Learning Objectives
By the end of this section, you will be able to:
- Examine how providing patient education meets nursing standards
- Determine the different roles of the nurse for providing patient education
- Recognize essential skills needed to provide effective teaching
Health care is an interdisciplinary effort, with members of the team representing a variety of professions. Each member, from physicians to nurses, varied therapists, counselors, and spiritual representatives, contributes their specific and specialty care. Registered nurses, as care planners and those who spend a great deal of their time in directly caring for patients, are in a natural position to educate patients and their families. It is more than the interaction that places nurses in a position for patient teaching; the nursing standards of practice (ANA, 2021) specify the RN’s roles and competencies relative to health teaching, promotion, and prevention of illness.
Patients and families encounter nurses in a multitude of settings, with nurses taking different positions and roles. Each role may involve nurses providing education on different topics, in different ways, and with different goals. Nurses must be able to evaluate teaching and learning to determine its effectiveness and assess a patient’s goal achievement.
Nurses need a variety of skills to be effective educators. Behaviors such as approachability, dependability, and flexibility are necessary to establish trust and develop quality relationships with patients and families. Knowledge of the topic to be taught is also essential, enabling the nurse to present information and manage discussion and questions, which may not be possible to anticipate. Perhaps the most important skill for patient and family education is communication. Proficiency in the other teaching skills may be manifested through excellence and clarity in communication.
In this section, how nursing standards are met by patient education will be detailed. Some of the roles played by nurses in the provision of patient education will also be discussed. Finally, the required skills for effective teaching will be explained.
ANA Scope and Standards of Practice
The ANA Scope and Standards of Practice offers decision-making and practice guidance for professional RN practice. The nursing profession involves a practice scope for RNs, which is expressed as “the who, what, where, when, and why” of nursing roles and professional practice (ANA, 2021, p. 3). Additionally, RNs practicing in any nursing role are expected to adhere to authoritative standards of practice. The standards are broken down into “Standards of Practice,” and “Standards of Professional Performance” (ANA, 2021, p. 4). The distinction is that practice standards relate to competency in nursing practice, whereas professional performance standards reflect professional role competency.
Competence is a key feature of professional nursing practice, and the ANA document defines competencies for each standard. Competencies are listed for RNs, as well as nurses with advanced practice licensure. Professional performance competence is displayed through involvement in leadership activities at the level of the nurse’s education, role, and expertise.
The ANA (2021) recognizes that professional nursing practice is anything but static and, therefore, is subject to change. Clinical and environmental circumstances may also influence how nursing standards apply to a particular situation. Although each standard offers several exemplars, the ANA also recognizes that additional competencies may be realized in certain situations. Health teaching and promotion are specifically addressed in Standard 5B as “the registered nurse employs strategies to teach and promote health and wellness” (ANA, 2021, p. 85).
Health Teaching and Health Promotion
A holistic, individualized approach to patient and family education is within the RN’s scope of practice and is expected to include health promotion and disease prevention strategies.
Educating patients and their families about their medical and healthcare concerns is both a natural and developed expectation of nursing practice. Health teaching and promotion, Standard 5B, include seven competencies for the RN, as listed in the ANA Scope and Standards of Practice (2021, pp. 85–86): In the areas of coping, adaptability, and resiliency, the RN
- Engages consumer alliance and advocacy groups in health teaching and health promotion activities for health-care consumers.
In the area of healthy lifestyles, the RN
- Provides anticipatory guidance to healthcare consumers to promote health and prevent or reduce risk.
- Provides healthcare consumers with information and education about intended effects and potential adverse effects of the plan of care.
- Provides opportunities for the healthcare consumer to identify needed health promotion, disease prevention, and self-management topics such as self-care and risk management.
- Uses feedback from the healthcare consumer and other assessments to determine the effectiveness of the strategies uses.
- Uses health promotion and health teaching methods in collaboration with the healthcare consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
- Uses technologies to communicate health promotion and disease prevention information to the healthcare consumer.
These competencies are clear in that health promotion and disease prevention are both critical topics of health education, and various aspects of patients’ lives may be relevant and incorporated into the teaching. As discussed previously regarding health literacy, nurses as educators also assist patients and families to access and comprehend information to make their own healthcare decisions (Healthy People 2030, n.d.).
