Chapter 1

Overview of Education in Health Care

Historical Foundations of the Nurse Educator Role

• Health education has long been considered a standard care-giving role of the nurse.

• Patient teaching is recognized as an independent nursing function.

• Nursing practice has expanded to include education in the broad concepts of health and illness.

Historical Foundations (cont’d)

Organizations and Agencies Promulgating Standards and Mandates:1. NLNE (NLN)

– first observed health teaching as an important function within the scope of nursing practice

– responsible for identifying course content for curriculum on principles of teaching and learning

Historical Foundations (cont’d)

2. ANA

- responsible for establishing standards and qualifications for practice, including patient teaching

3. ICN

- endorses health education as an essential component of nursing care delivery

Historical Foundations (cont’d)

4. State Nurse Practice Acts

- universally includes teaching within the scope of nursing practice

5. JCAHO

- accreditation mandates require evidence of patient education to improve outcomes

6. AHA

- Patient’s Bill of Rights ensures that clients receive complete and current information

Historical Foundations (cont’d)

7. Pew Health Professions Commission

- puts forth a set of health profession competencies for the 21st century

- over one-half of recommendations pertain to importance of patient and staff education

Current Mandates for Nurse as Educator

Institute of Medicine 2001CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE

21ST CENTURY focuses more broadly on how the health system

can be reinvented to foster innovation and improve the delivery of care.

Six Aims for Improvement

Ten Rules for Redesign

Joint Commission:Patient and Family Education

The organization provides education that supports patient and family participation in care decisions and care processes.

Education and training help meet patients’ ongoing health needs.

Education methods consider the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur.

Current Mandates for Nurse as Educator

Healthy People 2020 (USDHHS)Federal initiatives outlined: To increase the quality & years of healthy lifeTo eliminate health disparities among different

segments of the population*Requires the nurse as educator to use theory

and evidenced based strategies to promote desirable health behavior.

Trends Affecting Health Care

Social, economic, and political forces that affect a nurse’s role in teaching:

• growth of managed care• increased attention to health and well-being of

everyone in society• cost containment measures to control

healthcare expenses • concern for continuing education as vehicle to

prevent malpractice and incompetence

Trends (cont’d)

• expanding scope and depth of nurses’ practice responsibilities

• consumers demanding more knowledge and skills for self-care

• demographic trends influencing type and amount of health care needed

• recognition of lifestyle related diseases which are largely preventable

• health literacy increasingly required• advocacy for self-help groups

Purpose, Benefits, and Goals of Patient, Staff and Student Education

Purpose: to increase the competence and confidence of patients to manage their own self-care and of staff and students to deliver high-quality care

Benefits of education to patients:- increases consumer satisfaction- improves quality of life- ensures continuity of care

Purpose, Benefits and Goals (cont’d)

- reduces incidence of illness complications

- increases compliance with treatment

- decreases anxiety

- maximizes independence

Benefits of education to staff:

- enhances job satisfaction

- improves therapeutic relationships

- increases autonomy in practice

- improves knowledge and skills

Purpose, Benefits and Goals (cont’d)

Benefits of preceptor education for nursing students

• prepared clinical preceptors

• continuity of teaching/learning from classroom curriculum

• evaluation and improvement of student clinical skills

Purpose, Benefits, and Goals (cont’d)

Goal: to increase self-care responsibility of clients and to improve the quality of care delivered by nurses

The Education Process

Definition of Terms

Education Process: a systematic, sequential, planned course of action on the part of both the teacher and learner to achieve the outcomes of teaching and learning

Teaching/Instruction: a deliberate intervention that involves sharing information and experiences to meet the intended learner outcomes

The Education Process (cont’d)

Learning: a change in behavior (knowledge, skills, and attitudes) that can be observed and measured, and can occur at any time or in any place as a result of exposure to environmental stimuli

The Education Process (cont’d)

Patient Education: the process of helping clients learn health-related behaviors to achieve the goal of optimal health and independence in self-care

Staff Education: the process of helping nurses acquire knowledge, attitudes, and skills to improve the delivery of quality care to the consumer

ASSURE Model

A useful paradigm to assist nurses to organize and carry out the education process.

Analyze the learner

State objectives

Select instructional methods and materials

Use teaching materials

Require learner performance

Evaluate/revise the teaching/learning process

Role of the Nurse As Educator

• Nurses act in the role of educator for a diverse audience of learners—patients and their family members, nursing students, nursing staff, and other agency personnel.

