Chapter Three

Meeting Individual Needs (Part 2 of this chapter)

You can find the first four installments of this series in our Spring 2005 archive, Fall 2005 archive, Sping 2006 archive, Fall 2006 archive and Spring 2007 archive.

Chapter Objectives

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

1. Discuss three developmental areas that should be assessed to provide age-appropriate education
2. Identify teaching strategies useful when teaching patients of different age groups
3. State four adult learning principles
4. Discuss how to assess the impact
5. Identify three strategies for family teaching
6. Describe the influence of culture on health care beliefs
7. Name three strategies for working with patients of different cultures
8. State how to assess a patient’s literacy level

Developing a partnership with the family

The concept of “family” is more than people that are biologically related.  JCAHO defines the family as “the person or persons who plays a significant role in the individual’s life, including persons not legally related to the individual.”  When viewed in this broader context, a “family” might include two people of the same or different sexes living together with or without sexual attachment, single-parent families, re-married families with children and stepchildren, and many other family forms.

When serious illness or disability strikes an individual, the family as a whole is affected.  Other family members must alter their lifestyle and take on some of the role functions of the ill person, which in turn affects their own normal role functioning.  The extent of family disruption depends on the seriousness of the illness, the family’s level of functioning before the illness, socioeconomic considerations, and the extent to which other family members can absorb the role of the person who is ill.  Problems with family organization and role definition can be barriers to learning.

No matter how it’s constructed, every “family” unit is unique.  Assess family function and style by talking with the patient and family and observing how they interact with each other.  Through conversations and observations, you can gain information about family function, stress, transitions, and expectations that will be invaluable in developing an effective teaching plan.  Teaching plans developed without input from the patient and family are often doomed to failure.  As a result, the health care team spends valuable additional time going back to assess the family and often learn about strengths and barriers that were present all along. 

Both the patient and the family members need time to tell their story about the illness and the impact it is having on their lives.  Gathering information about the family does not have to be restricted to structured interviews.  Informal conversations with the patient and family while you are passing medications, adjusting an intravenous rate, or giving a tube feeding can yield data that will help enrich your family assessment.  Table 8 shows areas of family assessment.

The COPE model, a system that focuses on helping family members become effective problem solvers, is one means of approaching family teaching. 

C stands for creativity/.  Creative strategies include helping the family overcome obstacles to carrying out health care management and learning how to generate alternatives. For example, instead of consuming time and energy with food preparation, an elderly parent could have food delivered by Meals on Wheels, or a neighbor could be approached to help with shopping and cooking. 

O stands for optimism.  This part of the model involves helping family caregivers learn how to view the care giving situation with confidence. 

P is for planning- learning how to plan for future problems developing contingency plans that reduces uncertainty. 

E stands for expert information – learning how to obtain expert information from health care providers about what to do in specific situations.  Expert information helps empower caregivers by enabling them to develop effective plans for solving care giving problems.

Using case studies of what other families in similar circumstances have done is an excellent teaching strategy.  Family caregivers are often very interested in learning how other caregivers solved problems and respond positively to learning through case examples.  Table 9 shows the type of information families need.

Patients and families coping with severe chronic illness such as cancer, heart disease, diabetes, chronic obstructive pulmonary disease, or Alzheimer’s disease face unique issues.  Important teaching needs for long-term family caregivers include information, education, respite, and support.  Such families need information about the disease process and resources to help with disease management, and education with a focus on planning, care giving, decision-making, and problem solving.  They also need information on respite resources and the knowledge that there is a place for them to turn to for support.

When family members assume the role of caregivers, they become part of the health care team.  To achieve the goal of self efficacy for family caregivers, support and encouragement from health care professionals is essential.  Some family caregivers expect health professionals to solve problems for them, and some health professionals believe they should be the primary problem solvers for the family.  This traditional authoritarian approach encourages dependence and provides little incentive for patients or families to develop effective problem solving skills. 

Health care professionals must learn to see the family caregiver as a true partner in providing care and to see themselves as health educators whose role is to teach families how to solve problems rather than as the “experts” who solve problems for them.

Teaching patients with low literacy skills

JCAHO and the American Hospital Association’s Patient’s Bill of Rights require that patients have health care information in terms that patients and families can understand.  JCAHO Patient and Family Education Standards specify that health care professionals consider their patient’s literacy, educational level, and language in providing health care instructions. 

Low literacy skills are a major problem for many patients.  The average American adult reads between the eight and ninth grade level.  Nearly two out of three people over age 65 and many people of all ages who are members of minority groups living in inner city areas read at or below the 5th grade level.  In addition, another 30 percent of the population has marginal reading skills – between a 5th and 9th grade level.  This means that one of every two patients you teach may not understand or will have trouble understanding written health-related materials because most health care instructions are written at or above the 9th grade reading level.

Despite attempts to simplify written materials from the typical ninth or 10th grade reading level to the sixth grade reading level, the patient with low literacy skills may still be lost.  It’s important for nurses to assess patient’s literacy levels. 

Two quick and simple reading skills tests are the WRAT (Wide Range Achievement Test) and the REALM (Rapid Estimate of Health Literacy in Medicine).  Once you’ve assessed your patient’s reading level, use strategies that match your patient’s abilities.  For example, if you find that your patient reads below the fifth grade level, choose interactive methods such as demonstration, short audiotapes, or flip charts that show a single concept. 

A patient with limited reading skills often has a short attention span; therefore, instruction should be short, direct, and specific.  You can also use “end use” strategies such as using a shopping list or restaurant menu to teach about food choices rather than written materials that the patient must be able to understand in order to apply them to real life situations.  The book Teaching Patients with Low Literacy Skills, listed in the appendix, is an invaluable resource for improving your abilities to help this significant group of patients.

By considering your patient’s age and developmental level, his or her family structure, determining the influence of the patient’s culture, and by assessing literacy levels, you can individualize patient teaching in a way that meets specific patient needs.  By increasing your awareness of individual differences, you can help ensure that your patient teaching activities help patients to manage their own health care needs.