46436 ch01 001-024 - jones & bartlett · pdf filehistorical foundations for the teaching...

PartOne

Perspectiveson Teachingand Learning

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Chapter 1

Overview ofEducation in Health Care

Susan B. Bastable

KEY TERMS

❑ education process ❑ staff education❑ teaching/instruction ❑ barriers to teaching❑ learning ❑ obstacles to learning❑ patient education

OBJECTIVES

After completing this chapter, the reader will be able to

1. Discuss the evolution of the teaching role of nurses.2. Recognize trends affecting the healthcare system in general and nursing practice in particular.3. Identify the purposes, goals, and benefits of client and staff/student education.4. Compare the education process to the nursing process.

3

CHAPTER HIGHLIGHTS

Historical Foundations for the Teaching Role ofNurses

Social, Economic, and Political Trends AffectingHealth Care

Purposes, Goals, and Benefits of Client and StaffEducation

The Education Process DefinedRole of the Nurse as Educator

Barriers to Teaching and Obstacles toLearning

Factors Impacting the Ability to TeachFactors Impacting the Ability to Learn

Questions to Be Asked About Teachingand Learning

State of the Evidence

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4 Chapter 1: Overview of Education in Health Care

5. Define the terms education process, teaching, and learning.6. Identify reasons why client and staff/student education is an important duty for professional

nurses.7. Discuss the barriers to teaching and the obstacles to learning.8. Formulate questions that nurses in the role of educator should ask about the teaching–

learning process.

Education in health care today—both patienteducation and nursing staff/student education—is a topic of utmost interest to nurses in everysetting in which they practice. Teaching is amajor aspect of the nurse’s professional role(Carpenter & Bell, 2002). The current trends inhealth care are making it essential that clientsbe prepared to assume responsibility for self-caremanagement. Also, these trends make it imper-ative that nurses in the workplace be account-able for the delivery of high-quality care. Thefocus is on outcomes that demonstrate the ex-tent to which patients and their significant oth-ers have learned essential knowledge and skillsfor independent care, or that staff nurses andnursing students have acquired the up-to-dateknowledge and skills needed to competentlyand confidently render care to the consumer ina variety of settings.

The need for nurses to teach others and tohelp others learn will continue to increase in thehealthcare environment (Carpenter & Bell,2002). With changes rapidly occurring in thesystem of health care, nurses are finding them-selves in increasingly demanding, constantlyfluctuating, and highly complex positions(Gillespie & McFetridge, 2006). Nurses in therole of educators must understand the forces,both historical and present day, that have influ-enced and continue to influence their responsi-bilities in practice.

One purpose of this chapter is to shed lighton the historical evolution of teaching as part of

the professional nurse’s role. Another purpose isto offer a perspective on the current trends inhealth care that make the teaching of clients ahighly visible and required function of nursingcare delivery. Also addressed are the continuingeducation efforts required to ensure ongoingpractice competencies of nursing personnel.

In addition, this chapter clarifies the broadpurposes, goals, and benefits of the teaching–learning process; focuses on the philosophy ofthe nurse–client partnership in teaching andlearning; compares the education process to thenursing process; identifies barriers to teachingand obstacles to learning; and highlights thestatus of research in the field of patient educa-tion as well as staff and student education. Thefocus is on the overall role of the nurse in teach-ing and learning, no matter who the audience oflearners may be. Nurses must have a basic pre-requisite understanding of the principles andprocesses of teaching and learning to carry outtheir professional practice responsibilities withefficiency and effectiveness.

Historical Foundations forthe Teaching Role of NursesPatient education has long been considered amajor component of standard care given bynurses. The role of the nurse as educator isdeeply entrenched in the growth and develop-ment of the profession. Since the mid-1800s,

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Historical Foundations for the Teaching Role of Nurses 5

when nursing was first acknowledged as aunique discipline, the responsibility for teach-ing has been recognized as an important role ofnurses as caregivers. The focus of teachingefforts by nurses has not only been on the care ofthe sick and on promoting the health of the wellpublic, but also on educating other nurses forprofessional practice.

Florence Nightingale, the founder of modernnursing, was the ultimate educator. Not onlydid she develop the first school of nursing, butshe also devoted a large portion of her career toteaching nurses, physicians, and health officialsabout the importance of proper conditions inhospitals and homes to improve the health ofpeople. She also emphasized the importance ofteaching patients of the need for adequate nutri-tion, fresh air, exercise, and personal hygiene toimprove their well-being. By the early 1900s,public health nurses in this country clearlyunderstood the significance of the role of thenurse as teacher in preventing disease and inmaintaining the health of society (Chachkes &Christ, 1996).

For decades, then, patient teaching has beenrecognized as an independent nursing function.Nurses have always educated others—patients,families, and colleagues. It is from these rootsthat nurses have expanded their practice toinclude the broader concepts of health and ill-ness (Glanville, 2000).

As early as 1918, the National League ofNursing Education (NLNE) in the United States(now the National League for Nursing [NLN])observed the importance of health teaching as afunction within the scope of nursing practice.Two decades later, this organization recognizednurses as agents for the promotion of health andthe prevention of illness in all settings in whichthey practiced (National League of NursingEducation, 1937). By 1950, the NLNE had

identified course content in nursing school cur-ricula to prepare nurses to assume the role asteachers of others. Most recently, the NLN devel-oped the first certified nurse educator (CNE)exam (National League for Nursing, 2006) toraise “the visibility and status of the academicnurse educator role as an advanced professionalpractice discipline with a defined practice set-ting” (Klestzick, 2005, p. 1).

