Learning Objectives
By the end of this section, you will be able to:
- Describe the different methods of learning
- Understand the different approaches to teaching
- Recall the methods used for effective teaching
Teaching and learning are dynamic processes of interaction between the educator and learner(s). Three methods or domains of learning have been identified: cognitive, affective, and psychomotor. Although each method is unique, they do not function in isolation; they work in concert with one another. Teaching is approached by focusing on one person at a time or a group of people together. Education also has multiple methodologies, with delivery of content through different means. In nursing, this includes lecture, demonstration, handouts, and simulation. Like the methods of learning, teaching techniques frequently overlap and combine for multimodal delivery and to maximize delivery and retention of content and concepts. This section will move from the “whys” of patient and family education and the “hows” of health promotion through self-care, to methods and approaches to teaching and learning.
Learning Objectives
There are multiple objectives of learning recognized by psychologists, educators, and nurses, and each focuses on a different component (or domain) of learning. In the process of learning and moving from little or no experience to levels of more understanding, awareness or ability is the expectation of progress and achievement in the academic setting. The three components of learning are: cognitive, affective, and psychomotor.
As a clinical, practice-oriented profession, it is important to understand and use these three domains of learning when developing patient education. is also affected, and as higher levels of cognition (the process of knowing, thinking, perceiving, or understanding) are reached, different feelings and emotions are recognized.
Cognitive Learning
The process of knowing, thinking, perceiving, or understanding is called cognition. Learning based on the process of understanding, or cognition, is called cognitive learning. Understanding includes, but is not only, basic knowledge; it encompasses remembering through analysis and evaluation and, ultimately, generation or creation of new information (data, ideas, groupings, and evidence of learning) (Iowa State University Center for Teaching and Learning [hereafter, Iowa State University], n.d.). Within education, the widely accepted categorization of levels of cognitive learning is Bloom’s Taxonomy, which was revised in 2001 (Figure 17.2) (Armstrong, 2023). Notably, the original taxonomy included the term “synthesize” in the familiar pyramid diagram as one step higher in cognition than “analyze.” The revised version retains the original concepts but changed “synthesis” to “create,” and moved it to the pinnacle of the pyramid.
At the lower levels of Bloom’s Revised Taxonomy, learners recognize and remember vocabulary and concepts, then move to understanding those concepts and then having an ability to make connections (Iowa State University, n.d.). At the next levels of application and analysis, the learner is first able to perform or employ a new task or idea, then to scrutinize it in more detail, with potential to reorganize findings in new ways and with novel considerations. The highest levels of Bloom’s Revised Taxonomy involve evaluation and creation, whereby learners are first able to assess and critique thoughts and, ultimately, to develop hypotheses, propose new ideas, and present their own knowledge. These high levels are sometimes referred to as metacognition, which is colloquially known as, “thinking about thinking.” A more comprehensive definition is that metacognition is an elevated level of thinking that allows comprehension, examination, and command of thoughts and the thinking process.
Cognitive learning is certainly a common focus on which patient education is based, with teaching presented through verbal instruction, essentially using a lecture format. Nurses explain parts of the care plan at various times while providing patient care. This may include describing how a medication works, possible side effects, and concerning adverse effects to be aware of, prior to administering the drug. Or they may include step-by-step instructions delivered verbally about a dressing change before demonstrating it by changing the dressing. These can be supported by written and visual aids. The supplemental written or visual tools give patients something to refer to after the teaching session, to recall what was taught, and reinforce what is remembered. Educating patients and families may also incorporate the use of affective and psychomotor learning methods as an accompaniment to cognitive learning. More information on these items and concepts appears later in this section, and evaluation of teaching and learning is discussed later in the chapter.
