Patient teaching is one of many important responsibilities of nurses working in a variety of health care settings. Of the people who are sick and seek care in this country, the overwhelming majority are elderly. It is estimated that about 48 percent of hospitalized patients, 85 percent of residents in nursing homes and 80 percent of all home care patients are elderly.1
Despite these facts, most nurses practicing today have had very little education directly related to the key components of patient teaching for older adults.
Key components of patient teaching for older clients and their families include:
1. Recognition of one's own and others' attitudes, beliefs, values and expectations about older adults and the impact of these values on the care provided to the aged and their families;
2. Individualized care (i.e., consideration of the uniqueness of each individual patient);
3. Effective communication skills; and
4. Accurate documentation related to both the teaching process and patient outcomes.2
Nurses working with older adults bring to the interaction all those stereotypes and perceptions of how they feel someone who is old should act, feel and think. While an in-depth discussion on this topic is beyond the scope of this article, theory and research on the relationship between attitudes and behavior suggest that attitudes and beliefs toward the aged probably play a major role in influencing the health care that older adults receive.
For example, if a nurse believes that the older adult is unable to learn new skills, the nurse is less likely to teach the older person with hypertension to use a sphygmomanometer to monitor his blood pressure. This behavior by the nurse promotes dependency of the aged person on others to monitor blood pressure, reinforcing a stereotype that older adults are dependent.3
The Table excerpts a few statements contained in Palmore's classic Facts on Aging Quiz,4 a tool to measure and compare levels of knowledge and the most frequent misconceptions about aging between different groups. Palmore's quizzes on aging have been used for more than 2 decades and remain useful as a springboard for discussion about older adults and to identify learning needs related to aging.
Individualized care related to patient teaching is just as important as it is to other aspects of care that nurses provide. Individualized care acknowledges older adults as unique people, recognizing their strengths and limitations while promoting participation in and direction of their own care.8
Essential to individualized care is getting to know the person. A thorough assessment of the patient is the first step and should reveal not only what needs to be taught but also how the patient will best understand the information. Most older adults have at least one chronic condition and many have multiple conditions. A thorough assessment will differentiate changes associated with normal aging from those associated with the patient's current and past medical problems.
Determining the impact these changes have on the individual's health status and functional abilities assists nurses in identifying how well older patients will be able to manage their health needs and how to individualize the teaching/learning process with the patient. Sensory deficits (vision, hearing, tactile sensation), musculoskeletal changes/mobility status, cognitive function, literacy level and functional abilities related to activities of daily living must be evaluated in order to teach cognitive and psychomotor skills and to set realistic goals with the patient.
Goals provide the framework for measuring the success of teaching and must: 1) be of immediate value and importance to the older adult, 2) be congruent with the patient's physical, mental and psychomotor status, and 3) consider the patient's resources and available support system.9 Sociological, psychological and cultural factors also should be considered as they, too, may impact on the teaching and learning process.
Sensory changes in hearing, vision and speech, as well as age-associated memory decline have a high potential to impair effective communication with older adults throughout the teaching and learning process. Compensatory strategies to assist nurses to overcome or minimize these communication barriers are essential to effective patient teaching.
Vision - Presbyopia, the decreased ability of the eyes to accommodate for close and detailed work, begins about the fourth decade of life. By age 60, individuals need two times the amount of light to see things as when they were age 20. Older adults also have an increased sensitivity to glare.10-12 Strategies to overcome visual problems or changes include:
Select or create handouts that have large easy-to-read typeface (if necessary, enlarge with a photocopier).
Use contrasting colors of black type on a white background on non-glossy paper. Avoid blues and greens that are poorly discriminated by the aged eye.
Have a magnifying glass available to assist the patient with reading difficulties.
Provide high intensity light on the object or surface that is involved in the learning activity.
Reduce glare by using soft white light, blinds or drapes. If necessary, move to a different location for the teaching session.
Hearing - Hearing loss increases with advanced age, particularly high frequency sounds. Presbycusis, a common neurosensory hearing problem, also causes difficulty in discriminating phonetically similar words. There is poor discrimination of consonant sounds such as "s, t, f, g." Inappropriate responses by the patient may be inaccurately labeled as confusion.10-12 Some helpful suggestions for teaching patients with hearing deficits include:
Lower the tone of your voice when speaking;
Sit when teaching and allow visualization of your face and lips as you speak. Speak slowly;
Eliminate background noise (intercoms and paging systems may mask conversation);
Repeat or clarify your message if the patient's response seems inappropriate;
When using audio or video presentations, adjust the volume to the individual (the hearing impaired may not do well with group presentations);
Check the functioning of assistive hearing devices and make sure the patient wears his device during teaching sessions;
Periodically check the patient's ears for excessive wax that will intensify presbycusis.
