1. Ashton, Kathleen PhD, RN
  2. Oermann, Marilyn H. PhD, RN, ANEF, FAAN


This article describes principles for patient education, beginning with assessment of learning needs through evaluation. Strategies for effective teaching in the home care setting are presented, including use of educational resources.


Article Content

J. P. is a 56-year-old male being discharged to home with a diagnosis of osteomyelitis of the right lower extremity, requiring long-term antibiotics via a recently placed peripherally inserted central catheter (PICC) in his right upper arm. J. P.'s comorbidities include Type 2 diabetes mellitus, chronic kidney disease, and depression. He lives with his wife and adult son in a one-story home. J. P. is unable to work at his regular job providing security at a local university because it requires him to ambulate for long hours. J. P. and his family need education about administering the antibiotics and the PICC line.

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M. J. is a 64-year-old female with a recent diagnosis of heart failure (HF). She was discharged home with a new regimen of medications and requires education about those medications and living with HF.


Both patients have been referred to a local home healthcare agency for ongoing nursing care. They received some information about their illness and treatment from healthcare providers before discharge, but neither of these patients is able to manage their healthcare needs independently. Although patient education is a nursing competency (National Research Council, 2011), there are barriers to effective patient teaching in acute care settings. Nurses in acute care are challenged by their limited time for teaching. Education is typically delivered based on the patient's medical condition rather than individualized learning needs, and patients are expected to retain a great deal of complicated and new information in a short amount of time (McBride & Andrews, 2013). In addition, patients may not be physically or psychologically ready to learn. These real challenges limit the effectiveness of patient education in the acute care setting and transfer the responsibility for teaching patients and their caregivers to clinicians who provide home nursing care.


Clinicians who provide care in the home setting also face challenges to effective patient education. Many patients have complex illnesses. A clinician may spend a lot of time providing direct hands-on care, reducing time for teaching. When a patient is experiencing pain and other symptoms, his or her ability to take in new information and learn is hindered. Clinicians have to build in time to support and educate caregivers as well. Despite their best intentions, patients with poor health literacy face numerous barriers in their attempt to follow a treatment plan. Limited health literacy can manifest itself as nonadherence (Bastable, 2008).


There may be cultural influences in the home that affect teaching and learning. Home care clinicians may not have easy access to interpreters when patients and caregivers speak a different language. Patients may have specific beliefs about illness and treatment options, relationships within the family and with healthcare providers, privacy, and diet. These factors can affect patient attitudes toward learning new information (Bastable, 2008).


Clinicians need to develop the skill set that will allow them to be effective teachers. They should understand the principles of adult learning and be educated about cultural influences on teaching and learning (McBride & Andrews, 2013; Rice, 2006). Effective patient education requires that clinicians provide the information patients need to know in a manner that reflects their readiness or capacity to learn (Bastable, 2008). Clinicians should understand the educational process and strategies for promoting patient learning, be aware of teaching methods, be able to direct patients and caregivers to quality and credible patient education materials and other resources, and have an understanding of the content. Although providing patient education is a fundamental nursing activity, effectively teaching patients is a complex process.


Despite the challenges, clinicians who provide care to patients in their homes are uniquely positioned to deliver patient education. They understand they are "guests" in the patient's home (Rice, 2006, p. 32). Patients have more autonomy regarding their healthcare practices in their home than they do in acute care (Ellenbecker et al., 2008). Clinicians' humility allows patients to participate in their care by leveling the power in the relationship. The teacher is seen as the "facilitator of information" and not as the "authoritative" figure (McBride & Andrews, 2012, p. 20). The purposes of this article are to describe principles for patient education, beginning with assessment of learning needs, and share strategies clinicians can use to be effective teachers in the home care setting.



The nursing process provides a framework for the clinician to use for patient education (Pearson, 2011). Teaching begins with an assessment of learning needs and other characteristics such as readiness to learn. What do patients know currently about their conditions, treatments, and self care? The assessment indicates gaps in knowledge and skills and where to begin with the education. Because of limited time for teaching, the clinician should focus instruction on essential information for the patient to understand the health problem and manage his or her own care independently or with caregiver assistance. An important component of assessment is determining the patient's readiness to learn. Readiness is evident when patients demonstrate an interest in learning and can engage in the instructional process (Bastable, 2008). Assessment is the first step in patient education (Bastable, 2008; McBride & Andrews, 2013; Pearson, 2011; Rice, 2006). In a survey, patient educators reported that the most important strategy for effective patient teaching was assessing the patient and adjusting education to those needs (Smith & Zsohar, 2013). Developing, implementing, and evaluating the teaching all follow assessment.


Factors to Assess Before Teaching

Assessing learning needs, or the gap between what patients know and need to learn, is a priority. Asking about patients' or caregivers' level of formal education is important but may not in and of itself describe their capacity to learn new information at the point the clinician encounters them (Pearson, 2011). Patients with higher education may be less motivated to learn, and conversely patients with limited formal education can be successful learners (Pearson, 2011). Questions from a patient or caregiver can demonstrate motivation to learn (Bastable, 2008). Assessing cognitive abilities and motivation are essential to effective teaching.


