Teaching is an interactive process that promotes acquisition of new information, attitudes, or skills. It involves steps that mirror the steps of the nursing process (assessment, analysis, planning, implementation, and evaluation). Learning is an active process that involves assimilation of information that produces the acquisition of new attitudes, behaviors, or skills. These activities help to promote wellness, prevent illness, and facilitate the acquisition of coping strategies to restore health or function.
A. Purposes of Teaching and Learning
1. Wellness promotion.
- Presents information and skills that support and develop health practices.
- Examples: Information about health, nutrition, exercise, and hygiene; prenatal and parenting classes.
2. Illness prevention.
- Presents information and skills that promote early detection or prevention of disease and disability.
- Examples: Information about risk factors of disease; dietary teaching to decrease the risk of cancer; information about immunizations, smoking cessation, and safe use of car seat restraining devices for infants and children.
3. Promotion of coping strategies.
- Presents information and skills that enable a client to better cope emotionally and physically with a new diagnosis, interventions, impaired function, or loss of a loved one.
- Examples: Information about using a walker safely, using an assistive device to eat, walking with a prosthesis, coping with role expectations, managing care for a loved one at home, coping with death and dying, administering a gastrostomy tube feeding, managing stress.
4. Restoration of health or function.
- Presents information and skills that enable a client to manage a current health problem, focusing on etiology, medical condition, treatment, and strategies to meet client needs.
- Examples: Information about self-injecting insulin, employing preoperative and postoperative interventions to prevent complications of surgery, and caring for a wound drain.
B. Learning domains
1. People learn through three different domains.
- Cognitive domain: Thinking.
- Affective domain: Feeling.
- Psychomotor domain: Doing.
2. Each domain requires the use of specific strategies that best promote learning.
II. INDIVIDUAL FACTORS THAT INFLUENCE LEARNING
People learn in different ways, such as by seeing, hearing, and touching. Learning is motivated by either an internal desire to achieve a goal (internal locus of control) or a desire to receive external recognition or a reward (external locus of control). In addition, people primarily use information-processing functions from either the left hemisphere (logical thinking) or right hemisphere (intuitive thinking) of the brain. The way in which learning occurs is never identical for two different people and is not identical for one person in different situations. Therefore, nurses must consider these factors when engaged in the teaching/learning process.
A. Learning Styles
1. Visual learners.
- Learn best by processing information with the eyes.
- Examples: Use of pictures, illustrations, photographs, models, and videos.
2. Auditory learners.
- Learn best by processing information by listening to words.
- Examples: Use of verbal instructions, discussions, and videos with verbal commentary.
3. Kinesthetic learners.
- Learn best when processing information by doing.
- Examples: Engage in physical activities and allow touching and handling of equipment.
B. Locus of control
1. Internal locus of control.
- Clients are motivated from within and hold themselves responsible for actions and consequences.
- Example: A person loses weight because of a desire to personally achieve the goals of improved health and appearance.
2. External locus of control.
- Clients are motivated by pressure or rewards from outside the self.
- Example: A person loses weight because a significant other places pressure on the client, such as praise, guilt, or rewards.
III. PRINCIPLES OF TEACHING AND LEARNING AND RELATED NURSING CARE
Implementing client education requires the nurse to assume the role of teacher. As a teacher, a nurse should use universal principles that guide client teaching, regardless of the content being taught or the personal factors of learners. However, when a client presents with specialized needs, these common universal principles should be augmented by individualized interventions that address the client’s specific needs.
A. Learning takes place within the learner
1. Support learning because it is a continuous process of growth throughout life.
2. Understand that learning occurs when the need to learn is relevant to the learner.
3. Assess understanding of the health problem; build a teaching plan based on developing what is already known and then moving on to the unknown. Use examples to which the client can relate.
4. Recognize that the ability and speed at which one learns depends on the individual.
5. Match teaching strategies to the client’s learning style and learning needs.
6. Accept that a teacher only facilitates learning.
B. Motivation facilitates learning
1. Motivation is the driving force that produces an action or promotes the achievement of a goal.
2. Identify behaviors that indicate the client’s readiness to learn.
- Acknowledging a need and believing that the need can be met through learning.
