Patient Ed Cumulative Final (copy)

how to determine what information to include when providing patient education

1.Identify the topic-specific objectives/goals

2.List the data points that MUST be included

3.Determine style/method of information sharing  

you are educating a first-time OCP user on how to use the medication. What should your 3 overarching goals be?

GOAL 1 – patient knows HOW to take the medication (ex. take at same time every day, no protection against STIs)

GOAL 2 – patient knows how to trouble-shoot common problems (ex. missed doses, common side effects)

GOAL 3 – patients knows what to watch for related to dangerous SE/interactions (ex. signs and Sx of DVT/PE)

what are the 4 main methods of sharing info with patients?

1.“How to” style: includes step-by-step instructions format, pictures/diagrams/videos very helpful add-ons

2.Frequently Asked Questions (FAQ) style: based on frequent patient questions OR questions you wish patients would ask

3.Mistakes style: “what not to do” for patients; helpful with more complex topics (ex. “the 9 worst mistakes to make when checking your sugar)

4.Story style: uses a real or theoretical patient case followed by bullet points of info to reach stated goals

House/regular hospital diet

Adequate in all essential nutrients; no restrictions or modifications

•All foods are permitted

•Can be modified according to patient’s food preferences

mechanical soft diet

Includes soft-textured or ground foods that are easily masticated and swallowed; indicated with decreased ability to chew or swallow

•Presence of oral mucositis or esophagitis

•May be appropriate for some patients with dysphagia

pureed diet

Includes liquids as well as strained and pureed foods; indicated with inability to chew or swallow solid foods

•Presence of oral mucositis or esophagitis

•May be appropriate for some patients with dysphagia

full liquid diet

Includes foods that are liquid at body temperature; may be appropriate for patients with severely limited chewing ability, not appropriate for lactase-deficient patients unless commercially available lactase enzyme tablets provided

•Includes milk/milk products

•Can provide approximately: 2500–3000 mL fluid, 1500–2000 cal, 60–80 g high quality protein, <10 g dietary fiber, 60–80 g fat/d

clear liquid diet

Includes foods that are liquid at body temperature; initial diet in transition from NPO to solids, bowel prep, and managing acute medical conditions warranting minimized biliary contraction or pancreatic exocrine secretion

•Foods are very low in fiber, lactose-free, virtually fat-free

•Can provide approximately: 2000 mL fluid, 400–600 cal, <7 g low-quality protein, 1 g dietary fiber, <1 g fat/d

a clear liquid diet is inadequate in all nutrients and should not be used _____ without supplementation

>3 days

low fiber diet

Foods that are low in indigestible carbohydrates; management of acute radiation enteritis and IBD when narrowing/stenosis of the intestine is present

•Decreases stool volume, transit time, and frequency

carbohydrate controlled diet

Calorie level should be adequate to maintain or achieve desirable body weight (DBW); indicated in Diabetes Mellitus

•Total carbohydrates are limited to 50–60% of total calories

•Ideally fat should be limited to ≈30% of total calories

low-fat diet

<50g total fat per day; indicated in pancreatitis and fat malabsorption syndromes

acute renal failure diet macros

• protein: 0.6 g/kg

• calories per kilogram DBW: 35-50

• sodium: 2-3 g/d

• potassium: variable

• fluid: urine output + 500mL

hemodialysis diet macros

• protein: 1-1.2 g/kg

• calories per kilogram DBW: 30-35

• sodium: 1-2g/d

• potassium: 1.5-3 g/d

• fluid: urine output + 500mL

peritoneal dialysis diet macros

• protein: 1.2-1.6 g/kg

• calories per kilogram DBW: 25-35

• sodium: 3-4g/d

• potassium: 3-4 g/d

• fluid: urine output + 500mL

low lactose/lactose free diet

Limits or restricts milk products; commercially available lactase enzyme tablets can be used

hepatic diet

Management of chronic liver disorders

•In the absence of encephalopathy do not restrict protein

•In the presence of encephalopathy initially restrict protein to 40–60 g/d then liberalize in increments of 10 g/d as tolerated

