Carol Einhorn, MS, RN, CURN, GNP, CS
Northwestern Memorial Hospital, Chicago, Ill.
Last Modified: June 24, 2005
As a clinical nurse specialist, the majority of my responsibilities lie in the area of patient education. One day, while evaluating a patient for stress incontinence, I asked if she had been taught pelvic muscle exercises. She said "yes" and proceeded to show me by putting her hands in the air and repeatedly opening and closing her fists. That was how she was doing her exercises, not by contracting her pelvic floor muscles. Another patient was seen for urodynamic testing and was told that part of the procedure was an electromyography of the urinary sphincter. After that explanation, he thought he had a chance of being electrocuted. It took much convincing on my part that this was not the case.
One of my colleagues told me that she taught a patient with vascular leg ulcers how to apply an expensive occlusive dressing. She repeatedly instructed the patient on the procedure and he stated that he understood the instructions. When the patient was seen by the home-health nurse, however, the patient was found to be throwing away the dressing and applying the wrapper to his leg.
These incidents and others like them made me think about the jargon we, as health professionals, use and the way we teach our patients. Today, more than ever. patients may not be sufficiently informed or perhaps don't understand what we're trying to teach them. This can be attributed to rapid advances in technology, the complex health-care system, and earlier discharges from the hospital setting. It is also possible for the patient to become confused because each nurse or professional may explain the same concept differently. Many times we use different words to express the same thing, such as "urinate," "void," "pass water," or "take a leak." When we began performing extracorporeal shock wave lithotripsy (ESWL), some of the nurses in our department taught the patients to strain their urine for the gravel to send for stone analysis. The patients were looking for chunks of stone, while the nurses had meant the sand-like par fides which the patients were throwing away. We had to clarify our terms so that stone analysis could be done. At times we must use words that the patient can understand instead of what we're used to. Also, it's important to take into consideration the fact that many different ethnic groups describe the same function differently. You and I may say, "I feel faint," whereas an African American might say, "I'm going to fall out."
Patient education is recognized as an integral part of nursing responsibility. Today this education is vital to the delivery of safe, quality patient care. The educational process is the same as the nursing process. We must assess the individual's needs, develop a plan of care, implement the plan, and evaluate the interventions. In years past, the nurse developed the plan of care. Today the nurse should collaborate with patients and significant others before the plan is devised. This ensures that the plan is individualized, goals are mutually agreed upon, and the patient is motivated to participate in meeting the goals. Before this collaborative effort was called for by the Joint Commission on Accreditation of Hospitals, patients were often not even aware of their plan of care and their outcome goals.
The Nurse Practice Act and the Patient's Bill of Rights set the standards for care. The courts have held nurses accountable for what they have or have not taught. If it's not documented, it's not considered as having been taught. For example, a nurse was sued for not teaching a diabetic patient proper foot care: the patient claimed that was the reason for the loss of his limb. In addition, we are not always comfortable in the role of teacher. There is a difference between wanting to teach and knowing how to teach, but patient education is not covered in the nursing curriculum.
We know patients need to be educated, but due to the many demands on us, that is not always our highest priority. Many times teaching is haphazard and inconsistent. Sometimes we decide when the patient should be taught according to our schedule, rather than being flexible. There should be negotiation and mutual agreement. Also, teaching may be done by several individuals from different departments just as patients are ready for discharge. Often, patients are given sheets of paper to read as they are leaving the hospital and are told to call if any questions or problems arise. However, we cannot be sure that they will actually read the material or that the patient will comprehend. The patient may be illiterate, may only speak or understand a foreign language, or may not understand the terminology and/or instructions. Others may learn not by reading but by doing. Finally, the patient may not even have a telephone. When that person returns to the clinic, office, or hospital, it is found that the instructions were not carried out or were not done appropriately.
Roe gives an example of an elderly woman who called the doctor complaining of nausea and vomiting. She was instructed by the nurse to use rectal suppositories. The nurse explained they were to be inserted into the rectum and would dissolve, thereby relieving the condition. The woman called later to ask how something wrapped in foil would dissolve. The nurse forgot to tell her to remove the foil before insertion. In another instance, a diabetic patient was taught the technique for insulin administration. He was taught by injecting an orange. The patient was admitted to the emergency room with a blood sugar level over 400. When asked to demonstrate drawing up his insulin, the patient did so. Then he asked for an orange to inject. He had been injecting the orange with insulin and then eating it!
It is important for us to consider several areas when teaching our patients. First is the age of the patient with whom we are working. Each age group has specific needs and requires age-appropriate interventions which will be discussed in greater length in "Options and Decisions" on page 2 of this issue. Another consideration is the patient's senses--sight, hearing, and dexterity. Older people cannot distinguish shades of blue. Therefore, something written in dark letters and on a blue background is hard to read. Also, bifocals make a difference in ability to see. I know this from my own experience typing on the computer. Sometimes the light hits the page the wrong way or there is blurring if the screen is not positioned property.
Patient education is an integral part of our responsibility. We must set aside time in our busy schedule to teach. Not all patients are motivated to learn or ready to learn when we're ready to teach; some are overwhelmed. We must provide them the opportunity to learn about their disease and the care required to remain as independent as possible. Many different strategies which will be discussed in this issue of innovations in Urology Nursing can be utilized to teach. Take the time to evaluate the patient's educational level, your own teaching methods, and the availability of educational materials. Comprehensive patient instruction is part of quality patient care and an essential part of the job!