So, too, the American Nurses Association(ANA) has for years put forth statements on thefunctions, standards, and qualifications for nurs-ing practice, of which patient teaching is a keyelement. In addition, the International Councilof Nurses (ICN) has long endorsed the nurse’srole as educator to be an essential component ofnursing care delivery.

Today, all state nurse practice acts (NPAs)include teaching within the scope of nursingpractice responsibilities. Nurses, by legal man-date of the NPAs, are expected to provide instruction to consumers to assist them to main-tain optimal levels of wellness and manage ill-ness. Nursing career ladders often incorporateteaching effectiveness as a measure of excellencein practice (Rifas, Morris, & Grady, 1994). Byteaching patients and families as well as health-care personnel, nurses can achieve the profes-sional goal of providing cost-effective, safe, andhigh-quality care.

In recognition of the importance of patienteducation by nurses, the Joint Commission (JC),formerly the Joint Commission on Accredi-tation of Healthcare Organizations (JCAHO),established nursing standards for patient educa-tion as early as 1993. These standards, known asmandates, describe the type and level of care,treatment, and services that must be provided byan agency or organization to receive accreditation.Required accreditation standards have providedthe impetus for nursing service managers to put

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greater emphasis on unit-based clinical staffeducation activities for the improvement of nurs-ing care interventions to achieve expected clientoutcomes (Joint Commission on Accreditationof Healthcare Organizations, 2001). Positiveoutcomes of patient care are to be achieved bynurses through teaching activities that must bepatient centered and family oriented.

More recently, the JC has expanded its expec-tations to include an interdisciplinary team ap-proach in the provision of patient education aswell as evidence that patients and their signifi-cant others participate in care and decision mak-ing and understand what they have been taught.This requirement means that providers mustconsider the literacy level, educational back-ground, language skills, and culture of everyclient during the education process (Cipriano,2007; Davidhizar & Brownson, 1999; JCAHO,2001).

In addition, the Patient’s Bill of Rights, firstdeveloped in the 1970s by the American Hos-pital Association, has been adopted by hospitalsnationwide. It establishes the guidelines to en-sure that patients receive complete and currentinformation concerning their diagnosis, treat-ment, and prognosis in terms they can reason-ably be expected to understand.

The Pew Health Professions Commission(1995), influenced by the dramatic changes sur-rounding health care, published a broad set ofcompetencies it believed would mark the suc-cess of the health professions in the 21st century.Shortly thereafter, the commission (1998) re-leased a fourth report as a follow-up on healthprofessional practice in the new millennium.Numerous recommendations specific to thenursing profession have been proposed by thecommission. More than one half of them pertainto the importance of patient and staff education

and to the role of the nurse as educator. Theserecommendations for the practice of nursinginclude the need to:

• Provide clinically competent and coordi-nated care to the public

• Involve patients and their families in thedecision-making process regardinghealth interventions

• Provide clients with education andcounseling on ethical issues

• Expand public access to effective care• Ensure cost-effective and appropriate

care for the consumer• Provide for prevention of illness and

promotion of healthy lifestyles for allAmericans

In 2006, the Institute for Healthcare Im-provement announced the 5 Million Lives cam-paign. The campaign’s objective is to reduce the15 million incidents of medical harm that occurin U.S. hospitals each year. Such an ambitiouscampaign has major implications for teachingpatients and their families as well as nursingstaff and students the ways they can improvecare to reduce injuries, save lives, and decreasecosts of health care (Berwick, 2006).

Another recent initiative was the formation ofthe Sullivan Alliance to recruit and educate staffnurses to deliver culturally competent care to thepublic they serve. Effective health care and healtheducation of our patients and their familiesdepends on a sound scientific base and culturalawareness in an increasingly diverse society. Thisorganization’s goal is to increase the racial and cul-tural mix of nursing faculty, students, and staff,who will be sensitive to the needs of clients ofdiverse backgrounds (Sullivan & Bristow, 2007).

Accomplishing the goals and meeting theexpectations of these various organizations calls

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Social, Economic, and Political Trends Affecting Health Care 7

for a redirection of education efforts. Since the1980s, the role of the nurse as educator hasundergone a paradigm shift, evolving from whatonce was a disease-oriented approach to a moreprevention-oriented approach. In other words,the focus is on teaching for the promotion andmaintenance of health. Education, once done aspart of discharge plans at the end of hospital-ization, has expanded to become part of a com-prehensive plan of care that occurs across thecontinuum of the healthcare delivery process(Davidhizar & Brownson, 1999).

As described by Grueninger (1995), this tran-sition toward wellness has entailed a progression“from disease-oriented patient education (DOPE)to prevention-oriented patient education (POPE)to ultimately become health-oriented patient edu-cation (HOPE)” (p. 53). This new approach haschanged the role of the nurse from one of wisehealer to expert advisor/teacher to facilitator ofchange. Instead of the traditional aim of simplyimparting information, the emphasis is now onempowering patients to use their potentials, abil-ities, and resources to the fullest (Glanville, 2000).

Also, the role of today’s educator is one oftraining the trainer—that is, preparing nursingstaff through continuing education, in-serviceprograms, and staff development to maintainand improve their clinical skills and teachingabilities. It is essential that professional nursesbe prepared to effectively perform teaching ser-vices that meet the needs of many individualsand groups in different circumstances across avariety of practice settings. The key to the suc-cess of our profession is for nurses to teach othernurses. We are the primary educators of our fel-low colleagues and other healthcare staff per-sonnel (Donner, Levonian, & Slutsky, 2005). Inaddition, the demand for educators of nursingstudents is at an all-time high.

