TEACHING-LEARNING

Teaching-Learning Content

Class Notes

    Everyone in this class has some experience in teaching clients and families. Additionally, some of you have taught groups of people in the community or have provided inservice programs to peers. As you encounter this module in NURS 330, you will find familiar precepts, but I hope that you can look anew at a variety of issues related to teaching-learning in nursing practice.

Assessment:

    The first step in the teaching-learning process is that of assessment. Essentially, two questions can be asked: Who is the learner(s)? and What does the learner need to know (do, or affectively display)?

1.  Who is the Learner?

Whether assessing an individual or a group of learners, a number of factors must be assessed, all of which influence learning needs and the methods you choose to employ. Often these factors are considered almost unconsciously in your practice:

        Age

        Gender

        Cognitive ability

        Attention span

        Ideas about health and illness

        The client’s attitude about his own role in healing

        Previous knowledge and skills

        Concept of self as a learner

        Motivation

        Agreement with health care recommendations

        Literacy

    I am sure you could add to this list, and have ample examples. Notice that how often we know how these factors might influence teaching and learning, but our practice of teaching becomes "canned" and we fail to act on what we know.

Once, when supervising students on an eye surgery floor, one of my students had a highly anxious preop patient, scheduled for cataract surgery that morning. She based her care on the assumption that his anxiety was related to the surgery, and that through good patient education, his fears could be allayed. The unit had a prescribed checklist of topics to review with the patient, a checklist that had been in place for some time, and seemed to "work." My student, armed with the list of topics, went in and "taught."

The patient became even more anxious. An experienced staff nurse decided to intervene, making the same assumption along with an additional one--the possibility that the student might not have taught well enough. The staff nurse, armed with the list of topics and years of clinical teaching, went in and "taught."

The patient’s anxiety continued to escalate. His wife was visibly upset as well, and the time for surgery came closer. I went in, sat down, and said, "You seem pretty upset. Sometimes people get upset when they don’t know what’s about to happen, so we teach about that. But you have had two nurses come in and teach you about your surgery and care. You are still anxious, and I do not think that teaching you something is helping. What is going on?"

The patient went on to explain that on this date, five years ago, his first wife had been diagnosed with cancer; on this date, three years ago, his first wife had died; and on this date, a year ago, he had driven a freight train across a bride that had just washed out, and he demolished the train completely. Now, on this date, he was having surgery, and he was anxious about this being the 4th event in a string of very unfortunate events. He had no questions about post op cataract care; his questions were at a different level!

No wonder that our "canned" teaching did not work. We had initially failed to assess this person as an individual; we made assumptions that were simply not valid!

 2.  What does the learner need to know?

    The second area of assessment is determining what the client needs to know. We may erroneously assume that because a patient has had diabetic teaching in the hospital, he now knows what to do at home. We may erroneously believe that an illiterate patient needs to know less, thinking that she is not intellectually capable. You have experienced this scenario often: Some things never get taught, and other aspects are taught repetitiously and needlessly. How can you determine what clients (or staff members, etc.) need to know? Here are some methods you may want to employ:

Interviewing the patient and family

            Advantages:

Promotes nurse-patient interaction and rapport.
Enables nurse to focus on specific needs and follow-up on spoken cues.
Can explore feelings and values.

    Disadvantages:

Provider-directed.
May be hard to interpret patient statements correctly.
Time consuming with a talkative patient.
Occasionally perceived as threatening ("too many questions").

Questionnaires and Forms

            Advantages:

Time-efficient for the nurse.
Can be written to elicit specific information.
Patients have time to think about answers.

            Disadvantages:

Impersonal.
May be misinterpreted.
May need to interview to clarify answers.
Relies on certain level of literacy.

Charts and Records

            Advantages:

Organized information.
Professional observations and judgments.

           Disadvantages:

Relies on others’ interpretations of patient behavior.
Time-consuming to extract the data.

Written Tests

            Advantages:

Quickly discovers knowledge.
Can be written to stimulate problem-solving and recall.

            Disadvantages:

Some people are poor test-takers.
Perceived negatively by many people.
Relies on certain level of literacy.

Observations

            Advantages:

Patient actually performs the skills or activities.
Nurse can make own interpretation of observations.

            Disadvantages:

Time-consuming.
Patient may feel uncomfortable being watched.

 

Stating the Goal and Objectives:

    Based upon the results of your assessment (what you know about the learner and his learning needs) the overall goal is stated and specific, measurable, behavioral objectives are identified. Note that the objectives all lead to meeting the overall goal of the teaching-learning experience. Behavioral objectives state what the learner will be able to do if learning has occurred. Behavioral objectives are learner-oriented, not nurse or teacher referenced:

(Learner) will choose foods low in sodium content, not "Teach the patient about low sodium foods."
(Client) will demonstrate correct application of the brace, not "Nurse will demonstrate the brace application."

