According to the Guide to Physical Therapist Practice, patient/client-related instruction is one of the three major components of physical therapist intervention.1In cardiovascular and pulmonary physical therapy, choosing an effective procedural intervention is based on the physiological evaluation of the patient. Similarly, choosing effective patient instruction or education methods is based on the learning needs assessment of the patient.2 The overall goal of patient education is for the patient to practice health behaviors that promote health, well-being, and independence in self-care. Cardiovascular and pulmonary patient education can pose a significant challenge to the physical therapist. Patient education interventions can range from teaching a hospitalized patient about cardiac risk factor modification to designing a series of community-based exercise classes for children with asthma. Meeting this challenge is important because the benefits of patient education include reduced health-care costs, reduced disability, enhanced patient decision making, improved patient knowledge, and increased quality of life. In addition, physical therapists share with other health-care providers the responsibility of ensuring that patients have the opportunity to make informed choices in their care. Unless effective patient education is implemented, this opportunity will be lost. Physical therapists believe that patient education is an important part of patient care.3 The teaching role of the physical therapist has been reported as highly valued by patients as well.4 According to the Consumer and Patient Health Information Section of the Medical Library Association (1996),5 patient education is “a planned activity, initiated by a health professional, whose aim is to impart knowledge, attitudes and skills with the specific goal of changing behavior, increasing compliance with therapy and, thereby, improving health.”5 The overall objective of patient education is to effect a durable cognitive improvement that results in a positive change in an individual’s or group’s health behavior. In most cases the physical therapist must embark on a process to meet this objective in the course of procedural interventions. The education process consists of assessing the learning needs of the patient, identifying measurable, realistic objectives, planning and implementing the patient education program, and finally, evaluating its effectiveness. Specific examples of patient education learning objectives are listed in Box 28-1. Achieving these objectives will lead to the achievement of a host of documented benefits of patient education. These include reduced length of hospital stay,6 reduced patient anxiety,7 improved health-related knowledge,8 increased quality of life,9 and improved response and adherence to medical treatment.10 Patient education has also been shown to empower patients to take more active roles in their health care.11 Patients who are educated partners in their care are able to be smart consumers in the health-care system and adapt more readily to the changes in their lifestyles that result from illness. Educated patients learn and understand the health consequences of their behaviors and choices. The social-cognitive theory as developed by Bandura (1986)12 posits that human behavior can be explained and predicted using the following key regulators: incentives, outcome expectations, and efficacy expectations. For example, a myocardial infarction patient perceives value in following the exercise program (incentive). Patients with this incentive will attempt to exercise if they believe that their current sedentary lifestyle poses a threat to health. These patients also believe exercise will reduce that threat (outcome expectation) and that they are personally capable of performing the exercise program (efficacy expectation). Outcome and efficacy expectations directly relate to patients’ beliefs about their capabilities and the relationship of their behaviors to successful outcomes. In essence, then, behavior is influenced by perceptions that create expectations for similar outcomes over time. To function competently in a given environment requires a belief in one’s ability to attain a certain level of performance. Bandura terms this self-efficacy.13 He argues that perceived self-efficacy influences all aspects of behavior, including learning new skills and inhibiting or stopping current behaviors. Self-efficacy has the following four primary determinants: 1. Performance accomplishments, which is the strongest determinant and refers to “acting out” the desired behavior and mastering the task, resulting in increased self-efficacy 2. Vicarious experience, which involves learning through observing the actions of others, especially actions with clear, rewarding outcomes 4. One’s physiological state as it relates to the perceived ability to perform a given task The health-belief model, developed in the early 1950s, theorizes that patients are likely to take a health action in the following situations: they believe they are at risk for illness; they believe that the disease poses a serious threat to their lives should they contract it; they desire to avoid illness and believe that certain actions will prevent or reduce the severity of the illness; and they believe that taking the health action is less threatening than the illness itself.14 This model was originally developed in an attempt to understand why large numbers of people failed to accept preventative care or screening tests for early disease detection. Subsequent studies have used the model to analyze compliance with regimes for hypertension, asthma, and diabetes.15 The health-belief model conveys that in the context of health behavior some stimulus or “cue to action” is necessary to initiate the decision-making process. These cues can be internal (i.e., a productive cough) or external (i.e., instructional video on pulmonary hygiene techniques). Once the behavior commences, it is understood that many demographic, structural, personal, and social elements are capable of influencing the behavior. In addition, perceived barriers (i.e., unpleasant side effects) may limit or prevent undertaking the recommended behavior. The behavior-modification approach has its roots in operant-learning theory and consists of techniques that manipulate environmental rewards and punishments in relationship to a specified behavior.16 The theme of this approach is that an individual’s behavior can gradually be shaped