Patient education - Clinical Tree

Introduction

Patient education is an integral part of every health care interaction. It is one of the most powerful tools that a health care provider can use to influence positive changes in health and wellness for patients. Whether the patient requires a diagnostic study, lifestyle changes, or a medication, the provider can offer the necessary education to the patient. Effective patient education provides patients with the information they need to make informed decisions regarding their health. Proper teaching must go beyond simple instructions, such as how to take a medication correctly. Patient education allows us to address disease prevention, safety, nutrition, and physical activity. It also serves to manage expectations for procedures or future visits. Perhaps most importantly, the process of patient education creates an environment that facilitates relationship-building, increases patient trust, and builds rapport between the patient and provider. Patients have an expectation that they will be fully informed about their health and treatment plans. The challenge then becomes how to teach effectively.

Barriers to patient education

If the process of educating patients were simple and straightforward, it is likely that the prevalence of some of the most common health problems, such as heart disease and type 2 diabetes, would decrease. Patients would take our simple instructions and implement them to improve their health. Nevertheless, many barriers can stand in the way of effective patient education and its ability to motivate patients to change. A variety of factors can adversely affect the communication between a physician assistant (PA) and her or his patient. Age, gender, socioeconomic status, ability to learn, provider skill, and a patient’s environment are just a few of the potential hurdles in the patient-provider interaction. In addition, simply arming patients with knowledge is not enough to create meaningful change. The provider must assess the patient’s motivation and ability to implement changes. This chapter is designed to help PAs understand some common reasons patient education fails to translate into positive health behavior change.

Barriers to patient education can be simplified into two categories: communication barriers and implementation barriers. An interaction with an elderly patient can illustrate both types of barriers. An older man with hearing loss may struggle to hear the provider but smile and nod anyway, indicating to the PA that he understands her message. Unfortunately, the patient will not be able to act on the PA’s advice because he never heard the advice. An implementation barrier exists when the patient hears and understands the instructions but faces obstacles that may prevent him from implementing these instructions. Common implementation barriers include the inability to afford recommended medications, lack of transportation to and from appointments, or the lack of vision or dexterity needed to carry out treatment recommendations. In most patient interactions, both communication and implementation barriers are present. They must be managed through negotiations between the patient and the provider. To successfully overcome these problems, a deeper understanding of these barriers is essential.

Patient barriers

Most patients want to avoid the discomfort and costs associated with chronic disease, yet providers struggle to get patients to follow their advice on how to prevent or effectively manage these disorders. Motivation is a determining factor in the successful implementation of patient education and a health care plan. Some patients receive the teaching that is provided and implement it successfully; however, many do not. It is common for providers to seek innovative ways to inspire and motivate patients. In the past, fear tactics were used as the primary tool to motivate patients. Fear works for some people, but for many, it isn’t enough to inspire action. Fear can lead patients to develop attitudes of denial, avoidance, or hopelessness, none of which help them move forward.

Motivation is an intrinsic quality that is difficult to influence. The Stages of Change model developed by Feldman allows the provider to assess where the patient is in his or her willingness to implement a change in behavior. PAs can use this tool to identify which patients are ready and motivated to make a change, and which patients need more information and encouragement. Feldman’s six Stages of Change are: precontemplation, contemplation, preparation, action, maintenance, and relapse. These stages can be applied in any situation during which a provider is asking a patient to make a behavioral change. Smoking cessation counseling is used as an example here.

A patient in the precontemplation stage is aware that smoking is bad for him or her but will either dismiss the concern or deny it. This patient might resist change by using an example of someone he or she knows who smoked his or her whole life and never became unwell. This patient is not motivated or willing to make a change yet.

In the contemplation stage , the patient is more aware of the problem, may begin to articulate a desire to quit smoking, and understands some of the benefits of doing so. This patient will weigh the desire to change against the perceived benefits of continuing to smoke. A patient in the contemplation stage might make a few attempts at change, but these efforts are often inconsistent and short-lived.

During the preparation stage , the patient is ready to commit to making a change. In this stage, the patient who smokes is willing to set a quit date. The patient has not yet implemented any changes but exhibits a willingness to do so. Patients in this stage are usually open to help from their PA.

Patients in the action stage are actively engaged in executing behavioral change. The patient has reached his or her pre-established quit date and is using a provider-recommended plan of action to avoid smoking. This stage requires daily effort to maintain the change. The PA can be a significant encouragement to patients in this stage.