•Specify sodium and fluid restriction according to severity of ascites and edema

fat/cholesterol restricted diet

Total fat >30% total calories; indicated with hypercholesterolemia

•Saturated fat limited to 10% of calories

•<300 mg cholesterol

•<50% calories from complex carbohydrates

Low-sodium diet

Sodium allowance should be as liberal as possible to maximize nutritional intake yet control symptoms; indicated in HTN, ascites, and edema

• “No added salt” is 4 g/d; no added salt or highly salted food; 2 g/d avoids processed foods (ie, meats)

• <1 g/d is unpalatable and thus compromises adequate intake

Teaching (or instruction):

deliberate interventions that involve sharing information and experiences to meet intended learner outcomes in the cognitive, affective and psychomotor domains according to an education plan.

Learning:

a change in behavior (knowledge, attitudes &/or skills) that can be observed or measured and that occurs at any time, or in any place as a result of exposure to environmental stimuli.

patient education

Any set of planned educational activities, using a combination of methods (teaching, counseling, and behavior modification), that is designed to improve patients’ knowledge and health behaviors.

VA issued bulletin titled patient education and the hospital program in…

1953

“the need for patient education” published in…

1971

benefits of patient education

■Increase patient satisfaction

■Improve quality of life

■Ensure continuity of care

■Decrease patient anxiety

■Reduce complications of illness and incidence of disease

■Promote adherence to treatment plans

■Empower patients to become actively involved in the planning of their care

provider barriers to patient education

1.Lack of time (!!!) - biggest barrier!

2.Lack of confidence

3.Lack of skill/competence

4.Minimal/No reimbursement

5.Workplace environment barriers (lack of space/privacy, noise)

patient barriers to learning

1.Lack of time

2.Stress of acute & chronic illness

3.Low literacy / Functional health illiteracy

4.Personal characteristics of the learner

5.Extent of needed behavioral changes

6.Denial of learning needs

learning theory

a logical framework of describing, explaining, or predicting how people learn.  May be used singly or in combination.

behaviorist learning theory

states that learning is the result of connections made between the stimulus conditions in the environment (S) and the individual’s responses (R) that follow; associated with motivation

motivation

desire to reduce some drive, such as the desire for food, security, recognition or money

behaviorist learning theory - respondent conditioning

learning through association; happens in 3 stages:

• stage 1: before conditioning

• stage 2: during conditioning

• stage 3: after conditioning

systematic desensitization and spontaneous recovery

two components of respondent conditioning

• systematic desensitization: process of extinguishing a conditioned response

• spontaneous recovery: return of a response after it has been extinguished

behaviorist learning theory - operant conditioning

learning occurs by rewards and punishments by the law of effect; behavior which is reinforced tends to be strengthened/repeated, and behavior which is not reinforced tends to be lost

• responses following behavior can be neural operants, reinforcers, or punishers

operant conditioning subtypes

1.Continuous Reinforcement – learner is positively reinforced every time a specific behavior occurs.

2.Fixed Ratio Reinforcement - behavior is reinforced only after the behavior occurs a specified number of times. 

3.Fixed Interval Reinforcement - one reinforcement is given after a fixed time interval providing at least one correct response has been made

4. Variable Ratio Reinforcement - behavior is reinforced after an unpredictable number of times.

5. Variable Interval Reinforcement - providing one correct response has been made, reinforcement is given after an unpredictable amount of time has passed.

behavior modification

set of therapies based on operant conditioning; token economy and behavior shaping

cognitive learning theory

focus on goes on inside the mind of the learner; for a person to learn, he/she must change his/her perceptions and thoughts and form new understandings and insights

• includes several perceptions each emphasizing one feature of cognition

cognitive learning theory - gestalt perspective

Gestalt Perspective – “the whole is greater than the sum of its parts”; essentially each person perceives, interprets, and responds to any situation in his/her own way.