Prolonged reaction time/longer time to learn- the older adult takes more time to process and respond to information than the younger adult. Age associated memory decline includes a reduction in initial learning and retention of material, especially with the transfer of information from short-term to long-term memory and with search and retrieval of information from long-term memory.9 It is important to remember, however, that older adults, even those with cognitive impairment, can learn. It just takes more time. Teaching tips include:
Provide the most important information first and clarify by using examples;
Instructions for motor skills should be given one step at a time. Wait for each step to be mastered before moving on to the next;
Increase time for teaching, especially motor skills;
Encourage associations between items;
Review major points by summarizing; and
Clarify with examples from everyday life.
For example, if your goal is to teach your patient to take his medications, the times for taking medication should be grouped and planned to coincide with the patient's daily routine. Telling the patient to take the pill three times a day at his usual meal times will have little meaning for the patient who eats only two meals a day. Identify whether the patient eats a snack during the day that could be substituted for what might be considered a meal. Provide reinforcement of your teaching by providing audio or visual materials that may be reviewed at a later time. The use of a medication information sheet (see Figure), for example, can be an invaluable aid for the older adult who is scheduled to take one or several medications.9
Documenting Patient Teaching
Who was taught (patient, family, significant other);
Specific goal(s) to be attained (should be developed collaboratively with the patient);
What was taught (specific content);
The patient's special learning needs (e.g., identified barriers to learning);
Learning preferences (audiovisual, demonstration, explanation, printed materials);
Teaching methods used;
Learning progress or response to teaching (e.g., verbal understanding, return demonstration, needed reinforcement);
Plan for follow-up.9,10,13
Accurate documentation related to both the teaching process and patient outcomes is essential to effective patient education. Documentation provides a means of communicating the nurse's assessment and the teaching provided and helps other members of the interdisciplinary team plan for further teaching. Whether your documentation is in the form of an interdisciplinary progress note or a patient education flow sheet entry, key elements include:
Accurate documentation is both a quality of care and legal issue that should be of importance to every nurse caring for patients.
In summary, nurses assume a major responsibility when teaching patients. Educating older adults presents many unique challenges. Greater understanding of how attitudes, beliefs and expectations about the elderly affect what and how we teach this group of patients is of prime importance.
A review of current literature to discover the true facts about aging and an effort to share this information with others providing care to older adults is strongly advocated. Before teaching the patient, the nurse must get to know the individual, her needs, strengths and limitations, and customize patient teaching using an individualized care approach that incorporates effective communication strategies.
Nurses also must document the care they provide. Teaching patients is not any one person's responsibility, but rather an interdisciplinary team effort. Everyone involved in this activity should be knowledgeable about the teaching process implemented and, more important, patient outcomes. Patient teaching doesn't necessarily end when the lesson ends. It is an ongoing process that is driven by the needs of the individual patient.
|Table: Facts on Aging
||True or False
||Implications for Teaching|
|The majority of old people are unable to adapt to change.
||False. Older adults adapt to many changes that occur in old age, such as retirement, children leaving home, widowhood, seriouse illness, etc.5
||While it may be difficult to change lifestyle, don't be fooled into thinking that change is impossible for the older adult. Believing the elderly are unable to change may limit their access to restorative/health maintenance information.|
|Older people usually take longer to learn something new.
||True. Most older adults can eventually learn new things as well as younger people if given enough time and repetitions of the material to be learned.6 Variables such as illness, motivation, and learning style are more important considerations than chronological age.
||Slow the pace of your teaching sessions and provide reinforcement and summary of information taught. Determine the patient's learning style preferences and allow more time for the patient's response to your questions or return demonstration.|
|In general, old people tend to be pretty much alike.
||False. There is as much variation among older people as there is at any age. In fact, as people age they may become less alike and more heterogeneous on many dimensions. 4,7
||Individualize your teaching approaches. Get to know the person, his learning style and barriers to learning.|
|Figure: Sample Medication Information Sheet
|Name of drug/prescribed dose/directions
||How much to take
||Times to take (Individualize based on daily routines)
||Reason for taking this drug
||Call physician if you have these symptoms|
|Nifedipine (10 mg) 3 times each day with meals
||8 a.m. with breakfast
1p.m. with snack
6p.m. with dinner
||Irregular heartbeat, swelling or weight gain, difficulty breathing, cough.|
|Furosemide (40mg) daily
||Daily with other med at breakfast
||Signs of edema, weight gain, muscle cramps, palpatations, unresolved nausea or vomiting, continued fatigue.|
Joan Stockman Wagner is coordinator of continuing nursing education at Fox Chase Cancer Center, Philadelphia. She has extensive experience in gerontological nursing as a nurse practitioner, administrator and consultant.