Health Education in Nursing - PDF

**HEALTH EDUCATION** **PURPOSE:** The purpose of patient education is to increase the competence and confidence of clients for self-management. The primary goal is to increase the responsibility and independence of clients for self-care. **HISTORICAL PERSPECTIVES** - **PHASE ONE:** Colonial per...

**HEALTH EDUCATION** **PURPOSE:** The purpose of patient education is to increase the competence and confidence of clients for self-management. The primary goal is to increase the responsibility and independence of clients for self-care. **HISTORICAL PERSPECTIVES** - **PHASE ONE:** Colonial period with British influence. The role of faculty was to teach - **PHASE TWO:** The Common Good (nation building), to serve society - **PHASE THREE:** Development of science: the research university **HISTORICAL FOUNDATIONS OF THE NURSE EDUCATOR ROLE** - Health education has long been considered a standard care-giving role of the nurse. - Patient teaching is recognized as an independent nursing function. - Nursing practice has expand to include education in the broad concepts of health and illness. **ORGANIZATIONS AND AGENCIES PROMULGATING STANDARDS AND MANDATES:** 1. **NLNE (NLN)** - **NATIONAL LEAGUE OF NURSING EDUCATION** - First observed health teaching as an important function within the scope of nursing practice - Responsible for identifying course content for curriculum on principles of teaching and learning 2. **ANA (AMERICAN NURSES ASSOCIATION)** - Responsible for establishing standards and qualifications for practice, including patient teaching 3. **ICN (INTERNATIONAL COUNCIL OF NURSES)** - Endorses health education as an essential component of nursing care delivery 4. **STATE NURSE PRACTICE ACTS** - Universally includes teaching within the scope of nursing practice 5. **JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATION)** - Accreditation mandates require evidence of patient education to improve outcomes 6. **AHA (AMERICAN HOSPITAL ASSOCIATION)** - Patient's Bill of Rights ensures that clients receive complete and current information 7. **PEW HEALTH PROFESSIONS COMMISSION** - Puts forth a set of health profession competencies for the 21^st^ century - Over one-half of recommendations pertain to importance of patient and staff education **JOINT COMMISSION:** **PATIENT AND FAMILY EDUCATION** - The organization provides education that supports patient and family participation in care decisions and care processes. - Education and training help meet patients' ongoing health needs. - Education methods consider the patient\'s and family\'s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur. **CURRENT MANDATES FOR NURSE AS EDUCATORS** **HEALTH PEOPLE 2010 (USDHHS)\ *[FEDERAL INITIATICE OUTLINED:]*** - To increase the quality & years of healthy life - To eliminate health disparities among different segments of the population - Requires the nurse as educator to use theory and evidenced based strategies to promote desirable health behavior. **TRENDS AFFECTING HEALTH CARE** **SOCIAL, ECONOMIC, AND POLITICAL FORCES THAT AFFECT A NURSE'S ROLE IN TEACHING:** - Growth of managed care - Increased attention to health and well-being of everyone in society - Cost containment measures to control healthcare expenses - Concern for continuing education as vehicle to prevent malpractice and incompetence - Expanding scope and depth of nurses' practice responsibilities - Consumers demanding more knowledge and skills for self-care - Demographic trends influencing type and amount of health care needed - Recognition of lifestyle related diseases which are largely preventable - Health literacy increasingly required - Advocacy for self-help groups **PURPOSE, BENEFITS, AND GOALAS OF PATIENT, STAFF AND STUDENT EDUCATION** **PURPOSE:** to increase the competence and confidence of patients to manage their own self-care and of staff and students to deliver high quality care **BENEFITS OF EDUCATION TO PATIENTS:** - Increases consumer satisfaction - Improves quality of life - Ensures continuity of care - reduces incidence of illness complications - increases compliance with treatment - decreases anxiety - maximizes independence **BENEFITS OF EDUCATION TO STAFF:** - enhances job satisfaction - improves therapeutic relationships - increases autonomy in practice - improves knowledge and skills **BENEFITS OF PRECEPTOR EDUCATION FOR NURSING STUDENTS** - prepared clinical preceptors - continuity of teaching/learning from classroom curriculum - evaluation and improvement of student clinical skills **GOAL:** to increase self-care responsibility of clients and to improve the quality of care delivered by nurses **EDUCATION PROCESS DEFINITION** It is a systematic, sequential, logical, scientifically based, planned course of action consisting of two ***major interdependent operations***: **TEACHING** and **LEARNING.