Advocacy
In professional nursing practice, advocacy is a process involving support and recommendations for a cause or action plan (ANA Scope and Standards of Practice, 2021). Standard 8 of the ANA Scope and Standards of Practice (2021) is dedicated to advocacy and states, “the registered nurse demonstrates advocacy in all roles and settings” (p. 91). Following the standard statement, there are 15 advocacy-related competencies, with more listed for graduate-prepared and advance practice nurses. Some examples of these competencies are in the following list (ANA Scope and Standards of Practice, 2021, pp. 91–92):
- Addresses the urgent need for a diverse and inclusive workforce as a strategy to improve outcomes related to the social determinants of health and inequities in the healthcare system.
- Champions the voice of the healthcare consumer.
- Considers societal, political, economic, and cultural factors to address social determinants of health.
- Develops policies that improve care delivery and access for underserved and at-risk populations.
- Embraces diversity, equity, inclusivity, health promotion, and health care for individuals of diverse geographic, cultural, racial, gender, and spiritual backgrounds across the life span.
- Empowers all members of the healthcare team to include the healthcare consumer in care decisions, including limitation of treatment and end of life.
- Promotes self-care, safe work environments, and sufficient resources.
- Recommends appropriate levels of care, timely and appropriate transitions, and allocation of resources to optimize outcomes.
Elements of advocacy apply to professional nursing in provision of patient care in a variety of ways, including
- Assistance with access to care
- Community programs
- Direct patient care and skills
- Ethics committees
- Patient and family education
- Policymaking
Professional nursing education programs include elements of advocacy in courses such as those focused on leadership, management, professional role development, policy, and global perspectives (Regis University, 2023-2024; University of Phoenix, 2023). Exposure to elements of advocacy while in nursing school, at a minimum, introduces these elements and more, so students are at least familiar with the concept of advocacy. Ideally, students begin to make connections during classroom and clinical experiences, realizing some of the places where advocacy is apparent or perhaps where it is lacking. For some, exposure to the concept of advocacy, and realizing at least some of the ways it can be used by nurses, is merely the first taste. Such students are intrigued by and become active participants in advocacy through the National Student Nurses Association and other organizations. This active appreciation for advocacy may continue through a nurse’s professional career.
The healthcare system is often confusing for patients and their families. Education is an important way to assist healthcare consumers as they navigate this large and complicated system. As with diagnoses and direct care, patients and their families tend to function better when they understand their circumstances. Teaching patients about the resources available for any aspect of the system represents advocacy and could include, for example, a Medicaid application or information on how to find safe housing. Referring a family member to appropriate people, departments, or agencies while their loved one is physically incapacitated is another example. As advocates of healthcare consumers, nurses may bring status changes and patient questions to the attention of the physician or advanced practitioner. Or the advocacy role can be reversed, when the nurse advocates to the patient through education, acting as an intermediary between the interdisciplinary team and the patient. Health promotion and disease-prevention-education ideas, plans, and programs can also be considered advocacy, because patients are assisted toward better health and wellness.
Roles of the Nurse
Nursing is a multifaceted profession, with varied roles in different practice areas and specialties. Regardless of the setting, the importance of education cannot be understated. Nurses, as the healthcare members who spend significant amounts of time with patients, play key roles not only as direct care provider but as teacher, counselor, and evaluator. These three roles are elaborated upon in the next sections.
Clinical Judgment Measurement Model
Prioritize Hypotheses: Discharge Teaching and Pain Control
Mr. Isaacson is being discharged to home after outpatient laparoscopic cholecystectomy. Until this surgery, Mr. Isaacson had no hospitalizations or surgeries, and his medical history includes only hypertension, which controlled with hydrochlorothiazide. Mr. Isaacson has required four 50-μg doses of fentanyl since surgery to maintain pain at ≤3 on a 1–10 scale. Mr. Isaacson is concerned he will become addicted to pain medicine, so he is hesitant to have his wife fill his prescription for home.
The nurse considers Mr. Isaacson’s needs for discharge education and prioritizes pain control as top priority, because surgical pain is usually most severe in the first day or two. Because Mr. Isaacson is concerned about the potential for addiction, the nurse first addresses that concern. Then, the patient and his wife are taught about pain, how the pain medicine he has a prescription for works to control pain, and proper use of the medication.
