Over the past two decades, research in learning has consistently demonstrated that the elderly perform poorly in fast-paced learning situations. Thus, for effective teaching, it is imperative that nurses slow their instruction for elderly clients. We conducted a study to examine the effect of pacing medication instruction on the learning of elderly clients, and the results confirmed the importance of slow instruction for the elderly.
Studies indicate that errors in self-administration of medication among the elderly are common and often lead to serious problems.1"3 Medication studies that categorized types of errors found that clients make one or a combination of the following types of self-medication errors: (a) omission, (b) inaccurate knowledge, (c) incorrect dosage, (d) improper timing and sequence, and (e) medication taken but not ordered by the doctor.4 Factors related to the occurrence of these medication errors included age, ability to cope with the environment, the number of medications prescribed, and knowledge about medications. The probability of making an error increased with age.1"3 As the client's ability to cope with the environment increased, the tendency to make medication errors decreased.3 The probability of error increased with the number of medications.3'5"7 As the client's knowledge of medication increased, the tendency to make medication errors decreased.1'2'6'8 Knowledge about medications is, thus, one factor related to the occurrence of self-medication errors, but there has been limited research documenting the effectiveness of teaching in reducing medication errors among the elderly.1'6'9"13
Recent research on learning in old age suggested many variables that influence learning. Learning deficits in old age are attributed to changes in sensory perception, memory, and/or intelligence; heightened arousal of the autonomic nervous system; increased cautiousness; slowed responses to environmental stimulation; and instructional variables such as pace of presentation, task relevance, and task difficulty.14"18 While little can be done about the cognitive variables, nurses can control instructional variables. Of these, pacing, defined as speed or rate of performance, is of major importance.
A number of studies reported that when the time to study visual materials is increased, the old benefit more than the young.19'20 The elderly also benefit from a longer time to give responses.19'21"23 The comprehension of speech can reveal speed deficits among the aged.24-26 Panicucci and associates27 conducted a study on the use of slow speech and self-pacing with the aged and found that slow speech increased the aged person's ability to integrate information and and respond appropriately. Thus, one way to help the older person is to slow the pacing of learning events.15
1. Elderly clients who are instructed at a slow pace will have greater gain from the pretest to the posttest score than those instructed at a normal pace and those receiving no instruction.
2. Elderly clients who are instructed at a slow pace will make fewer total response errors to questions during the medication instruction than those instructed at a normal pace.
In addition to testing these hypotheses, we also examined the time the elderly clients took in giving their self-paced responses during the medication instruction.
Definition of Terms
Normal pace: Rate of 159 words per minute. An average speaking rate of English-speaking college students was used for establishing rate.28
Slow pace: Rate of 106 words per minute. Thus, normal pace was 50% faster than slow pace.
Self pace: Rate controlled by the subject, an opportunity to take as much time as needed for a performance.
Gain score: Difference in the pretest and the posttest scores.
Response error: Incorrect or no responses by the subject during the medication instruction.
Self-paced response time: Number of seconds the subject used in recalling and repeating the drug information given in the instruction. In self -pacing responses, the subject was allowed to take as much time as needed within a limit of four minutes.
The study was conducted in a 1200 bed public hospital, located in the Midwest and serving adult patients with chronicdiseases. From a total of 410 patients in two units, 48 were selected. Patients 65 years of age or older with a prescription for a diuretic, antihypertensive, or digitalis drug were identified using the medication Kardex. We obtained permission from the attending physician for the patient's participation in the study. After consulting the nurse in charge as to the advisability of including the patient in the sample, one of us (KK) met with each patient to evaluate that patient's orientation to time, place, and person. If the patient met the sample selection criteria, the purpose of the study was explained and the patient's consent to participate was obtained. A number was assigned to each patient according to the order selected for the study. The patient was then assigned to one of three study groups using a block randomization method. Two of the 48 patients refused to participate; one patient became too ill to take the posttest and was replaced. Thus, a total of 45 patients was studied, 15 in each of the three groups.