- Demonstrating health-seeking behaviors, such as asking questions, attempting to participate in own care, and requesting reading material or referrals to support groups.
- Believing that the information to be learned has value.
- Believing that identified goals are attainable.
3. Identify behaviors that indicate the client’s lack of readiness to learn.
- Exhibiting moderate to high anxiety: Identify level of anxiety and promote expression of feelings and concerns.
- Exhibiting behaviors that indicate avoidance, denial, or lack of participation in own care: Accept where the client is at and support the client emotionally until ready to participate in the teaching/learning process.
- Expressing presence of pain: Medicate the client to address pain before the teaching session or postpone the session because the client’s physiological status can impede concentration and energy.
4. Begin teaching and learning activities as soon as the need is identified by the nurse or client and as soon as possible, such as on admission to the agency.
5. Formulate a learning contract with the client that includes both short and long-term goals. Short-term goals are desired outcomes that can be obtained within hours or days Long-term goals are desired outcomes that can be obtained within weeks to months.
- Goals should be client centered, realistic, measurable, and time bound.
- Short-term goals provide more opportunities for achievement that supports motivation.
- Learning contracts support mutual respect and responsibility.
6. Provide prompt feedback.
7. Identify progress and employ rewards and incentives for goal achievement.
8. Understand that discussing potential complications may provoke mild anxiety that can increase motivation.
9. Avoid using fear tactics (e.g., “Unless you stop smoking, you may get lung cancer”) to motivate a client.
10. Identify and investigate the cause of nonachievement of goals. Recognize that nonadherence to a treatment regimen may be due to the presence of competing incentives rather than a lack of motivation; for example, learning new ways to achieve independence may be less important than the gains related to continuing in the sick role.
11. Modify the teaching plan according to the client’s progress and changing needs.
NCLEX!!! All behavior has meaning, and a logical connection exists between client behavior and the reasons for the behavior. To identify the true cause of failure to meet outcome goals, nurses must first identify client behaviors or statements that indicate nonadherence to a plan of care, and then they must explore the etiology of the nonadherence. In addition, the terms noncompliant and uncooperative should never be used when describing or documenting client behavior; failure to meet outcome goals should be described, and the reasons for the behavior should be explored and identified.
C. Teaching strategies must be appropriate for the client’s developmental and cognitive levels
1. According to Piaget, cognitive development progresses through three levels.
- Age 2 to 7 years: Find meaning through use of symbols and pictures.
- Age 7 to 11 years: Have logical thinking and understand relationships.
- Age 11 and older: Use abstract thinking and deductive reasoning.
2. Use teaching strategies that are appropriate for the learner’s gross and fine motor development when teaching psychomotor skills.
3. Use teaching strategies that are appropriate for the learner’s level of intellectual ability.
4. Encourage participation in the teaching/learning process; recognize that adults prefer to be partners in this process.
5. Encourage independence; recognize that adults are more independent and self-directed than are children.
6. Reinforce that one is never too old to learn; recognize that adults may believe that they are too old to learn, fear failure, or feel threatened and therefore resist change.
7. Identify and build on positive past learning experiences; recognize that adults have previous life experiences that can hinder or enhance learning.
8. Build repetition into the teaching plan; recognize that older adults might take longer to learn than younger adults do, but they are able to learn.
D. Teaching must be consistent with the client’s cultural and religious beliefs
1. Understand that culture and religion influence beliefs, values, and behaviors; identify factors, such as customs and taboos, that can influence content to be taught or teaching strategies to be used.
2. Identify whether the client is the decision maker; be aware that, in some cultures, women are not allowed to make decisions, and therefore the decision maker in the family should be included in teaching sessions.
3. Identify behaviors that may be culturally related, such as avoiding eye contact to demonstrate respect and smiling and nodding the head to indicate that teaching is understood, even if it is not, so as not to embarrass the nurse.
4. Respect and accept a client’s values and beliefs; incorporate them into the learning plan unless they are unsafe.
5. Use humor cautiously; the intended meaning may be lost in translation by a client from a different culture, or a client may consider the comment condescending rather than funny.
E. Learning occurs best in an environment that is physically and emotionally conducive to learning
1. Schedule teaching so that it does not interfere with rest, meals, tests, and treatments; when appropriate, schedule sessions when a family member can be present to offer support and also learn what is being taught.
