1. Whitman, Marjorie MSN, RN

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THE FIRST STEP OF THE NURSING process that guides professional nursing practice is assessment. Many patients need complex information for proper self-care upon discharge. In our hurry to provide information efficiently, we often focus on the educational materials rather than determining first what the patient already knows and what he or she is most concerned about. We have to learn what the patient sees as a problem before we guide the patient to a solution. My experience with a patient I'll call "Nathan," age 23, is a case in point.

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Nathan was quite well-known on our unit, where he was undergoing diagnostic testing and being treated for hypercalcemia. Finally the specific subtype of non-Hodgkin lymphoma (NHL) was confirmed. As the oncologist hurriedly stepped into the hospital elevator to leave for his office, he asked me to prepare Nathan to receive the most common chemotherapy combination for the initial treatment of his NHL subtype. The regimen consists of four drugs: cyclophosphamide, doxorubicin, vincristine, and prednisone.


In his room, I greeted Nathan in a friendly manner. I said, "I understand you're going to start your chemotherapy today. What concerns you most about your treatments?" With almost no hesitation, Nathan asked, "Will these drugs make it impossible for me to father a child?" I responded that these drugs, particularly the cyclophosphamide and doxorubicin, could cause infertility. "Well," he said, "I think I'd like to have my own children someday. Is there a way to make that possible?" Again I replied positively; sperm banking could preserve his potential to father children, and he could make a sperm deposit at a nearby urology clinic. He told me he'd really like to do that before starting chemotherapy.


I called the oncologist and communicated our conversation. Without hesitation, the oncologist asked me to make the appropriate arrangements at the urology clinic. Nathan returned after the sperm banking was completed, ready for chemotherapy and interested in learning more about his treatment.


Patients first

As an oncology-certified nurse, I was prepared to teach Nathan the risks associated with his chemotherapy, but my priorities were based on the seriousness of each potential adverse drug reaction. The risks of infection and bleeding were significant, and my patient needed to know how to protect himself from both of these possibilities.


Although I understood the risk of infertility, I hadn't considered it to be more important than infection and bleeding. But from Nathan's perspective, this was the number one concern. In light of the risk of infertility caused by even one treatment, sperm banking needed to be done first. Until then, Nathan's concerns and fears would impair his ability to learn more about self-management.


Theorists in adult learning have identified the following characteristics of adult learners: Adults want to know why they need to learn something before learning it, are self-directed, have many experiences that may affect receptivity to learning, accept information on the basis of need-to-know, and are motivated by inner pressures more than external stimuli.1 The theorists recommend conducting a learner analysis before patient education begins in order to involve the learner and choose the best approach to learning activities.


Learner analysis consists of estimating the patient's attitude and adaptability. Using open-ended questions to learn the patient's experience, prior knowledge, attitude, and preparedness to learn new information, the nurse uses the responses to tailor the organization and presentation of information.


Teach, don't preach

Engaging patients in making decisions about their health and disease management is an important step toward developing responsibility for self-care. In one study, researchers found that 91% of participants preferred to be involved in decision making rather than simply being told how to manage their conditions.2 The shift to more outpatient healthcare and the rise in chronic diseases highlight the need for well-informed patients who are prepared to care for themselves. Teaching based on assessment of the patient's concerns is preferable to the traditional pedagogical approach, which simply involves telling people what to do. Most patients have some knowledge about their disease and how they prefer to manage their health.3 Because of this, patients' fears and concerns should be addressed first according to their perceived and identified needs.


Education based on life experience

The following events from my personal and professional experiences illustrate the importance of considering patient concerns and knowledge first.


* The morning after I delivered my sixth child, an RN woke me to ask me to come to a baby bath demonstration. As the mother of five children, I wasn't happy with this interruption of my sleep. A simple assessment would have revealed that I was an RN with extensive child care experience.


* My patient was very eager to be discharged and a friend was waiting to take him home. I finally received the discharge orders, which included a "laundry list" of medications, three of them new to the patient. I approached the patient, who was dressed and ready to leave, to teach him about the prescribed medications. After I hurriedly described each type of medication and their dosage schedules, the patient said, "I can't afford the medicine I was already supposed to be taking, and there's no way I can buy these new drugs." This was a new problem. I could have addressed it more effectively if I'd begun by saying, "I see you regularly take four medications. The doctor has written prescriptions for three more medications for you to take. What concerns you most about this?" In addition, this patient's ability to learn was undermined by poor timing: At the moment of discharge he was focused on returning home, not absorbing new information.


* A patient had just been diagnosed with type 2 diabetes and was about to begin insulin therapy. I needed to teach her about many aspects of care, including education about insulin administration and blood glucose monitoring. I arrived to teach the patient with an armload of booklets, a glucose monitor and strips, and various other supplies. But I was reminded almost immediately that this patient had diminished visual acuity. Instead of diving into my standard diabetes presentation, I took a deep breath and instead asked, "What concerns you most about your new diagnosis?" As it turned out, this patient's sister lived with her; the sister also required education because she'd be helping with diabetes management.



Assessing a patient's personal concerns and needs helps the nurse identify readiness to learn. When concerns are revealed, the nurse and patient can work together to prioritize education. When patients have different priorities than healthcare professionals, frustration will develop if an understanding isn't reached.


Self-care success

When nurses assess and address patients' concerns about personal healthcare issues, they acknowledge the importance of patient responsibility and engagement in self-care. Patient education should strengthen patients' ability to anticipate difficulties, prevent problems, and manage their own healing. By learning the patient's priority of needs and concerns, the nurse can tailor education in a way that encourages the patient to adhere to therapy, leading to better outcomes.




1. Slot KB, Berge E. Thrombolytic treatment for stroke: patient preferences for treatment, information, and involvement. J Stroke Cerebrovasc Dis. 2009;18(1):17-22. [Context Link]


2. Knowles MS, Swanson RA, Holton EF. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. 7th ed. Boston, MA: Elsevier; 2011. [Context Link]


3. Beebe CA, Schmitt S. Engaging patients in education for self-management in an accountable care environment. Clinical Diabetes. 2011;29(3):123-126. [Context Link]