Nurse as a Teacher
The role of teacher is often a natural one for nurses, and its value cannot be overstated. Patients who are educated about their health, well-being, and illness or injury prevention express increased satisfaction in their healthcare interactions (Bordonada et al., 2020). These patients also tend to participate more in self-care, health promotion, and illness or injury prevention activities.
As providers of direct care and members of the healthcare team who spend much time with patients, nurses can establish relationships with patients and have many opportunities for interaction throughout a shift. Teaching moments present themselves during different activities nurses do with patients. For example, the opportunity may arise while a dressing is being changed and a patient asks questions, or the nurse simply teaches as the task is accomplished by describing the steps and explaining normal versus abnormal findings. Another example would be when the nurse and aide have a patient dangle their legs from a sitting position in bed in anticipation of standing and walking. This is the perfect opportunity to explain why these careful steps must be taken for the patient’s well-being. The nurse can then teach the safety features of a gait belt, while putting it on for transfer or ambulation.
Patients and family members tend to be more comfortable when providers clearly communicate with them, and when they understand roles they have in the plan of care. Comprehension of the diagnosis, diagnostic tests, procedures, and recovery all help reduce worry, facilitate adequate pain control, and prevent complications. A patient who is concerned about an upcoming surgery will benefit when nurses can offer repeated preoperative teaching. This can be especially valuable when a patient is in hospital and day and night shift staff nurses can both reiterate teaching topics and ensure the patient and family have all their questions answered.
Nurse as a Counselor
Although nursing degrees do not license RNs specifically as counselors, an element of counseling is often associated with the role of a nurse. Patients facing new limitations, diagnoses, and treatment recommendations are coping with challenges and the need for emotional and physical support, as well as education (Figure 17.8).
Nurses play an important role in counseling patients and families in primary care with chronic health diagnoses. By addressing concerns such has health literacy, knowledge deficits, acute and chronic illness, and emotional and educational needs, nurses counsel patients in multiple ways. Nurses assess, and assessments of learning needs and preferences, literacy and health literacy, and physical limitations are all well within nursing practice. The relationships established between nurses and their patients and families provides a natural venue for this aspect of nursing care. Counseling, including coaching, advising, and teaching, as well as guiding patients toward techniques for self-care, follows intuitively within professional nursing practice.
Nurse as an Evaluator
The nursing process includes assessment, analysis or diagnosis, planning, implementation, and evaluation. When presented in this way, the process looks linear, with the evaluation step as the final place on the line. Evaluating the process at completion is based on the assessment findings that led to the diagnosis, the creation of the care plan (e.g., goal setting, planning interventions), and implementation of the interventions. Evaluation is used to determine if goals were met or an identified problem resolved.
However, the nursing process is not linear. It is often represented more accurately as a cycle in which evaluation leads to a continuation of the process, and assessment, once again, starts a new iteration of priorities and actions (Figure 17.9).
In spring 2019, a newsletter from the National Council for State Boards of Nursing (NCSBN) introduced the Clinical Judgment Measurement Model (CJMM). This model provides a more comprehensive approach to the clinical judgment of nursing. Within the model, the evaluation process occurs in the second and third layers and includes both action-taking and outcome evaluation steps (see Nursing Process and 43.1 Clinical Judgment Measure Model). Whichever model is used, evaluation plays an integral role in determining the accomplishment of goals and outcomes, and guides a return to either assessment or recognition of cues from the component of hypothesis-formation component of the CJMM.
Link to Learning
For more of the NCSBN’s description of the CJMM, read the first three pages of the spring 2019 newsletter, followed by the action model.
Skills Needed for Effective Teaching
As previously introduced, the purposes of patient education include promoting health, preventing disease, restoring function, and facilitating coping and adjustment to the new normal when necessary. To accomplish goals related to patient education, the nurse should understand teaching theories and use them suitably to maximize the effectiveness of the teaching for an individual patient and/or family.