2. Determine appropriate teaching session length and frequency on the basis of the client’s condition, such as attention span or activity tolerance.
- Short, more frequent sessions are better than long, infrequent sessions.
- Enough time should occur between sessions so that information can be absorbed and applied.
3. Provide an environment that is private, quiet, and free from distractions and interruptions.
4. Ensure that the environment is physically comfortable.
- Room temperature should not be too hot or too cold.
- Lighting should be adequate and free from glare.
5. Ensure that the environment is emotionally comfortable and provides privacy; close the door, pull the curtain, and drape the client appropriately when teaching personal physical skills.
6. Identify the client’s level of anxiety; be aware that mild anxiety enhances motivation and learning, whereas moderate and higher levels of anxiety impede learning; teaching sessions may have to be shortened or postponed depending on the client’s level of anxiety.
7. Emphasize what is most important to know first for a client who is very ill because fatigue shortens teaching sessions.
8. Address the client’s fears and concerns before beginning teaching and learning activities.
F. Literacy, language, and communication are essential components of the teaching and learning process
1. Commonalities of nursing care related to literacy, language, and communication.
- Use a variety of teaching strategies to present information; stimulate as many of the senses as possible, such as hearing, vision, and touch.
- Use short, simple words and sentences; speak clearly and slowly; use words the client understands; and avoid clichés, slang words, colloquialisms, medical jargon, abbreviations, and ambiguous words.
- Present information so that it progresses with increasing complexity, such as simple to complex and known too unknown.
- Pace teaching sessions so that learning is achieved before moving on to the next concept; identify whether teaching is too fast or too slow and modify the pace accordingly.
- Build repetition of information into the teaching plan; repetition reinforces learning.
- Provide written materials that have many drawings, photographs, and illustrations; avoid handouts with large amounts of written information.
- Document teaching interventions and learning progress; be aware that some facilities have teaching and learning activity forms that document progress and are signed by both teacher and learner.
2. Nursing care specific to literacy.
- Understand that literacy involves the ability to use print and written information to function in society to develop one’s knowledge and potential and achieve one’s goals.
- Never assume that a client is literate.
- Assess a client’s ability to read.
- Teach at the fifth grade level, and move up levels as appropriate.
- Check the reading level of presented written materials and ensure that it is at the level of the client’s ability; most educational materials are written at the high-school level, which can be challenging for some clients to read.
3. Nursing care specific to language.
- Determine whether the client clearly understands English.
- Use a professional interpreter if the client does not understand English because clients have a right to be taught in a language that they understand. The Joint Commission mandates the use of interpreters for non–English-speaking clients.
(1) Employ the use of a language line service, whereby a bilingual operator provides translation, if available.
(2) Do not use family members as interpreters because information must be communicated accurately, objectively, and confidentially.
(3) Talk to and look at the client when using an interpreter.
- Provide information in written and audio formats in the client’s language.
4. Nursing care specific to communication.
- Understand that teaching requires effective interpersonal verbal and nonverbal interaction.
(1) Teaching can be formal or informal.
(2) Teaching can be planned or spontaneous.
(3) Teaching can be performed with an individual or with a group.
- Encourage the client to ask questions and to write down questions that arise between teaching sessions.
IV. SPECIAL NEEDS POPULATIONS REQUIRE SPECIFIC TEACHING STRATEGIES
A. Clients who have visual impairments.
- Encourage use of prescription eyeglasses.
- Provide written material in large print.
- Provide special equipment or learning materials, such as prefilled or automatic-stop syringes, Braille learning materials, and audio learning materials.
B. Clients who have hearing impairments.
- Encourage the use of hearing aids.
- Talk toward the client’s ear with the most acute hearing.
- Speak slightly louder than normal, but do not yell.
- Face the client when speaking; speak slowly and enunciate each word clearly, but do not overly enunciate each word because doing so can interfere with lip reading.
C. Clients who have sensory or motor impairments.
- Understand that sensory and motor impairments interfere with learning psychomotor skills.
- Plan more practice time for clients with sensory or motor impairments, such as neuropathy or hemiplegia.