When the patient reaches the maintenance stage , the implemented behavioral change has become a habit. The patient may not need to use daily strategies to feel like he or she is able to maintain a smoke-free life. During this stage, the change begins to feel more integrated into normal life. The final stage is relapse, which is exactly as it sounds. This is when the patient begins to smoke again after a period of success. Not all patients will relapse. Feldman’s model, however, encourages both patients and providers to anticipate and plan for what will happen if relapse occurs.

PAs who take the time to assess where a patient is in terms of willingness to change can tailor the message to the patient in a way that encourages him or her to move toward the action and maintenance stages. For example, if a patient is solidly in the precontemplation stage, the provider should not see the task as impossible and avoid a conversation with the patient about smoking cessation. It would also be premature for the provider to attempt to engage the patient in a plan of action for smoking cessation because the patient is not yet ready for this step. Instead, the PA should engage the patient in a conversation targeted at moving the patient from the precontemplation stage to the contemplation stage. The provider should use the time to understand the patient’s concerns and correct any misperceptions the patient might have. The provider should always encourage the patient to let the provider know when he or she might want to talk about making a change. Similar provider strategies exist for each stage, which are designed to increase and encourage patient readiness for change ( Table 16.1 ).

Table 16.1

Provider Strategies

From Feldman MD, Christensen JF, eds. Behavioral Medicine: A Guide for Clinical Practice. 4th ed. New York: McGraw-Hill Education; 2014.

Stage of Change	Patient Characteristics	Provider Strategies
Precontemplation	Denies problem and its importance Is reluctant to discuss problem Problem is identified by others Shows reactance when pressured High risk of argument	Ask permission to discuss problem. Inquire about the patient’s thoughts. Gently point out discrepancies. Express concern. Ask the patient to think, talk, or read about the situation between visits.
Contemplation	Shows openness to talk, read, and think about the problem Weighs pros and cons Dabbles in action Can be obsessive about problem and can prolong stage Understands that change is needed Begins to form a commitment to specific goals, methods, and timetables	Elicit the patient’s perspective first. Help identify the pros and cons. Ask what would promote commitment. Suggest trials. Summarize the patient’s reasons for change. Negotiate a start date to begin some or all change activities.
Preparation and determination	Can picture overcoming obstacles May procrastinate about setting a start date for change Follows a plan of regular activity to change the problem Can describe the plan in detail	Encourage the patient to announce the plan publicly. Arrange a follow-up contact at or shortly after the start date. Show interest in the specifics of the plan. Discuss the difference between a slip and relapse. Help anticipate how to handle a slip.
Action	Shows commitment in facing obstacles Resists slips Is particularly vulnerable to abandoning effort impulsively Has accomplished change or improvement through focused action Has varying levels of awareness regarding the importance of long-term vigilance	Support and reemphasize the pros of changing. Help modify the action plan if aspects of it are not working well. Arrange follow-up contact for support. Show respect and admiration. Inquire about feelings and expectations and how well they were met. Ask about slips and any signs of wavering commitment.
Maintenance	May already be losing ground through slips or wavering commitment Has feelings about how much the change has actually improved life May be developing a lifestyle that precludes relapse into former problem	Help create a plan for intensifying activity if slips occur. Support lifestyle and personal redefinition that reduce the risk of relapse. Reflect on the long-term and possibly permanent nature of this stage as opposed to the more immediate gratification of initial success.

Patients give many reasons for their previous failed attempts to change behavior or their current unwillingness to attempt change. Common reasons include lack of time, lack of family support, level of difficulty, cost, time of high stress, and lack of resources. If two similar patients want to start an exercise program, both of whom are in the preparation stage but have similar barriers such as stressful jobs, lack of time, and no gym access, why is one successful and the other unsuccessful? Patients have belief systems that influence their faith in their ability to overcome obstacles. These barrier-beliefs create rationalizations and excuses that undermine a patient’s ability to succeed. Ultimately, if these rationalizations and excuses are not managed by the health care provider and the patient together, the patient will give up on change. Barrier beliefs are created by the patient’s past experiences and perceptions and can be divided into three distinct categories: attributions, self-efficacy, and negative outcome expectations. For a provider to successfully encourage patients to adhere to treatment plans, these three elements should be considered.

