Educating Patients

Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques

Linda Beagley, MS, BSN, RN, CPAN

Health care delivery and education has become a challenge for providers.

Linda Beagley, M

cator, Swedish Cov

Conflict of intere

Address corresp

nant Hospital, 51

e-mail address: lbe

� 2011 by Ame 1089-9472/$36.


Journal of PeriAnesth

Nurses and other professionals are challenged daily to assure that the

patient has the necessary information to make informed decisions.

Patients and their families are given a multitude of information about

their health and commonly must make important decisions from these

facts. Obstacles that prevent easy delivery of health care information

include literacy, culture, language, and physiological barriers. It is up

to the nurse to assess and evaluate the patient’s learning needs and read-

iness to learn because everyone learns differently. This article will

examine how each of these barriers impact care delivery along with

teaching and learning strategies will be examined.

Keywords: patient education, barriers, culture, literacy, perianesthesia nursing.

� 2011 by American Society of PeriAnesthesia Nurses

EDUCATING PATIENTSHAS become a challenge for health care providers because the patient

length of stay has decreased and the need to deliver

complex information has increased. A new version

of the melting pot society requires special efforts

by health care professionals to ensure that the pa-

tient understands the information given to him or

her. Barriers that inhibit patient education are liter- acy, language, culture, and physiological obstacles.

Assessing and evaluating the learning needs of

the patient are essential before planning and im-

plementation of an educational plan. Presenting

a well-formulated plan will increase the likelihood

of a successful recovery for the patient. In this

article, barriers will be dissected and strategies

examined to determine what will best suit the edu- cational needs of the patient.

S, BSN, RN, CPAN, is a PACU Clinical Edu-

enant Hospital, Chicago, IL.

st: None to report.

ondence to Linda Beagley, Swedish Cove-

40 N. California Ave, Chicago, IL 60625;

rican Society of PeriAnesthesia Nurses



esia Nursing, Vol 26, No 5 (October), 2011: pp 331-337

Adult Learning

To effectively educate patients, health care pro-

viders must have an understanding of the princi-

ples of adult learning. Malcolm Knowles, who

began to study adult learners in the 1960s, is

known as the father of adult learning principles be-

cause of his extensive writing on adult education. The term andragogy, the art and science of teach-

ing adults, is synonymous with that of Knowles.

He deduced that adults learn differently than chil-

dren. His studies determined five assumptions on

learning: self-concept, experience, readiness to

learn, orientation to learning, and motivation to

learn.1 According to Knowles, as a person ma-

tures, his self-concept moves from one of being a dependent personality towards one of being

a self-directed human being. Humans accumulate

a growing reservoir of knowledge, followed by

a readiness to learn, which increasingly is oriented

towards developmental tasks related to social roles

with immediate application of their new knowl-

edge. Knowles’ final assumption reflects the moti-

vation of learning as moving from external to internal.1,2 Table 1 compares and summarizes

Knowles’ assumption regarding the adult (andra-

gogy) and the child (pedagogy) learner.


Table 1. Assumptions Differences of Pedagogy and Andragogy1,2

Assumptions Pedagogy Andragogy

Self-concept Dependency Self-directed

Experience Happens to learner Rich resource

Readiness Biologic and academic development Evolving social and life roles

Orientation to learning Logical; directed by teacher Life centered; task/problem centered

Motivation External approval of teacher Internal drive; life goals


Literacy Barrier

Literacy is defined as ‘‘an individual’s ability to

read, write and speak in English and compute

and solve problems at levels of proficiency neces-

sary to function on the job and in society, to

achieve one’s goals, and to develop one’s knowl-

edge and potential.’’3 Illiteracy does not discrimi- nate; it can be found in all populations, and

a person’s grade level is not an accurate gauge

for reading ability.4 Having any level of illiteracy

can cause a number of problems with activities

of daily living, such as analyzing a transportation

schedule, following directions, understanding rec-

ipes, and completing job applications. Low liter-

acy is described as those people who have the ability to read, write, and understand information

only at the seventh grade reading level. According

to the US Department of Health and Human Ser-

vices (DHHS),3 demographics does play a role in

literacy; certain groups demographically have

a higher prevalence of low literacy. Table 2 out-

lines this population.