Another very important role of the nurse aseducator is serving as a clinical instructor for stu-dents in the practice setting. Many staff nursesfunction as clinical preceptors and mentors toensure that nursing students meet their expectedlearning outcomes. However, evidence indicatesthat nurses in the clinical and academic settingsfeel inadequate as mentors and preceptors due topoor preparation for their role as teachers. Thischallenge of relating theory learned in the class-room setting to the practice environment requiresnurses not only to be up to date with clinical skillsand innovations in practice, but to possess theknowledge and skills of the principles of teachingand learning. However, knowing the practice fieldis not the same thing as knowing how to teach thefield. The role of the clinical educator is a dynamicone that requires the teacher to actively engagestudents to become competent and caring profes-sionals (Gillespie & McFetridge, 2006).

Social, Economic, andPolitical Trends AffectingHealth CareIn addition to the professional and legal stan-dards put forth by various organizations andagencies, many social, economic, and politicaltrends nationwide affecting the public’s healthhave led to increased attention to the role ofthe nurse as teacher and to the importance ofclient and staff education. The following aresome of the significant forces influencing nurs-ing practice in particular and the healthcare sys-tem in general (Birchenall, 2000; Bodenheimer,Lorig, Holman, & Grumbach, 2002; Cipriano,2007; DeSilets, 1995; Glanville, 2000; U.S. De-partment of Health and Human Services, 2000;Zikmund-Fisher, Sarr, Fagerlin, & Ubel, 2006):

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• The federal government has publishedHealthy People 2010: Understanding andImproving Health, a document that putforth national health goals and objec-tives for the future. These goals andobjectives include the development ofeffective health education programs toassist individuals to recognize andchange risk behaviors, to adopt or main-tain healthy practices, and to makeappropriate use of available services forhealth care. Achieving these nationalpriorities would dramatically cut thecosts of health care, prevent the prema-ture onset of disease and disability, andhelp all Americans lead healthier andmore productive lives. Nurses, as thelargest group of health professionals,play an important role in making a realdifference by teaching clients to attainand maintain healthy lifestyles.

• The growth of managed care has resultedin shifts in reimbursement for healthcareservices. Greater emphasis has beenplaced on outcome measures, many ofwhich can be achieved primarilythrough the health education of clients.

• Health providers are recognizing theeconomic and social values of reachingout to communities, schools, and work-places to provide education for diseaseprevention and health promotion.

• Politicians and healthcare administratorsalike recognize the importance of healtheducation to accomplish the economicgoal of reducing the high costs of healthservices. Political emphasis is on pro-ductivity, competitiveness in the mar-ketplace, and cost-containment measuresto restrain health service expenses.

• Healthcare professionals are increasinglyconcerned about malpractice claims anddisciplinary action for incompetence.Continuing education, either by legisla-tive mandate or as a requirement of theemploying institution, has come to theforefront in response to the challenge ofensuring the competency of practition-ers. It is a means to transmit newknowledge and skills as well as to rein-force or refresh previously acquiredknowledge and abilities for the continu-ing growth of staff.

• Nurses continue to define their profes-sional role, body of knowledge, scope ofpractice, and expertise, with client educa-tion as central to the practice of nursing.

• Consumers are demanding increasedknowledge and skills about how to carefor themselves and how to prevent dis-ease. As people are becoming moreaware of their needs and desire a greaterunderstanding of treatments and goals,the demand for health information isexpected to intensify. The quest for con-sumer rights and responsibilities, whichbegan in the 1990s, continues into the21st century.

• Demographic trends, particularly theaging of the population, are requiringan emphasis to be placed on self-relianceand maintenance of a healthy status overan extended lifespan. As the percentageof the U.S. population over 65 yearsclimbs dramatically in the next 20 to 30years, the healthcare needs of the babyboom generation of the post–WorldWar II era will become greater as mem-bers deal with degenerative illnesses andother effects of the aging process.

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Social, Economic, and Political Trends Affecting Health Care 9

• Among the major causes of morbidityand mortality are those diseases nowrecognized as being lifestyle relatedand preventable through educationalintervention. In addition, millions ofincidents of medical harm occur everyyear in U.S. hospitals, making itimperative that clients, nursing staff,and nursing students be educatedabout preventive measures that willreduce these incidents (Berwick,2006).

• The increase in chronic and incurableconditions requires that individuals andfamilies become informed participantsto manage their own illnesses. Patientteaching can facilitate an individual’sadaptive responses to illness.

• Advanced technology is increasing thecomplexity of care and treatment inhome and community-based settings.More rapid hospital discharge and moreprocedures done on an outpatient basisare forcing patients to be more self-reliant in managing their own health.Patient education is necessary to assistthem to independently follow throughwith self-management activities.

• Healthcare providers are becomingincreasingly aware that client health lit-eracy is an essential skill if health out-comes are to be improved nationwide.Nurses must attend to the educationneeds of their clients to be sure thatthey adequately understand the infor-mation required for independence inself-care activities to promote, maintain,and restore their health.

• There is a belief on the part of nursesand other healthcare providers, which is

supported by research, that client edu-cation improves compliance and, hence,health and well-being. Better under-standing by clients and their families ofthe recommended treatment plans canlead to increased cooperation, decisionmaking, satisfaction, and independencewith therapeutic regimens. Health edu-cation will enable patients to indepen-dently solve problems encounteredoutside the protected care environmentsof hospitals, thereby increasing theirindependence.

• An increasing number of self-helpgroups exist to support clients in meet-ing their physical and psychosocialneeds. The success of these supportgroups and behavioral change programsdepends on the nurse’s role as teacherand advocate.