** Hence, the education process is a framework for a participatory, shared approach to teaching and learning. **TEACHING AND INSTRUCTION** - One component of the education process. - Often used interchangeably. - Deliberate interventions that involve sharing information and experiences to meet intended learner outcomes in the cognitive, affective, and psychomotor domains according to an education plan. **DEFINITION OF TERMS** **LEARNING** is defined as a change in behavior (knowledge, attitudes, and/or skills) that can be observed or measured and that occurs at any time or in any place resulting from exposure to environmental stimuli. It is also an action by which knowledge, skills, and attitudes are consciously or unconsciously acquired such that behavior is altered in some way. **PATIENT EDUCATION** is a process of assisting people to learn health-related behaviors that they can incorporate into everyday life with the goal of achieving optimal health and independence in self-care. Friedman, Cosby, Boyko, Hatton-Bauer, and Turnbull (2011) specifically define it as *\"any set of planned educational activities, using a combination of methods* (teaching, counseling, and behavior modification), that is designed *to improve patients\' knowledge and health behaviors".* **STAFF EDUCATION**, by contrast, is the process of influencing the behavior of nurses by producing changes in their knowledge, attitudes, and skills to help them maintain and improve their competencies for the delivery of high-quality care to the consumer. **ASSURE MODEL** **ASSURE** model is a useful paradigm originally developed to assist nurses to organize and carry out the education process (Rega, 1993). This model is appropriate for all health professional educators. **ROLE OF THE NURSE AS EDUCATOR** - Nurses act in the role of educator for a diverse audience of learners -- patients and their family members, nursing students, nursing staff, and other agency personnel. - Despite the varied levels of basic nursing school preparation, legal and accreditation mandates have made the educator role integral to all nurses. - Nurses function in the role of educator as: - the giver of information - the assessor of needs - the evaluator of learning - the reviser of appropriate methodology - The partnership philosophy stresses the participatory nature of the teaching and learning process. **BARRIERS TO TEACHING** *Barriers* to teaching are those factors impeding the nurse's ability to optimally deliver educational services: **MAJOR BARRIERS INCLUDE:** - lack of time to teach - inadequate preparation of nurses to assume the role of educator with confidence and competence - personal characteristics - low-priority status given to teaching - environments not conducive to the reaching-learning process - absence of 3rd party reimbursement - doubt that patient education effectively changes outcomes - inadequate documentation system to allow for efficiency and ease of recording the quality and quantity of teaching efforts *Obstacles* to learning are those factors that negatively impact on the learner\'s ability to attend to and process information. **MAJOR OBSTACLES INCLUDE:** - limited time due to rapid discharge from care - stress of acute and chronic illness, anxiety, sensory deficits, and low literacy - functional health illiteracy - lack of privacy or social isolation of health care environment - situational and personal variations in readiness to learn, motivation and compliance, and learning styles - extent of behavioral changes (in number and complexity) required - lack of support and positive reinforcement from providers and/or significant others - denial of learning needs, resentment of authority and locus of control issues - complexity, inaccessibility, and fragmentation, of the healthcare system **THE CONTEMPORARY ROLE OF THE NURSE AS EDUCATOR** - Is every nurse adequately prepared to assess for learning needs, readiness to learn, and learning styles? - Can every nurse determine whether the information given is actually