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Reprinted from the July 1996 issue of RESPIRATORY CARE [Respir Care 1996; 41(7):658–663]

AARC Clinical Practice Guideline

Providing Patient and Caregiver Training

CGT 1.0 PROCEDURE

A health-care provider-initiated process to facilitate the patient or caregiver's acquisition of knowledge and skills related to his or her medical condition and participation in its management.

PCGT 2.0 DESCRIPTION/DEFINITION

2.1 Patient and caregiver education provides the patient and family with the means of participating in the patient's health-care management to the extent feasible, depending on physical condition and awareness. (The term family encompasses the person(s) who play a significant role in the patient's life and may include persons who are not legally related to the patient.)(1-3)
2.2 The training process should occur with every encounter between the health-care provider (HCP) and the patient. (The health-care provider is defined as any health-care professional involved in the care of the patient.)
2.3 The goal of the HCP should be to elicit a positive change in the patient's behavior through the use of verbal, written, and visual communication in the affective, cognitive, and psychomotor domains. Coordinated efforts by HCPs should provide the patient with an improved understanding of health-care needs, therapy, and the importance of adherence to medical regimen and candid communication with caregivers. This should enable the patient to better manage the disease through cooperation with the caregiver and HCP in an active partnership.(2,3) All members of the team need to be aware of these goals as an aspect of the patient's total care.
2.4 A final goal of the HCP is to provide the patient and family with the means to reap the economic benefits of improved utilization of the health-care system.(4-6)

PCGT 3.0 SETTINGS

Patient training settings include, but are not limited to:
3.1 Acute care hospital
3.1.1 Patient's room
3.1.2 Designated teaching area
3.1.3 Pulmonary rehabilitation department
3.2 Outpatient rehabilitation center
3.3 Patient's home
3.4 Physician's office
3.5 Extended care or skilled nursing facility
3.6 Patient support group meetings(7)
3.7 Community education seminars (eg, industry- and school-based programs)(7)

PCGT 4.0 INDICATIONS

The presence of a patient population with the need to
4.1 increase knowledge and understanding of health status and therapy;(3)
4.2 improve skills necessary for safe and effective health care (ie, inability to perform needed therapy);(3)
4.3 foster a positive attitude, stronger motivation, and increased compliance with therapeutic modalities.(3,6,8)

PCGT 5.0 CONTRAINDICATIONS

There are no contraindications to patient and caregiver training when a need exists.

PCGT 6.0 HAZARDS/COMPLICATIONS

Omission of essential steps in care, inconsistency in information presented, or failure to validate the learning process can lead to untoward results.

PCGT 7.0 LIMITATIONS OF METHOD

7.1 Patient limitations:
7.1.1 Lack of motivation or interest in acquiring knowledge or skills. (This may include denial.)(7,9-12)
7.1.2 Impairment (eg, in hearing or vision, decreased energy or stamina, age-specific, pain, or medication side effects.)(2,7,8,10,13)
7.1.3 Inability to comprehend due to factors such as anxiety, depression, hypoxemia, substance abuse(8,14,15)
7.1.4 Negative response to past educational experiences or encounters(7,12,16)
7.1.5 Illiteracy despite level of education completed.(17,18) This may include functional illiteracy dealing with the health-care process.(19)
7.1.6 A mind-set that leads to misapplication, misinterpretation, or rejection of instruction as irrelevant(7,12,16,20)
7.1.7 Language barriers(2,8)
7.1.8 Conflict of religious beliefs and/or cultural practices with material presented(2)
7.2 HCP limitations
7.2.1 Lack of positive attitude or adaptability(2,8,9,10,21)
7.2.2 Limited understanding of knowledge or skill to be taught(1,3,21,22)
7.2.3 Inadequate assessment of patient's need or readiness to learn and inability to individualize the instructional approach to the patient, including age-specific needs(2,8,20,21,23)
7.2.4 Multiple patient needs to be met in the allotted time(11)
7.2.5 Inappropriate or inadequate communication skills (eg. unnecessary use of medical terminology; lack of listening skills); lack of documentation or discussion with other team members; inconsistency in information presented(1,9,11)
7.2.6 Inadequate knowledge of cultural or religious practice that may affect educational process(2)
7.3 System limitations
7.3.1 Hospital stay too brief(7)
7.3.2 Absence of interdisciplinary cooperation(2) and communication
7.3.3 Inconsistency in information provided
7.3.4 Failure to provide interpreters(2,8)
7.4 Social limitations
7.4.1 Absence of support system(10,12,24)
7.4.2 Reimbursement issues(9-12)
7.5 Environmental limitations
7.5.1 Inadequate lighting, poor temperature control, uncomfortable seating, inadequate space for demonstrations(8,10)
7.5.2 Interruptions, distractions, and noise(8,10)
7.6 Poorly chosen resources, including inappropriate reading level and vocabulary(8,14,17,25)