Nurses recognize the need to develop theirexpertise in teaching to keep pace with thedemands of patient and staff education. As theycontinue to define their role, body of knowl-edge, scope of practice, and professional exper-tise, nurses realize more than ever before thattheir role as educator is central to the practice ofnursing and should be captured to even a greaterextent as part of their professional domain.Nurses are in a key position to carry out healtheducation. They are the healthcare providerswho have the most continuous contact withclients, are usually the most accessible source ofinformation for the consumer, and are the mosthighly trusted of all health professionals. InGallup polls taken since 1999, nurses continueto be ranked No. 1 in honesty and ethics among45 occupations (Mason, 2001; McCafferty, 2002;Saad, 2006).

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Purposes, Goals, andBenefits of Client and StaffEducationThe purpose of patient education is to increasethe competence and confidence of clients forself-management. The goal is to increase theresponsibility and independence of clients forself-care. This can be achieved by supportingpatients through the transition from beinginvalids to being self-sustaining in managingtheir own care; from being dependent recipientsto being involved participants in the careprocess; and from being passive listeners toactive learners. An interactive, partnership edu-cation approach provides clients the opportunityto explore and expand their self-care abilities(Cipriano, 2007).

The single most important action of nursesas caregivers is to prepare clients for self-care.If they cannot independently maintain or im-prove their health status when on their own, wehave failed to help them reach their potential(Glanville, 2000). The benefits of client educa-tion are many. Effective teaching by the nursehas demonstrated the potential to:

• Increase consumer satisfaction• Improve quality of life• Ensure continuity of care• Decrease client anxiety• Effectively reduce the complications of

illness and the incidence of disease• Promote adherence to treatment plans• Maximize independence in the perfor-

mance of activities of daily living• Energize and empower consumers to

become actively involved in the plan-ning of their care

Because many health needs and problems arehandled at home, there truly does exist a need toeducate people on how to care for themselves—both to get well and to stay well. Illness is a nat-ural life process, but so is mankind’s ability tolearn. Along with the ability to learn comes anatural curiosity that allows people to view newand difficult situations as challenges rather thanas defeats. As Orr (1990) observed, “Illness canbecome an educational opportunity . . . a ‘teach-able moment’ when ill health suddenly encour-ages [patients] to take a more active role in theircare” (p. 47). This observation remains relevanttoday.

Numerous studies have documented the factthat informed clients are more likely to complywith medical treatment plans, find innovativeways to cope with illness, and are less likely toexperience complications. Overall, clients aremore satisfied with care when they receive ade-quate information about how to manage forthemselves. One of the most frequently citedcomplaints by patients in litigation cases is thatthey were not adequately informed (Reising,2007).

Just as the need exists for teaching clients tohelp them become participants and informedconsumers to achieve independence in self-care,the need also exists for staff nurses to be exposedto up-to-date information with the ultimategoal of enhancing their practice. The purpose ofstaff and student education is to increase thecompetence and confidence of nurses to functionindependently in providing care to the con-sumer. The goal of our education efforts is toimprove the quality of care delivered by nurses.Nurses play a key role in improving the nation’shealth, and they recognize the importance oflifelong learning to keep their knowledge andskills current (DeSilets, 1995).

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The Education Process Defined 11

In turn, the benefits to nurses in their role aseducators include increased job satisfactionwhen they recognize that their teaching actionshave the potential to forge therapeutic relation-ships with clients, enhanced patient–nurseautonomy, increased accountability in practice,and the opportunity to create change that reallymakes a difference in the lives of others.

Our primary aims, then, as educators shouldbe to nourish clients, mentor staff, and serve asteachers and clinical preceptors for nursing stu-dents. We must value our role in educating oth-ers and make it a priority for our clients, ourfellow colleagues, and the future members of ourprofession.

The Education ProcessDefinedThe education process is a systematic, sequential,logical, scientifically based, planned course ofaction consisting of two major interdependentoperations, teaching and learning. This processforms a continuous cycle that also involves twointerdependent players, the teacher and thelearner. Together, they jointly perform teachingand learning activities, the outcome of whichleads to mutually desired behavior changes.These changes foster growth in the learner and,it should be acknowledged, growth in theteacher as well. Thus, the education process is aframework for a participatory, shared approachto teaching and learning (Carpenter & Bell,2002).

The education process has always been com-pared to the nursing process—rightly so, be-cause the steps of each process run parallel to oneanother, although they have different goals andobjectives. Both processes provide a rational

basis for nursing practice rather than an intu-itive one. The education process, like the nurs-ing process, consists of the basic elements ofassessment, planning, implementation, and eval-uation. The two are different in that the nursingprocess focuses on the planning and implemen-tation of care based on the assessment and diag-nosis of the physical and psychosocial needs ofthe patient. The education process, on the otherhand, focuses on the planning and implemen-tation of teaching based on an assessment andprioritization of the client’s learning needs,readiness to learn, and learning styles (Carpenter& Bell, 2002). The outcomes of the nursingprocess are achieved when the physical and psy-chosocial needs of the client are met. The out-comes of the education process are achievedwhen changes in knowledge, attitudes, andskills occur. Both processes are ongoing, withassessment and evaluation perpetually redirect-ing the planning and implementation phases ofthe processes. If mutually agreed-on outcomesin either process are not achieved, as determinedby evaluation, then the nursing process or theeducation process can and should begin againthrough reassessment, replanning, and reimple-mentation (Figure 1–1).

It should be noted that the actual act of teach-ing or instruction is merely one component of theeducation process. Teaching and instruction,terms often used interchangeably with oneanother, are deliberate interventions that involvesharing information and experiences to meetintended learner outcomes in the cognitive,affective, and psychomotor domains accordingto an education plan. Teaching and instruction,both one and the same, are often formal, struc-tured, organized activities prepared days inadvance, but they can be performed informallyon the spur of the moment during conversations

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or incidental encounters with the learner.Whether formal or informal, planned well inadvance or spontaneous, teaching and instruc-tion are nevertheless deliberate and consciousacts with the objective of producing learning(Carpenter & Bell, 2002).