Affective Learning
Centered on feelings, including attitudes, interests, and values, affective learning fosters the ability to recognize and address a person’s own emotions and morals, and one’s aptitude and comfort when facing ethical dilemmas and necessary decisions (Iowa State University, n.d.). Affective learning is associated with feelings typically internalized and not necessarily shared externally. The affective learning domain includes the following subdomains (Peak Performance Center, 2024):
- Receiving: passive awareness of ideas or incidents; open to situations
- Responding: active involvement in learning; aware of and responsive to stimulus
- Valuing: seeing value in something and being able to express its worth; motivation and commitment
- Organizing: an ability to sort and accumulate ideas, values, and materials; makes associations with existing beliefs; invests in prioritized beliefs and values
- Characterizing: actions represent the established, internalized values; able to analyze and describe behaviors and values
These subdomains can be visualized similarly to Bloom’s Revised Taxonomy using a pyramid, representing the process of increasing complexity as a person’s affect internalizes and influences behavior—from the general awareness of receiving, through the total devotion and internal motivation of characterizing (Figure 17.3) (Peak Performance Center, 2024).
In nursing, affective traits tend to be visible through caring practices seen in interpersonal interactions, particularly with patients and families. Helping patients and families identify and cope with new feelings about changes in health status, limitations to mobility, and pain, are examples of teaching and learning within the affective method of learning. Some techniques used to heighten patients’ affective learning and identify changing, growing affective elements within themselves include journaling, simulation, group discussions, and participation in role-play activities (Iowa State University, n.d.).
Psychomotor Learning
The development of organized patterns of muscular activities guided by signals from the environment is called psychomotor learning. Coordination is a combination of neurological control and musculoskeletal movement, with development over time, and through learning and doing. In patient education, some tasks are taught through all three learning methods, and psychomotor learning may be the best example of combining them for success (Alqahtani, 2022).
Often, patients are introduced to a diagnosis first through cognitive learning, at which time affective learning is also influenced because something new (perhaps involving an emotional reaction) is confronted. Adjustments to the patient’s prior norm can result in new tasks, techniques, and skills for the patient and/or family members.
An example is a patient newly diagnosed with type I DM who must now learn how to use a glucometer, analyze its results, and self-inject insulin. Or, if the patient is a young child, family will need to learn how to perform the tasks. There is important information to be delivered by the nurse through cognitive teaching and learning methods to build an adequate level of understanding of the pathophysiology, current physiological status, and medications. Through psychomotor learning methods, the appropriate people will be taught and demonstrate acquisition of the following skills: glucometer use, read and respond to the appropriate insulin order, and inject the appropriate dose. Details on specific psychomotor teaching methods and evaluation of learning are discussed later in this section and chapter.
Patient Conversations
Teaching about Insulin Administration
Scenario: The provider has prescribed regular insulin before meals for the patient, Mrs. Lovato, and has provided verbal and written directions about when and when not to inject insulin and how much insulin to inject. The provider has now asked the nurse to teach Mrs. Lovato how to check her glucose and use an inulin pen.
Nurse: Mrs. Lovato, I’m Melinda. I’ve been asked to teach you about checking your blood sugars and how to inject insulin.
Patient: Nice to meet you, Melinda. Yes, I need to learn. The doctor was telling me about how I just became diabetic after that infection I had. It’s scary how that happened. But now I need to learn how to take care of myself.
Nurse: What a great attitude you have. I see you already have your glucometer, or glucose machine.
Patient: Yes, I do. I read the manual and think I know how to do this, but I’m glad you’ll show me.
Nurse: First, I’m going to explain the steps. First, wash your hands, then put one of the strips from the little bottle into the glucometer. Then, take one of the devices with the sharp lancet and prick the tip of your finger. Touch the drop of blood to the test strip so it takes the blood and starts analyzing it. As you wait for the result, you can hold a cotton ball or tissue on your fingertip to stop any bleeding. When the meter finishes its analysis, it will show you your blood glucose level. Now you can take the used test strip out and throw it away. The lancet should go in a container for sharps, like for used needles. With the number from the glucometer, you can look at the directions the doctor gave you about insulin, and determine how much to give yourself. Don’t worry, I have this all in a pamphlet for you, so you don’t have to memorize the steps.
Patient: Oh good. I was so glad the doctor gave me the list of what to do when.