Several other factors are equally important for clinicians to assess, including the patient's age, goals of treatment, and financial well-being (Pearson, 2011; Rice, 2006). Many patients who receive home care services are elderly and have limited resources. Patients with adequate financial resources may be more likely to adhere to medication treatment plans and have access to needed medical equipment and supplies (Ellenbecker et al., 2008; Rice, 2006).


Clinicians also should assess readiness to learn. Being ready to learn means the patient is ready physically, psychologically, and cognitively to engage in learning. Health status and limitations because of the patient's condition, pain, medications, and other conditions affect physical readiness to learn and the energy of the patient to engage in learning. J. P.'s multiple conditions combined with his depression may influence his learning about his antibiotics and PICC line, and the clinician may decide to teach the wife and son and recommend educational resources J. P. can access at a later time. In addition to the medical problems, knowing the patient's vision acuity or ability to hear the spoken word will influence teaching.


Psychological readiness is the degree of acceptance or denial of the condition, and is influenced by anxiety and stress, ability to concentrate, and developmental stage. These influence motivation to learn and the ability of the patient to retain the information. Other areas that affect readiness to learn are cultural values (what are the patient's perceptions of illness and health beliefs?), current health practices (what are they, and do they promote or hinder care?), learning styles (do patients prefer to learn visually, by listening to instructions, by reading materials, or by experiencing?), literacy (can patients read and at what level?), and use of the Internet (do patients search the Web for health information?) (Inott & Kennedy, 2011; Orlowski et al., 2013; Wright, 2011).


Assessment Strategies

Clinicians can use several strategies to obtain data for this assessment, including informal and targeted conversations and observations during the delivery of care. Developing a relationship with the patient, though, is essential to this process (Bastable, 2008; McBride & Andrews, 2013). One of the best strategies for assessment of learning needs and readiness to learn is by questioning patients about their understanding of their conditions and treatments and what they want to learn. These questions should be open ended and probing. Asking M. J., "Do you have any questions about your new medications?" is of limited value in assessing her understanding. A more effective line of questioning would be, "Tell me about the medications you are taking for your heart failure and whether they are helping. What problems are you still having, and what are you doing about them?" By using open-ended questions geared to the essential content to be learned, the clinician can identify the actual learning needs and use wisely the limited time available for teaching.


Asking the right questions and observing the patient's responses provide information about readiness to learn. In addition, this enables the clinician to identify misconceptions about the health problem and treatments. Assessment not only provides a foundation for teaching but also reflects principles of patient-centered care (McBride & Andrews, 2013). Assessment engages patients in learning and keeps the teaching focused on them.


Planning and Implementation

Once the assessment data are gathered and summarized, the clinician can begin to develop the teaching plan. Formal teaching plans may be developed with goals and objectives created for specific content, which will be used to evaluate progress, or available teaching plans may be adapted for the patient. Validating goals and objectives with the patient and caregiver reinforces that the clinician's plan is aligned with the patient's needs and will likely contribute to a successful learning activity.


Teaching Strategies

The choice of the teaching strategy will depend on the topic. If the patient or caregiver needs to learn a psychomotor skill, the clinician may begin with an explanation and follow with a demonstration and return demonstration. Although time consuming, this strategy provides an opportunity for the patient or caregiver to practice the new skill under the watchful eye of the clinician and for the clinician to provide specific feedback to guide performance. J. P. and his wife and son will need guided practice for administering antibiotics via the PICC line.


Use Your Conversation for Teaching

Patient teaching should not be viewed as a one-time occurrence. Instead it should be integrated in the clinicians' interactions with the patient and caregiver. No matter how brief the interaction, the clinician should be teaching as part of that dialog. Adopting a conversational tone creates a more informal teaching situation, can foster discussion and asking questions by the patient and caregiver, and takes advantage of teachable moments (McBride & Andrews, 2013). Breaking down information into smaller, manageable segments can facilitate the transfer of information (Rice, 2006). An important principle regardless of the information to be taught is to "keep it simple."


Use the Teach-Back Method

By integrating teaching within conversations with the patient and caregiver, the clinician can more easily reinforce the health information. Patients can be asked to explain in their own words what they learned and why that information is needed for their care. This is the teach-back method, explicitly asking patients to repeat back key points of instruction, and it is an effective strategy for assessing patient understanding and if the information needs to be explained again (Jager & Wynia, 2012). Asking patients "do you understand?" may be answered with a "yes" response and not reveal their lack of comprehension about the health information. White et al. (2013) found that the teach-back method was effective for retaining information about care among hospitalized HF patients and post discharge. The teach-back method would be relevant for MJ as the focus of her education is on learning about medications and living with HF.


