Just last week I heard about a situation that went something like this: A woman had a cardiac catheterization in a Toronto hospital. A professional attended the women while she was recovering from sedation and proceeded to read her a list of things she needed to know in order to care for herself. The professional instructed the women to “listen carefully” and then read several paragraphs of instructions and precautions. Several moments later, the woman, still waking from sedation, had a pen placed in her hand and was instructed to sign stating that she had been given the education. Hours later, the women asked her companion, who had witnessed the event, what she had been told because she could not recall any details.
Is this an extreme case? I would like to think so, but I am concerned it is more typical than not. Professionals are terrified of making errors and organizations need to track quality indicators—whether patient education is meaningful or even heard is not the primary concern. Patient education programs may serve professional interests, but many are failing to have an impact on persons in the context of their day-to-day lives.
Patients are often referred to education programs where professionals have to ensure certain numbers of people are processed. For example, another woman attending the diabetes education clinic is informed by a professional that her diet has to change. She is told to prepare certain foods and to eat at certain times. She is given information about how food impacts blood glucose levels and is instructed to test her sugars regularly. After 10 minutes a different professional enters to discuss foot care. Later the women expressed confusion, concern, worry, and fear. She had not understood some of the words used, she had little control over the selection of foods in her home because she had to move in with her daughter who is a single working mother with two teenagers. She had no information on how to start new strategies or how to get help if she could not figure things out. And she had no sense of relationships or connection with the team members who had just sent her on her way.
So here is the point: traditional patient education is founded on the assumption that people do not know what they are supposed to do to be healthy. Further, if they did know, it is assumed that they would do what is “right.” “Right” from the perspective of those not involved or knowledgeable about the person’s life and family. These assumptions are deeply misguided.
We all pay attention to things that are most important in our lives. Health professionals need to begin to listen to what is most important in the lives of people they are trying to help—like those living with diabetes, heart disease, or dementia. If I cannot afford to feed my children or if I cannot get to a grocery store, then that is what will take my attention and that is what I need help with. It is extremely difficult to make changes in your life, especially if you are living with lots of health issues and family problems.
To see the scope of the failure of traditional patient education, one need only look at the multitude of systematic reviews that can, at best, only grasp at weak evidence to support patient education for creating health change and at the reality that millions of people know about the health issues of obesity, diabetes, and cardiovascular disease and yet the issues grow. Maybe, and there are many who concur, the problem is not with individuals who do not know, but rather, the problems are layered in issues of poverty, industrialized food, inaccessible resources, social stigma, and prejudice/judgment from health professionals. I cannot tell you how many times I have heard people living in poverty say that they would rather go without than face the judgmental attitudes of the very people who are supposed to be helping them.
To my colleagues, I ask: Does it matter if our help, our education, is meaningful to people? Or, just that we provide the information and keep moving people through with the hope that some will be helped, but knowing most will not. Ironically, we are in the same boat as the rest of the population: we know that what we are doing is not working, but we keep doing it
So how do we begin to change this reality? As a first step, what if we just started to listen to people about their circumstances and concerns before expecting anything from them and before imposing our own agenda?
The comments section is closed.
Thank you for your post, Gail. Working with persons with complex physical and mental health challenges, one encounters numerous occasions when health teaching is an appropriate nursing intervention but it is evident that the person is not ready to receive that teaching.
Ideally, time exists to build trust and to gradually work toward a mutual understanding of the issues in question but when we transfer care after each 12-hour shift, the question often arises “What did you do about it?”
I would like to see care plans as living documents: ongoing conversations among persons and their caregivers that follow each person’s lead as they reveal what is most important to them in the moment rather than records of action/reaction that may not address the complex concerns of the persons we work with.
First of all, thank you Gail for asking a question that I have been pondering for quite some time: “Does it matter if our help, our education, is meaningful to people?”