    Always choose words that describe action and are measurable. In other words, what is the learner doing when demonstrating that the objective has been achieved? The following box provides you will a partial listing of words commonly used:

Measurable verbs

to write to recite to find
to solve to list to state
to choose to name to trace
to adjust to compare to contrast
to identify to conduct to express
to explain to classify to select
to construct to differentiate to demonstrate
to answer to locate to attend

    In addition to being measurable, when you select the words listed above, you can select the best learning activities since the learner behavior is precisely defined—and appropriate evaluation procedures can be used because the meaning of the objective is clear!

    Contrast those verbs with non-behavioral terms. Here are some on the "bad dog" list: to know, to learn, to remember, to understand, to think, to be acquainted with, to be aware of, to enjoy, to be familiar with, to appreciate, to comprehend, to perceive…..

    In other words, do not use these in writing behavioral objectives! Although you may see these phrases used (even by educators upon occasion), you do not want to commit an educational faux pas. Right? Notice that the real problem with those words is that you are stuck with trying to figure out how to measure them. These words describe something that is happening in the learner’s head where others cannot see it, and they permit a wide variety of interpretation.

Examples of well-stated, measurable activity:

State three ways to discipline a toddler without spanking or using other physical means.
List two reasons why it is important not to stop your medication abruptly.
Demonstrate good body mechanics when getting into a wheel chair.
Attend AA meetings at least 3 times per week.

When designing objectives, you may choose to select verbs from different domains. Bloom identified (and people who teach, have used these ever-after) three domains—cognitive, affective, and psychomotor. The cognitive domain involves thinking; the affective domain involves feelings; and the psychomotor domain involves motor behavior. Each domain is organized into subcategories, arranged from simple to complex.  How do you use these domains in a practical way? As you look at the learner’s needs, ask yourself: do I want to effect a change in thinking, behaving, motor skills, and/or feelings? Look at the next example, noting how both cognitive and psychomotor domains are apparent:

Goal: Client’s wound will heal completely without infection or other complications.

Objectives:   Client will:

  1. Describe normal wound healing.
  2. Describe signs and symptoms of wound infection.
  3. Demonstrate wound cleansing and bandaging.
  4. Describe appropriate action if questions or complications arise.
  5. Identify date, time, and location of follow-up appointment for suture removal.

    Well-stated objectives should also be time-referenced. If you hope to accomplish all objectives in a single period of time, you may write this as:

    Upon completion of the teaching session (class, program, workshop), the learner (participant, client, student) will be able to:

Or, you may selectively target different time-frames for each objective:

   Describe normal wound healing by 10/22.

   Describe normal wound healing after attending the discharge teaching group.

   Keep follow-up appointment for suture removal on 10/27.

Want to try your hand at critiquing an objective?
 

Last note on objectives: If you design well-stated objectives (learner-centered, measurable, time-referenced and attainable), the rest of the teaching plan will fall into place.

Content Outline:

Now that you have assessed the learner and learning needs—and developed an appropriate goal and objectives to reach the goal—the next step is to organize the content outline for your teaching plan. Keep logic in your organization so that transitions to subtopics will be clear.

The purpose of your teaching plan will determine the amount of detail in the outline. Brief detail is sufficient for CEU applications, record-keeping, or for a proposal for a presentation. You may want greater detail to teach from directly, but not so much detail as to make it cumbersome. Do not write out a narrative; you will end up reading rather than talking and relating to your learner(s).

Choose a font size that makes the outline easy to read, given where you will have the outline placed—a table, in your hands, a podium, or lecturn.

Here is an example of a partial outline of content for a teaching session:

Overview of session’s purpose and objectives

Stress as a common human response

All people experience stress

Manifest stress differently

Key to health is to manage stress

Common manifestations of stress

Physical responses

Emotional responses

Behavioral responses

Effects of stress over time

Organ system vulnerability

Resetting the physiological "thermostat"

 

Teaching Strategies:

In selecting teaching strategies, choose those that will hold the attention of the learner. Think of how you would hold the interest of 3rd graders versus 10th graders, of persons with chronic illnesses versus parents in childbirth classes, or of your colleagues at work versus beginning nursing students. Whatever the strategy, it is best to set the expectation that learning is both probable and possible. How would you like a class to begin like this: "Well, I am not sure that you can get this. It’s pretty confusing….." or "Most people do not find this very helpful, but…."?

