No More Patient Education, Please
Before the New Year, we need to step back and figure out how to add value to our patient care starting at the level of the visit. This is the only way that we are going to improve outcomes and reduce costs simultaneously. Both cost reduction and outcomes improvement are imperative for survival in 2012.
One way we can do this is to turn our attention away from patient education. It does not work. Every day I read something like, ‘taught to eat low sodium diet. Pt. Verbalized Understanding.’ I can easily see how such highly skilled care would keep a patient out of the hospital especially when his hypertension has exacerbated three times over two episodes.
In order for our patents to get better, they must change their behavior. They must develop skills that they didn’t have before.
I love sports. Once I suffered through an incredibly boring conversation with my Dad (an engineer) about the physics involved in hitting a home run so I know a lot about hitting homers and my Dad knows even more. Neither of us has ever hit one, though. My son, on the other hand, regularly hit the ball out of the field (and onto cars passing by but that’s another whole blog about auto safety near ballparks).
Sadly, my son really doesn’t know a lot about physics; nor does he care. In fact, nobody ever really ‘taught’ my son to play ball. A couple of men over the years coached my son and countless other boys and young men into becoming competent players.
The first thing that a coach assesses is who really wants to play ball. Until college, all that’s required to play is willingness. There are good players and bad players but everyone gets a little better as the season goes on because they like playing ball.
Coaches always build on the basics. They start off with fundamentals before they move onto more complicated plays.
Coaches set goals. They obviously like to win but long before the season even starts, they are coaching players to improve their stats a little at a time.
Coaches ‘motivate’ players. Some of us are a bit put off when coaches call players ‘sissies’ and use language no child under 35 should ever hear but I must admit it is effective.
Finally, there isn’t a coach worth their whistle that doesn’t keep up with the numbers. Baseball is all about statistics. Football – not so much – but I guarantee you that every coach knows the number of yards, field goals, etc. that their team accomplished during last week’s game.
How do we apply that to patient care? Starting at the beginning we have to get our patients to ‘want to be on the field’. But we also know that less than one percent of people who play sports growing up become a professional athlete. (We also know that some people willingly play football for Alabama and I can only guess it is because they are desperate for an education or just love football and this blog could not begin to cover that psychopathology). In other words, for most athletes, the reason why they play is because it adds quality to their life. So start by finding out what your patient considers important to his or her quality of life. Here are a few suggestions I wrote a few weeks ago.
Build on the basics. If you are admitting a patient newly diagnosed with hypertension, what is the first thing that he should know? For most people it would be how to take medications safely but not always. Your patient may be obsessive about medications but feels that with all the pills he or she is taking they can eat anything they want. That would be the first basic need for that patient – adhering to a low sodium diet.
We are very much aware of our nursing goals on the care plan but what about the patient’s goals? How does he or she know how well they are doing? Feedback is critical when changing a behavior. Setting small goals is important so that our patients can enjoy some success on their way to the big leagues and we can intervene when the numbers move too much in the wrong direction.
Obviously, no matter what kind of day we are having, we are not allowed to yell at patients or to call them sissies. We are not allowed to threaten them, bribe them with money or chocolate (esp if diabetic) or otherwise coerce or harass them into doing what we want them to do. Isn’t that just like Medicare? They task us with making homebound patients well and then they tie our hands with all these stupid rights and responsibilities.
So, that leaves us with motivating a patient by turning their goals to our goals. The patient’s goal may be to get clearance from his MD to drive a car again. Your nursing goal may be to get the patient to comply with a reduced sodium diet and lose weight. Work it, baby! Coach the patient on keeping a food diary and daily weights. Give the patient tools to monitor his numbers. Get the patient to practice! Involve the patient as much as possible.
How many times do you get the feeling that a patient has just given up? They have tried for years to cope with their hypertension and blood sugars, etc. and quit caring a long time ago. Let them see some success. Regularly. Remember, they may have tried before but this time they have you as a nurse and let that be the difference between past failures and future success.
Finally, keep up with the numbers. Don’t set a system in place for a patient and never follow-up. It is a very powerful tool to hold someone accountable for their behavior. Often, just knowing that the nurse is going to weigh them and look at their food diary and daily weights is enough to get them through a rough spot. Call them once or twice a week if they have forgotten to weigh themselves in the past week. Use a free internet text messaging system to text them in the mornings. Be creative.
As the patient begins to experience success they will undoubtedly enjoy feeling better, too. Each week, keep adding to their playbook. Replace one or two visits with a phone call if the patient is doing very well. This will give you the resources to take care of the patient in the unlikely event of another exacerbation.