1.People strive towards simplicity, equilibrium, and regularity

2.Perception is selective – No one can focus on all possible surrounding stimuli at any given time; will focus on certain features of an experience while ignoring others.

• When educating patients, what is effective for with one person may not work with another.

cognitive learning theories - information processing perspective

Emphasizes thinking, reasoning, the way information is encountered and stored, and memory functioning; 4 Stages:

1.Attention – Key to Learning!

2.Processing – Remember to use VARK

3.Memory Storage – Information is encoded briefly into short-term memory and from there either is disregarded & forgotten or stored in long term memory

4.Action – Based on how the information was processed and stored

cognitive learning theories - cognitive development perspective

Focuses on advances and changes in perceiving, thinking and reasoning as individuals grow and mature; very helpful when educating children/teenagers

–Assimilation vs Accommodation

–Adult learning

cognitive learning theories - social cognition perspective

Emphasizes the effects of social factors on perception, thought and motivation; individual interpretations and responses to any given situation are strongly influenced by their social and cultural experiences.

social learning theory

bridge between behaviorist and cognitive theories; learning occurs via observation, imitation, and modeling

• PA acts as the role model, assesses internal regulation of the patient, and provides feedback on performance

• constant reeducation is necessary, as well as a proper environment to complete a task!

• attention → retention → reproduction → motivation

psychodynamic learning theory

largely a theory of motivation; emphasis is on patient’s emotions

• Behavior may be conscious or unconscious

• the most primitive source of motivation comes from the id, which is held in check by the superego; Id and superego mediated by the ego

repression

unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious

denial

blocking external events from awareness; if some situation is just too much to handle, the person just refuses to experience it

projection

individuals attributing their own unacceptable thoughts, feeling and motives to another person

displacement

satisfying an impulse with a substitute object

regression

movement back in psychological time when one is faced with stress

sublimation

satisfying an impulse with a substitute object in a socially acceptable way

Erikson stages - infant to 18 months

trust vs. mistrust; sensorimotor

Erikson stages - 18 months to 3 years

autonomy vs. shame and doubt; sensorimotor

erikson stages - 3 to 5 years

initiative vs. guilt; preoperational

Erikson stages - 5 to 13 years

industry vs. inferiority; concrete operations

Erikson stages - 13 to 21 years

identity vs. role confusion; formal operations

Erikson stages - 21-39 years

intimacy vs. isolation; formal operations

Erikson stages - 40 to 65 years

generatively vs. stagnation; formal operations

Erikson stages - >65

ego integrity vs. despair; formal operations

humanistic learning theory

assumes each individual is unique and all individuals have a desire to grow in a positive way; also largely a theory of motivation – the motivation to act stems from each person’s needs, feelings about the self and the desire to grow in a positive way.

• Humanists believe that self-concept and self-esteem are necessary for learning.

• Role of an educator is to serve as a facilitator

• Learner-directed approach

• hierarchy of needs: physiological needs → safety needs → belongingness and love needs → esteem needs → self actualization

lessons derived from learning theories for patient education

1.Put patients in charge of their own education as much as possible.

2.Show this education can help them make a meaningful, positive change in their day-to-day lives

3.Provide a collaborative, supportive experience that allows patients to check in on their progress.

4.Tie patient education back to goals whenever possible

5.Realize that not all adults learn the same way, and everyone brings their own background and knowledge

what is the first step of patient education?

assessment of patient needs, readiness and style of learning

–Learning Needs – gaps in knowledge between a desired level of performance and the actual level o performance . “What the patient needs and wants to learn”

–Readiness to Learn – the time when the patient demonstrated an interest in learning the information necessary for optimal health

–Learning Styles – the way individuals process information and their preferred approaches to different learning tasks