In addition to teaching and learning theories, styles, and strategies, there are skills based on behaviors and the ability for human interactions. These include the ability to effectively communicate and be approachable, knowledgeable, flexible, and dependable. These skills can be found throughout the history of nursing, nursing practice, and nursing education. Florence Nightingale, for example, was knowledgeable, as evidenced by her hands-on approach to nursing care, nursing (and pharmacy) education, and statistical prowess (Lewis, 2020). Watson’s Caring Science and Theory of Human Caring, and implications noted by Gandhi and Mukherji (2023) can also be found within skills for effective teaching. The following sections explore these skills in more depth.
Effective Communication
The ability to communicate effectively has been a recurring theme in this chapter. Assessment of patients’ and families’ needs and goals, literacy and health literacy, cultural background, learning preferences, surroundings, comfort, tools needed for the session, and physical status are all considerations for the nurse when planning and implementing education. Preparation for teaching fosters the nurse’s ability to effectively communicate by allowing them the time to review any lapse in knowledge, which they can use to optimize the delivery of information. This also permits time for skill review, if the nurse has not recently performed a particular task.
Cultural Context
Cultural Considerations
Culture influences many facets of a patient’s life, including spiritual and religious behaviors and practices, diet and nutrition, communication and displays of respect, and ADLs. If and when time allows, it can be helpful for the nurse to become familiar with cultural practices that are important to each patient and family. Generalizations may cause unnecessary expenditure of time, effort, and education, with teaching focused on a practice not followed by a particular patient. An example is the nurse making an assumption about a patient who belongs to a group noted for having many members who are vegetarians. The nurse plans potential goals and dietary education based on a meatless diet, only to discover that the patient eats fish and chicken.
Even when nurses are familiar with a particular culture, they need to be wary of inherent assumptions based on broad conceptual strokes, which can lead to misunderstandings. When setting educational goals and priorities with patients and their families, perhaps the best method for clarifying cultural practices and preferences is to ask straightforward questions. There may be surprises, and the inquiry can become a pathway to building a positive relationship. The act of asking illustrates an interest and respect for the individual, and actively listening to the replies indicates the specific interests, practices, preferences, and behaviors are important to the nurse.
Another element of effective communication is the ability to discuss necessary information, including medical terminology, procedures, and medications, in lay terms. This can be time-consuming and is similar to translating between different languages. But if patients and families do not have the necessary vocabulary, understanding more complicated concepts will be difficult or impossible, and will ultimately take longer time. Effective communication avoids confusion and establishes and fosters trust between nurses and their patients (Wright, 2021).
Communication should be clear, the volume of speech or audio-visual materials should be adequate, visual enhancement (e.g., closed captioning) should be provided for any audience member with hearing impairment, and communication should be at a level of understanding for the patient and family. Visual impairment should also be considered and accommodated with assistive resources. For example, large print can be used on teaching material. Information should be delivered through varied methods, such as written or video formats. Multiple methods support behavioral, linguistic, and community preferences. All materials should be culturally appropriate. Post-session evaluation of teaching effectiveness should be incorporated through opportunities including questions and answers, teach-back, and demonstration.
Approachability
Being easy to talk to or interact with is known as approachability. Some consider friendliness as akin to approachability. There is a common tendency among those who choose nursing as their career to be caring and compassionate individuals who have a desire to help people and alleviate suffering. These traits commonly associated with nurses and nursing practice have led to nurses being considered approachable by patients even—and perhaps especially—at the most difficult times (Petronio-Coia & Schwartz-Barcott, 2020; Thakur & Sharma, 2021).
Research has explored the influence of smiling on the patients’ healing process and revealed that patients felt nurses who smiled were more approachable and caring, which tends to support the synonymous nature of the term friendliness with approachability (Thakur & Sharma, 2021). These welcoming traits help nurses cultivate relationships and settings that foster effective teaching. This can include teaching moments, spontaneous and scheduled, as well as a safe and comfortable environment for learners to ask questions, make mistakes and learn from them, establish competence with new skills, and demonstrate acquisition of new knowledge and abilities.
Link to Learning
Explore Dr. Watson’s 10 Caritas Processes and consider the characteristics and behaviors of effective teaching and the roles of the nurse. Compare the processes. Where do you think caring intersects with nursing?
