BOX 8-1 ● Social Policy Statement Regarding Teaching
Nursing practice includes, but is not limited to, initiating and maintaining com- fort measures, promoting and supporting human functions and responses, estab- lishing an environment conducive to well-being, providing health counseling and teaching, and collaborating on certain aspects of the health regimen.
Excerpted and reprinted with permission from American Nurses Association.
(2003).Social Policy Statement(2nd ed.). Washington, DC: Author, p. 8.
BOX 8-2 ● Activities That Promote Learning
COGNITIVE PSYCHOMOTOR AFFECTIVE
DOMAIN DOMAIN DOMAIN
Listing Assembling Advocating
Identifying Changing Supporting
Locating Emptying Accepting
Labeling Filling Promoting
Summarizing Adding Refusing
Selecting Removing Defending
FIGURE 8-1
•
The nurse uses pamphlets and a book, which appeal to this client who prefers the cognitive domain of learning. (Copyright B. Proud.)Stop • Think + Respond BOX 8-1 Identify the learning domain that relates to each of the following teaching methods:
1. The nurse watches as a client with diabetes practices administering an injection.
2. The nurse asks a client who had a mastectomy to speak to women attending a health seminar about the importance of monthly breast self-examinations.
3. The nurse explains the technique for performing leg exercises to a client scheduled for surgery.
4. The nurse helps a client self-administer nutritional formula through a gastrostomy tube.
5. The nurse gives a client with back strain a pamphlet on using good posture and body mechanics.
mation through a combination of teaching approaches.
Evidence supporting this method is that “learners retain 10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they see and hear, 70% of what they teach/talk, and 90% of what they talk/do”
(Heinrich et al., 2002; Rega, 1993).
C H A P T E R 8 ● Client Teaching 103
Age and Developmental Level
Educators emphasize that learning takes place differ- ently depending on a person’s age and developmental level. Experts agree that teaching tends to be more effec- tive when it is designed to accommodate unique age- related differences.
Nurses and all those who provide instruction must be aware of the learning characteristics of children, adult, and older adult learners (Table 8-1). Recently a distinction has been made between learners at the early and later ends of the adult spectrum (Formosa, 2002;
Pearson & Wessman, 1996). Currently there are three major categories:
• Pedagogyis the science of teaching children or those with cognitive ability comparable to children.
• Androgogyis the principles of teaching adult learners.
• Gerogogyis the techniques that enhance learning among older adults.
Although most clients with health problems are in their later years, nurse educators are advised to prepare them- selves to teach young adults who belong to “Generation X,”
“Generation Y,” and the “Net Generation,” as they age.
Generation X refers to those born between 1961 and 1981; Generation Y refers to young adults who graduated from college in the late 1990s; and the Net Generation refers to those born after 1981 (sometimes called “cyber- kids”). Technology and imposed independence as a con- sequence of growing up in single-parent households or
homes in which both parents work are greatly affecting the learning characteristics of these groups (Brown, 1997;
Skiba & Barton, 2006; Tulgan & Martin, 2001). In gen- eral, these groups share many of the following learning characteristics:
• They are technologically literate, having grown up with computers.
• They crave stimulation and quick responses.
• They expect immediate answers and feedback.
• They become bored with memorizing information and doing repetitious tasks.
• They like a variety of instructional methods from which they can choose.
• They respond best when they find the information to be relevant.
• They prefer visualizations, simulations, and other meth- ods of participatory learning.
Stop • Think + Respond BOX 8-2 Identify the age-related learner for whom the following teaching techniques are most appropriate. Explain the basis for your analysis.
1. The nurse’s goal is to limit the teaching session to no more than 20 minutes.
2. The nurse emphasizes knowledge or techniques that the client is interested in learning.
3. The nurse reinforces that the client’s discharge from the health agency correlates with becoming competent in self-administering insulin injections.