to meet a set objective. According to Becker (1990),17 the behavior-modification approach frequently follows a general plan: “identify the problem; describe the problem in behavioral terms; select a target behavior that is measurable; identify the antecedents and consequences of the behavior; set behavioral objectives; devise and implement a behavior change program; and evaluate the program.”17 This plan is similar to the patient/client management model1 that physical therapists use to achieve optimal patient care outcomes. The physical therapist examines the patient, describes the problem(s) in functional terms (evaluation and diagnosis), sets short-term and long-term functional goals, designs a plan of care to meet those goals (prognosis), implements the plan (intervention), and reevaluates the patient. These similarities may facilitate the use of the behavioral-modification approach by physical therapists. Health-care contracts can be useful in implementing the behavior-modification approach. An example of such a contract may be seen in Box 28-2. The contract should be realistic, measurable, and renewable.18 Specific goals, time frames, behaviors, and contingencies are written in the contract. The clinician and patient discuss and then sign the contract. Positive and negative reinforcements are used to facilitate the desired behaviors in the patient. Ideally, once the contract expires, the patient feels competent and is able to continue the desired behaviors without the external reinforcements. The most important aspect of planning for patient education is assessing the learner. The process of patient education requires assessment of the total patient and family, including an understanding of the psychosocial, socioeconomic, educational, vocational, and cultural qualities of the patient and family unit.19 Assessing educational needs of the patient allows the physical therapist to determine what the patient needs to know to meet the desired cognitive and behavioral teaching objectives. This assessment also increases patient-teacher rapport and allows the physical therapist to individualize the learning experience. The American Physical Therapy Association’s Commission on Accreditation of Physical Therapy Education in their Normative Model of Physical Therapist Professional Education: Version 200420 requires that the graduate physical therapist be able to “effectively educate others using culturally appropriate teaching methods that are commensurate with the needs of the learner.”20 Learning needs can be assessed in a variety of ways. These include patient and family interviews, questionnaires and surveys, written tests, and observation of patient performance.21 Interviews allow the physical therapist to ask questions directed at determining the patient’s view of the illness, including associated beliefs and attitudes. Questionnaires and surveys can be used in conjunction with the interview to document the patient’s responses to specific questions about his or her condition. Open-ended questions such as “What are the major problems your illness has caused for you and your family?” elicit more information than a multiple-choice format. Written tests can be helpful in determining what patients already know when the tests are given, before any teaching. These tests can also identify problems with reading, comprehension skill, and health literacy. Observing patients as they perform a skill, such as diaphragmatic breathing, reveals whether the patient can demonstrate the correct technique. The physical therapist can also pose questions to the patient during the demonstration to determine whether the patient knows the rationale for the exercise. The learning needs assessment encompasses the following five major areas: perceptual, cognitive, motor, affective, and environmental (Box 28-3). By addressing these five areas, the physical therapist will obtain an accurate picture of the patient’s learning abilities, knowledge level, performance skills, attitudes, and cultural influences. Box 28-3 Learning Needs Assessment Areas Motivation (readiness to learn) Perception of overall wellness Personal and societal resources Amount of instructor contact and setting Cultural influences (language, traditions, roles, religion, and lifestyle) All five of these areas can be addressed with the use of a learning needs assessment survey (Box 28-4). By using a survey in combination with the physical therapy patient evaluation, the therapist can gather all the necessary information to create an optimal patient education experience. The survey in Box 28-4 consists of three parts, which can be adapted to any patient care setting. In the pediatric setting, some of the questions could be asked of the parent(s) or rephrased to address school-age children. Part I primarily assesses the patient’s perception of the illness or disability and its impact on the patient’s life. Part II lists a wide variety of teaching methods and asks the patient to indicate which methods he or she personally feels are most useful. Part III identifies specific topics about which the patient would like to know more. This part is also helpful in alerting the therapist that referrals to other members of the interprofessional health-care team may be required. For example, if the patient selects “I would like to know more about what I should eat,” the therapist would make a referral to the dietitian. Patients’ answers provide clues to learning style preferences that work best for them and can often provide clues to health literacy issues. Box 28-4 Learning Needs Assessment Survey Please describe your illness and/or disability here: 1. Do you have any problems seeing or hearing? 2. Do you have any body areas that are numb (can’t feel)? 3. How long have you had this illness/disability? 4. What problems has it caused you? 5. Are you able to care for yourself at home? 6. Are you responsible for the care of any others at home? 7. Do you have someone at home to help you? If so, whom? 8. What questions or concerns do you have? 9. Do you practice a religion? If so, which? 10. What language(s) do you understand best? 11. How much education/schooling have you had?
Patient Education
Defining Patient Education
Objectives
Learning Theory: Concepts Pertinent to Cardiopulmonary Patient Education
Needs-Based Approach to Patient Education
Learning Needs Assessment
Tools
Areas to Assess
Ability to receive input (vision, hearing, and touch)
Comprehension of symbols (figures, numbers, words, and pictures)