Attributions are the reasons a patient uses to explain lack of success in implementing a change or a strategy. It is human nature to ascribe meaning and reasoning to an undesirable behavior or outcome. These attributions can be factual, interpreted, or even implausible. For example, if a patient is asked to take a medication for hypertension every day, he or she may use the following attributions to explain why he or she is unable to do so. Factual: “I cannot afford the medication.” Interpreted: “Taking medication every day will be too many chemicals for my body to handle.” Implausible (or misinformed): “Lowering my blood pressure will make my heart have to work harder to get blood to my feet, so it will wear out my heart if I take this medication.” The type of attribution deployed by the patient will direct the PA’s response.

Self-efficacy is the patient’s belief that he or she is capable of completing an action or meeting a goal. Self-efficacy is often the decisive factor in determining success or failure. If one patient believes he or she can exercise on a regular basis, then that patient will overcome a busy schedule and lack of gym membership. If the patient does not believe he or she is capable of exercising on a regular basis, however, the barriers will prevent the patient from achieving his or her goal. Many factors influence a person’s self-efficacy: previous failures or successes, other people’s failures or successes, other people’s opinions regarding their ability to succeed, low self-esteem, and knowledge about the steps needed to achieve the goal.

Negative outcome experiences are beliefs that implementing change will precipitate an undesirable outcome. These outcomes could be social, physical, or monetary. For example, dieters may have one of the following reasons for not dieting. Social: “My family won’t eat the healthy food I make, and it is important that we eat the same foods.” Physical: “I feel tired in the afternoons when I eat healthy so I have to eat more.” Monetary: “Healthy food is really expensive, and the food spoils so quickly. I can’t afford to do this.”

Health care providers must consider all these dynamics when counseling their patients. If the provider does not account for a patient’s willingness to change and the patient’s belief in his or her ability to make a change, the provider cannot tailor the message to the patient to give the greatest opportunity for long-term success. Without tailored education, the patient is less likely to succeed ( Fig. 16.1 ).

Fig. 16.1, Physician assistant counseling her patient.

Provider barriers

PAs may also encounter personal barriers that can limit the potential for effective patient education. One of the most frequently cited barriers for providers is lack of time. Providers are asked to accomplish much in the brief span of an office visit. Health information is complex. When faced with limited time, PAs may provide partial information, rush the delivery of information, or choose not to provide the information at all. PAs may eliminate patient education as a part of a patient encounter because of a developed sense that education is a waste of time and does not result in appreciable change. Providers who do not develop the skills to overcome patient education barriers will find patient education frustrating and perhaps even pointless.

Some PAs may think that they are not qualified to teach patients. Although PAs spend much of their education learning clinical medicine, the training they receive tailored specifically to teaching and educating patients is less extensive. PAs may believe they lack detailed knowledge of rarer diagnoses and may feel inadequate to teach the patient about these diseases and their management. Providers should develop a set of readily available resources to overcome this barrier.

Another barrier to effective patient communication is the tendency by some providers to speak in medical jargon. Patients often feel uncomfortable interrupting a provider to say that he or she did not understand a term or phrase. Patients often simply nod and agree with the provider to hide their lack of understanding. Patients feel frustrated that they were not able to get the information they needed out of the encounter. Providers should monitor their own speech and ensure they are using lay terms when speaking with patients. Asking the patient to explain the concept back to the provider is an effective way to assess the patient’s understanding of the information given during the encounter.

Providers are often frustrated by the difficulties patients have in recalling crucial health information provided at the visit. Even if the provider has accounted for the potential barriers to communication, research suggests that a patient will only remember a maximum of seven new pieces of information from each visit. Providers commonly err by giving too much information during a single patient encounter. Less is more. Too much information overwhelms the patient, which inhibits both understanding and recall. Providers must develop the ability to prioritize information and structure the presentation of new information logically to help the patient retain the most crucial messages from the visit.

Health literacy

Health literacy is the degree to which a patient can obtain, communicate, process, and understand health information and services to make informed health decisions. Improving health literacy should begin with identifying the barriers to effective communication with a particular patient. Common health literacy barriers include:

1.
The patient does not speak English.
2.
The patient has never learned to read or reads poorly in any language.
3.
The patient does not have sufficient numeracy to be able to manage medications or complete self-management charts.
4.
The patient does not know the basics of how the body works.
5.
The patient has limited education and does not understand how the scientific process is applied to diagnosis and treatment in medicine.
6.
The patient does not understand statistics, probability, or the concepts of risk that are used in medical decision making.
7.
The patient does not have access to a computer or does not know how to use a computer.