When the patient has enjoyed a stable blood pressure for a few weeks and has lost weight and is eating well on a low sodium diet, do not discharge the patient. Graduate them! Give them a certificate of recognition for taking back control over the disease process that was controlling them. They deserve it. After all, if you did your job right, most of the real work was done by the patient. You were just the coach.
That kind of care and follow up is something I would pay 120.00 for if my mom or dad needed it. I would pay a bonus if you were subjected to a spontaneous informercial on the physics of home runs and why an ultra-light baseball bat is important to the process. I would understand, however, if you quit when he decided it was time that you learned how to use a slide rule. No one gets paid that much.
I agree with you wholeheartedly. Teaching and training when performed in the traditional sense has never been shown to have a significant positive effect on patient outcomes. I would add to your list of suggestions, The HHC nurse is in a unique position to identify possible obstacles present that may prevent the patient from achieving their goals. This is a very valuable and underutilized skill.
Danny Crudo. Pharm. D. M. S.
HHC Compliance / Integrity Consultant
Teaching is important, but like any skill you need some form of measurement or return demonstration to measure effectiveness. Just telling a patient to watch their sodium intake means little. Showing sodium content on labels and helping them to understand sources of sodium in packaged foods is more useful.
I agree with your ideas- love to see patients take control. It can be a struggle though. We hope through education of what factors are exacerbating their illness that they will be motivated to do whatever it takes to control these things. Recording weights, documenting food intake, recording blood sugars, these are useful to keep the patient involved. I don’t think that it eliminates the need for teaching though.
Yeah. Maybe eliminating teaching all together is a bit drastic. I think in my mind, ‘coaching’ was a more involved, patient centered way of teaching.
However, there are those jewels of patients out there who take what you teach them and incorporate the knowledge into their behavior. They are so rare that I forget about them:)
I hate the word coach. Because I hate sports and sports analogies. I prefer calling it what it is – facilitating learning. You do not teach adults. That is why college courses geared for working adults are so different than those that are geared for 18 year-olds. Because in many of them, you don’t have teachers, you have facilitators.
The key is not to lecture. They key is to empower. And you do this best by finding out what your patient already knows, what they want to learn AND how they learn best.
Giving handouts to someone with never really diagnosed dyslexia who can’t even read at a 3rd grade level is pretty well useless. And so is giving them in English to someone who reads only Russian. We assume that because something worked with patient A, it will work on patient B.
I really believe how we learn is somewhat based on our age. I feel young people learn less by reading than us old folk do who grew up on newspapers and magazines or by listening because of radio or very dry TV news. We didn’t have all the eye candy they do today.
But how many people out there ever ask anyone HOW DO YOU LEARN? Even our newly hired nurses are all treated equal.
Okay off my soapbox. I do so love reading your blog and cry that I can’t read it and share it with everyone at work. (WordPress is blocked)
You said a lot that was very important but I just can’t get past the fact that you hate sports. Really?
You are correct. I learn by reading. I suspect most of you who end up here do as well. I also know that if most people did read, I wouldn’t have a job. Some people are visual and some remember what they hear. Some are educated and some do not have the luxury of an education. Vision, confusion, age related dementia and hearing all impair learning ability. Being successful with one patient does NOT give you the ability to be successful with all patients. A good nurse listens to their patients, watches their responses and measures how their behavior changes in response to the teaching. If all it took was a teaching handout, none of us would have jobs.
I keep a teaching library on my computer. I have multiple teaching guides on many subjects. I wish that there were more downloadable videos to share on iPads with patients. I wish that people would start adding the V-code for functional illiteracy in their diagnosis list. It would give us great information a few years down. My wish list is long for a Sunday night. The week hasn’t even begun yet.
Try going to http://www.haydelcs.com and see if you back into the blog that way. It is a domain for my company but keeping a real website is too complicated so it points here. I will leave that to real geeks and just blog even though I hate the word ‘blog’ as much as you hate the word ‘coach’. It just sounds bad like an insult to my auditory faculties.
We have standardized handouts so that (1) the content is uniform and (2) a dared, signed copy goes in the medical record and (3) the patient has something in writing (because none of us retain 100% of instructions or coaching
the medical record documents content for any reviewer, the nurse doesn’t have to write a book to document content, and the patient has something to refer to if needed
I do like handouts because they simplify documentation and they are very explicit about what is taught. Having said that, I collect handouts from all over the place. Different patients have different needs and literacy levels. Sometimes you may want to bring a very large print handout with pics for the patient with very poor vision and a more detailed handout for a family member who can read and see better. I love standardization almost as much as I hate it:) I think as long as standardization does not substitute for critical thinking, they are great but don’t be afraid to broaden your available handouts. I will eventually put mine up for you to share. There are already some if you look on the right hand margin under patient handouts. These are good for when you find a new diagnosis but I think they are not as complete as our patients require to really become competent in handling a disease process.