PCGT 8.0 ASSESSMENT OF NEED

8.1 Determine the gap between what patient already knows and what he or she needs to know(4,7,8,26)
8.1.1 Interview patient regarding past experience with topic being taught.(7,15,16) A published or self-generated guide may be used.(13)
8.1.2 Discuss what patient perceives as knowledge relevant to his care. (A written test may be used to determine knowledge deficit in the context of pulmonary rehabilitation services. In many other clinical settings, a written test is not recommended)(15,16,20,21,26)
8.2 Observe patient's performance of therapy and determine whether skills are adequate for self-care. (If psychomotor skills are markedly impaired, an occupational or physical therapy assessment may be indicated.)(9)
8.3 Determine whether patient's attitude and outlook appear to be conducive to participation in his or her health care.
8.3.1 By observation and questioning, determine whether patient perceives himself as able to cope with his health care.(12)
8.3.2 By questioning patient and/or family, determine whether denial persists. (A psychological consult may be helpful.)(9)
8.3.3 Assess patient's motivation or emotional readiness to learn and change behavior as it relates to his health care.(2,6,8,9,12,15,21)
8.3.4 Consider using quality-of-life profiles to determine patient's general outlook and attitude or to determine the presence of low self-efficacy.(12,17,27)

PCGT 9.0 ASSESSMENT OF OUTCOME

9.1 Assessment of knowledge gained
9.1.1 In a nonthreatening manner, question patient about specific aspects of information presented and note questions asked.(10,16)
9.1.2 Request patient to repeat information given, in his own words.(16)
9.1.3 Paper and pencil tests may be used but are not the recommended approach.(15,16)
9.1.4 Note behavior changes that appear to be manifestations of increased knowledge.
9.2 Assessment of skills mastered
9.2.1 Observe patient performing skill, without prompting or assistance.(2,10,28)
9.2.2 Discuss the new skill with patient and question him as appropriate.
9.2.3 Observe patient's ability to adapt new skill to novel or unfamiliar situations.(13)
9.2.4 Determine skill adaptability in home environment by phone calls and home visits.(10)
9.3 Assessment of patient outlook and attitude
9.3.1 Observe patient and quantitate appropriate variables for evidence of life style changes (eg, weight change, smoking cessation, increased physical activity).
9.3.2 Determine through discussion with patient and family whether patient feels more in control of condition and care.(9)
9.3.3 Use quality of life inventories; such as the COPD Self-Efficacy Scale,(29) the Chronic Respiratory Disease Questionnaire,(30) the SF-36,(31) the Sickness Impact Profile,(32) or CES-D (Center for Epidemiologic Studies Depression Scale).(33)

