costly hospital care for preventable problems, and when a large percentage of the public continue to practice health habits that inevitably lead to serious disease.

The bottom line is that patients control what they do with the health teaching you provide. Your responsibility is to assist patients in achieving and maintaining health by sharing knowledge, helping with the practical problems of carrying out instructions, and supporting patients as they integrate new knowledge and skills. By following some basic steps, you can help make it easier for patients and families to comply.

The first step is to make sure that health care instructions are understandable and compatible with patient goals. It is vital to remember that patients cannot carry out recommendations they don't understand and will not carry out recommendations they do not agree with.

The next step is to include the patient as a partner in the process rather than as a passive recipient of health teaching. We should not approach patients as passive learners who are obligated to change their behaviors based solely on our directions. By using teaching strategies that are interactive and allow patients equal participation, you can help promote compliance.

The third step is to view the patient teaching as a process that requires a strong interpersonal relationship with the patient and his or her family. There is a growing consensus among researchers that the health care professional's ability to communicate and explain information while expressing empathy and concern for the patient is associated with increased patient compliance.

One study showed that nurses and other health care professionals who motivated patients to comply shared certain characteristics. These effective health care educators discussed treatment and self-care with patients, worked with patients to develop a teaching plan, demonstrated interest in how patients fit self-care needs into daily life, helped patients problem solve, discussed issues with patients in order to plan care, and listened to patients' opinions. Other strategies you can use to help increase compliance are listed in Table 2.

The key to effective health teaching is to develop an equal partnership that enables patients and families to manage health care problems with skill and confidence. Understanding the goals of patient education, knowing your role and how to work with other team members, using theories as a base for patient teaching, and employing strategies that help patients comply will significantly increase your effectiveness as a patient teacher.