AGE-RELATED DIFFERENCES AMONG LEARNERS*
TABLE 8-1
PEDAGOGIC LEARNERS ANDROGOGIC LEARNERS GEROGOGIC LEARNERS Physically immature
Lack experience Compulsory learners Passive
Need direction and supervision Motivated to learn by potential
rewards or punishment Learning is subject-centered Short attention span
Convergent thinkers (unidirectional;
e.g., see one application for new information)
Need immediate feedback Rote learning
Short-term retention Task-oriented Think concretely Respond to competition
Physically mature Building experience Voluntary learners Active
Self-directed and independent Seek knowledge for its own sake or
personal interest
Learning is problem centered Longer attention span
Divergent thinkers (process multiple applications for new information) Can postpone feedback
Analytical learning Long-term retention Goal-oriented Think abstractly Respond to collaboration
Undergoing degenerative changes Vast experience
Crisis learners Passive/active
Need structure and encouragement Motivated by a personal need or goal Learning is self-centered
Attention affected by low energy level, fatigue, and anxiety
Practical thinkers (process new information as it applies to a unique personal problem) Respond to frequent feedback
Experiential learning
Short-term unless reinforced by immediate use Outcome-oriented
Concrete/abstract
Respond to family encouragement
* Each learner is unique and may demonstrate characteristics associated with other age groups.
104 U N I T 3 ● Fostering Communication
ical regimens, keep appointments or seek help early in the course of a disease.” Functional illiteracy may be the consequence of a learning disability, not a below-average intellectual capacity.
Because many illiterate or functionally illiterate people are not apt to volunteer information about their reading problems, literacy may be difficult to assess. Those who are illiterate and functionally illiterate usually develop elaborate mechanisms to disguise or compensate for their learning deficits. To protect the client’s self-esteem, the nurse can ask, “How do you learn best?” and plan accord- ingly. Some useful approaches when teaching clients who are illiterate or functionally illiterate include the following:
• Use verbal and visual modes for instruction.
• Repeat directions several times in the same sequence so the client can memorize the information.
• Provide pictures, diagrams, or tapes (audio and video) for future review.
Sensory Deficits
The abilities to see and to hear are essential for almost every learning situation. Older adults tend to have visual and auditory deficits, although such deficits are not exclusive to this population. Nursing Guidelines 8-1 pre- sent some techniques for teaching clients with sensory impairment.
Cultural Differences
Because teaching and learning involve language, the nurse must modify approaches if the client cannot speak 4. The nurse indicates that the client can use a computer-
ized game for 30 minutes when he or she can name the number of recommended servings in each category within the food pyramid.
5. The nurse challenges the client to devise a plan for managing her colostomy when she returns to work following discharge.
NURSING GUIDELINES 8-1
Teaching Clients With Sensory Impairments
Ensure that the client with visual impairment is wearing prescription eyeglasses or that the client with hearing impairment is wearing a hearing aid, if available.
Visual and auditory aids maximize ability to perceive sensory stimuli.
For clients with visual impairment:
❙ Speak in a normal tone of voice. Clients with visual impairment do not necessarily have hearing impairment. Increased volume does not compensate for reduced vision.
❙ Use at least a 75- to 100-watt light source, preferably in a lamp that shines over the client’s shoulder. Ceiling lights tend to diffuse light rather than concentrate it on a small area where the client needs to focus.
❙ Avoid standing in front of a window through which bright sunlight is shining.It is difficult to look into bright light.
❙ Provide a magnifying glass for reading. Magnification enlarges standard or small print to a comfortable size.
❙ Obtain pamphlets in large (12- to 16-point) print and serif lettering, which has horizontal lines at the bottom and top of each letter (Fig. 8-2).
Letters and words are usually more distinct when set in large print with a style that promotes visual discrimination.
❙ Avoid using materials printed on glossy paper. Glossy paper reflects light, causing a glare that makes reading uncomfortable.
❙ Select black print on white paper. This combination provides maximum contrast and makes letters more legible.
For clients with hearing impairment:
❙ Use a magic slate, chalkboard, flash cards, and writing pads to communicate.Writing can substitute for verbal instructions.
❙ Lower the voice pitch. Hearing loss is generally in the higher-pitch ranges.