Teach-back provides an opportunity for patients to think about the information and explain it in their own words to the clinician, which serves as a review to help retention. It also reveals gaps in learning. In later interactions with the patient or through use of educational resources, the information can be reviewed again, promoting retention. Box 1 summarizes strategies for learning.


Provide Educational Resources

Because of limited time for teaching and need for repetition and practice, patients should be given or directed to resources for further learning about their conditions. These resources can include brochures, handouts, and other written materials; video recordings, DVDs, and YouTube videos; and Web sites, depending on their appropriateness for the patient. However, those resources need to be evaluated for their quality and readability (ease with which materials can be read and understood) before use with patients. Studies of the readability of patient education materials have found that many materials are written at too high a level for most patients to read and understand. Wilson (2009) analyzed the readability of 35 patient education materials, developed by government agencies, other professional sources, or providers, used in community settings. The reading levels were all above the recommended level of sixth grade or lower (U.S. National Library of Medicine, 2013). Most patients, even those with higher literacy skills, prefer the readability of their health-related educational materials to fall below their usual reading level (Bastable, 2008). Clinicians can improve the readability of patient education materials by using visuals to communicate the content and less text requiring reading.


Clinicians should assess the readability or grade level of the educational materials they will be using for their teaching. If they are working in Microsoft Office, they can check the readability score in Microsoft Word or Outlook according to two tests: the Flesch Reading Ease and Flesch-Kincaid Grade Level. The instructions can be found by "clicking" on the question mark in the upper right area of the tool bar. There also are several Internet sites that provide the clinician with the readability level of patient education materials. They can be found by doing an Internet search for "readability scores."


With more people searching online for health information, the Internet has become a valuable resource for patient education as long as patients are guided to reputable Web sites. A survey by the Pew Research Center's Internet & American Life Project indicated that as of September 2012, 81% of U.S. adults used the Internet, and among those, 72% have searched online for health information (Fox & Duggan, 2013). However, not all health Web sites provide accurate, up-to-date, and unbiased information, and it may be too high a reading level for many patients and consumers to understand. Health information on the Internet needs to be evaluated for quality and readability before use by patients similar to written materials. Schmitt and Prestigiacomo (2013) assessed the readability of patient education materials provided by the American Association of Neurologic Surgeons, U.S. National Library of Medicine (NLM), and U.S. National Institutes of Health (NIH). None of the documents were at or below the recommended sixth-grade reading level. Even the patient education materials from the NLM and NIH were above the recommended level.


Not only are patients finding information on various Web sites, but they are increasingly using YouTube to learn about medical conditions (Desai et al., 2013). However, most YouTube videos are not peer reviewed; they may not communicate balanced information; and similar to Web sites the information may not be accurate or from a credible source (Stamelou et al., 2011; Steinberg et al., 2010). Sorensen et al. (2014) assessed 55 videos on YouTube related to pediatric adenotonsillectomy and ear tube surgery. Most of the videos presented low-quality information and testimonials. Clinicians cannot control the quality of health information on the Web, but they can evaluate and then recommend quality Web sites and YouTube videos for patient education. JP and his family would benefit from these to provide a review about administering antibiotics via his PICC line.


A quick and reliable method of evaluating the quality of patient education resources for clinicians to use is the suitability assessment of materials (SAM) checklist (Doak et al., 1996). Six factors are examined and rated as superior, adequate, or not suitable (see Box 2). Hoffmann and Ladner (2012) recommended use of SAM to identify specific elements of materials that should be modified before given to patients. Although developed originally for written materials, the SAM also has been used successfully to evaluate health information on the Web (Rhee et al., 2013).


Evaluation of Learning

Evaluation is an integral part of any teaching, and the clinician should continually assess how well patients are understanding the information and developing their ability to perform skills. This can be done by asking questions to assess the extent of learning, through the teach-back method, and by observing performance of skills. Using this information, the clinician can modify the teaching, for example, explaining the content again and in a different way, suggesting other resources, or teaching a family member or caregiver.



Patient education begins with an assessment of learning needs and other characteristics because the teaching should be based on those needs and individualized for each patient. Clinicians use several strategies for this assessment, including asking the right questions during informal and targeted conversations and observing the patient. Although the choice of teaching strategy depends on the topic and patient needs, the information presented needs to be provided in small, manageable parts to facilitate learning: keeping it simple is critical. There are many educational materials and resources clinicians can recommend to patients including Web sites if appropriate, but they need to be evaluated for their quality and readability. This article presented some key principles for teaching patients and meeting their learning needs.


Box 1. Strategies for Effective Learning



* Current knowledge and understanding


* Readiness to learn


* Barriers to learning or to disease management


* Health literacy


* Cultural issues that may affect acceptance to what is being taught




* Teach-back


* Keep it simple


* Reinforce with appropriate educational materials


Box 2. Factors Examined in Suitability Assessment of Materials Checklist


* Content


* Literacy demand


* Graphics


* Layout and type


* Learning stimulation and motivation


* Cultural appropriateness


Source: Data from Doak et al., 1996.




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