Moving Beyond Teaching Checklistsby Fran London, M.S., R.N.
You've seen those teaching checklists. They're lists of specific things to teach patients, such as those with asthma or congestive heart failure. Teach a topic and check it off. Move down the list and your teaching is done. There are even books that claim to help you do patient education, composed entirely of teaching checklists on tests, treatments, and diagnoses.
Some think JCAHO requires teaching checklists, but they are not reading the guidelines carefully. JCAHO is not looking for evidence of what was taught, but what the patient knows.
Teaching checklists can be used, quite effectively, to enhance education. But we tend to look at them as To Do Lists of tasks to be completed. But is this really patient education? Why not?
Teaching checklists are inconsistent with adult learning principles. Teaching from a list doesn't take advantage of teachable moments, and ignores the learner's issues. Adults learn best when they want to solve a problem. It is more efficient and effective to identify what the patient sees as a problem, and address that first. If we teach down a checklist, ignoring the learner's responses and needs, we waste time when the learner isn't engaged and isn't motivated to change behaviors.
Teaching checklists discourage individualized teaching. Lists promote mini-lectures rather than conversation. Why assess learning needs, if, no matter what you find, you still have to teach the topics on the list? What if the learner already knows the content of the first three items? Do you have to teach them anyway? What if the list says to provide a handout, but you know the patient and family can't read? Would a video be more helpful? Lists turn patient education into a series of tasks to check off, instead of emphasizing the interactive process individualized to the learner's needs. The mere existence of a teaching checklist communicates that when everything is checked off, teaching is done. But is it?
Teaching checklists frustrate staff. They see a short admission and a long teaching checklist, and they give up. They know they can't cover everything on the list. I have heard some nurses say they don't document their teaching intentionally because it looks better to have a blank sheet where you assume teaching was done but not documented, rather than show, in writing, teaching was not completed.
Teaching checklists are not accurate. What a specific person needs to learn most may not be on the list. It may be something unrelated to the diagnosis, but until it is addressed, it may prevent the learner from listening to anything else you say. For example, a patient who is having financial difficulties may not be open to hearing the diagnosis of a chronic illness involving the expense of long-term medications. Survival skills may not be the same for everyone, depending on what they already know and what they have to work with. It may not be appropriate for all learners to be taught the topics in the order in which they appear on the list. Their most pressing questions may be further down on the list.
Teaching checklists may subliminally discourage a full evaluation of understanding. The mere existence of a teaching checklist implies all these items need to be covered. The list itself encourages the educator to check an item off and proceed down the list, before fully ensuring the learner understands and can apply the new information. A nod of “yes, I understand" may be taken as evidence of understanding.
Some think JCAHO requires teaching checklists, but they are not reading the guidelines carefully. JCAHO is not looking for evidence of what was taught, but what the patient knows. It is more important to document how well the patient demonstrated self-care skills, than to document what topics you covered, what handouts you gave, or what video you told the patient to watch. JCAHO wants to see that you assessed learning needs and evaluated understanding.
So if we don't use teaching checklists to standardize teaching, what do we do?
Focus your patient education on preparing the patient for self-care. Use every interaction with the patient and family to integrate teaching into care. Listen to the learners' concerns and questions, so you can present teaching in ways they see as relevant. Explain your assessments and interventions as you do them. Anticipate what patients and families will need to know.
Since you will never have enough time to teach absolutely everything, teach what is most important right now. This keeps your teaching goals more realistic and doable.
Instead of a list, standardize the goal of patient education to ensure every learner
- is able to perform self-care skills to stay safe
- understands what to do to optimize self-care, and the consequences of not doing those things
- knows how to recognize problems and knows how to respond
Teaching is never done. Assess who the patient is, what he knows, what he needs to learn to stay safe, and teach the most important skills and behaviors first. Since you will never have enough time to teach absolutely everything, teach what is most important right now. This keeps your teaching goals more realistic and doable. This is more efficient because teaching time isn't spent on items at the top of the checklist that may be less important when the real issue for this patient is 2/3 down the list.
Then communicate to continuing care providers what the learner mastered, what needs review, and what has not yet been addressed. Let everyone else on the health care team, across the continuum of care, know where teaching left off through your documentation. Teaching is more efficient if we build on one another's progress.
If you must keep your teaching checklists, use them in ways that respect your learners as adults.
If your learner can read, put each list item on a card, and ask the learner to put them in order of most to least interested in learning about. A newly diagnosed diabetic may be willing to talk about diet, but have no interest in learning about self-injection (which you know is essential to teach). Let this card sort guide you. Teach what the learner wants to know first, and coach the learner towards approaching avoided aspects of the illness.
Glance at the checklist AFTER you're done teaching, to see if you left out some important topic (such as medications or diet). This will help if you have to comply with requirements of third party payers.
Remember the point of patient education is not to increase information, but to improve health outcomes. Let your assessment and the interaction with the learner guide the content of your teaching session, not some list. You get to do your job as a professional, and your patient gets to keep his or her dignity as a self-directing adult.