❙ Try to select words that do not begin with “f,” “s,” “k,” and “sh.” These letters are formed with high-pitched sounds and are therefore difficult for clients with hearing impairment to discriminate.
❙ Rephrase rather than repeat when the client does not understand.
Rephrasing may provide additional visual or auditory clues to facilitate the client’s understanding.
❙ Insert a stethoscope into the client’s ears and speak into the bell with a low voice. The stethoscope acts as a primitive hearing aid. It projects sounds directly to the ears and reduces background noise.
Capacity to Learn
For the person to receive, remember, analyze, and apply new information, he or she must have a certain amount of intellectual ability. Illiteracy, sensory deficits, cultural differences, shortened attention span, and lack of moti- vation and readiness require special adaptations when implementing health teaching.
Literacy
It is essential to determine a client’s level of literacy(abil- ity to read and write) before developing a teaching plan.
Approximately 21% of U.S. adults are illiterate(cannot read or write) (Davis et al., 1998; Toffler, 2002). An addi- tional 27% are considered functionally illiterate(possess minimal literacy skills), which means they can sign their name and perform simple mathematical tasks (e.g., make change) but read at or below a ninth-grade level. Toffler (2002, p. 3) reports “at least 30% . . . could not comprehend the written instructions on prescrip- tion bottles . . . and (because of their functional illiteracy) are less likely to use screening procedures, follow med-
C H A P T E R 8 ● Client Teaching 105
English or if English is a second language (see Chap. 6, Nursing Guidelines 6-1). Language barriers do not jus- tify omitting health teaching. In most cases, if neither the nurse nor the client speaks a compatible language, a translator is used.
Attention and Concentration
The client’s attention and concentration affect the dura- tion, delivery, and teaching methods employed. Some helpful approaches include the following:
• Observe the client, and implement health teaching when he or she is most alert and comfortable.
• Keep the teaching session short.
• Use the client’s name frequently throughout the instruc- tional period; this refocuses his or her attention.
• Show enthusiasm, which you are likely to communicate to the client.
• Use colorful materials, gestures, and variety to stimulate the client.
• Involve the client in an active way.
• Vary the tone and pitch of voice to stimulate the client aurally.
Motivation
Learning is optimal when a person has a purpose for acquiring new information. Relevance of learning depends on individual variables. The desire for learning may be to satisfy intellectual curiosity, restore independence, pre- vent complications, or facilitate discharge and return to
the comfort of home. Less desirable reasons are to please others and to avoid criticism.
Learning Readiness
When capacity and motivation for learning exist, the nurse can determine the final component, learning readi- ness. Readiness refers to the client’s physical and psy- chological well-being. For example, a person who is in pain, is too warm or cold, is having difficulty breathing, or is depressed or fearful is not in the best condition to learn. In these situations, it is best to restore comfort and then attend to teaching.
Learning Needs
The best teaching and learning take place when both are individualized. To be most efficient and personalized, the nurse must gather pertinent information from the client.
Second-guessing what the client wants and needs to know often leads to wasted time and effort.
The following are questions the nurse can ask to assess the client’s learning needs:
• What does being healthy mean to you?
• What things in your life interfere with being healthy?
• What don’t you understand as fully as you would like?
• What activities do you need help with?
• What do you hope to accomplish before being dis- charged?
• How can we help you at this time?
Informal teaching is unplanned and occurs sponta- neously at the bedside. Formal teaching requires a plan.
Without a plan, teaching becomes haphazard. Further- more, without some organization of time and content, the potential for reaching goals, providing adequate information, and ensuring comprehension is jeopar- dized. Potential teaching needs generally are identified at the client’s admission, but they may be amended as care and treatment progress.
A student nurse may work with a staff nurse or instruc- tor in developing a teaching plan. Usually one or more nurses carry out certain specific parts of a teaching plan (Fig. 8-3). This approach is the most desirable so that a client is not overwhelmed with processing volumes of new information or learning skills that are difficult for novices to perform. Skill 8-1 serves as a model when an adult client needs teaching.