Nurse: Let’s check your glucose now. This time, I will tell you the steps, and you can concentrate on trying to do them. I’ll be right here to help if you need some help at any point.
Scenario follow-up: The patient successfully completes the process of checking her glucose, with just a little help getting the lancet to open. Her blood glucose is 172 mg/dL. The nurse now teaches her about her insulin pen.
Nurse: Your insulin pen is loaded with the type of insulin the doctor wants you to take. This is a pretty easy device to use: you look at the amount of insulin you need from the note. For 172 mg/dL, you need 3 units, so you dial that in with this, then you take the pen, hold it to the spot you are going to inject, and push this button. These are subcutaneous injections, and you should rotate the sites: you can use your upper arms, thighs, buttocks, and abdomen. Don’t use the same place every time; rotate the spots to avoid lumps or deposits of fat.
Patient: It sounds easy enough. Let’s try this.
Nurse: Absolutely!
Scenario follow-up: Like the glucometer, the patient demonstrates understanding of the insulin pen by injecting a dose of 3 units as prescribed.
Approaches to Teaching
Patient-centered care and patient engagement are important inclusions of patient and family teaching. Nurses need to incorporate topics of education that are important to the healthcare team, as well as the patient’s (and caregiver’s) interests, preferences, and priorities for information, by collaboration and mutual goal setting (Kuipers et al., 2021). Although some teaching moments are captured spontaneously by questions being asked, many times nurses can plan education sessions.
Assessing the audience’s capability for learning, learning style, and health literacy is a valuable step for preparation of a teaching session. The patient’s physiological condition and availability of family or other members of their support team are also important considerations. Once the nurse knows who will compose the audience—one or more people and who those people are, the nurse is able to better consider other details about approaches to teaching.
Individual Teaching
One-to-one teaching sessions may be preferred by either the patient or nurse for a variety of reasons (Figure 17.4). When the topic of education is particularly sensitive, for example, teaching only the affected person is often favored. Another example is urgency, when the patient is alone and something must be taught without delay. Sometimes, there is discord between family members and the patient, and patients may request to be the sole recipient of education.
Additionally, people are likely to have different goals, even when the same diagnosis or procedure is the topic of teaching and learning. Consider multiple patients anticipating knee replacement: different postoperative pain-control drugs and delivery devices may be ordered, so use and understanding of them will vary. Expectations for pain control are similarly variable, and personalized teaching for reasonable goal setting is ideal. One patient may expect, and desire, return to normal function at home, promptly; another anticipates transfer to a rehabilitation facility to improve strength prior to discharge home.
Teaching one individual allows the nurse to take advantage of the relationship established with the patient. When there is a positive foundation in place, the patient is typically more receptive to education. This is particularly valuable if difficult content, or undesired behavioral change, must be discussed. Individual teaching is probably preferred, for example, for a patient diagnosed with breast cancer. Because the patient is to be taught about caring for an incision and multiple drains as part of the upcoming surgical plan, both the nurse and the patient are apt to prefer a private discussion and the ability to very specifically address concerns of one, rather than several, patients. Personalized instruction also supports ongoing relationships as the patient is more able to participate in the conversation, including freedom to ask questions, and be part of individualized goal setting. There are times when teaching, of necessity or by design, must be implemented in a group setting.
Link to Learning
The nurse in this video provides a patient with teaching about pain. Watch how the nurse is able to gather information and provide education.
Group Teaching
In certain situations, such as a patient who is unable to make their own healthcare decisions, teaching should include the family or caregivers. Nurses will have to rely on family and/or friends to assist with reinforcing and reminding the patient of new behaviors or forgotten instructions. It is necessary to include these people in teaching whenever possible. Even for people who are independent in decision-making, having another person present for education can be helpful. Individuals understand things differently and may have questions to ask and concepts that need clarification.
Link to Learning
Watch this video and notice how the nurse provides care and education after the patient has ambulated and the responses of the patient and her husband.