Low literacy and low health literacy are related but

not interchangeable. Health literacy is defined in

Healthy People 2010 as ‘‘the degree to which indi-

viduals have the capacity to obtain, process, and

understand basic health information and services

needed to make appropriate health decisions.’’5

Low health literacy is content specific. An individ-

Table 2. Demographics of Low Literacy3

Fewer years of education

Lower cognitive ability


Some racial or ethnic groups from the South or




Low income status

ual may be able to read and write in certain con-

texts but struggle to comprehend the unfamiliar

vocabulary and concepts found in health-related

materials or instructions.5 According to the US Department of Education, which conducts a na-

tionwide survey of adult Americans to evaluate lit-

eracy skills,5 an estimated nearly one half of

Americans (90 million) have difficulty understand-

ing and acting on health information. These stud-

ies have linked low health literacy with delayed

diagnosis, poor disease management skills, and

higher health care costs. These same individuals demonstrate a limited understanding of their dis-

ease processes resulting in worse health care out-

comes.6 Unnecessary health care costs ranging

from $106 to $238 billion are attributed to limited

health literacy.7

Factors associated with health literacy are depen-

dent on the skills, preferences, and expectations of health information providers. At times, health

care professionals may be oblivious to the effect

of limited health literacy on patients and the health

care system. In one study7 of 240 health care pro-

viders and students, researchers found fewer than

12% of participants were aware of their degree of

limited health literacy. Twenty-five percent were

found to have a common misconception that health literacy could be determined by race, eth-

nicity, culture, age, or socioeconomic status.7 To

heighten matters, responders inaccurately be-

lieved that patients with a higher level of education

were not at risk for having limited health literacy

(7.4%). In health care, nurses comprise the largest

group of providers and are responsible for ensur-

ing patient education. The researchers recom- mend health literacy education for nurses during

the education process.

Cutilli8 completed a systematic review of the liter-

ature for the purpose of analyzing and evaluating

the research on health literacy and the elderly.


Age becomes an important demographic marker

with an inverse relationship to health literacy.

Cutilli found that as the patient’s age increases,

the health literacy level decreases. This is an

important element because of the aging popula- tion in the United States and the projected trend

of aging. By 2030, it is estimated that 20% of the

population will be 65 years and older.9 The

Federal Interagency Forum on Aging9 reports older

Americans are proportionately more likely to have

below basic health literacy than other age groups.

Thirty-nine percent of people aged 75 years or

older have below average health literacy skills compared to 23% of people aged 65 to 74 years

and 13% of people aged 50 to 64 years.

Language and Culture Barrier

The United States has been known as a melting pot

of diversity over the last 100 plus years. Some

changes, however, have occurred from those early years. Ethnicities are found in large urban neigh-

borhoods, as well as the suburbs and rural areas

of the country. The diversity now existing across

the country has presented many challenges for

health care providers. In 2001, DHHS published

national standards on culturally and linguistically

appropriate services. These DHHS standards10 re-

quired health care institutions to demonstrate cul- tural competency while caring for patients in

a manner responsive to their beliefs, interpersonal

styles, attitudes, language, and behaviors of the in-

dividual and required that care be provided in

a manner that demonstrates respect for individual

dignity, personal preference, and cultural differ-


Health care providers must be knowledgeable of

cultural competencies. Nurses should have aware-

ness of biases and prejudices by examining gener-

alizations they might use routinely about cultures

other than their own. Any biases must be con-

fronted. A commitment to learn more about the

cultures that have been generalized in the past

must be made.11 Second, core cultural values need to be examined and understood about the

varying populations that frequent the institution.

Cultures have several core values on which all

other values are based.12 This foundation is a start-

ing point for health care providers in understand-

ing different cultures.