received and understood? Are all nurses capable of taking appropriate action to revise the approach to educating the patient if the patient does not comprehend the information provided through the initial approach? - Do nurses realize that they need to transition their role as educator from being a content transmitter to being a process manager, from controlling the learner to releasing the learner, and from being a teacher to becoming a facilitator? **INTERPORFESSIONAL EDUCATION & PRACTICE** **INTERPORFESSIONAL EDUCATION (IPE)** - is included in many accreditation standards as an educational requirement to prepare health profession students for future interprofessional practice & collaboration. Major Barriers: *time constraints, rigid curriculum structures, desire to maintain professional identity & limited faculty support.* **PATIENT ENGAGEMENT** nursing and patient education were put forth to guide patient-provider relationships for the improvement of quality and safety in care delivery ***Berwick (2008) Crossing the Quality Chasm*** outlined the six dimensions that health care needed to improve: 1. **SAFETY** - not harming people with the care that is rendered. 2. **EFFECTIVENESS** - avoiding overuse of things that do not help and ensuring the use of things that do help. 3. **PATIENT-CENTEREDNESS** - people should be in control of their own care by making decisions about what affects them. 4. **TIMELINESS** - avoiding delays by reducing needless wait times to be seen by a provider. 5. **EFFICIENCY** - avoiding waste by reducing duplication of tests and procedures, giving things that do not help, and losing ideas of the workforce by not listening to employee solutions. 6. **EQUITY** - closing the gap in justice as it relates to who receives health care in type and extent **NURSING ALLIANCE FOR QUALITY CARE (NAQC)** In response to the concern for safe, better-quality care, proposed a strategic policy in 2010 to advocate for the highest quality consumer-centered care. The NAQC (2010) established **FOUR GOALS** addressing key areas to support excellence in the delivery of health care: 1. **CONSUMER-CENTERED HEALTH CARE**: Establish nursing health and safety goals to achieve safe, effective, timely, efficient, and equitable patient-centered care. 2. **PERFORMANCE MEASUREMENT AND PUBLIC REPORTING**: Advocate for the development, implementation, and public reporting of performance measures that reflect nursing\'s contribution to patient care. 3. **ADVOCACY**: Establish policy reform focused on evidence-based nursing practice to improve patient care. 4. **LEADERSHIP**: Promote nursing's capability to serve in leadership roles that advance patient care standards **QUALITY & SAFETY EDUCATION IN NURSING** In 2005, the Robert Wood Johnson Foundation (RWIF) funded a national study, the QSEN. (Phase 1) In 2007, the RWIF funded phase II of the OSEN project, which included launching a website (http://QSEN.org) dedicated to teaching strategies and resources. **6 COMPETENCIES WERE DEVELOPED** (QSEN 2012): 1. **PATIENT-CENTERED CARE**: The patient has control of and is a full partner in the provision of holistic, compassionate, and comprehensive care based on the patient\'s values, needs, and preferences. 2. **TEAMWROK AND COLLABORATION**: Nurses and other health professionals must collaborate effectively with open communication, respect, and mutual decision making to achieve high quality care. 3. **EVIDENCE-BASED PRACTICE**: Current evidence must be integrated to support clinical expertise in providing optimal health care. 4. **QUALITY IMPROVEMENT**: Measure data and monitor patient outcomes to develop changes in methods to continuously improve the quality and safety in healthcare delivery. 5. **INFORMATICS:** Use information technology to effectively communicate, manage knowledge, eliminate error, and support collaborative decision making. 