- Teach clients to use assistive devices to facilitate psychomotor skills when appropriate.
V. TEACHING STRATEGIES
The selection of an instructional approach should be based on a client’s educational needs and personal factors, the time available for teaching, and the resources available. Each instructional approach has advantages, disadvantages, and related specific nursing actions. To maximize learning, nurses should use a variety of teaching approaches.
A. Lecture
1. A lecture presents information verbally and may be accompanied by written material.
2. Advantages.
- Is cost effective.
- Is easy to use with large groups.
3. Disadvantages.
- Does not permit individualization of the material.
- Is not effective in the psychomotor or affective domains.
- Can be a challenging format for a person with impaired hearing as well as for visual learners unless additional teaching strategies are used.
4. Nursing care.
- Provide time for discussion at the end of the program.
- Provide time for additional questions and answers and to correct misconceptions.
B. One-to-one discussion
1. A one-to-one discussion allows the teacher and learner to talk about content to be learned without interference from another learner.
2. Advantages.
- Allows for development of a relationship with the learner.
- Is learner-centered.
- Allows time for frequent feedback.
- Is effective in all three learning domains.
3. Disadvantages.
- Can be labor intensive.
- Isolates the learner from others who may provide support.
4. Nursing care.
- Use for clients who have special learning needs, such as cognitive or sensory impairment, learning disability, mental illness, and activity intolerance.
- Individualize the program to meet the learner’s needs.
C. Demonstration
1. A demonstration involves hands-on manipulation of equipment with time to practice a skill.
2. Advantages.
- Is effective for teaching psychomotor skills.
- Can be used with small groups.
3. Disadvantages.
- Is not effective with large groups.
- Is time consuming and labor intensive.
4. Nursing care.
- Demonstrate each step slowly and accurately; move on to the next step only after it is determined that the previous step is mastered via return demonstration.
- Allow adequate time to practice the skill within and between teaching sessions.
D. Groups (instructional and support)
1. A group consists of two or more individuals interacting, thereby enhancing learning with the exchange of information.
2. Advantages.
- Is effective when teaching in the affective domain.
- Promotes interaction among participants.
3. Disadvantages.
- Occurs in a less-structured environment that allows for unexpected responses by group members.
- Is not effective for the psychomotor domain.
4. Nursing care.
- Use when participant interaction is desired so that learners learn from each other; learners can share ideas, foster development of positive attitudes, solve problems, and offer solutions to each other.
- Function as a group facilitator to keep the group on task.
E. Role playing
1. Role playing is the acting out of a character in a protected environment to practice a response that can be used when confronted with a similar situation in real life.
2. Advantages.
- Offers a safe environment to rehearse and practice responses before being confronted with a real-life situation.
- Raises issues that can be pursued through discussion.
3. Disadvantages.
- May be uncomfortable for people who are too embarrassed or feel awkward engaging in role playing.
- May increase anxiety when emotionally charged areas are explored.
4. Nursing care.
- Set an example by demonstrating behaviors or attitudes that should be learned.
- Establish the situation so that participants involved in the role playing develop an understanding of the principles to be learned.
- Recognize when an increase in anxiety occurs and provide emotional support.
VI. TEACHING TOOLS
The selection of a teaching tool should be based on a client’s educational needs and personal factors, the time available for teaching, and the resources available. Each teaching tool has advantages, disadvantages, and related nursing care. To maximize learning, nurses should use a variety of teaching tools.
A. Printed materials
1. Printed materials present information in a written format; they support comprehension of complex concepts and relationships.
2. Include materials such as pamphlets, booklets, brochures, drawings, and charts.
3. Advantages.
- Allow for standardization of information.
- Can be read at learner’s own pace.
- Are efficient.
- Can be provided in the client’s first language.
4. Disadvantages.
- Cannot be used with clients who are illiterate.
- Cannot be used with clients who have visual impairments unless the materials are in large print or Braille.
5. Nursing care.
- Ensure that the learner is literate and able to see.
- Provide materials in the primary language of the learner.
- Use printed materials especially for clients who are visual learners.
- Ensure that printed materials are easy to read, current, and accurate.
- Use charts to present key points because charts provide easy retrieval of highly condensed information.