A challenging aspect is the ability to communicate

effectively to the patient whose native language is

not English. Thoroughly assessing the patient’s

comprehension and the need for a translator is vi-

tal. Every attempt must be made to provide a qual- ified translator whether the translator is physically

present or available via a telephone translation

line. Family members as translators may not be

able to translate important terms needed in obtain-

ing informed consent or education. Furthermore,

caregivers must provide written education mate-

rials for the patient to take home. Many concepts

are not easily translated, and it is imperative to have a fluent translator translate the written

word into the targeted language.11

An estimated 40 different languages are spoken by

the patients who use the services at one Midwest

community hospital. Managing multiple languages

and cultures has proven to be a challenge. The hos-

pital intranet offers resources for many of the cul- tures including common practices, values, and

beliefs. Another unique attribute for this hospital

is the diverse nursing population. In the surgical

arena, every effort is made to pair similar culture/

language of the patient to the health care provider.

This luxury of a diverse nursing population is not

common for many facilities, creating a need to

rely on telephone language lines or hospital- employed interpreters.

Madeleine Leininger’s theory of cultural care diver-

sity and universality defines culture as a guide

whereby the individual’s thinking, aswell as his de-

cisions and actions, is patterned and usually passed

on from one generation to another.12 A person

uses culture as a framework in viewing the world, including health and the need for health care. Be-

cause patients can feel a sense of losing control,

they have a tendency to hold onto family beliefs

when they become ill. Successful teaching plans

are congruent with patient and family values.4

Nursing care that incorporates cultural values

and practices can be positively related to patient

satisfaction, and patient compliance to treatment will be greater. Conflict will result if nursing care

is in discord with the patient’s belief systems.

Knowing one’s patient is important for delivery of

care. A recent Swahili refugee was admitted to

have a cholecystectomy. She had been treated

with tribal medicine, which resulted in several


healed burn scars on her abdomen. Arousing from

anesthesia, the patient relayed through her inter-

preter that she wanted to see what was removed

during surgery. The nurse tried to explain that

the patient’s gallbladder had been removed and sent to pathology. The patient continued to insist

that she needed to see the gallbladder. For this pa-

tient, it was imperative to visualize the gallbladder

to confirm that she was healed from her illness.

The nurse recognized the needs of the patient,

contacted the surgeon, and between the two of

them, they were able to have the patient see her

gallbladder through pictures taken during surgery.

Another example of the importance of cultural

awareness is demonstrated in the story below.

The diabetic educator consults with patients

who have gestational diabetes frequently in the

clinic. A Muslim patient and her husband were

scheduled for education. In this patient’s culture,

the educator was not permitted to address the patient directly and was to speak only to the

husband. To acknowledge the patient’s cultural

beliefs, the educator instructed the husband,

who then instructed the patient in her presence.

The educator used several different teaching tech-

niques to quantify that the patient could safely ad-

minister insulin to herself.

In the American culture, the patient is the key deci-

sionmaker in health care.13 Thepatientmay consult

with other family members, but ultimately, the pa-

tient makes the final decision.14 Traditionally, Amer-

ican families have been defined as having a mother,

father, and child/children. Familial hierarchy can be

different for some cultures. How is the ‘‘family’’ de-

fined for this patient? Is it the immediate nuclear family or the family that may include extended fam-

ilymembers, close friends, or neighbors? Identifying

who is thehealth care decisionmaker for thepatient

is important.4,13 For some cultures, the decision

maker is the head of the household or the entire

extended family. All key players must be involved

in any decisions because they will either reinforce

or block health care behaviors.

The nurse must be aware of both verbal and non-

verbal communication behaviors. There are vast

differences in culturally defined communication

behaviors. Before discussion of personal informa-

tion, it is important to understand cultural prac-

tices related to nonverbal communication during

conversation, communication practices related to

the opposite gender, and cultural practices of so-

cial conversation.4 Gender-specific topics could

be taboo for some cultures. For some, direct eye

contact is a sign of disrespect. Be aware of cultures in which disagreement is perceived as impolite-

ness. The patient may be agreeing with what the

health provider is saying purely out of civility

rather than out of agreement.13,15

Physical and Environmental Barriers

Physiological factors play a role in how the patient is

able toprocess health information. As a person ages,

visual clarity and auditory acuity will decrease, mak-

ing it difficult for the person to receive information.