6. **SAFETY:** Minimize the risk of harm to patients and healthcare providers through self and system evaluation. **PERSPECTIVES ON RESEARCH** - further investigation is needed on the cost-effectiveness of education efforts - future research must address: - gender issues - measurement of behavioral outcomes - effects of educational interventions - theoretical basis for education in practice - cost-effectiveness of educational efforts **MODELS AND THEORIES\ AN OVERVIEW OF VARIOUS HEALTH EDUCATION MODELS AND THEORIES AND THEIR APPLICATION IN NURSING PRACTICE** **PSYCHOLOGICAL LEARNING THEORIES** summarizes the basic concepts and principles of the behaviorist, cognitive, social learning, psychodynamic, and humanistic learning theories. **APPROACHES IN PSYCHOLOGY** - Behaviorist Approach - Cognitive Approach - Social Learning Theory - Psychodynamic Approach - Humanistic Approach - Biological Approach 1. **BEHAVIORIST LEARNING THEORY** Focusing mainly on what is directly observable, behaviorists view learning as the product of the stimulus conditions (S) and the responses (R) that follow. behaviorists closely observe responses to a situation and then manipulate the environment in some way to bring about the intended change **BEHAVIOURIST APPROACH** - Behavior should be observable and measurable (moving away from Wilhelm Wundt) - Animal behavior is comparable to human behavior - All behavior is learned from the environment **1.A. RESPONDENT CONDITIONING (**also termed **ASSOCIATION LEARNING, CLASSICAL CONDITIONING, OR PAVLOVIAN CONDITIONING) -- BY IVAN PAVLOV** learning takes place when the newly conditioned stimulus (CS) becomes associated with the conditioned response (CR) - a process that may wall occur without conscious thought or awareness.  **KEY CONCEPTS** **GENERALISATION --** when the conditioned stimulus (bell) could be generalized to other sounds. The volume or tone could change and still produce salivation. **DISCRIMINATION --** where the sound becomes too different from the original bell sound that no salivation occurs. **EXTINCTION --** if the conditioned stimulus continues to be presented but the real uncoditioned stimulus never appears , the association eventually weakens and becomes extincts. - the gradual weakening of the conditioned response **SPONTANEOUS RECOVERY --** sudden display of behavior that was thought to be extinct **SYSTEMATIC DESENSITIZATION** is a technique based on respondent conditioning that is used by psychologists to reduce fear and anxiety in their clients (Wolpe, 1982). The assumption is that fear of a certain stimulus or situation is learned; therefore, it also can be unlearned or extinguished. **STIMULUS GENERALIZATION** is the tendency of initial learning experiences to be easily applied to other similar stimuli. For example, when listening to friends and relatives describe a hospital experience, it becomes apparent that a highly positive or negative personal encounter may color patients' evaluations of their hospital stays as well as their subsequent feeling about having to be hospitalized again. With more and varied experience learn to differentiate among similar stimuli. **DISCIMINATION LEARNING** patients who have been hospitalized a number of times often have learned a lot about hospitalization. As a result of their experiences, they make sophisticated distinctions and can discriminate among stimuli (e.g., what the various noises mean and what the various health professionals do), which novice patients cannot. **SPONTANEOUS RECOVERY** Although a response may appear to be extinguished, it may recover and reappear at any time (even years later), especially when stimulus conditions are similar to those in the initial learning experience. **1.B. OPERANT CONDITIONING BY B.F. SKINNER (1974, 1989)** **Stimulus -\> Response** was NOT ENOUGH when it came to understanding human behavior. "Behaviour is determined by its consequences" - *B.F. Skinner* **OPERANT CONDITIONING** Learning through consequences - **REINFORCEMENT** - A consequence that **INCREASES** the likelihood of a particular behavior being repeated. - It strengthens behaviour. - **PUNISHMENT** - A consequence that **DECREASES** the likelihood of a particular behaviour being repeated +-----------------------------------+-----------------------------------+ | **POSITIVE** | **POSITIVE** | | | | | **REINFORCEMENT** | **PUNISHMENT** | | | | | (More likely to be repeated) | (Less likely to be repeated) | | | | | Jimmy completes his homework | Suzie does not complete her | | | homework. | | Teacher praises him. | | | | Give Suzie's mom a phone call. | | Given a shiny gold sticker! | | | | Give Suzie a telling off in front | | | of class. | +===================================+===================================+ | **NEGATIVE** | **NEGATIVE** | | | | | **REINFORCEMENT** | **PUNISHMENT** | | | | | (More likely to be repeated) | (Less likely to be repeated) | | | | | Jimmy completes his homework. | Suzie does not complete her | | | homework. | | No destruction