The fact that teaching and instruction areintentional does not necessarily mean that theyhave to be lengthy and complex tasks, but itdoes mean that they comprise conscious actionson the part of the teacher in responding to anindividual’s need to learn. The cues that some-one has a need to learn can be communicated inthe form of a verbal request, a question, a puz-zled or confused look, a blank stare, or a gestureof defeat or frustration. In the broadest sense,then, teaching is a highly versatile strategy thatcan be applied in preventing, promoting, main-taining, or modifying a wide variety of behav-

iors in a learner who is receptive, motivated, andadequately informed (Duffy, 1998).

Learning is defined as a change in behavior(knowledge, attitudes, and/or skills) that can beobserved or measured and that occur at any timeor in any place as a result of exposure to envi-ronmental stimuli. Learning is an action bywhich knowledge, skills, and attitudes are con-sciously or unconsciously acquired such thatbehavior is altered in some way (see Chapter 3).The success of the nurse educator’s endeavors atteaching is measured not by how much contenthas been imparted, but rather by how much theperson has learned (Musinski, 1999).

Specifically, patient education is a process ofassisting people to learn health-related behav-iors that can be incorporated into everyday lifewith the goal of optimal health and indepen-dence in self-care. Staff education, by contrast,

Figure 1–1 Education process parallels nursing process.

Appraise physical and psychosocialneeds

Ascertain learning needs,readiness to learn, and learningstyles

Develop teaching plan basedon mutually predeterminedbehavioral outcomes to meetindividual needs

Perform the act of teaching usingspecific instructional methods andtools

Determine behavior changes(outcomes) in knowledge,attitudes, and skills

Develop care plan based on mutualgoal setting to meet individual needs

Carry out nursing care interventionsusing standard procedures

Determine physical and psychosocialoutcomes

ASSESSMENT

PLANNING

IMPLEMENTATION

EVALUATION

Nursing Process Education Process

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Role of the Nurse as Educator 13

is the process of influencing the behavior ofnurses by producing changes in their knowl-edge, attitudes, and skills to help nurses main-tain and improve their competencies for thedelivery of quality care to the consumer. Bothpatient and staff education involve forging arelationship between the learner and the edu-cator so that the learner’s information needs(cognitive, affective, and psychomotor) can bemet through the process of education (seeChapter 10).

A useful paradigm to assist nurses to orga-nize and carry out the education process is theASSURE model (Rega, 1993). The acronymstands for:

• Analyze the learner• State the objectives• Select the instructional methods and

materials• Use the instructional methods and

materials• Require learner performance• Evaluate the teaching plan and revise as

necessary

Role of the Nurse asEducatorFor many years, organizations governing andinfluencing nurses in practice have identifiedteaching as an essential responsibility of all reg-istered nurses in caring for both well and illclients. For nurses to fulfill the role of educator,no matter whether their audience consists ofpatients, family members, nursing students,nursing staff, or other agency personnel, theymust have a solid foundation in the principles ofteaching and learning.

Legal and accreditation mandates as well asprofessional nursing standards of practice havemade the educator role of the nurse an integralpart of high-quality care to be delivered by allregistered nurses licensed in the United States,regardless of their level of nursing school prepa-ration. Given this fact, it is imperative to exam-ine the present teaching role expectations ofnurses, irrespective of their preparatory back-ground. The role of educator is not primarily toteach, but to promote learning and provide foran environment conducive to learning—to cre-ate the teachable moment rather than just wait-ing for it to happen (Wagner & Ash, 1998).Also, the role of the nurse as teacher of patientsand families, nursing staff, and students cer-tainly should stem from a partnership philoso-phy. A learner cannot be made to learn, but aneffective approach in educating others is toactively involve learners in the education process(Bodenheimer et al., 2002).

Although by license all nurses are expectedto teach, few have ever had formal preparationin the principles of teaching and learning(Donner et al., 2005). As you will see in thistextbook, there is much knowledge and thereare skills to be acquired to carry out the role aseducator with efficiency and effectiveness.Although all nurses are able to function asgivers of information, they need to acquire theskills of being a facilitator of the learningprocess (Musinski, 1999). Consider the follow-ing questions posed:

• Is every nurse adequately prepared toassess for learning needs, readiness tolearn, and learning styles?

• Can every nurse determine whetherinformation given is received andunderstood?

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• Are all nurses capable of taking appro-priate action to revise the approach toeducating the client if the informationprovided is not comprehended?

• Do nurses realize the need to transitiontheir role of educator from being a con-tent transmitter to being a process man-ager, from controlling the learner toreleasing the learner, and from being ateacher to becoming a facilitator(Musinski, 1999)?

A growing body of evidence suggests thateffective education and learner participationgo hand in hand. The nurse should act as afacilitator, creating an environment conduciveto learning that motivates individuals to wantto learn and makes it possible for them tolearn (Musinski, 1999). The assessment oflearning needs, the designing of a teachingplan, the implementation of instructionalmethods and materials, and the evaluation ofteaching and learning should include partici-pation by both the educator and the learner.Thus, the emphasis should be on the facilita-tion of learning from a nondirective ratherthan a didactic teaching approach (Knowles,Holton, & Swanson, 1998; Musinski, 1999;Mangena & Chabeli, 2005; Donner et al.,2005).

