The Nursing Process in Patient Teaching
The steps of the nursing process—assessment, diagnosis, plan-ning, implementation, and evaluation—are used when con-structing a teaching plan to meet an individual’s teaching and learning needs (Chart 4-2).
Assessment in the teaching–learning process is directed toward the systematic collection of data about the person’s learning needs, the person’s readiness to learn, and the family’s learning needs. All in-ternal and external variables that affect the patient’s readiness to learn are identified. A learning assessment guide may be used for this purpose. Some of the available guides are very general and are directed toward the collection of general health information, whereas others are specific to common medication regimens or disease processes. Such guides facilitate the assessment but must be adapted to the individual’s responses, problems, and needs.
As soon as possible after completing the assessment, the nurse organizes, analyzes, synthesizes, and summarizes the data col-lected and determines the patient’s need for teaching.
Formulating nursing diagnoses makes educational goals and eval-uations of progress more specific and meaningful. Teaching is an integral intervention implied by all nursing diagnoses, and for some diagnoses education is the primary intervention. Ineffective therapeutic regimen management, Impaired home maintenance, Health-seeking behaviors, and Decisional conflict are examples of nursing diagnoses that direct planning for educational needs. The diagnosis “Deficient knowledge” should be used cautiously, because knowledge deficit is not a human response but a factor relating to or causing the diagnosis (eg, Ineffective therapeutic regimen management related to a deficiency of information about wound care is a more appropriate nursing diagnosis than “Defi-cient knowledge”) (Carpenito, 1999). A nursing diagnosis that relates specifically to the patient’s and family’s learning needs will serve as a guide in the development of the teaching plan.
Once the nursing diagnoses have been identified, the planning component of the teaching–learning process is established in ac-cordance with the steps of the nursing process:
·Assigning priorities to the diagnoses
·Specifying the immediate, intermediate, and long-term goals of learning
·Identifying specific teaching strategies appropriate for at-taining goals
· Specifying the expected outcomes
· Documenting the diagnoses, goals, teaching strategies, and expected outcomes on the teaching plan
As in the nursing process, the assignment of priorities to the diagnoses should be a joint effort by the nurse and the learner or family members. Consideration must be given to the urgency of the individual’s learning needs, with the most critical needs re-ceiving the highest priority.
After the priorities of the diagnoses have been established, the immediate and long-term goals and the teaching strategies ap-propriate for attaining the goals are identified. Teaching is most effective when the objectives of both the learner and the nurse are in agreement (Lorig, et al., 1996). Learning begins with the es-tablishment of goals that are appropriate to the situation and re-alistic in terms of the individual’s ability and desire to achieve them. Involving the patient and family in establishing goals and subsequently in the planning of teaching strategies promotes their cooperation in the implementation of the teaching plan.
Expected outcomes of teaching strategies can be stated in terms of behaviors of the person, the family, or both. Outcomes should be realistic and measurable, and the critical time periods for attaining them should also be identified. The desired out-comes and the critical time periods will serve as a basis for evalu-ating the effectiveness of the teaching strategies.
During the planning phase, the nurse must consider the se-quence in which the subject matter will be presented in each of the teaching strategies. Critical information (eg, survival skills for the person with diabetes) and material that the person or family identifies to be of particular importance receive high priority. An outline is often helpful for arranging the subject matter and for ensuring that all necessary information is included. Also during this time, appropriate teaching aids to be used in implementing the teaching strategies are prepared or selected.
The entire planning phase of the teaching–learning process is concluded with the formulation of the teaching plan. This teach-ing plan communicates the following information to all members of the nursing team:
1) The nursing diagnoses that specifically relate to the indi-vidual’s learning needs and the priorities of these diagnoses
2) The goals of the teaching strategies
3) The teaching strategies, expressed in the form of teaching orders
4) The expected outcomes, which identify the desired behav-ioral responses of the learner
5) The critical time period within which each outcome is expected to be met
6) The individual’s behavioral responses (which must be doc-umented on the teaching plan)
The same rules that apply to writing and revising the plan of nursing care apply to the teaching plan.
In the implementation phase of the teaching–learning process, the patient, the family, and other members of the nursing and health care teams carry out the activities outlined in the teaching plan. The nurse coordinates all the activities.
Flexibility during the implementation phase of the teaching– learning process and ongoing assessment of the individual’s re-sponses to the teaching strategies support modification of the teaching plan as necessary. Creativity in promoting and sustain-ing the learner’s motivation to learn is essential. New learning needs that may arise after discharge from the hospital or after home care visits have ended should also be taken into account.
The implementation phase is concluded when the teaching strategies have been completed and when the individual’s re-sponses to the actions have been recorded. This record serves as the basis for evaluating how well the defined goals and expected outcomes have been achieved.
Evaluation of the teaching–learning process determines how ef-fectively the person has responded to the teaching strategies and to what extent the goals have been achieved. An important part of the evaluation phase addresses the question, “What can be done to improve the teaching and enhance the learning?” An-swers to this question will direct the changes to be made in the teaching plan.
An evaluation must be made of what was done well, and what needs to be changed or reinforced. It cannot be assumed that indi-viduals have learned just because teaching has occurred: learning does not automatically follow teaching. A variety of measurement techniques can be used to identify changes in behavior as evidence that learning has taken place. These techniques include directly ob-serving the behavior; using rating scales, checklists, or anecdotal notes to document the behavior; and indirectly measuring results through oral questioning and written tests. Measurement of actual behavior (direct measurement) is the most accurate and appropri-ate technique in many patient teaching situations. Nurses often do comparative analysis using patient admission data as the baseline: selected data points observed during the period when nursing care is given and self-care was initiated are compared with the patient’s baseline data.
Some examples of indirect measurements are patient satisfac-tion surveys, attitude surveys, and instruments that evaluate spe-cific health status variables. All direct measurements should be supplemented with indirect measurements whenever possible. Using more than one measuring technique enhances the reliabil-ity of the resulting data and decreases the potential for error from a specific measurement strategy.
Measuring is only the beginning of evaluation. It must be fol-lowed by interpreting the data and making value judgments about the learning and teaching. Such evaluation should be conducted periodically throughout the teaching–learning program, at its con-clusion, and at varying periods after the teaching has ended.
Evaluation of learning after hospitalization is highly desir-able, because the analysis of teaching outcomes must extend into home care. With shortened lengths of hospital stay and with short-stay and same-day surgical procedures, follow-up evaluation in the home is especially important. Coordination of efforts and sharing of information between hospital-based and community-based nursing personnel facilitates post-discharge teaching and home care evaluation.
Evaluation is not the end step in the teaching–learning process, but the beginning of a new patient assessment. The information gathered during evaluation should be used to redirect teaching ac-tions, with the goal of improving the learner’s responses and out-comes.