Effective health education is invaluable to the health care of society.

Respiratory therapists (RTs)

educate patients by providing information about disease processes, medications, and treatment
procedures. They teach patients how to perform diagnostic tests like basic spirometry, and they educate
patients about health promotion issues such as tobacco cessation. RTs educate patients in all age
groups, including geriatric, adult, adolescent, and pediatric patients. In certain situations, RTs educate
the parents or the spouse of the patient in the home-care setting. RTs are also frequently called on to
provide educational programs to patients with asthma and cystic fibrosis.
For these reasons, this chapter reviews important issues related to patient education, disease
management, and health promotion.
The top five causes of death in the United States are heart disease, cancer, cerebrovascular disease,
chronic obstructive lung disease (i.e., bronchitis and emphysema), and accidents.1 It is believed by most
experts in health care that the majority of these illnesses are preventable. Public education about risk
factors is the key to the prevention of these diseases and probably has the greatest potential for making
an impact on health care in this country. Therefore, the emphasis in health care should be on health
promotion and disease prevention. RTs will play a greater role in health promotion and prevention in
the future.
Patient Education
If we think of patient care as customer service—which it indeed is—then we cannot ignore education as
a crucial component of that service. Whether we buy a car or a television set, we expect the salesperson
to educate us about the essential aspects of our purchase. We also expect this information to be
provided in writing. Likewise, education is an essential component of patient care. For patients to
assume or resume control of their health, they must be educated. Because they rely on the health care
practitioner to provide this education, every respiratory care education program should include
instruction regarding patient education.
Performance Objectives
Initially it is helpful for the RT to develop learning objectives that are appropriate for the specific patient
education topic to be addressed. These learning objectives will help to clarify the teaching strategies
that are needed for patient education sessions. Objectives should be stated in measurable terms so that
the RT and the patient can recognize when the objective has been accomplished. Clear objectives
describe what is to be accomplished and how evaluation will occur.
The format for writing an objective is as follows:
1. Begin with the phrase, “At the end of the lesson, the patient will … .”
2. Write the action verb (e.g., “list,” “describe,” “demonstrate”).
3. Write a condition, if needed (e.g., with or without the use of notes).
4. Write a standard, if needed (e.g., how fast, how accurate).
For example: At the end of the session, the patient will be given a metered-dose inhaler and spacer and
be able to demonstrate the correct technique for using the metered-dose inhaler in 5 minutes or less.
Action verb: “demonstrate” (from the psychomotor domain; the relevant domains are discussed later in
this chapter)
Condition: “given a metered-dose inhaler and spacer”
Standard: “in 5 minutes or less”
Learning Domains
Learning occurs in three domains: cognitive, psychomotor, and affective. Some learning sessions will
involve only one domain, whereas others may involve all three. The cognitive domain is very important,
because it will address the knowledge that a patient needs regarding his or her illness and how to
manage it. The psychomotor domain addresses the skills that the patient will need to acquire to perform
specific treatment modalities (e.g., the use of metered-dose inhalers). The affective domain involves
teaching patients about the necessary attitudes and motivations for successfully living with their
diseases.
Mini Clini
Developing Learning Objectives for the Use of an Albuterol Metered-Dose Inhaler
image Problem
Your 31-year-old patient is newly diagnosed with asthma, and she is being discharged tomorrow. She
requires instruction regarding how to properly use her albuterol metered-dose inhaler. Develop learning
objectives for her, and address each learning domain.
Solution
Use a variety of learning objectives, including the following:
Cognitive domain: Describe the action of albuterol on the bronchial smooth muscle; recognize when it is
necessary to seek medical attention.
Affective domain: Agree that it is important not to skip a dose; verbalize willingness to use the metered-
dose inhaler; feel satisfaction by controlling the disease.
Psychomotor domain: Demonstrate the ability to assemble the metered-dose inhaler and spacer; inhale
slowly and deeply with an inspiratory hold.
Cognitive Domain
The cognitive domain is probably the easiest to translate into learning objectives because it involves the
facts and concepts that the RT wants the patient to know and apply by the end of the education session.
Objectives for the cognitive domain might include the following:
1. List the indications for oxygen therapy.
2. Discuss the importance of using the prescribed liter flow.
3. Explain the relationship between oxygen and combustion.
Any factual information that you expect the patient to understand and apply falls under the cognitive
domain. Action verbs for the cognitive domain are included in Table 49-1.2
TABLE 49-1
Verbs for the Cognitive Domain
Purpose Example Verbs
1. Knowledge Cite, define, read, identify, list, label, name, outline, recognize, select, state
2. Comprehension Convert, describe, defend, explain, illustrate, interpret, give examples of,
predict, paraphrase, summarize, translate
3. Application Apply, compute, construct, demonstrate, change, calculate, use, estimate, modify,
present, prepare, solve, proceed, relate, utilize
4. Analysis Analyze, associate, compare, contrast, determine, diagram, differentiate, discriminate,
distinguish, outline, illustrate, separate
5. Synthesis Categorize, combine, compile, compose, create, design, develop, devise, integrate,
modify, organize, plan, propose, rearrange, reorganize, revise, rewrite, translate, write
6. Evaluation Appraise, assess, compare, conclude, contrast, critique, discriminate, make a decision,
support, evaluate, judge, weigh
Modified from French D, Olrech N, Hale C, et al: Blended learning: an ongoing process for Internet
integration, Victoria, Canada, 2003, Trafford Publishing.