• Despite the varied levels of basic nursing school preparation, legal and accreditation mandates have made the educator role integral to all nurses.

Role of Nurse As Educator (cont’d)

• Nurses function in the role of educator as:

- the giver of information

- the assessor of needs

- the evaluator of learning

- the reviser of appropriate methodology

• The partnership philosophy stresses the participatory nature of the teaching and learning process.

Barriers to Teaching

Barriers to teaching are those factors impeding the nurse’s ability to optimally deliver educational services.

Major barriers include:• lack of time to teach • inadequate preparation of nurses to assume the

role of educator with confidence and competence• personal characteristics• low-priority status given to teaching

Barriers to Education (cont’d)

• environments not conducive to the reaching-learning process

• absence of 3rd party reimbursement• doubt that patient education effectively

changes outcomes• inadequate documentation system to allow

for efficiency and ease of recording the quality and quantity of teaching efforts

Obstacles to Learning

Obstacles to learning are those factors that negatively impact on the learner’s ability to attend to and process information.

Major obstacles include:• limited time due to rapid discharge from care• stress of acute and chronic illness, anxiety,

sensory deficits, and low literacy• functional health illiteracy

Obstacles (cont’d)

• lack of privacy or social isolation of health-care environment

• situational and personal variations in readiness to learn, motivation and compliance, and learning styles

• extent of behavioral changes (in number and complexity) required

Obstacles (cont’d)

• lack of support and positive reinforcement from providers and/or significant others

• denial of learning needs, resentment of authority and locus of control issues

• complexity, inaccessibility, and fragmentation, of the healthcare system

Questions (cont’d)

• What are the common mistakes made in the teaching of others?

• How can teaching and learning best be evaluated?

What other questions might you ask?

Chapter 3Applying Learning Theories to

Healthcare Practice

LEARNING

• Learning: a relatively permanent change in mental processing, emotional functioning, and behavior as a result of experience

• Learning Theory: a coherent framework of integrated constructs and principles that describe, explain, or predict how people learn

CONTRIBUTION OF LEARNING THEORIES

• Provides information and techniques to guide teaching and learning

• Can be employed individually or in combination

• Can be applied in a variety of settings as well as for personal growth and interpersonal relations

Application Questions to Keep in Mind

• How does learning occur?

• What kinds of experiences facilitate or hinder the process?

• What held ensure that learning becomes permanent?

BEHAVIORIST THEORY

• Concepts: stimulus conditions, reinforcement, response, drive

• To change behavior, change the stimulus conditions in the environment and the reinforcement after a response

Behaviorist Dynamics

• Motivation: drives to be reduced, incentives

• Educator: active role; manipulates environmental stimuli and reinforcements to direct change

• Transfer: practice and provide similarity in stimulus conditions and responses with a new situation

Respondent Conditioning

• Learning occurs as the organism responds to stimulus conditions and forms associations

• A neutral stimulus is paired with an unconditioned stimulus–unconditioned response connection until the neutral stimulus becomes a conditioned stimulus that elicits the conditioned response

Operant Conditioning

• Learning occurs as the organism responds to stimuli in the environment and is reinforced for making a particular response.

• A reinforcer is applied after a response strengthens the probability that the response will be performed again under similar conditions.

Changing Behavior Using Operant Conditioning

• To increase behavior– positive reinforcement– negative reinforcement (escape or

avoidance conditioning)

• To decrease behavior– nonreinforcement– punishment

Advantages of Behaviorism

• Highly structured situations

• Skills training in which steps and sequences can be clearly delineated

Disadvantages of Behaviorism

• Instruction is mechanistic

• Minimizes student involvement in learning

• Inappropriate for complex mental processes, problem-solving, and critical thinking

COGNITIVE THEORY

• Concepts: cognition, gestalt, perception, developmental stage, information-processing, memory, social constructivism, social cognition, attributions

• To change behavior, work with the developmental stage and change cognitions, goals, expectations, equilibrium, and ways of processing information

Cognitive Dynamics

• Motivation: goals, expectations, disequilibrium, cultural and group values

• Educator: organize experiences and make them meaningful; encourage insight and reorganization within learner

• Transfer: focus on internal processes and provide common patterns with a new situation

Gestalt Perspective

• Perception and the patterning of stimuli (gestalt) are the keys to learning, with each learner perceiving, interpreting, and reorganizing experiences in her/his own way

• Learning occurs through the reorganization of elements to form new insights and understanding

Information-Processing Perspective

• The way individuals perceive, process, store, and retrieve information from experiences determines how learning occurs and what is learned.