Many times, a patient may refuse to wear corrective

devices. Altered mental capacity because of patho- logic disease processes, such as Alzheimer disease,

or pharmacologic interventions, such as medica-

tions, can create a barrier for effective teaching.

Increased agingmay causedecline in cognitive capa-

bilities in processing information, memory, and

comprehending abstractions.16 As the adult ages,

the ability to reason and process information occurs

at a slower rate and reaction or response time in- creases significantly after the age 65. Managing

multiple messages simultaneously is harder to do.

Short-term memory loss and the quantity of new

information may limit the length of the teaching

session and amount of information given. The

capacity to draw conclusions from inference

decreases in the older adult. Vague terms of

‘‘adequate,’’ ‘‘several times a day,’’ and ‘‘often’’ can have multiple meanings. Directions should be spe-

cific to time and order with quantities defined.

Physical conditions can limit mobility and the pa-

tient’s ability to sit and be receptive to learning.

Many times, patients seek out health care be-

cause of pain or not feeling well. Uncontrolled

pain will block the patient’s ability to receive in- formation. Anticipation, anxiety, and fear are all

contributing factors in diminishing reception of

knowledge. In the perianesthesia area, pain and

anxiety are obstacles that must be identified

and controlled for the patient to comprehend


Because of busy schedules, environmental barriers are challenging at times. Poor lighting, noise levels,

and room temperatures can inhibit the learning

Table 3. Learning Styles With Teaching Strategies

Learn Styles Teaching Strategies

Visual Visual material

Handouts—easy to read

Variety of technology—computers,

overhead, video, TV, Internet

Auditory Rephrase key points

Vary speed, volume, and pitch

Write down key points

Positioned to hear the message clearly

Use multimedia—tapes, music

Kinesthetic Frequent breaks to move around

Learner writes own notes

Provide tactile activities

Product samples


process. These barriers are difficult to control be-

cause of capped thermostats and controlled light-

ing. Noise levels are under careful consideration

because of the complaints of patients who have

not been able to rest because of noise while hospi- talized. Hospitals have responded by instituting

quiet times during the day. Physical space for the

health care professional to share information

with the patient that is private, quiet, and with

minimal distractions can be at a premium,

although necessary for effective learning. Lastly,

time to devote to adequate teaching is a large bar-

rier in today’s health care environment. Profes- sionals are asked to do more with less, including

time. Patients’ length of stay has shortened be-

cause of many factors, giving the nurse less time

with the patient to accomplish important teaching


Learning Styles

Besides understanding barriers that impact the re-

ception of education, the nurse must be aware of

how an individual learns. Learning patterns are de-

veloped as a child and the ‘‘learner’’ discovers what

works best for his or her individual learning style. Assessment of the patient is essential for effective

teaching, which may require more than one learn-

ing style for comprehension. Learning patterns in-

clude visual, auditory, and kinesthetic.17 A visual

learner prefers to see what he or she is learning.

Pictures and images help the learner understand

ideas and information better than an explanation.

The auditory learner needs to hear the message or instructions being given. This type of learner

wants to be talked through a process rather than

reading about it first. The kinesthetic learner

does not like lecture or discussion, preferring the

movement of the skill or task. Demonstration

and return demonstration works best with kines-

thetic learners.17,18

Once the learning style is established, the nurse

adapts the teaching materials to the preferred

style. For the visual learner, the nurse will havema-

terials for the patient to read or watch. The infor-

mation should be well organized, interesting,

appealing, and easy to read. With today’s advance-

ment of technology, there are many choices to of-

fer the visual learner, including computers, live video feeds, close circuit television, photography,

and the Internet.

For the auditory learner, the nurse should rephrase

important points and questions in several different

ways to communicate the intended message. Vary-

ing the speed, volume, and pitch helps create an

interesting aural texture. An environment where the patient and family can hear the message is im-

portant while encouraging the patient to write key

elements. A quiet space, preferably with the ability

to close the door along with minimal distractions,

assists the teacher to maximum the learning for an

auditory learner. To assist the auditory learner, in-

corporate multimedia of sounds, music, or speech.