Establishing relationships with patients was mentioned as a positive aspect of individual teaching, but connections can also be created between nurses and groups, and the group itself may enhance the dynamic of the education environment. Group teaching may involve a patient and spouse or significant other, or it may be several people with the same diagnosis. Some groups are formal support or interest groups, like members of Alcoholics Anonymous (AA), or a particular cancer survivors’ support group. Nurses may need to be more intentional in creating smaller groups within a larger population, but if desired, more intimate groups can be fostered for patients and/or their family members.
Depending on the goals of teaching and learning, group settings may be favored. Cognitive learning, for example, fits well with either individual or group environments, but the final selection may be based on whether several questions are anticipated or there is a psychomotor aspect to be demonstrated and exemplified. Such activities can require extra time, and the physical setting requires visibility of the action to be taught.
Affective learning can be nurtured through group interactions because some of the techniques used to establish and foster emotions, attitudes, and interests include storytelling, role-playing and simulation, and shared discussions. Sharing with others, receiving feedback, and inspiring discussion often results in patients learning and realizing more about their own feelings, and, essentially, how they feel about those emotions and responses. Group therapy relies on the nature of this dynamic for the beneficial outcomes of sharing, interacting, and supporting.
Psychomotor learning lends itself to either setting, depending on the complexity and sensitivity of the skills. Ostomy care, for example, is probably not ideal for a group setting, unless it is being taught initially on manikins. However, patients in a preoperative hip replacement surgery class could be taught as a group about postoperative positioning and use of walkers and other assistive devices. The facilitator’s time could be well spent in such a setting, with demonstration and return demonstration being evaluated during one session.
Methods of Teaching
Instruction methods can be distinguished as direct or indirect. Both methods are considered effective strategies in education (Lakha, 2023; Renard, 2023). Learning that involves active engagement of the educator and learners is called direct instruction (Austin Peay State University, n.d.). The teacher leads the teaching and learning through examples such as lecture, discussions about assigned readings, a question-answer session, or sharing a video. On the other hand, indirect instruction involves learners using learned tools to fulfill an assignment, with limited involvement from the educator (Austin Peay State University, n.d.). Examples of assignments within indirect instruction include reading an assigned article or chapter, submitting an assignment (e.g., presentation or paper), or viewing a recorded lecture.
Educating patients may involve using a combination of indirect and direct instruction, and may make use of multiple learning methods. Patient and family education can be delivered in different ways, including lecture, demonstration, handouts, or simulation. Understanding a patient’s learning preferences enables the nurse to have the right delivery method prepared. Preparation provides the best potential for achieving patient care goals.
Lecture
Lecture is a familiar teaching method and is often seen as an ideal way to deliver high volumes of information. Teachers and learners tend to be familiar with the lecture format, and it brings an inherent feeling of comfort (Baylor University Academy for Teaching and Learning [hereafter, Baylor University], n.d.). Although it is efficient at delivery, it is less efficient at the receiving end, because much of the information is unlikely to be retained (Baylor University, n.d.; Berkeley Center for Teaching and Learning [hereafter, Berkeley], n.d.; Bosnich & Lee, 2022). Verbal instructions may also be misunderstood or quickly forgotten.
One recommendation to make the content more easily understood and retained is to make the lecture more interactive (Baylor University, n.d.; Berkeley, n.d.). Strategies for supplementing a lecture include ensuring the presenter has expertise in the topic being presented, is well prepared for the lecture, and is using an active method of delivery (Figure 17.5). Lectures may also be supported by other teaching methods (Stanford et al., 2019), including diagrams, handouts, videos, moments for discussion and/or question-answer periods, demonstration, or time to work through a case study.
When nurses are educating patients, there are added components that may influence the retention of information that is presented. Both literacy and health literacy are concerns, because patients may have deficits in reading and general writing abilities. Additionally, those with high levels of literacy may not understand health-specific information. Ensuring that medical terms and concepts are fully defined in plain language prior to delivery of a large amount of information is an important step. Continuing with a simple-to-complex format can be helpful because it allows the nurse to continue to provide a foundation before moving on with more intricate details. In the healthcare setting, enhancing the lecture format with other methods, such as activities and practical applications, can be even more valuable for maintaining patient interest and comprehension.