No longer should teachers see themselves assimply transmitters of content. Indeed, the roleof the educator has shifted from the traditionalposition of being the giver of information tothat of a process designer and coordinator. Thisrole alteration from the traditional teacher-centered to the learner-centered approach is aparadigm shift that requires skill in needs assess-ment as well as the ability to involve learners in

planning, link learners to learning resources, andencourage learner initiative (Knowles et al.,1998; Mangena & Chabeli, 2005).

Instead of the teacher teaching, the new edu-cational paradigm focuses on the learner learn-ing. That is, the teacher becomes the guide onthe side, assisting the learner in his or her effortto determine objectives and goals for learning,with both parties being active partners in deci-sion making throughout the learning process.To increase comprehension, recall, and applica-tion of information, clients must be activelyinvolved in the learning experience (Kessels,2003; London, 1995). Glanville (2000) describesthis move toward assisting learners to use theirown abilities and resources as “a pivotal transferof power” (p. 58).

Certainly patient education requires a col-laborative effort among healthcare team mem-bers, all of whom play more or less importantroles in teaching. However, physicians are firstand foremost prepared “to treat, not to teach”(Gilroth, 1990, p. 30). Nurses, on the otherhand, are prepared to provide a holistic ap-proach to care delivery. The teaching role is aunique part of our professional domain. Be-cause consumers have always respected andtrusted nurses to be their advocates, nurses arein an ideal position to clarify confusing infor-mation and make sense out of nonsense.Amidst a fragmented healthcare delivery sys-tem involving many providers, the nurse servesas coordinator of care. By ensuring consistencyof information, nurses can support clients intheir efforts to achieve the goal of optimalhealth (Donovan & Ward, 2001). They also canassist their colleagues in gaining knowledgeand skills necessary for the delivery of profes-sional nursing care.

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Barriers to Teaching and Obstacles to Learning 15

Barriers to Teaching andObstacles to LearningIt has been said by many educators that adultlearning takes place not by the teacher’s initi-ating and motivating the learning process, butrather by the teacher’s removing or reducingobstacles to learning and enhancing the processafter it has begun. The educator should notlimit learning to the information that is in-tended but should clearly make possible thepotential for informal, unintended learning thatcan occur each and every day with each andevery teacher–learner encounter (Carpenter &Bell, 2002).

Unfortunately, nurses must confront manybarriers in carrying out their responsibilitiesfor educating others. Also, learners face a vari-ety of potential obstacles that can interferewith their learning. For the purposes of thistextbook, barriers to teaching are defined as thosefactors that impede the nurse’s ability to de-liver educational services. Obstacles to learningare defined as those factors that negativelyaffect the ability of the learner to pay attentionto and process information.

Factors Impacting the Ability toTeachThe following include the major barriers inter-fering with the ability of nurses to carry outtheir roles as educators (Carpenter & Bell, 2002;Casey, 1995; Chachkes & Christ, 1996; Duffy,1998; Glanville, 2000; Honan, Krsnak, Petersen,& Torkelson, 1988):

1. Lack of time to teach is cited by nursesas the greatest barrier to being able to

carry out their educator role effectively.Early discharge from inpatient and out-patient settings often results in nursesand clients having fleeting contact withone another. In addition, the schedulesand responsibilities of nurses are verydemanding. Finding time to allocate toteaching is very challenging in light ofother work demands and expectations.In one survey by the Joint Commission,28% of the nurses claimed that theywere not able to provide patients andtheir families with the necessary instruc-tion because of lack of time during theirshifts at work (Stolberg, 2002). Nursesmust know how to adopt an abbreviated,efficient, and effective approach to clientand staff education by first adequatelyassessing the learner and then by usingappropriate instructional methods andinstructional tools at their disposal.Discharge planning plays an ever moreimportant role in ensuring continuity ofcare across settings.

2. Many nurses and other healthcare per-sonnel admit that they do not feel com-petent or confident with their teachingskills. As stated previously, althoughnurses are expected to teach, few haveever taken a specific course on the prin-ciples of teaching and learning. Theconcepts of patient education are usuallyintegrated throughout nursing curricularather than being offered as a specificcourse of study. As early as 1965, Pohlfound that one third of 1,500 nurses,when questioned, reported that theyhad no preparation for the teaching theywere doing, while only one fifth felt

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they had adequate preparation. Almost30 years later, Kruger (1991) surveyed1,230 nurses in staff, administrative,and education positions regarding theirperceptions of the extent of nurses’responsibility for and level of achieve-ment of patient education. Although allthree groups strongly believed thatclient and staff education is a primaryresponsibility of nurses, the vast major-ity of them rated their ability to per-form educator role activities asunsatisfactory. Few additional studieshave been forthcoming on the nurses’perceptions of their educator role(Trocino, Byers, & Peach, 1997). Today,the role of the nurse as educator stillneeds to be strengthened in undergrad-uate nursing education, but fortunatelyan upswing in interest and attention tothe educator role has been gaining sig-nificant momentum in graduate nursingprograms across the country.

3. Personal characteristics of the nurseeducator play an important role indetermining the outcome of a teaching–learning interaction. Motivation toteach and skill in teaching are primefactors in determining the success of anyeducational endeavor (see Chapter 11).

4. Until recently, low priority was oftenassigned to patient and staff educationby administration and supervisory per-sonnel. With the strong emphasis onJoint Commission mandates, the levelof attention paid to the educationalneeds of consumers as well as healthcarepersonnel has changed significantly.However, budget allocations for educa-tional programs remain tight and can

interfere with the adoption of innova-tive and time-saving teaching strategiesand techniques.

5. The environment in the various settingswhere nurses are expected to teach is notalways conducive to carrying out theteaching–learning process. Lack of space,lack of privacy, noise, and frequent inter-ferences due to client treatment sched-ules and staff work demands are justsome of the factors that negatively affectthe nurse’s ability to concentrate and toeffectively interact with learners.