I am a diabetes educator and dietitian with The Guelph Family Health Team and Diabetes Care Guelph currently completing my Master of Science degree and recently conducted research in the area of adult diabetes education specifically looking at the delivery method of diabetes education.
While conducting a literature review, the gap in research on patient attitudes and perceptions of education techniques became quite evident. Although many research studies, including RCT’s, investigated methods of education, the objectives of most studies looked mainly at outcome measurements such as Hb Alc, Chol, BP, Wt, etc. There seems to be few studies looking at patient attitudes and how this influences behaviour (they do exist, but in low numbers).
Speaking about people in general – our attitudes change each day based on daily life, circumstances, mood, etc. Our attitudes also change directly based on how we perceive a situation. Our perception toward a topic/event can be influenced by existing feelings, life experiences, thoughts, and knowledge that we have about the topic/event. We know this to be true as it is presented to us time after time in different theories of adult education and learning.
So why then is there a gap in research? Why are we so interested in whether knowledge changes improve outcomes? What about attitude and perceptions? Instead of outcomes, why are we not looking more directly at behavioural changes that will eventually lead to improved outcomes?
I would like to see more research conducted on attitude changes and patient perceptions of education techniques. Perhaps this will help us on our journey toward improving education techniques in providing health education.
As for my research, I am comparing traditional diabetes education methods to conversation maps looking specifically at changes in patient knowledge, attitudes, and behaviours. I will be defending my thesis this month!
This is a very timely topic, my partner recently wrote a similar post where he proposed a patient education bill of rights. I’d love to hear your thoughts.
http://incendant.com/blog/?p=39
We all know there are many places where the doctor-patient education can break down. At Incendant, we are trying to make the education concise and consistent in words the average person can understand (native language, 4th grade reading level). Video instruction helps with engagement which in turn improves understanding and compliance. Video instruction also makes it possible for the patient to access the same education as many times as needed from wherever they are over the internet.
Unfortunately, even perfect delivery of the materials does not guarantee understanding or compliance with the care plan. It is a good place to start though.
Thanks,
Joe Hunt
What you call traditional patient education is actually outdated, and not evidence based. Patient education has two layers: (1) providing information and making sure it’s understood and (2) health coaching to help the learner apply the new skills to life. Assessments and evaluations of understanding would uncover the challenges in applying new information, such as inability to afford food.
So you are right, assessment comes first (“listen to people about their circumstances and concerns before expecting anything from them”). I propose we then should never impose our agenda, but individualize teaching based on our assessment. We need to involve the learner in the process and, with the learner, develop an actionable plan that moves forward toward improved health outcomes.
I summarize the research in patient education in my book No Time to Teach: The Essence of Patient and Family Education for Health Care Providers. I add the latest findings through Twitter @notimetoteach and my website, http://www.notimetoteach.com.
Thanks Gail for this timely overview on such an important topic. As long as patient education and discharge planning consists of ticking boxes on some hospital form, we’ll continue to see overworked, burned-out health care providers continuing the futile and ineffective practices you describe in these two cases. The medical blog KevinMD ran a similar post this week called “Patient Education is Often An Afterthought”. The doctor who wrote the post tells of a pediatric patient whose parents do not speak English, but are given a take-home brochure about their child’s condition – IN ENGLISH. But even more distressing to me was the tone of the reader comments responding to this post – especially from doctors acknowledging the shortfalls of patient education but utterly unwilling to do any further unpaid efforts to address them.
And in a shocking report from The Center For Advancing Health, we learn that “91%t of chronically ill patients did not receive a written plan of care when they were discharged from the hospital.” Horribly short-sighted – given that we know lack of effective discharge planning is clearly tied to higher re-admission rates.
This was certainly the case when I was discharged from the CCU after surviving a heart attack. To hospital staff, I was merely the M.I. in Bed 8 who needed to vacate a bed that others were waiting for. I wrote more about this at: http://myheartsisters.org/2012/11/11/study-91-discharged-without-written-care-plan/