Knowledgeable
Nursing relies on conceptual and procedural knowledge. Courses in nursing curricula include focus on both aspects. However, because nursing is a practice discipline, theoretical and didactic classes are not the only approach. Clinical courses are required, offering experiential teaching and learning. Clinicals set in outpatient clinics, mental health and community facilities, and acute care facilities offer students experiences with direct patient care. This provides interactions with patients and their families and friends, opportunities for therapeutic communication, skills practice, and an introduction to patient teaching.
Patients and their families rely upon and trust nurses for personification and practice of both the art and science of nursing. To teach effectively, nurses should have knowledge not only of the specific patient situation, diagnosis, pathophysiology, treatment plan, medications, and procedures, but also some understanding of teaching and learning theories and principles. The patient learning-needs assessment, in addition to frank discussion with the patient and family about literacy, health literacy, and how much they already know and understand, all provide guidance for the nurse on the patient’s needs.
To best meet those needs and achieve goals, knowing at least some basics of the different learning theories, including how learning is received and processed, techniques, and implications for the learner(s), allows for individualizing educational interventions. There are five major learning theories: behaviorism, cognitivism, constructivism, connectivism, and humanism, with implications for applying learning theories to both the traditional classroom-and-student scenario and patients (Table 17.3) (Ghandi & Mukherji, 2023).
| Learning Theory | Description | Teacher Implications | Learner Implications |
|---|---|---|---|
| Behaviorism |
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| Cognitivism |
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| Constructivism |
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| Connectivism |
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| Humanism |
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Flexibility
The nature of nursing requires flexibility: the ability to modify (or change) or be modified. Patient care is very dynamic; physical status can change unexpectedly and quickly, and nurses must act promptly in response. Anticipation of potential alterations to plans and proactive maneuvers are often even more effective than reactive responses. Even when a patient is stable and remains so, other patients can influence the nurse’s priorities. Wait times may lengthen, surgery or other procedures may be rescheduled, and personnel may be called to other care areas when more urgent or emergent situations arise.
From the onset of nursing school, students learn to become flexible. Some situational examples that would require the nurse’s flexibility are:
- COVID-19 resulted in canceled in-person classes and clinicals.
- Patient assignments can change as patients are transferred to other areas or discharged.
- Patient death
- Patient isolation requirements may prohibit students from direct interaction (e.g. tuberculosis).
- Student or faculty illness and absence
Upon licensing, nursing responsibilities increase from those of students. The ability to leave work on a regular schedule at the end of every shift can change because nurses are considered essential personnel. Nurses have obligations to be relieved by another nurse, and one may have to wait for relief to arrive. Natural disasters and weather conditions may require flexibility; for example, a blizzard may halt traffic in an affected area, and essential personnel may be expected to stay within a designated region for availability.
Other situations requiring flexibility include equipment malfunctions and availability of certain rooms or supplies. As part of a larger multidisciplinary team, nurses and other partners do not always have complementary schedules, so waiting is sometimes necessary for treatments, therapies, or tasks to be completed. Education may be one of the items postponed or rescheduled, or it may need to be modified such that it can be delivered under different circumstances than those originally planned. Discharge teaching, for example, may be delayed while something else of higher priority must be handled first, or it may be provided by another nurse.
If a patient’s status has deteriorated and immediate transfer to higher level of care is needed, the focus of teaching changes from detailed to limited, and the importance of follow-up should be highlighted. An example is telling a family member, “Your wife is being transferred to intensive care. I need to call report to the nurse there and get her moved. One of my colleagues will show you to the ICU waiting room, and I’ll come talk to you after she’s settled into the room there.” By providing at least that explanation, family members do not feel forgotten and have some idea of what to expect next.
Dependability
Being reliable, or trusted, describes dependability. Through clear and effective communication, an approachable attitude, a strong knowledge base, reliability, flexibility, and consistency, nurses demonstrate and personify dependability. Effective teaching is strengthened by nurses who are dependable, follow through with expectations, and establish themselves through the combination of actions and words. Patients, families, and interdisciplinary team members rely on dependable nurses, as do other partners in health care. Trust in nurses as dependable professionals fosters strong relationships among healthcare providers, with open communication and collaboration contributing to enhanced patient outcomes.