PCGT 10.0 RESOURCES

10.1 Essentials of the training process (See the Appendix).
10.2 Training materials
10.2.1 Written material
10.2.1.1 Readability and comprehension should be at approximately the 5th-6th grade level. (This may be assessed by the SMOG scale.)(14,17,20,25) A glossary may be helpful.
10.2.1.2 Large, dark print on white page is preferable.(15,18)
10.2.1.3 Material should be easy to handle with space for instructions and/or notes.(8)
10.2.1.4 Simple terms and short sentences encourage use of material.(8,17)
10.2.1.5 Illustrations may aid comprehension.(18,34)
10.2.2 Audiovisual equipment (eg, videocassette player, audiotapes, slides, models) may be helpful.
10.2.3 Computers and software may be useful both for instruction and documentation.(7,23,28)
10.3 Training site should be an appropriate environment with adequate space, few interruptions or other distracters, adequate lighting and temperature, and comfortable seating.(2,8,10)
10.4 Personnel: All HCPs should have patient training skills commensurate with the level of care that they provide to the patient.2 Skills should include but are not limited to
10.4.1 appropriate communication skills, including verbal, nonverbal, and listening skills;(9,14,16,20,21)
10.4.2 compassion, empathy, and a non-judgmental attitude;
10.4.3 good knowledge of principle and theory, with the ability to present information in a manner consistent with that of the rest of the health-care team;(9,21,22)
10.4.4 ability to use appropriate language levels in written and verbal instruction;(1,10,20,25)
10.4.5 ability to be patient, use repetition, project a positive attitude, and build rapport;(1,8,10,12,15,20,21)
10.4.6 ability to view patient as individual and to assess all aspects of his educational needs and limitations, including those of an age-specific, psychosocial, and cultural nature.(2,7,9,15,20,21)

PCGT 11.0 MONITORING

11.1 Monitoring the patient training process should include awareness of patient's verbal and nonverbal responses to what is being taught, noting
11.1.1 good eye contact vs drowsiness,
11.1.2 active listening vs preoccupation,
11.1.3 active discussion vs silence.
11.2 Observation and questioning allow for on-going patient monitoring.
11.3 The assessment of readiness for self-care may be made by working with the discharge planner.
11.4 Patient's instruction and the outcome should be documented (See Appendix).

PCGT 12.0 FREQUENCY

12.1 Spontaneous--as often as patient contact is made.
12.2 Schedule patient appointments as needed.
12.3 Scheduled group sessions may meet as often as once or twice a week up to once a month.
12.4 Closed-circuit hospital video presentations may be presented several times on a given day and repeated as indicated.

PCGT 13.0 INFECTION CONTROL

13.1 Implement Universal Precautions and tuberculosis control measures as indicated.(35,36)
13.2 Observe all infection control guidelines posted for patient.
13.3 Any equipment used should be appropriately cleaned and stored.

Pulmonary Rehabilitation Focus Group:

Lana Hilling CRTT RCP, Chairman, Concord CA
Phillip D Hoberty EdD RRT, Columbus OH
Rebecca J Hoberty BS RCP RRT, Columbus OH
Dennis C Sobush MA PT, Milwaukee WI
Peter Southorn MB, Rochester MN