6. An absence of third-party reimbursementto support patient education relegatesteaching and learning to less than high-priority status. Nursing services withinhealthcare facilities are subsumed underhospital room costs and, therefore, arenot specifically reimbursed by insurancepayers. In fact, patient education in somesettings, such as home care, often cannotbe incorporated as a legitimate aspect ofroutine nursing care delivery unlessspecifically ordered by a physician.

7. Some nurses and physicians questionwhether patient education is effective asa means to improve health outcomes.They view patients as impediments toteaching when patients do not display aninterest in changing behavior, when theydemonstrate an unwillingness to learn,or when their ability to learn is in ques-tion. Concerns about coercion and viola-tion of free choice, based on the beliefthat patients have a right to choose andthat they cannot be forced to comply,explain why some professionals feel frus-trated in their efforts to teach. Unless allhealthcare members buy into the utility

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Barriers to Teaching and Obstacles to Learning 17

of patient education (that is, they believeit can lead to significant behavioralchanges and increased compliance totherapeutic regimens), then some profes-sionals may continue to feel absolvedfrom their responsibility to provide ade-quate and appropriate patient education.

8. The type of documentation system usedby healthcare agencies has an effect onthe quality and quantity of patientteaching. Both formal and informalteaching are often done (Carpenter &Bell, 2002) but not written downbecause of insufficient time, inattentionto detail, and inadequate forms onwhich to record the extent of teachingactivities. Many of the forms used fordocumentation of teaching are designedto simply check off the areas addressedrather than allow for elaboration of whatwas actually accomplished. In addition,most nurses do not recognize the scopeand depth of teaching that they performon a daily basis. Communication amonghealthcare providers regarding what hasbeen taught needs to be coordinated andappropriately delegated so that teachingcan proceed in a timely, smooth, orga-nized, and thorough fashion.

Factors Impacting the Ability toLearnThe following are some of the major obstaclesinterfering with a learner’s ability to attend toand process information (Glanville, 2000;Weiss, 2003):

1. Lack of time to learn due to rapidpatient discharge from care and the

amount of information a client isexpected to learn can discourage andfrustrate the learner, impeding the abil-ity and willingness to learn.

2. The stress of acute and chronic illness,anxiety, and sensory deficits in patientsare just a few problems that can dimin-ish learner motivation and interferewith the process of learning. However,it must be pointed out that illness aloneseldom acts as an impediment to learn-ing. Rather, illness is often the impetusfor patients to attend to learning, makecontact with the healthcare professional,and take positive action to improvetheir health status.

3. Low literacy and functional health illiter-acy has been found to be a significant fac-tor in the ability of clients to make use ofthe written and verbal instructions givento them by providers. Almost half of theAmerican people read and comprehend ator below the eighth-grade level and aneven higher percentage suffer from healthilliteracy (see Chapter 7).

4. The negative influence of the hospitalenvironment itself, resulting in loss ofcontrol, lack of privacy, and social isola-tion, can interfere with a patient’s activerole in health decision making andinvolvement in the teaching–learningprocess.

5. Personal characteristics of the learnerhave major effects on the degree towhich behavioral outcomes are achieved.Readiness to learn, motivation and com-pliance, developmental-stage character-istics, and learning styles are some ofthe prime factors influencing the successof educational endeavors.

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6. The extent of behavioral changesneeded, both in number and in com-plexity, can overwhelm learners anddissuade them from attending to andaccomplishing learning objectives andgoals.

7. Lack of support and lack of ongoingpositive reinforcement from the nurseand significant others serve to block thepotential for learning.

8. Denial of learning needs, resentment ofauthority, and lack of willingness totake responsibility (locus of control) aresome psychological obstacles to accom-plishing behavioral change.

9. The inconvenience, complexity, inacces-sibility, fragmentation, and dehuman-ization of the healthcare system oftenresult in frustration and abandonmentof efforts by the learner to participate inand comply with the goals and objec-tives for learning.

Questions to be AskedAbout Teaching andLearningTo maximize the effectiveness of client and staff/student education by the nurse, it is necessary toexamine the elements of the education processand the role of the nurse as educator. Many ques-tions arise related to the principles of teachingand learning. The following are some of theimportant questions that the chapters in thistextbook address:

• How can members of the healthcareteam work together more effectively tocoordinate educational efforts?

• What are the ethical, legal, and eco-nomic issues involved in patient andstaff education?

• Which theories and principles supportthe education process, and how can theybe applied to change the behaviors oflearners?

• What assessment methods and tools canbe used to determine learning needs,readiness to learn, and learning styles?

• Which learner attributes negatively andpositively affect an individual’s abilityand willingness to learn?

• What can be done about the inequities(in quantity and quality) in the deliveryof education services?

• Which elements need to be taken intoaccount when developing and imple-menting teaching plans?

• Which instructional methods and mate-rials are available to support teachingefforts?

• Under which conditions should certainteaching methods and materials be used?

• How can teaching be tailored to meetthe needs of specific populations oflearners?

• What common mistakes are made whenteaching others?

• How can teaching and learning be bestevaluated?

State of the EvidenceThe literature on patient and staff education isextensive from both a research- and nonresearch-based perspective. The nonresearch literature onpatient education is prescriptive in nature andtends to give anecdotal tips on how to take indi-vidualized approaches to teaching and learning.

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State of the Evidence 19

A computer literature search, for example,reveals literally thousands of nursing and alliedhealth articles and books on teaching and learn-ing that are available from the general to thespecific.