Psychomotor Domain
Repetition and active involvement are important when teaching a psychomotor skill. RTs who teach new
skills to patients need to provide plenty of opportunity for the patient to practice the activity. Simple
demonstration of the skill to the patient is not enough. To confirm performance in the psychomotor
domain, have your patients provide a return demonstration. Be sure to provide help and
encouragement as needed. Be patient; not everyone develops skills at the same rate.
Examples of action verbs for the psychomotor domain are included in Table 49-2.2
TABLE 49-2
Verbs for the Psychomotor Domain
Purpose Example Verbs
1. Perception: prepares and recognizes sensory cues to want to respond Detect, distinguish,
differentiate, identify, isolate, relate, recognize, observe, perceive, see, watch
2. Ready to act and respond Begin, explain, move, react, show, state, establish a body position,
place, posture, assume a stance, sit, stand, position
3. Guided response: imitate and practice; rough sequencing of events Copy, duplicate, imitate,
manipulate, operate, try, practice, dismantle
4. Efficiency: smooth sequencing of events Assemble, calibrate, construct, display, fasten, fix, grind,
manipulate, measure, mix, sketch, demonstrate, execute, increase speed, improve, make, show
dexterity, pace, produce
5. Perform alone: modifies, responds as needed Act habitually, advance confidently, control, excel,
guide, manage, master, organize, perform quickly and more accurately
6. Creates a new or original model
Affective Domain
The patient’s attitudes and motivations influence his or her ability to learn. It is important to remember
that, with patient education, timing is everything. Patients who have recently been given a poor
prognosis or who are in pain are not in an optimal position to learn. Maslow suggested a hierarchy of
needs, and he identified physiologic needs as the most basic of human needs, followed by safety, love,
esteem, and self-actualization.3 Lower-level needs must first be satisfied before moving on to higher-
level needs. For example, if a patient is dyspneic or in pain, he or she will probably not be receptive to
learning the steps that are involved in cleaning a small-volume nebulizer. It is important for RTs to assess
a patient’s readiness to learn by talking with the patient and his or her family and by listening to the
patient’s concerns. It is important to develop a relationship of trust and to be empathetic with the
patient.
The RT should begin with easy-to-master facts and skills. After the patient conquers these, motivation
should increase, and the patient will have a feeling of accomplishment. Motivation is also enhanced by
presenting material clearly with the use of a variety of teaching methods and by relating the facts and
skills to practical applications. Getting patients to see how these skills will benefit them is the key to
motivation. Communicating to the patient that there is something that he or she can do to maintain or
improve his or her health and sense of well-being is important.
Objectives in the affective domain—using the oxygen therapy example mentioned earlier—might
include the following:
1. Demonstrate genuine concern for yourself by using your oxygen therapy correctly.
2. Demonstrate a willingness to learn by being an active participant in the program.
Affective domain action verbs are included in Table 49-3.2
TABLE 49-3
Verbs for the Affective Domain
Purpose Example Verbs
1. Receive: becoming aware of Accept, acknowledge, alert, choose, give, attend, notice, perceive,
tolerate, select
2. Respond: interested in or doing something about something Agree, assist with, aid, answer, assist,
comply, conform, communicate, consent, label, obey, cooperate, follow, read, report, visit, volunteer,
study
3. Value: concerned about, developing an attitude Adopt, assume, behave, choose, demonstrate,
commit, desire, initiate, join, exhibit, express, prefer, seek, share
4. Organize: arranging systematically, confirming Adapt, adjust, arrange, classify, conceptualize,
group, rank, validate, verify, strengthen, substantiate, corroborate, confirm
5. Characterize: internalizing a set of values, championing Demonstrate a change in lifestyle,
discriminate, defend, influence, invite, listen, preach, qualify, question, serve, act upon, advocate,
devote, expose, justify, support
Modified from French D, Olrech N, Hale C, et al: Blended learning: an ongoing process for Internet
integration, Victoria, Canada, 2003, Trafford Publishing.
Teaching Tips
Following is a list of time-honored suggestions for improving patient education:
• Address the patient’s immediate concerns first.
• Create an optimal learning environment. Teach in a quiet and relaxed setting.