As PAs, it is our job to identify patients who may have health literacy struggles and provide them the information in a way that is accessible to them. Effective strategies to overcome health literacy barriers include:

1.
Choose the essential information that the patient must have today and discuss only those topics. Schedule the patient for another visit soon to give them further information. The more information you give the patient, the less likely he or she is to retain any of it. Dole it out in small pieces for easy digestion.
2.
Use translators and translated materials with non–English-speaking patients. Translators (or the use of a phone translation line) are required by law in the United States. Although providers occasionally use an adult friend or family member to help clarify the discussion with a limited English speaker, it is never appropriate to use a child for translation or clarification.
3.
Write all patient handouts at a third grade level or below. Most commercially available word processing software includes tools for assessing the grade level of the handout. Even better educated people benefit from simple and clearly written health information.
4.
Always use pictures that demonstrate the proper way to do something. Never use pictures that demonstrate the improper way to perform a skill. Patients who cannot read may confuse the two.
5.
If possible, schedule a double appointment for patients who struggle with one or more health literacy challenges to allow you more time for your discussion. Use this extra time to ask the patient to explain what you have just said back to you to assess their level of comprehension.
6.
Explain concepts of risk with drawings. For example, show patients what 1 in 10 means by drawing 9 people with a blue marker and one person with a red marker.
7.
Ask patients if they have a computer, if they know how to use a computer, or if they have a tech-savvy friend who can help them with a computer before you refer them to online education or self-management resources. Giving a URL to patients who do not have or cannot access a computer is the same as giving them no information at all.

Providing structure for effective patient education

Structure and organization are essential components to maximizing the amount of information that a patient recalls from the patient–provider interaction. Although there are many models for how to structure the process of giving information to patients, most providers develop their own method and style to accomplish this task. There are key elements that should be included in the provider’s approach to communication that are critical to the provider’s ability to overcome barriers and work toward patient understanding and adherence. The following elements can serve as a step-by-step guide for a new provider to develop his or her process for effective patient education ( Box 16.1 ):