Positive reinforcement goes a long way. "Yes, you’ve got the idea." "I think you really understand how to …." And do not forget the nonverbal positive reinforcement! Learning situations may be pleasant in your memory, but many people have flashbacks of being told they were stupid in school or fear of punishment by teachers. It doesn’t take much for some 40 year-olds in a teaching-learning session to feel as if they were seven years old again and under the scrutiny of the Cruella Deville of grade school. As you choose strategies, find a variety and be prepared to switch when necessary. Just remember that no one likes being "talked at." Here are some teaching techniques you might want to employ:

Teaching Techniques for Patient Education

    General Principles

Organize the material, partitioning it into easy-to-understand parts, especially if there is extensive information.
Keep instructions clear and specific, giving the key information the learner needs at this time.
Repeat important points, and tailor the message to the person.
Illustrate or demonstrate information to accompany each of the partitioned information parts.
Reinforce through written instructions. Note the suggestions to improve comprehension with clients who have low literacy skills.  (Next semester, you will be designing a patient education brochure, and this article will be of great help.)
Offer examples, including visual examples and testimonies from others.

    One-on-one instruction

Explanations/Lecture

Quality-quantity issues.

Demonstration/Return Demonstration

Lay careful groundwork

Prepare equipment in advance (test it!!).

Use real objects, the kind people will use at home.

Let the patient handle all equipment before using.

Break down the sequence of steps (write it, too).

Reinforce correct performance. Note that incorrect performance gives you important information.

Journal Writing

Set time limit of a few days.

Provide a framework for the journal.

Help the patient to set a certain time to do the writing.

Review journal entries.

Electronic Resources

 

An interesting review of health information on the Web with great links. At the site, choose "Archives" and then "09/98  Patient Education by Lazoff."    

               

A brief editorial on educated patients.
A "drug store" that also dispenses health information.
University of Virginia search page on asthma.

              

    Group Instruction

Lecture

Keep learning about your topic.

Keep notes in outline form.

Bring yourself to the lecture.

Anticipate questions and problems.

Select audiovisuals.

Discussion

Encourage full participation.

Keep the discussion on target.

Don’t let one or two people dominate.

Reinforce contributions.

Summarize at end.

Small Group Work

Think ahead of time and plan thoroughly.

Keep group small.

Have a group recorder/reporter.

Record on a flip chart.

Role Playing

Provide enough information.

Never begin a new group with a role play.

Assign a role to everyone.

Debrief.

Demonstrations/Return Demonstrations

    Teaching  patients with low literacy skills

Teach the smallest amount possible to achieve the objectives.
Make your points as vivid and explicit as possible.
Teach one step at a time.
Have the patient restate or demonstrate.
Repeatedly review information and procedures.

Evaluation:

The final component of the teaching-learning plan is evaluation. Just as in a nursing care plan, you should evaluate to what extent each objective was achieved!

When you choose a particular method to evaluate, watch your choice of words…think of these words: "test," "critical appraisal," or "what I did wrong." Your learners will definitely react to your choice of words! However you choose to evaluate the learning, remember one rule!

Know where your learner started!

If you do not know what the learner already knew (or did not know) when you started out teaching, you will have no idea if your teaching really effected the change. Maybe your learner watched a good TV program and you though you made the change!

Whenever you can, employ pre and post teaching testing (or "assessment" for a kinder, more gentle word). If possible, use tools with established reliability and validity; that is, well-developed tools that have been tested out by other teachers assessing patient knowledge are usually more accurate than our "home-made" instruments. Nevertheless, there are not lots of these floating around, and you may want to make your own assessment tool to administer before and after the teaching you do. Some options you have include: true/false statements, fill-in-the-blank, circle correct word (or picture), draw, essay, multiple choice. Paper and pencil "assessments" are not the only way, however. You may use other techniques such as:

  1. Discussion Does the client mentioned enough of what you are looking for to indicate learning? If not, is it because the client needs more education, or is your impression based upon a feature of discussion itself; i.e., some things might not get mentioned even though the learner has an excellent grasp of the knowledge? Sometimes you will choose to infer learning, based upon discussion; but remember, that this form of assessment may not be accurate.
  2. Oral questioning "Tell me what side effects you should watch for." "What is the first thing you should do if your baby won’t stop crying?"
  3. Direct observation of behavior Observe a client nursing her baby. Watch the wife change the husband’s dressing.
  4. Self-reports and self-monitoring "Bring your record of blood pressure readings." " When you come next time, tell me about your Alanon meeting."
    Less accurate methods: "How much did you learn?"    "Did you enjoy this class?"  (note that "enjoying" something is nice, but may not mean anything in terms of learning).

    Affective learning is more difficult to evaluate. Listen to the client’s responses, how the client speaks about the subject, and by observing behavior that expresses feelings and values.

Other evaluation

    Teachers often solicit other information essential to understand the teaching-learning process. Here are some common areas of consideration:

What did you find most helpful?
What did you find least helpful?
I had my questions answered (strongly agree, agree, neutral, disagree, strongly disagree).
Room heating, lighting, seating
Suggestions for improvement?
I still have questions about _________________ .

 

 

Home        Teaching-Learning Activity - (please see Course Description for learning activity)