• Organizing information and making it meaningful aids the attention and storage process; learning occurs through guidance, feedback, and assessing and correcting errors.

• Focus on describing the way information is tracked, the sequence of mental operations, and the results of operations.

Cognitive Development Perspective

• Learning depends on the stage of cognitive functioning, with qualitative, sequential changes in perception, language, and thought occurring as children and adults interact with the environment.

• Recognize the developmental stage and provide appropriate experiences to encourage discovery.

Social Constructivist Perspective• A person’s knowledge may not

necessarily reflect reality, but through collaboration and negotiation, new understanding is acquired.

• Learning is development

• Assimilation, accommodation, & construction are part of learning

Social Constructivist Perspective ( cont)

• Learning is heavily influenced by the culture and occurs as a social process in interaction with others.

• A learner constructs new knowledge by building on internal representations of existing knowledge thru personal interpretation of experience.

Social Cognition Perspective

• An individual’s perceptions, beliefs, and social judgments are affected strongly by social interaction, communication, groups, and the social situation.

• Individuals formulate causal explanations to account for behavior that have significant consequences for their attitudes and actions (attribution theory).

SOCIAL LEARNING THEORY

• Concepts: role modeling, vicarious reinforcement, self-system, self-regulation

• To change behavior, utilize effective role models who are perceived to be rewarded, and work with the social situation and the learner’s internal self-regulating mechanisms

Social Learning Dynamics

• Motivation: compelling role models perceived to be rewarded, self-system regulating behavior, self-efficacy

• Educator: model behavior and demonstrate benefits; encourage active learner to regulate and reproduce behavior

• Transfer: similarity of setting, feedback, self-efficacy, social influences

COGNITIVE THEORY-Advantages

• Use of intellectual development gives teacher ↑ professional & personal satisfaction

• ↑ satisfaction in relationship with learner• ↑ Increased use of a variety of instructional

strategies → teacher creativity• ↑ learner satisfaction as move into

improved cognitive ability & look forward to more challenging/ stimulating life

• ↑ Critical thinking in learner

COGNITIVE THEORY-Disadvantages

↑ time & energy by teacher to become knowledgeable about different viewpoints

Students stressed if looking for certainty or absolute answers

PSYCHODYNAMIC THEORY

• Concepts: stage of personality development, conscious and unconscious motivations, ego-strength, emotional conflicts, defense mechanisms

• To change behavior, work to make unconscious motivations conscious, build ego-strength, and resolve emotional conflicts

Psychodynamic Dynamics

• Motivation: libido, life force, death wish, pleasure principle, reality principle, conscious and unconscious conflicts, developmental stage, defenses

• Educator: reflective interpreter; listen and pose questions to stimulate insights

• Transfer: remove barriers such as resistance, transference reactions, and emotional conflicts

HUMANISTIC THEORY

• Learning occurs on the basis of a person’s motivation, derived from needs, the desire to grow in positive ways, self-concept, and subjective feelings.

• Learning is facilitated by caring facilitators and a nurturing environment that encourage spontaneity, creativity, emotional expression, and positive choices.

Humanist Dynamics• Education motivates student to develop their

potential & progress to self-actualization• Motivation: needs, desire to grow, self-

concept• Educator: act as facilitator who respects

learner’s uniqueness and provides freedom to feel, express, and grow creatively

• Transfer: positive or negative feelings and choices as well as freedom to learn, promote, or inhibit transfer

HUMANISTIC THEORY- Advantages

• Focuses on honesty, Integrity, manners, respect for others, & accepting responsibility for self-development

• Students engage in all aspects of learning experiences—teachable moments

• Appropriate for learning critical thinking, problem solving, & different points of view.

HUMANISTIC THEORY- Disadvantages

• Direction by faculty is necessary to ensure all domains of learning are adequately addressed.