B. Programmed instruction
1. Programmed instruction presents information in a “frame” and requires a response before the learner can move onto the next frame; some programmed instructions are linear, and some are branching.
2. Includes computer programs, programmed textbooks, and booklets.
3. Advantages.
- Allows learners to proceed at their own pace.
- Requires learners to be actively engaged in learning.
- Provides immediate feedback for right and wrong answers.
- Allows for efficient use of a teacher’s time.
4. Disadvantages.
- Is not as stimulating as an audiovisual-type presentation.
- Requires a motivated, independent learner.
5. Nursing care.
- Teach the learner how to use the program.
- Explain that the program is a written sequential presentation of learning steps that actively engages the learner in the learning process.
- Teach that programmed instruction is designed so that the learner can proceed at his or her own pace as well as receive immediate feedback for right and wrong answers.
C. Audiovisual aids
1. Audiovisual aids present information that stimulates both the eyes and ears.
2. Include CD programs, computer apps, and videos.
3. Advantages.
- Stimulate the hearing and sight of the learner.
- Can be used with individuals or large groups.
4. Disadvantages.
- May require expensive equipment, such as computers and software.
- Require participants to be able to hear or see material being presented.
- Require a large room when being presented to a large group.
5. Nursing care.
- Ensure that all participants have adequate hearing and vision and are positioned to see and hear the material presented.
- Use audiovisual aids for all clients but especially for auditory learners or individuals with literacy issues.
- Use audiotapes for clients who have visual impairments.
D. Equipment and models
1. Equipment and models provide hands-on items that can be observed, touched, and sometimes utilized.
- Models provide a two- or three-dimensional representation of subject matter that can be observed and touched.
- A piece of equipment may be the actual apparatus that is the focus of the teaching session.
2. Includes materials such as a skeleton, heart model, manikin for CPR, simulation manikin used to mimic clinical situations, various catheters, and syringes.
3. Advantages.
- Are effective in teaching kinesthetic learners.
- Are effective when teaching psychomotor skills.
4. Disadvantages.
- Are expensive.
- Require storage.
5. Nursing care.
- Use for clients who are kinesthetic learners because it allows for manipulation of objects.
- Use for clients who are learning psychomotor skills to promote transfer of information from the brain (cognitive learning) to the hands (psychomotor learning).
- Use to provide visual reinforcement of verbally presented information.
- Employ to teach use of new equipment and related skills presented in continuing education or in-service programs for health-care professionals.
E. Internet
1. The Internet provides immediate access to a vast amount of information using a computer connected to the Internet.
2. Advantages.
- Is entertaining, informative, and convenient.
- Offers a diversity of resources, including electronic learning platforms, search engines, electronic libraries, content portals, and social networking such as chat rooms, bulletin boards, and blogs that offer sharing of information, counseling, and support.
3. Disadvantages.
- Exposes the learner to information that might not be accurate, reliable, or current and content that is unregulated.
- May require the learner to read above a fifth grade reading level.
- Can be accessed without input from a knowledgeable health-care professional.
4. Nursing care.
- Ensure that the learner knows how to access the Internet.
- Teach the learner ways to evaluate the reliability of a site, such as by determining whether an author or organization is reputable and using readily available checklists to assess the quality of a Web site.
- Encourage the learner to access recommended, quality Web sites.
- Review the suitability of a site before making a client referral.
F. Computer-assisted instruction
1. Computer-assisted instruction works like a programmed text in that a frame requires a response before the learner moves to the next frame; however, has more capabilities than a linear approach and can branch to a multiple number of responses based on the learner’s response and is therefore significantly more interactive and individualized.
2. Advantages.
- Allows the learner to proceed at his or her own pace.
- Usually includes interactive activities to engage the learner.
- Commonly includes pretests and post-tests so that learning can be self-evaluated.
- Is convenient if the client has a personal computer.
- Allows the teacher to design a learning prescription and/or corrective action plan that addresses a learner’s specific learning needs.
3. Disadvantages.
- Requires access to a computer.
- Client may not be computer literate.
- Can be costly for an agency if it provides the computers.
4. Nursing care.
- Teach the learner how to use the computer to access the learning program software.
- Use when a learner response pattern is desired to select future lessons.