at lunch. | | | | This away break/lunch times. | +-----------------------------------+-----------------------------------+ 2. **COGNITIVE LEARNING THEORY** According to this perspective, the key to learning and changing is the individual\'s cognition (perception, thought, memory, and ways of processing and structuring information). Cognitive learning is viewed as a highly active process largely directed by the individual **INTERNAL MENTAL PROCESSES** Private actions or processes of the mind that mediate (come between) stimulus and response. - PERCEPTION - MEMORIES - LANGUAGE - PROBLEM SOLVING - ATTENTION 3. **SOCIAL LEARNING THEORY\ ALBERT BANDURA (1977, 2001)** According to this perspective, it is the learning that Includes consideration of the personal characteristics of the learner, behavior patterns, and the environment Bandura\'s model of social learning, the learner is now viewed as central (what Bandura calls a \"human agency\") **3.A. ROLE MODELING** To facilitate learning, role models need to be: 1. Enthusiastic 2. Professionally organized 3. Caring 4. Self-confident 5. Knowledgeable 6. Skilled 7. Good communicators **3.B. VICARIOUS REINFORCEMENT** The learning of a behavior by observing the positive and negative consequences of the actions of others. Vicarious reinforcement often involves a person observing a role model, who they begin to imitate. The **Health Belief Model (HBM)** is a psychological model used to explain and predict health-land behaviors. It was originally developed in the 1950s by social psychologists in the US. Public Health Service to understand why people faded to adopt disease prevention strategies. **HEALTH BELIEF MODEL (HBM)** - Is a psychological health behaviour change model developed to explain and predict health related behaviors. Proposed by **Irwin M. Rosenstock and Backer.** - It was developed in the early 1950s by social scientists at the US. Public Health Service in order to understand the failure of people to adopt disease prevention strategies of screening tests for the early detection of disease. This model focuses on individual beliefs and perceptions about health behaviors. It suggests that people are more likely to take action to prevent or control a health problem if they perceive themselves as susceptible to it, believe the consequences are serious, believe that taking action would be beneficial, and perceive few barriers to taking action. Key Components of the Health Belief Model. The HBM is based on six key constructs that influence health behaviors: 1. **PERCEIVED SUSCEPTIBILITY -** a person's belief about the likelihood of getting a disease or condition. **Example:** "I am at high risk of developing diabetes because of my family history." 2. **PERCEIVED SEVERITY -** a person's belief about how serious a disease or condition is. **Example:** "If I get diabetes, it could lead to severe complications like blindness or amputation." 3. **PERCEIVED BENEFITS -** a person's belief in the effectiveness of a recommended health behavior. **EXAMPLE:** "Exercising regularly and eating healthy will lower my risk of diabetes." 4. **PERCEIVED BARRIERS -** the perceived obstacles to performing a health behavior**.** **EXAMPLE:** "Eating healthy is expensive, and I don't have time to cook nutritious meals." 5. **CUES TO ACTION -** factors that prompt or trigger behavior change. **EXAMPLE:** "Seeing a news story about diabetes complications reminded me to schedule a checkup." 6. **SELF-EFFICACY -** a person's confidence in their ability to successfully perform a behavior. **EXAMPLE:** "I believe I can commit to exercising three times a week to improve my health." **APPLICATIONS OF THE HEALTH BELIEF MODEL:** 1. **PUBLIC HEALTH CAMPAIGNS:** used in designing campaigns for smoking cessation, vaccination, and disease prevention. 2. **PATIENT EDUCATION:** helps healthcare professionals encourage patients to adopt healthier behaviors. 3. **BEHAVIORAL INTERVENTIONS:** guides strategies to promote lifestyle changes in chronic disease management. 