Dunn and Dunn learning styles - 5 basic stimuli affect the ability to learn

1.Environmental elements

2.Emotional elements

3.Sociological  elements

4.Physiological elements: perceptual – VARK

5.Psychological elements

–Global: overall concept first before details

–Analytic: step by step approach

–Impulsive: like to participate in group

–Reflective: tend not to volunteer info, must be asked for it

VARK

visual, auditory, reading/writing, kinesthetic

Jung and Myers Briggs personality types

• introverted/extroverted

• sensing/intuition

• thinking/feeling

• judging/perceiving

gardner’s 8 types of intelligence

• verbal/linguistic

• logical/mathematical

• visual/spatial

• bodily/kinesthetic

• musical/rhythmic

• intrapersonal

• interpersonal

• naturalist

compliance

the extent to which the patient’s behavior coincides with clinical advice

adherence

the extent to which a patient’s behavior corresponds with agreed recommendations from a health care provider

locus of control

an individual’s sense of responsibility for his/her own behavior and the extent to which motivation to take action originates from within the self (internal) or is influenced by others (external)

motivation

an internal state that arouses, directs, and sustains human behavior. A willingness of the patient to embrace learning which leads to a change in behavior

• factors include personal attributes, environmental influences, and learner relationship systems

rules that set the stage for motivation

1.State of Optimal Anxiety

2.Learner Readiness

3.Realistic Goal Setting

4.Learner Satisfaction/Success

assessing for motivation: the 5 A’s

–Ask

–Advise

–Assess

–Assist/Agree

–Arrange

the 5 A’s - application to a tobacco cessation case

–Ask – identify and document tobacco use status for every patient at every visit

–Advise – urge each patient to quit -clear, strong, personalized

–Assess – patient readiness to change (quit)

–Assist – develop personalized treatment strategy

–Arrange – schedule follow-up

patient centered interviewing

Focuses on the patient’s needs

Activates the patient to play a larger role

Characterized by active listening

Positive impact on patient outcomes

motivational interviewing

■Based on humanistic theory: free choice and change in behavior through self-actualization

■Ambivalence can be resolved by working with your patient's intrinsic motivations and values.

■Collaborative partnership

health belief model

willingness to change behavior based on:

1.Perceived Susceptibility – a person will not change their health behaviors unless they believe that he/she is at risk.

2.Perceived Threat – Influenced by demographic, sociopsychological, & structural variables.  AND Perceived Severity – probability of change depends on how serious the patient believes the consequences are .

3.Likelihood of Action = perceived benefit – perceived barriers  

benefits to the health belief model

realistically frames behavior b/c it recognizes the fact that sometimes wanting to change a health behavior isn't enough to actually make someone do it; 2 Elements addressing what it takes to get a patient to “take the leap” and change a behavior…

–Cues to Action

–Self Efficacy

stages of change model

change occurs gradually and relapses are an inevitable part of the process of making a lifelong change

■Pre-contemplation: encourage patient to rethink their behavior, self-analysis and introspection

–Explain the risks of the current behavior

■Contemplation: weigh the pros & cons of changing a behavior, confirm readiness to change

–Identify barriers to change

■Preparation: have patient write down their goals and prepare a plan of action together

–Supply a list of motivating statements

■Action: reward system for successes, suggest social support resources

–List of motivating statements

■Maintenance: discuss coping strategies to help patient deal with temptation

–Continue to reward for successes

■Relapse: help identify triggers and develop plan to overcome barriers

–Reaffirm goals

stages of change - physical activity example statements

1.I am currently not physically active, and do not intend to start being physically active in the next six months.

2.I am currently not physically active, but I am thinking about becoming physically active in the next six months.

3.I currently am physically active, but not on a regular basis.

4.I currently am physically active regularly, but I have only begun doing so within the last six months.

5.I currently am physically active regularly, and have done so for longer than six months.

