1. Bonnel, Wanda Blaser PhD, ARNP


Patient education can play a key role in quality long-term care, but is often an under-developed resource. Potential challenges related to the older adult population, staffing patterns, and setting are described. Topics, strategies, and resources are provided to promote patient education for older adults and their families.


Most of us enjoy finding bargains. Recent experiences in long-term care facilities have reminded me what a bargain patient education can be, especially in areas such as safety, time savings, and quality of life. Many would agree that patient education in long-term care settings is an under-developed resource. Are long-term care facilities affiliated with staff development programs making the most of the patient education bargain?


Why should nursing staff development be concerned about the patient education bargain long-term care facilities provide? Nursing homes are changing. As the patients' ages increase, so does the complexity of their physical and mental health care needs. Types of nursing care units vary and can include subacute care, palliative care, and dementia units as well as "nonskilled" nursing units. Nursing homes are physically expanding to include assisted-living units and independent-living apartments (even the terms and types of care can be confusing to patients and families). Long-term care staff provide a myriad of care services to these complicated patients and families. Staff educators who do not think ahead to working with long-term care staff are missing a key role.


What makes patient education a bargain in long-term care facilities? Increasing physical frailty can put patients at risk for falls. As such, safety is a potential patient education bargain. Teaching patients and families the benefits of strengthening exercises, including simple walking programs, can promote healthy outcomes. Families can learn the benefits of activity and exercise programs for their loved ones.


Another potential bargain is that of saving time, particularly when working with worried families. Good patient teaching about a patient's health problems (such as chronic lung disease) can help families better understand the physical or mental changes a loved one may experience and why particular treatments are important. For example, reviewing the outcomes and benefits of respiratory care treatments can save questions about a loved one's increased coughing following a treatment. Patient teaching can also include educating families in being more involved with their loved one's care (for example, offering fluids on a regular basis).


Patient education can be a bargain in quality of life. Older adults are particularly at risk for adverse drug reactions and that can potentially make an impact on their quality of life (Lee, 1996). We can educate patients and families about the medications patients are taking and outcomes staff are trying to achieve. Families and patients can also learn to advocate for minimizing drugs and the consequential risks of adverse drug reactions. Preventing and recognizing potential medication-related illnesses can be major bargains in quality of life.


To promote the patient education bargain in long-term care facilities, specific approaches to patient education should be considered. For example, do the topics for patient education in the long-term care setting differ from traditional patient education topics? While chronic disease topics and end-of-life care issues are not foreign to other settings, they are often a focus in long-term care facilities. Topics such as ethical decision making, palliative care, and the inevitability of death can become common, important topics for patients and families. Family and staff support of patients' maximal autonomy and quality of life are also key concepts.


Teaching complex topics in clear, simple terms is a critical skill in the long-term care facility. For example, when teaching patients about advance directives, do patients and families truly understand what is being said? A family at one facility wanted their loved one to have "full code" status. When staff very specifically described "full code," the patient and family assured staff that was not what they wanted. Patients and families should also understand the concept of palliative care and know that the words "no code" do not equate to "no care." Nurse aides also need to hear this patient education.


Consideration of the "correct" content for patient education is also important. Specific educational content for the frail elderly may be different from content for younger adults; diet issues of older adult diabetic patients serves as a good example. While tight control of blood sugars to promote future health is the current care standard for the general diabetic population, older adults have already achieved longevity. With the older, more frail population in nursing homes, patients are often at risk for weight loss and malnourishment. Well-meaning staff can work very hard to "control" diabetic diets when often many patients' health and their quality of life can be maintained with more liberalized diets. Patient and family education can include advocacy for making informed diet choices.


Teaching strategies or approaches to patient education can differ among patient populations. Estimates are that 50-60% of nursing home patients have some type of non-reversible dementia such as Alzheimer's Disease (Ouslander, Osterweil, & Morely, 1997). In these instances patient teaching changes format and becomes simple reminders or directions to patients on a repeated basis. In the early stages of Alzheimer's Disease, these repeated "brief" patient teachings are helpful in promoting patient success at tasks and promoting patient dignity. Physical aging changes should also be considered for patient teaching in long-term care. Hearing and vision alterations common to older adults are good examples. Using quiet areas with little background noise and providing large print visual aides in contrasting colors helps older patients (and even older family members) better understand educational presentations.


The persons providing patient education in long-term care may not be nurses. Often, nurse assistants, instead of professional nurse caregivers, spend the most time with patients and families in long-term care facilities. Are nurse assistants providing basic patient education correctly and at appropriate times? Are they notifying professional staff of the need for follow-up education? What is the staff development educator's strategy for incorporating nurse aides as "assistant" patient educators?


Standardized quality education on traditional topics such as congestive heart failure, hip fracture rehabilitation, and coping with Alzheimer's Disease are important in long-term care. There are currently good patient education materials from many organizations, often with Internet sites (see Table 1). Referring patients and families to community resources such as stroke support groups and Alzheimer's Association chapters can also be an approach to patient education.


To provide bargains in safety, time savings, and quality of life, patient education in long-term care facilities should be a major focus. While some aspects of patient education in long-term care settings differ from patient education with younger populations, staff development educators have the expertise to build on these differences. Knowledge of common patient problems and long-term care strategies can help staff development educators design patient education programs that benefit older adults and their families. Patient education is an important bargain that deserves attention in the long-term care setting.