Kinesthetic learners prefer frequent breaks so that

they can move around. The nurse should encour-

age the patient to take notes while providing tacti-

cal and hands-on activities. Providing samples

will allow the kinesthetic learner to practice

what he or she is learning, verifying comprehen-

sion through return demonstration. Table 3 sum-

maries learning styles with teaching strategies.

In the perianesthesia arena, more than one type of

teaching strategy may be necessary to successfully

deliver the message and establish comprehension.

For example, the follow-up telephone call was indi-

cating negative outcomes for several patients who

were to remove their urinary catheter at home. The

patient teaching before going home for this patient population had become labor intensive, yet urinary

catheters were still being removed without deflat-

ing the catheter balloon, causing harm to the

patient and unhappy surgeons. Brainstorming,


a group of nurses looked to see how those in the

unit could improve the education process and out-

comes. The result was to continue to demonstrate

to the patient and significant other how to deflate

the balloon and remove the catheter. A return dem- onstration was verified by both the patient and the

family member, each practicing using the syringe

and inserting it into the catheter port (without re-

moving the catheter). The department also devel-

oped a step-by-step handout with pictures for the

patient to take home. All three learning styles

were instituted to ensure a positive change of no

longer having patients remove the urinary device with the balloon intact.

Teaching Methodologies

Teaching methodologies are multiple, and not all will work in the perianesthesia setting. The most

commonmethod is lecture, inwhich the presenter

gives information to the learner and learning is pas-

sive. Discussion allows for participation and for

the ability of the learner to ask and answer ques-

tions and share feelings. Demonstration is a useful

technique using both psychomotor and social

skills of the learner. In health care, demonstration with return demonstration is commonly used

when a new technique or skill is to be learned by

the patient. An example of demonstration was the

urinary catheter instructions and patient demon-

stration previously mentioned.

Another common method of teaching is the use of

printed instructions. Printed health care informa- tion should avoid technical language: use short

simple sentences and write at a level that most pa-

tients will understand.4 The recommendation for

written instructions is that they be at the fifth

grade level. Avoidance of glossy paper and small

fonts also assists the learner.

The Internet can be a friend or foe when obtaining health care information. Hospitals are setting up

Web sites for patients to obtain information. In

one pre-surgical testing department, the nurse

gives the scheduled surgical patient a Web site

where he or she can learn more about anesthesia

before coming to the hospital. Health care profes- sionals also need to establish that the patient is ob-

taining reliable information on the Internet and

steer the patient to government and academic sites

that are proven to be more trustworthy.19 Inpa-

tients can watch health-related stations on their

televisions.11 On the obstetric unit, patients can

access the television to learn about a variety of is-

sues related to the mother and care of the new baby. The disadvantage of watching a television

station or already-taped segment is the inability

to ask and have questions answered immediately.

The nurse must be diligent in following up with

the patient to answer questions and reinforce the

teachings from the video.


For effective delivery of health information and ed-

ucation, the nurse must be aware of the barriers that can impede the patient’s ability and readiness

to learn. Awareness of the potential barriers of lit-

eracy, culture, language, and physiological factors

will help the nurse determine what tools he or

she may need to assist in the delivery of informa-

tion. Awareness of one’s biases and prejudices

and overcoming them will assist in the education

process. The nurse assesses the patient’s under- standing by looking at both verbal and nonverbal

cues that the patient is displaying. Using more

than one way of delivering the message will pro-

mote the patient’s learning. A family member pres-

ent during key moments will assist and help the

patient to remember the information. The astute

nurse will be more successful in overcoming bar-

riers if she or he is aware of patient’s needs and areas where additional assistance is needed.


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  • Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques
    • Adult Learning
    • Literacy Barrier
    • Language and Culture Barrier
    • Physical and Environmental Barriers
    • Learning Styles
    • Teaching Methodologies
    • Conclusion
    • References

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