REFERENCES

  1. Hilton G. Does patient education work? Br J Hosp Med 1992;47(6):438-441.
  2. Joint Commission on Accreditation of Healthcare Organizations. Section 1. Education (PF). In: 1995 Comprehensive Accreditation Manual for Hospitals: 189-206. Oakbrook IL: JCAHO, 1994.
  3. Edelman NH, Kaplan RM, Buist AS, Cohen AB, Hoffman LA, Kleinhenz ME, et al. (Task Force on Research and Education for the Prevention and Control of Respiratory Disease.) Chronic obstructive pulmonary disease. Chest 1992;102(3, Suppl):243S-256S.
  4. Tougaard L, Krone T, Sorknaes A, Ellegaard H. Economic benefits of teaching patients with chronic obstructive pulmonary disease about their illness. Lancet 1992;339(8808):1517-1520.
  5. Wilson SR, Scamagas P, German DF, Hughes GW, Lulla S, Coos S, et al. A controlled trial of two forms of self-management education for adults with asthma. Am J Med 1993;94(6):564-576.
  6. Damrosch S. General strategies for motivating people to change their behavior. Nurs Clin North Am 1991;26 (4):833-843.
  7. Hartmann RA, Kochar MS. The provision of patient and family education. Patient Educ Couns 1994;24(2): 101-108.
  8. McFadden K. Redesigning patient education materials: one home care agency's approach. J Intravenous Nurs 1994;17(3):129-134.
  9. Maycock JA. Role of health professionals in patient education. Ann Rheum Dis 1991;50(Suppl 3):429-434.
  10. Dellasega C, Clark D, McCreary D, Helmuth A, Schan P. Nursing process: teaching elderly clients. J Gerontol Nurs 1994;20(1):31-38.
  11. Lipetz MJ, Bussigel MN, Bannerman J, Riley B. What is wrong with patient education programs? Nurs Outlook 1990;38(4):184-189.
  12. Green LW, Frankish CJ. Theories and principles of health education applied to asthma. Chest 1994;106(4): 219S-230S.
  13. Brundage DJ, Swearengen P, Woody JW. Self care instruction for patients with COPD. Rehabilitation Nurs 1993;18 (5):321-325.
  14. Estey A, Musseau A, Keehn L. Patient's understanding of health information: a multihospital comparison. Patient Educ Couns 1994;24:73-78.
  15. Kick E. Patient teaching for elders. Nurs Clin North Am 1989;24(3):681-686.
  16. Gessner BA. Adult education: the cornerstone of patient teaching. Nurs Clin North Am 1989;24(3):589-595.
  17. Jackson RH, Davis TC, Bairnsfather LE, George RB, Crouch MA, Gault H. Patient reading ability: an overlooked problem in health care. South Med J 1991;84 (10):1172-1175.
  18. Morgan PP. Illiteracy can have major impact on patient's understanding of health care information. Can Med Assoc J 1993;148(7):1196-1197.
  19. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, Nurss JR.Inadequate functional health literacy among patients at two public hospitals. JAMA 1995;274(21):1677-1682.
  20. Redmond MC. The importance of good communication in effective patient-family teaching. J Post Anesth Nurs 1993;8(2):109-112.
  21. Close A. Patient education: a literature review. J Advanced Nurs 1988;13:203-213.
  22. Cote J, Golding J, Barnes G, Boulet LP. Educating the educators: how to improve teaching about asthma. Chest 1994;106(4):242S-247S.
  23. Armstrong ML. Orchestrating the process of patient education: methods and approaches. Nurs Clin North Am 1989;24(3):597-604.
  24. Howard JE, Davies JL, Roghmann KJ. Respiratory teaching of patients: how effective is it? J Adv Nurs 1987;12:207-214.
  25. Stephens ST. Patient education materials: are they readable ? Oncol Nurs Forum 1992;19(1)83-85.
  26. Ekstrom I. Nine steps to organizing patient teaching. Plastic Surg Nurs 1994;14(1):45-46.
  27. Hopp JW, Gerken CM. Making an educational diagnosis to improve patient education. Respir Care 1983;28(11): 1456-1461.
  28. Tolsma DD. Patient education objectives in healthy people 2000: policy and research issues. Patient Educ Couns 1993;22(10):7-14.
  29. Wigal JK, Creer TL, Kotses H. The COPD self-efficacy scale. Chest 1991;99(5):1193-1196.
  30. Guyatt GH, Berman LB, Townsend M. Long-term outcome after respiratory rehabilitation. Can Med Assoc J 1987;137:1089-1095.
  31. Ware JE, Sherbourne CD. Medical outcomes study short form (MOS SF-36). Available from Health Outcomes Institute, 2001 Killebrew Dr, Suite 122, Bloomington MN 55425.
  32. Gibson BS, Gibson JS. The sickness impact profile-development of an outcome. Ann Intern Med 1975;65(12): 1304-1310. Available from M Bergner, Dept of Health Sciences, Johns Hopkins Univ, 624 N Broadway, Baltimore MD 21205.
  33. Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure 1977;1:385-401. Available from EL Frazier, Epidemiology & Psychopathology Branch, Div of Clinical Research, NIMH, 5600 Fishers Ln, Rm 10C-09, Rockville MD 20857.
  34. Austin PE, Matlack R II, Dunn KA, Kesler C, Brown CK. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med 1995;25(3): 317-320.
  35. Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
  36. Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990;39(RR-17):1-29.
ADDITIONAL BIBLIOGRAPHY