4. **PSYCHODYNAMIC LEARNING THEORY** **Based on work of Sigmund Freud** It is largely a theory of motivation that stresses emotions rather than cognition or responses. The psychodynamic perspective emphasizes the importance of conscious and unconscious forces in guiding behavior, personality conflicts, and the enduring effects of childhood experiences on adult behavior. According to Freud, our personality develops from a conflict between two forces our biological aggressive and pleasure-seeking drives versus our internal (socialized) control over these drives. - **ID** - the most primitive source of motivation, based on libidinal energy (the basic instincts, impulses, and desires humans are born with) **2 COMPONENTS OF ID**: - **EROS** which contains the libido (the desire for pleasure and sex, sometimes called the life force - **THANATOS** (aggressive and destructive impulses, or the death wish) - **SUPEREGO** - Countering the id (primitive drives). which involves the internalized societal values and standards, or the conscience - **EGO** - Mediating these two opposing forces in the personality, which operates based on the reality principle **Ego Defense Mechanisms: Ways of Protecting the Self from a Perceived Threat** unconscious psychological processes that protect the self from anxiety producing thoughts and feelings related to internal conflicts and external stressor 1. **DENIAL -** Ignoring or refusing to acknowledge the reality of a threat 2. **RATIONALIZATION -** Excusing or explaining away a threat 3. **DISPLACEMENT -** Taking out hostility and aggression on other Individuals, rather than directing anger at the source of the threat 4. **REPRESSION -** keeping unacceptable thoughts, feelings, or actions from conscious awareness 5. **REGRESSION -** returning to an earlier (less mature, more primitive) stage of behavior as a way of coping with a threat 6. **PROJECTION -** seeing one's own unacceptable characteristics or desire in other people 7. **INTELLECTUALIZATION** **-** minimizing anxiety by responding to a threat in a detached, abstract manner without feeling or emotion 8. **REACTION FORMATION -** expressing or behaving the opposite of what is really felt 9. **SUBLIMATION -** converting repressed feelings into socially acceptable action 10. **COMPENSATION -** making up for weakness by excelling in other areas **DIFFICULTIES IN LEARNING\ difficulties arise and learning is limited due to:** **RESISTANCE -** an indicator of underlying emotional difficulties; resist talking about or learning **TRANSFERENCE -** occurs when individuals project their feelings, conflicts, and reactions - especially those developed during childhood with significant others such parents - onto authority figures and other individuals in their lives **TRANSFERENCE VS. COUNTERTRANSFERENCE:** **TRANSFERENCE -** *patient views nurse* as being similar to an important person in his/her life. **COUNTERTRANSFERENCE** *patient reminds the nurse* of someone in his/her life. **COUNTERTRANSFERENCE** **DEFINITION:** Countertransference refers to a therapist\'s emotional reactions and projections towards a client, often influenced by the therapist's own personal experiences or unresolved feelings. It can arise from the therapist\'s response to the client\'s transference or from the therapist\'s own personal history. **EXAMPLES** - **Over-Identification:** The therapist relates too closely to the client\'s experience, seeing themselves in the client and blurring professional boundaries. - **Parental:** **Countertransference:** The therapist begins to relate to the client in a parental manner. 5. **HUMANISTIC LEARNING THEORY** - Underlying the humanistic perspective on learning is the assumption that every individual is unique and that all individuals have a desire to grow in the positive way - Is largely a motivational theory. From a humanistic perspective, motivation is derived from each person's need, subjective feelings about the self, and the desire to grow. **ABRAHAM MASLOW** - Hierarchy of Needs Theory - Outlined a hierarchical structure for humans needs: - PHYSIOLOGICAL - SAFETY - LOVE AND BELONGINGNESS - SELF-ESTEEM - SELF-ACTUALIZATION - Maslow's marked the beginning of Behavioral Science - He believed that all have a natural drive to healthiness and self-fulfillment, which he called the quest for authenticity. - The [lower level] needs need to be satisfied before higher-order needs can influence [behavior]. - The four levels (lower-order needs) are considered ***physiological needs,*** - The top level is considered ***growth needs*** **COMPARISON OF LEARNING THEORIES** **TABLE 3-1** provides a comparative summary of the five psychological learning theories. Each theory highlights important considerations in any learning situation, involving the relative influence of external social factors and internal psychological processing.