Neuropsychology and Learning

• Brain and nervous system information processing

• Neurological conditions, mental health issues, and learning disabilities

• Relationship between stress and learning

• Integration of learning theories

Generalizations about Learning

• Learning is a function of developmental changes

• Brain processing is different for each learner

• Learning is active, multifaceted and complex

• Stress can interfere with or stimulate learning

ENVIRONMENTAL INFLUENCES (external)

• stimulus conditions and configuration of elements

• social and cultural influences

• role models, experts, and guides

• reinforcements

• feedback

LEARNER INFLUENCES (internal)

• developmental stage

• habits

• perception

• thoughts and reasoning

• schema

• ways of processing information

• memory storage

• conscious and unconscious motivation

• self-regulation

• subjective feelings

• self-concept

• expectations

• goals

• needs

LEARNER INFLUENCES (internal)

How to promote change

• Relate to what learner knows and is familiar with

• Keep experiences simple, organized, and meaningful

• Motivate learner (deprivation, goals, disequilibrium, needs, tension)

• May need incentives and rewards, but not always

• Experiences must be at the appropriate developmental level

• Make learning pleasurable, not painful

• Demonstrate by guidance and attractive role models

How to promote change

How to make learning relatively permanent

• Relate experiences to learner• Reinforce behavior• Rehearse and practice in variety of

settings• Have learner perform and give

constructive feedback• Make sure interference does not occur

before, during, or after learning

How to make learning relatively permanent (cont’d)

• Promote transfer

• Have learner mediate and act on experience in some way (visualize, memory devices, discuss, talk, discuss, write, motor movement)

State of the Research Evidence

• Tests and modifies theories, methods, and assumptions

• Challenges conventional wisdom and myths

• Interdisciplinary focus is beneficial

• Lack of resources is hindrance

Questions to Consider

• In what ways do the learning theories differ?

• In what ways are they similar?• How can the learning theories be used

in combination to change behavior and enhance learning?

• Why are some theories more effective with certain individuals than with others?

Chapter 4

Determinants of Learning

Educator’s Role in Learning

The educator plays a crucial role in the learning process by:• assessing problems or deficits• providing information in unique ways• identifying progress made• giving feedback• reinforcing learning• evaluating learners’ abilities

The Educator’s Unique Position

The educator is vital in giving support, encouragement, and direction during the process of learning.

The educator assists in identifying optimal learning approaches and activities that can both support and challenge the learner.

Assessment of the learner includes attending to the three determinants of learning:

* Learning Needs

(WHAT the learner needs to learn)

* Readiness to Learn (WHEN the learner is receptive to learning)

* Learning Style (HOW the learner best learns)

Haggard, 1989

ASSESSING LEARNING NEEDS

Assessment of Learning Needs

• Identify the learner• Choose the right setting• Collect data about, and from, the learner• Involve members of the healthcare team• Prioritize needs• Determine the availability of educational

resources• Assess demands of the organization• Take time-management issues into account

Needs are prioritized based on the following criteria:

Mandatory: Needs that must be learned for survival when the learner’s life or safety is threatened

Desirable: Needs that are not life-dependent but are related to well-being

Possible: Needs for information that are “nice to know” but not essential or required because they are not directly related to daily activities or the particular situation of the learner

Methods to Assess Learning Needs

• Informal conversations

• Structured interviews

• Focus groups

• Self-administered questionnaires

• Tests

• Observations

• Patient charts

Assessing Learning Needs of Nursing Staff

• Written job descriptions

• Formal and informal requests

• Quality assurance reports

• Chart audits

• Rules and regulations

• Knox Four-Step approach

Take TIME to take a PEEK at the four types of Readiness to

Learn!

P = Physical readiness

E = Emotional readiness

E = Experiential readiness

K = Knowledge readiness

The Four Types of Readiness to Learn Are:

– measures of ability– complexity of task– health status– gender – anxiety level – support system

The Components of Each Type of Readiness1. Physical readiness

The Components of Each Type of Readiness2. Emotional readiness

- Anxiety level- Support system- motivation - risk-taking behavior- frame of mind- developmental stage

The Components of Each Type of Readiness3. Experiential readiness

– level of aspiration– past coping mechanisms– cultural background– locus of control– orientation

The Components of Each Type of Readiness 4. Knowledge readiness

– present knowledge base

– cognitive ability

– learning disabilities

Learning Styles

Six Learning Style Principles

• Both the teacher’ style prefers to teach and the learner’s style prefers to learn can be identified.