However, many research-based studies arebeing conducted on teaching specific populationgroups about a variety of topics, but onlyrecently has attention been focused on how tomost effectively teach those with long-termchronic illnesses. Much more research must beconducted on the benefits of patient educationas it relates to the potential for increasing thequality of life, leading a disability-free life,decreasing the costs of health care, and manag-ing independently at home through anticipatoryteaching approaches. Studies from acute-caresettings tend to focus on preparing a patient fora procedure, with emphasis on the benefits ofinformation to alleviate anxiety and promotepsychological coping. Evidence does suggestthat patients cope much more effectively whentaught exactly what to expect (Donovan &Ward, 2001; Duffy, 1998; Mason, 2001).

More research is definitely needed on thebenefits of teaching methods and instructionaltools using the new technologies of computer-assisted instruction, online and other distancelearning modalities, cable television, and Inter-net access to health information for both patientand staff education. These new approaches toinformation require a role change of the educa-tor from one of teacher to resource facilitator aswell as a shift in the role of the learner frombeing passive to an active recipient. The rapidadvances in technology for teaching and learn-ing also will require a better understanding ofgenerational orientations and experiences of thelearner (Billings & Kowalski, 2004). Also, theeffectiveness of videotapes and audiotapes with

different learners and in different situationsmust be further explored (Kessels, 2003). Giventhe significant incidence of low-literacy ratesamong patients and their family members,much more investigation needs to be done onthe impact of printed versus audiovisual mate-rials as well as written versus verbal instructionon learner comprehension (Weiss, 2003).

Gender issues, the influence of socioeconom-ics on learning, and the strategies of teachingcultural groups and special populations needfurther exploration as well. Unfortunately, pri-mary sources of information from nursing liter-ature on the issues of gender and socioeconomicattributes of the learner are scanty, to say theleast, and the findings from interdisciplinaryresearch on the influence of gender on learningremain inconclusive.

Nevertheless, nurses are expected to teachdiverse populations with complex needs and arange of abilities in both traditional settings andnontraditional, unstructured settings. For morethan 30 years, nurse researchers have been study-ing how best to teach patients, but much moreresearch is required (Mason, 2001). Also, fewstudies have examined nurses’ perceptions abouttheir role as educators in the practice setting(Trocino et al., 1997). We need to establish astronger theoretical basis for intervening withclients throughout “all phases of the learning con-tinuum, from information acquisition to behav-ioral change” (Donovan & Ward, 2001, p. 211).Also, emphasis needs to be given to research innursing education to ensure that the nursingworkforce is prepared for “a challenging anduncertain future” in health care (Stevens &Valiga, 1999, p. 278).

In addition, further investigation should beundertaken to document the cost effectiveness ofeducational efforts in reducing hospital stays,

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decreasing readmissions, improving the personalquality of life, and minimizing complications ofillness and therapies. Furthermore, given thenumber of variables that can potentially inter-fere with the teaching–learning process, addi-tional studies must be conducted to examine theeffects of environmental stimuli, the factorsinvolved in readiness to learn, and the influencesof learning styles on learner motivation, com-pliance, comprehension, and the ability to applyknowledge and skills once they are acquired.One particular void is the lack of information inthe research database on how to assess motiva-tion. The author of Chapter 6 proposes param-eters to assess motivation but notes the paucityof information specifically addressing this issue.

Although it was almost 20 years ago thatOberst (1989) delineated the major issues inpatient education studies related to the evaluationof the existing research base and the design offuture studies, the following four broad problemcategories she identified remain pertinent today:

1. Selection and measurement of appropri-ate dependent variables (educationaloutcomes)

2. Design and control of independent vari-ables (educational interventions)

3. Control of mediating and interveningvariables

4. Development and refinement of thetheoretical basis for education

SummaryNurses are considered information brokers—educators who can make a significant difference

in how patients and families cope with their ill-nesses, how the public benefits from educationdirected at prevention of disease and promotionof health, and how staff and student nurses gaincompetency and confidence in practice througheducation activities that are directed at contin-uous, lifelong learning. Many challenges andopportunities are ahead for nurse educators inthe delivery of health care as this nation movesforward in the 21st century.

The teaching role is becoming even moreimportant and more visible as nurses respond tothe social, economic, and political trendsimpacting on health care today. The foremostchallenge for nurses is to be able to demonstrate,through research and action, that definite linksexist between education and positive behavioraloutcomes of the learner. In this era of cost con-tainment, government regulations, and health-care reform, the benefits of client, staff, andstudent education must be made clear to thepublic, to healthcare employers, to healthcareproviders, and to payers of healthcare benefits.To be effective and efficient, nurses must bewilling and able to work collaboratively withother members of the healthcare team to provideconsistently high-quality education to the audi-ences they serve.

The responsibility and accountability of nursesfor the delivery of care to the consumer can beaccomplished, in part, through education basedon solid principles of teaching and learning. Thekey to effective education of our audiences oflearners is the nurse’s understanding of and ongo-ing commitment to the role of educator.

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References 21

REVIEW QUESTIONS

1. How far back in history has teaching been a part of the professional nurse’s role?2. Which nursing organization was the first to recognize health teaching as an important

function within the scope of nursing practice?3. What legal mandate universally includes teaching as a responsibility of nurses?4. How have the ANA, NLN, ICN, AHA, JC, and PEW Commission influenced the role

and responsibilities of the nurse as educator?5. What current social, economic, and political trends make it imperative that clients and

nursing staff be adequately educated?6. What are the similarities and differences between the education process and the nurs-

ing process?7. What are three major barriers to teaching and three major obstacles to learning?8. What common factor serves as both a barrier to education and as an obstacle to learning?9. What is the current status of research- and non-research-based evidence pertaining to

education?

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References 23

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