1 = pre contemplation, 2 = contemplation, 3 = preparation, 4 = action, 5 = maintenance

patients with low health literacy skills have…

• Significantly higher medical costs

• increased numbers of hospitalizations and readmissions

• Greater risk of death when ill

• Greater perceived physical and psychosocial issues

literacy

 the ability to use printed and written information to function in society, to achieve one’s goals and to develop one’s knowledge and potential

low literacy (marginally literate)

 adults with the ability to read, write and comprehend information at 5th-8th grade level

functional illiteracy

 adults who lack the basic reading, writing, and comprehension skills that are needed to operate effectively in today’s society

health literacy

 the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information  and services to make appropriate health decisions

e-health literacy

the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving health problems

increasing proportion of Americans with low literacy levels due to…

• Increase in number of immigrants

• Aging of the population

• ­Increasing amount and complexity of information

• Increasing sophistication of technology

• More people living in poverty

• Changes in policies for public education

• Disparities between minority vs nonminority populations

populations at risk for health literacy deficiencies

 Economically challenged

 Older adults

 Immigrants

 English as a second language

 Racial minorities

 High school dropouts

 Unemployed

 Prisoners

 Inner-city and rural residents

 Medicaid patients

clues to watch for that may indicate low literacy levels

• ­Reacting to complex learning situations by withdrawal, avoidance or noncompliance

• Excuses to maintain attention span when given written info/other excuses

• Overcompensating appearance that they CAN read well

• Insisting that they take the information HOME to read

• Appearing nervous, confused, talking out of context

• ­Showing frustration and restlessness when attempting to read

• Listening/watching closely to memorize how things work

• Demonstrating difficulty for following instructions

• Failing to ask questions about information received

• Turning in forms incomplete

• ­Revealing a discrepancy between what is understood by listening vs reading

• ­Missing appointment/referrals

• ­Not taking medications as prescribed

patient’s bill of rights

patients have the RIGHT to receive complete and current information regarding their diagnoses, treatments and prognoses in terms they can UNDERSTAND

Flesch-Kincaid scale

­5th grade – college level; uses average sentence length (in words) and average word length (measure in syllables).

Fog index

­4th grade – college level; uses average sentence length and percentage of multisyllabic words in a 100 word passage

Fry readability graph - extended

­1st grade – college level; uses number of syllables and number of sentences in 3 100-word selections

SMOG formula

­EASY, HIGH VALIDITY

­4th grade – college level; uses number of multisyllabic words

patient education materials should be at a ____ grade reading level

5th

Cloze test for comprehension

specifically recommended for assessment of understanding of health education materials

­60% or > = sufficient comprehension

­40-59% = moderate level of difficulty

­<40% = material is too difficult and should not be used for patient education

listening test comprehension criteria

­90% or > --- material is EASY for patient

­75-89% --- material is appropriate for patient

­<75% --- material is too DIFFICULT

WRAT – word recognition/pronunciation

measures general reading skills by the following formula…

• total # or words - total # words missed/not tried = raw score. (compare to standard chart)

REALM literacy tool

 measures patient’s ability to read medical/health related vocabulary.  Score given as a grade level

TOFHLA literacy tool

 tests reading comprehension and numeracy

newest vital sign

assesses how well a patient can understand a nutrition label and gives a score out of 6; QUICK, and can be conducted in multiple languages

tips to simplify PEMS

general content: limit content to 1 or 2 key objectives, limit content to what patients REALLY need to know, use only words that are well known to people without medical training, make certain content is appropriate for age and culture of the target audience

text construction: 5th grade reading level, 1-2 syllable words, short paragraphs, active voice, SIMPLE tables/graphs

fonts/type style: large font with serifs, no more than 2-3 styles per page, use upper and lowercase letters, highlight important ideas with bold type or underlines

layout: ensure a good amount of empty space, use headings/subheadings, bulleted lists, SIMPLE illustrations

strategies to promote health literacy

• Establish a trusting relationship with the patient BEFORE beginning the teaching process.

• Use the smallest amount of information possible to accomplish the behavioral objectives

• Make points of information as VIVID and explicit as possible

• Teach one step at a time

• Use MULTIPLE teaching methods and tools requiring fewer literacy skills

• Allow patients the chance to restate information in their own words and demonstrate any procedures being taught (TEACH-BACK METHOD)

• Elicit feedback by asking questions and making statements appropriately

• Work to keep motivation HIGH

• Use TAILORING and CUEING

• Use repetition to reinforce information