• Have patients use as many of their senses as possible during their learning session. Whenever
possible, include hearing, seeing, smelling, speaking, touching, and doing.
• Keep sessions short. If the material is complex, break it down into brief segments.
• Repeat, repeat, repeat!
• Provide many opportunities for the patient to practice psychomotor skills.
• Be prepared.
• Be organized. People learn more quickly when they are presented with information that is well
organized.
• Demonstrate enthusiasm for what you are doing. The learner can always sense your level of
motivation.
• Evaluate in a nonthreatening manner, and provide helpful feedback. Use evaluation as a learning tool.
Teaching Children As Compared With Teaching Adults
Teaching children is often very different than teaching adults. Children are more motivated by external
factors (e.g., prizes) as compared with adults, who tend to have internal motivating factors. This
suggests that adults will learn quicker if they can easily see the intrinsic value of knowing more about
their illness. Alternatively, children may need a more obvious reward system in place before learning
can take place. They have no problem taking instruction from adults, because they are often dependent
on such instruction. Adults, however, are more independent, and they do not like being dependent on
others. This suggests that adults should be more involved in setting program goals and that they will
readily learn skills that make them more independent. Other important issues related to differences
between children and adult learners are listed in Box 49-1, and allocated time for teaching is given by
age in Box 49-2.4
Box 49-1 Learning Differences Between Children and Adults
Child
• Motivated by external factors like grades
• Directed by others
• Learning is a big part of his or her life
• Trusts teacher
• Has limited experience
• Learns for the future
• Learns quickly
• Tends to learn in accordance with his or her developmental stage
• Has no problem with a slow pace of learning
• Subject oriented
Adult
• Motivated internally
• Is self-directed
• Learning is only one part of his or her life
• Questions the teacher
• Has rich life experiences
• Learns for the present
• May learn more slowly
• Varies with regard to learning ability
• Dislikes a slow pace of learning
• Problem oriented
Box 49-2 Attention Spans for Different Ages
• Toddlers: about 2 to 3 minutes
• School-aged children: about 10 to 15 minutes
• Adolescents and adults: about 20 to 30 minutes
Evaluation of Patient Education
The critical question that remains when all of the patient education sessions are complete is, “Has the
patient learned?” Evaluation is the process that answers that question. The method used to evaluate
learning is determined by the measurable learning objectives (i.e., cognitive, affective, or psychomotor).
Cognitive objectives are often evaluated with the use of a written examination. Objectives in the
affective and psychomotor domains are evaluated with the use of performance checklists.
Informal evaluation should occur during the educational process. The RT can ask simple questions along
the way to identify whether the patient has comprehended the information. If the patient provides an
answer that is not correct, the RT should view this as an opportunity to repeat previous discussions or to
present the material with a new approach. The RT must never convey disappointment or frustration
when patients are having trouble learning new material.
Mini Clini
Metered-Dose Inhaler Instruction for a Pediatric Patient
image Problem
How would you change the approach to the metered-dose inhaler situation described in the previous
Mini Clini if your patient was a 7-year-old boy with asthma?
Solution
Although the learning objectives may remain the same, the methods may be different. You may
compare the slow, deep inspiration to getting ready to blow out the candles on a birthday cake. You
may use swimming under water as an image to encourage breath holding. Use simple diagrams to show
how the medication will act on the patient’s lungs. If he likes sports, tell him about athletes who
compete well despite having asthma (you may also use this illustration to stress the importance of
controlling asthma). An abundance of resource materials are available for children with asthma; make
use of them. Many local, state, and national lung associations (www.ala.org) offer such learning aids as
age-appropriate books, coloring books, and puppets to make the learning process more fun for children.
49-1 Providing Patient and Caregiver Training
AARC Clinical Practice Guideline (Excerpts)*
American Association for Respiratory Care Clinical Practice Guideline (Excerpts)* updated June of 2010.
www.rcjournal.com/cpgs/pdf/06.10.0765.pdf
Indications
Patients who need to increase knowledge and understanding of health status and therapy; improve
skills needed for safe and effective health care; and develop a positive attitude, strong motivation, and
increased compliance. Patients need to know the answers to “Ask Me 3”: What is my main problem?
What do I need to do? Why is it important for me to do this?
Contraindications
None.
Complications
Omission of essential steps concerning care, presentation of inconsistent information, or failure to
validate the learning process can lead to unfavorable results. Lack of cultural competence, and
information appropriate in the language other than English will result in less than desirable outcomes.
Lack of trust.
Limitations
• For the patient: Lack of motivation; impairment (physical, mental, or emotional); inability to
understand instruction; illiteracy; language barriers; religious and/or cultural beliefs that are at odds
with the material presented. Lack of health literacy, despite educational completed and conflicts of
religious and/or cultural practices.