Demonstration
Teaching of patients and families often is focused on psychomotor learning. The teacher typically begins by explaining the topic of education (the lecture [cognitive learning] component). At that time, the nurse may supplement with written information (e.g., handouts [cognitive learning]), and demonstration provides a complete illustration of the procedure. Imagine a nurse working with a patient who has a new ostomy and needs to learn how to assess the surgical stoma, as well as perform ongoing care like emptying the bag and replacing appliances, as needed. The nurse first explains the stoma, normal and abnormal findings, appliances, and what is involved in each step of care. At that time, the nurse demonstrates the assessment and procedures, offers a chance for questions if they were not asked during the demonstration, and provides the learner(s) with written and/or video information for review and ongoing reference (Figure 17.6). The patient and/or family member is expected not only to demonstrate the task back to the nurse but reiterate steps and entertain questions while performing the skill.
Either at a scheduled time or when assessment indicates it is time to repeat the procedure, the nurse again welcomes questions and asks the patient (or the individual who will be completing the actions) to provide a return demonstration by explaining and performing the process. Upon completion by the learner, the nurse may ask for clarification and understanding of any part of the return demonstration or critique the process. Questions and reflection by the patient and family at this stage may offer insight into their emotional state (affective learning) and adjustments being made internally relative to feelings and attitudes about the tasks, and their implications. The nurse may need to repeat part or all of the demonstration. As with any new technique, the level of skill should improve with repeated attempts.
Handouts
Informational handouts are useful for patient and family education (Bosnich & Lee, 2022; Kostie, 2019). Some benefits to handouts are that they can be referred to after the educational session ends and reviewed for clarification. Often, the amount of information being taught quickly is overwhelming to the learner. Even if defined clearly, medical and technical terminology can be confusing. Additionally, printed handouts may include illustrations and diagrams that help support verbal explanations from the lecture style of teaching (Figure 17.7). Visual learners find these features especially helpful. Handouts can also include links for electronic resources, websites for further information, and audio links to hear unusual sounds, informational podcasts, and videos for animations, narrative information, and context.
Written information is not well received by all, especially patients whose reading abilities are extremely limited (Stanford et al., 2019). Therefore, including multiple, complementary ways of teaching for patient and family education is more effective than using one method exclusively (Bosnich & Lee, 2022).
Link to Learning
The nurse in this video instructs a patient and family on use of a walker. Notice how the nurse incorporates lecture, demonstration, and handouts.
Interactive Simulation
Simulation can be a valuable teaching method or method to enhance information provided either verbally through lecture or on written handouts. Simulation can be very simple, such as working through a straightforward case study or having a group role-play activity. Case studies can also increase in complexity. In specific laboratory settings for simulation, it may also involve technically advanced, high-fidelity manikins, hospital-like sets, scripts, and/or standardized actors in particular roles and scenarios. No matter the level of fidelity, the educator is involved in facilitating the scenario and ensuring important concepts are identified and resolved or explained.
Link to Learning
This simulation demonstrates a nurse educating a patient and his mother about DM. Watch for the nurse’s teaching style, what is included in the education, how it is presented, and the inclusion of psychomotor skills, as well as cognitive, informative teaching and learning.
Simulation can incorporate lecture-type verbal teaching with demonstration, through the addition of a realistic scenario that includes the desired educational objectives for the patient and/or family. This allows the learner(s) to see information presented through a varied teaching methodology and practice or demonstrate competence by actions.
Unfolding Case Study
Unfolding Case Study 3: Part 4
Refer to Unfolding Case Study 3: Part 3 for a review on the patient data.
| Nursing Notes | 1000: Assessment Patient reports her children are agreeable to her decision to pursue palliative care. She expresses interest in receiving care in her own home and that her daughters would like to learn how they can help care for her as well. These requests were passed on to palliative care team who will be back to speak to the patient and family members later this afternoon. |