• Educators need to guard against relying on teaching methods and tools which match their own preferred learning styles.

• Educators are most helpful when they assist learners in identifying and learning through the their own style preferences.

Six Learning Style Principles(cont.)

• Learners should have the opportunity to learn through their preferred style.

• Learners should be encouraged to diversify their style preferences.

• Educators can develop specific learning activities that reinforce each modality or style.

Learning Style Models and Instruments

• Brain Preference Indicator (Right-Brain, Left-Brain, and Whole-Brain)

• Embedded Figures Test (EFT) (Field-Independent/Field-Dependent)

• Environmental Preference Survey (EPS) (Dunn and Dunn Learning Style Inventory)

• Myers-Briggs Type Indicator (MBTI)

Right-Brain/Left-Brain andWhole-Brain Thinking

• Brain Preference Indicator• Right hemisphere—emotional, visual–spatial,

nonverbal hemisphere Thinking processes using the right brain are

intuitive, subjective, relational, holistic, and time free

• Left hemisphere—vocal and analytical side Thinking process using reality-based and

logical thinking with verbalization

Right-Brain/Left-Brain andWhole-Brain Thinking

• No correct or wrong side of the brain• Each hemisphere gathers in the same

sensory information but handles the information in different ways

• Knowledge of one’s own brain hemispherical performance can help educators identify the strengths and weaknesses of various teaching methods

Examples of Right-Brain/Left-Brain and Whole-Brain Thinking

• Prefers talking and writing• Recognizes/remembers

names• Solves problems by

breaking them into parts• Conscious of time and

schedules

• Prefers drawing and manipulating objects

• Recognizes/remembers faces

• Solves problems by looking at the whole, looks for patterns, uses hunches

• Not conscious of time and schedules

Left Brain Right Brain

Whole brain—combining both sides of the brain

Environment Preference Survey (LSI)

Stimuli

Environmental

Emotional

Sociological

Physical

Psychological

Myers-Briggs Type Indicator

Extraversion (E) Introversion (I)

Sensing (S) Intuition (N)

Thinking (T) Feeling (F)

Judgment (J) Perception (P)

Kolb Learning Style Inventory

Concrete experience Abstract conceptualization

Active experimentation Reflective observation

Diverger Converger Assimilator Accommodator

Gardner’s Eight Types of Intelligence

(#8 identified in 1999--naturalistic)

Linguistic intelligence Musical intelligence

Spatial intelligence LogicalĞmathematical intelligence

Bodily kinesthetic intelligence Intrapersonal intelligence

Interpersonal intelligence

Generational Styles- Silentsborn 1925-1942 >61 years old

This group is not clueless about technology; the fastest growing group of Internet users

Older adults may need technology training. Let your students dictate the pace; don’t rush things. Be polite, say “please” and “thank you”. Use proper grammar at all times Avoid all off-color language or humor. Even if you’re using computers for training, provide

plenty of opportunity for personal

***interaction: Older learners like to interact with people, not machines.

Generational Styles-Baby Boomersborn 1943-1960 43-60 years old Show them that you care, Be nice Fairness is important. Tell them they are important. Know their names. Give them a chance to talk-they want to show you what they

know. Dialogue and participation is key. Don’t be authoritarian; don’t boss them around. Be democratic--Treat them as “equals” Acknowledge what they know; ask them lots of questions so

they can demonstrate what they know Treat them as though they’re young, even if they aren’t Avoid “sir” and ma’am”, which they may take as an insult Respect their experience

Older peopleDo’s and Don’ts

– All printed material should be clear, easy to read, large enough font.

– Provide a summary of topics and goals. – Be pleasant, personal but not too intimate. – Don’t put them on the spot. Give them time to prepare. – If you’re a 20-something trainer… – Get coaching from someone older to understand the

mindset of this generation. – Invite someone with a little more gray hair to be a

guest presenter in your class, to help with credibility. – Show respect for age and experience.

Generational Styles- Gen Xers

born 1961- 1981FlexibleIndependentCan multitask wellPessimisticUsed to changeWant to get job doneVisual & dynamicState of art technology & know how to use itOnly read when they have to!

Generational Styles- Gen Yborn 1981- 2003 Accept authority & follows rules Balance work & personal life Direct & Vocal Optimistic Socially aware & involved Team player Technology expected Active-let them move around Frequent and instantaneous feedback ARE readers—provide backup info

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