American Association of Cardiovascular & Pulmonary Rehabilitation. Guidelines for pulmonary Rehabilitation programs. Champaign IL: Human Kinetics Publishers, 1993:25-26,49-50.

Davis TC et al. Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics 1994;93(3):460-468.

Falvo, DR. Effective patient education: a guide to increased compliance. Aspen Publishers Inc, 1994.

Fitzgerald JF, et al. A case manager intervention to reduce re-admissions. Arch Intern Med 1994;154(15):1721-1729.

How to teach patients. Springhouse PA: Springhouse Corporation, 1989.

Howell JH, Flaim T, Lum Lung C. Patient education. Pediatr Clin North Am 1992;39(6):1343-1361.

Lorig, K. Patient education: a practical approach. St Louis: Mosby-Year Book Inc, 1992.

Self TH, Rumbak MJ, Kelso TM. Correct use of metered-dose inhalers and spacer devices. Postgrad Med 1992;92(3): 95-96,99-103,106.



APPENDIX

(References are listed following the body of the Guideline)

Essentials of the Training Process

Health-care professionals should know how to teach and how to modify their teaching approach to provide the desired outcome.

I. Complete a needs assessment to establish measurable goals and outcomes for patient training.
A. Involve the patient or family as active participant(s) in goal setting. (Family refers to the person or persons who play a significant role in the patient's life. This may include individuals who are not legally related to the patient.)(2,16)
B. Set realistic goals for the individual patient.(8,10)
II. Try to determine how the patient learns best through discussion of past educational experiences, observation, or experimentation with different teaching tools:(2,9,16)
A. Visualization, or learning by reading;
B. Auditory, or learning by listening;
C. Tactile/psychomotor, or learning by doing.
III. Select the training approach and style that you believe will most benefit the patient. This may vary as the patient situation changes. No one approach is inherently superior to another.(2,7,12,20,27)
A. One to one and/or group sessions.
B. As a rule, use simple vocabulary and short phrases tailored to the patient's life experiences.(4)
C. Encourage active patient participation in the training experience (often more effective than didactic teaching).(1,7,12,16)
D. Speak slowly and clearly, lower your voice, and stand where you can easily be seen.(10,15)
IV. Present material in organized sequence using appropriate terminology.(1,20)
A. Ensure the patient's attention.(6,26)
B. Discuss the learning objectives to be addressed and their relevance.(1,20,26)
C. Review what the patient may know from past experience, and build on similarities and differences compared to current topic.(12,20,26,28)
D. Present specific information in a concise, clear manner using short words and sentences.(6) Progress from the simple to the more complex.(20)
E. Ask the patient to determine and articulate the concept or technique taught.(26)
F. Patiently repeat important points, answer questions, and give specific feedback for correction of technique theory.(1,15,20,26)
G. Reinforce objectives through positive feedback.(12,20,26,28)
V. Document what has been taught (link to expected learning outcome) and at what level the patient has mastered knowledge and skill and has improved behavior. Incorporate this information into the medical record in a clear, concise manner that communicates needed information to other team members.(2,7,23,28)
VI. For patient training to be effective, on-going reinforcement and follow-up are needed.
A. Provide written material as review.(3)
B. Activate support system.(3,6,23,24)
C. Allow time for repeated patient demonstration of learned material; incorporate a behavioral and skills mastery emphasis.(1,6,20,28)
D. If appropriate, allow for periodic follow-up phone calls.(10,13,23)

Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

Reprinted from the July 1996 issue of RESPIRATORY CARE [Respir Care 1996; 41(7):658–663]

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