1.
Introduce the patient to the topic to be discussed. This is an important starting point. Often, providers will move into advice and instructions without providing a context for the conversation to the patient. Providing a preview of the discussion allows the patient to establish an organizational structure for the conversation in his or her brain. It informs the patient of the purpose of the interaction and what he or she can expect from the information that will be shared. It also allows the provider to be organized and thoughtful in the approach to the information. Think of this as a road map for both the provider and the patient.
2.
Assess the patient’s level of knowledge and expectations. If the PA does not assess what the patient already knows and doesn’t know, she will be unable to tailor the message to meet the patient’s needs. For example, if a PA is teaching a patient with diabetes about how many units of insulin to take for each carbohydrate unit and the patient has no understanding of carbohydrate counting, this patient education would be completely ineffective and potentially dangerous. Taking time to assess the patient’s current knowledge allows the provider to identify misinformation, prioritize information delivery, and determine a starting point for teaching. A PA might ask a patient with diabetes, “Can you tell me what you have been taught about diabetes?” “How do you think the treatment will help your diabetes?” or “How does exercise affect the control of your diabetes?” Providers under time pressure often make the mistake of skipping this step in the process.
- It is also critical to understand patient expectations for the visit and for the future. If a provider fails to assess and fully address these expectations, it provides an additional barrier to the implementation of the treatment plan. The provider can simply asked the patient if he or she has ideas about what is wrong, if the patient has concerns or worries about what could happen, or if he or she has any expectations about what should be done at today’s visit. The acronym “ICE” can be used to remember ideas, concerns, and expectations. Understanding the patient’s perspective allows the provider to address the patient’s concerns. For example, a patient may report to the PA that he or she believes that elevated blood sugar levels are attributable to a new exercise regimen. If the PA is aware of this belief, he or she can educate the patient about exercise and diabetic management. If a patient confides that he or she is terrified of needles and will do anything to avoid insulin shots, the provider can evaluate other potential treatments or manage the concern if insulin is needed. Finally, if the patient has an expectation, no matter how outrageous, the provider must know about it to be able to meet it or address it. For example, if a patient with diabetes expects that he or she will eventually be cured by a pancreas transplant and assumes that other treatments are temporary, the provider can spend time educating the patient about realistic current treatments and potential future treatments.
3.
Present prioritized information in plain language. This is the provider’s opportunity to teach the patient what he or she needs to know. The goal is to provide enough information for success but avoid providing so much information that the patient is overwhelmed. Start with the most important piece of information first and keep the number of items addressed small. ^, Speak in plain language. The patient should not need to ask the definition of a word or the meaning of a phrase. Patient understanding can be enhanced by using drawings, models, or other visual aids when appropriate.
- The provider should make sure all messages are specific. If the PA recommends behavior change, he or she should work with the patient to set a goal. The goals set must be manageable, measurable, and tailored to the patient’s current situation. For example, asking a patient to start exercising every day for 60 minutes is measurable, but it is not manageable or tailored to a patient who currently gets winded walking to the mailbox each day. Instead, the PA may start with a recommendation that the patient set a goal of walking to the mailbox twice a day for 1 week and then progress to walking to the end of the street daily the next week. Have the patient return to clinic to assess progress toward current goals and to set new goals.
4.
Assess the patient’s level of understanding and reactions to the information provided. The best way to implement this step is to perform it concurrently with step 3. As part of providing good structure for the information, it should be presented in segments that make sense together. As the provider reaches the end of a segment, allow the patient to ask questions, offer concerns, and share her or his understanding of the information. Armed with the data garnered from these checkpoints, the provider can continually shape the subsequent education to fit the patient’s specific needs. The provider can also take the time to reteach or dispel misinformation immediately if necessary.
- Continuous assessment is also helpful when a patient has an emotional reaction to information presented by a PA. Some emotional reactions can stop the flow of communication and become a barrier to the effective delivery of any education that follows. For example, if the provider has recommended a magnetic resonance imaging (MRI) scan for the patient and the patient is claustrophobic, the patient may miss all further information as he or she worries about panicking during the scan. Pausing to check understanding allows the patient time to process, share those emotions, and react to the information. When the provider becomes aware that the patient has had an emotional response to a certain component of the plan, the messages can be adapted to the patient’s needs, both medical and emotional.
5.
Use negotiation and shared decision making. When students learn about patient education in clinical medicine courses, the formula for educating patients about each disease can be “one size fits all.” For example, the education for an obese patient includes a healthy, calorie-restricted diet; routine exercise 4 or 5 days a week; and follow-up for success. Unfortunately, real-world application is not that simple. After providing information to the patient and taking time to check for the patient’s understanding and reactions, the PA should take the time to negotiate with the patient a plan of action that they both can agree on. This process allows for barriers to be addressed and managed in the planning process. The provider needs to be able to recognize that there are options for how to achieve a desired goal and allow for a creative, collaborative approach to common problems. This creative approach allows for the patient’s preferences and ideas to be part of the plan. Patients should be encouraged to share the things that they believe will make a recommendation difficult, and he or she should be engaged in the process of finding solutions. When patients feel invested in the decisions and the plan creation, they are more likely to adhere to that plan. Treat the patient as the expert in his or her own health and help him or her make informed decisions.
6.
Ask the patient to summarize the plan in his or her own words. It is likely that a great deal of information has been shared and many new ideas have been discussed. This check of patient understanding is one of the most important parts of effective patient education. Do not skip it because of time constraints. In this step, the PA gauges if the patient knows what he or she is supposed to do when he or she leaves the office. Asking the patient to speak the plan aloud also solidifies the recommendations through repetition, increasing patient retention. Providing patients with written instructions to reinforce the information also increases retention. Written information should never replace any of the previous steps but should assist the patient in remembering the discussion.
7.
Plan for a follow-up visit. Not every office visit will require a follow-up visit. Assisting the patient with behavior changes or managing a chronic illness, however, will require regular visits to the clinic. These visits allow the provider to join the patient in celebrating the victories and developing new strategies for challenges. Even when ideal collaboration with the patient exists, barriers may not become apparent until the patient attempts implementation. Following up allows the provider time to revisit and reinforce the goals and recommendations and to develop new approaches to allow for continued progress toward the patient’s goals for better health. Documentation of the patient–provider interaction is an important element of effective follow-up. The documentation should be complete enough so that other providers who might see the patient can easily understand the recommendations and goals.

Box 16.1

From Lloyd et al, Matthys et al., and Elwyn et al.

Steps to Effective Patient Education

1.
Introduce the patient to the topic to be discussed.
2.
Assess the patient’s level of knowledge and expectations.
3.
Present prioritized information in plain language.
4.
Assess the patient’s understanding and reactions to the information.
5.
Use collaborative negotiations and shared decision making.
6.
Ask the patient to summarize the plan in his or her own words.
7.
Plan for a follow-up visit.

Read Case Study 16.1 to see how these steps might apply to a clinical encounter.

Case Study 16.1

Applying Patient Education Principles

Ms. Jones (MJ) came to the clinic for a routine physical examination but has expressed that she would like to lose weight. The PA will provide guidance on how to get started losing weight.

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