The medication instruction included five areas: name of the drug, purpose, frequency, dosage, and time of drug administration. The instruction was presented to the patients using audiotape and written learning material. The audiotape was used to control the presentation of learning material at a normal pace (159 words per minute) and a slow pace (106 words per minute). The tape was prepared by blocking the script into 30-second intervals; the number of words in each interval depended on the desired rate of presentation. The speaker spoke at an even pace, visually checking the end of each 30-second interval on a stop watch. The written learning material listed the five content areas of instruction, and was typed in large print.
The measurement tools, the pretest and the posttest, were essentially the same as to content, number of items, and scoring system. The tests covered the areas included in the medication instruction. For each content area one recall and two recognition items were developed, resulting in a total of 15 items for each test. Content validity was established in accordance with the opinion of experts. Reliability of the instruments was tested using a test-retest procedure (r = .84, ? < .05).
A pre test -posttest control group design2 was used in the study. The research design included two experimental groups, the normal-paced and the slow-paced groups, and a control group. The pretest was administered to all three groups individually, in a private room. The first author read each question slowly and loudly for the patient and recorded the patient's answers on a prearranged recording sheet. The tests took 10 to 20 minutes and were administered during one day.
Immediately following the pretest, one experimental group received the medication instruction at the normal pace, while the second group was given the instruction at the slow pace. Each patient received instruction for one prescribed medication. The control group was not given the medication instruction. All patients received individual instruction from the first author in a private room. The instruction took approximately 5 to 10 minutes.
Before presenting the medication instruction the volume of the audiotape recording was adjusted to the patients' hearing level; this volume was maintained throughout the instruction. First, the patients were told the name of drug, its purpose, frequency, dosage, and time of drug administration. The patients then were asked to recall these five items of drug information. They were told to take as much time as needed to answer the questions. It should be noted that the written learning material was presented to the patients during the first part of the instruction, but was removed from the patient when they were responding to the questions. The instructor gave correct answers to the questions immediately after the responses.
During the medication instruction, patients' responses to questions were recorded on tape. Response errors used to test the second hypothesis were measured from these responses, and were not taken from the posttest. The tape recording was used later with a stop watch to measure the time it took a patient to give each response. The time interval between asking the question and the patient's verbal response was used as a measure of the self-paced response time.
Approximately 24 hours after giving the medication instruction, the posttest was administered to the two experimental groups. The control group also was given the posttest at a comparable time but without the medication instruction. For ethical reasons, the control group was given slow-paced instruction after the posttest.
The 45 subjects ranged from 65 to 94 years, (mean 77.7 years). There were 1 7 men and 28 women in the sample. All subjects had at least one diagnosed medical problem. Statistical analysis showed that the three groups did not differ as to age, sex, formal education, and number of prescribed medications. To ascertain the complexity of the learning task, length of the drug name was examined. Chi-square analysis revealed that the three groups did not differ with respect to the number of letters in the drug name. The average number of letters in each drug name was seven to eight. Analysis of variance of the pretest scores revealed that the three groups also did not differ as to knowledge of drugs prior to instruction (Table 1.)
KNOWLEDGE OF MEDICATION GAINED BY ELDERLY PATIENTS
FREQUENCY OF RESPONSE ERRORS BY ELDERLY PATIENTS
The mean gain score of the slowpaced group was significantly greater than that of the normalpaced group, t(28) = 3.543, and that of the control group, t(28) = 4.761, p < .0 1 , one-tail test (Table 1 ). There was no significant difference in the mean gain scores of the normalpaced group and the control groups, t(28) = 1 .5 14, ? > .05. In the posttest, the number of patients recognizing the name of their drug was greater than those recalling the drug names. The ratio between the percentage of patients recognizing the drug name and recalling it in the normal -paced and the slow-paced groups was 33.3%:6.7% and 73.3%:20.0%, respectively.
The mean number of response errors by the slow-paced group are significantly less than those of the normal-paced group, t(28) = 1.856, ? < .05, one-tail test (Table 2). The normal -paced group correctly recalled slightly more than one third (35%) of the items during the medication instruction, while the slowpaced group recalled 56% of the items correctly. When response errors to each question were examined, recalling the name of the drug was the most difficult learning task: 77% of the 30 patients in the two instruction groups were unable to recall the name of the drug 1.5 minutes after receiving the information and 40% of these patients made response errors in the frequency of the drug administration question.
Self- Paced Response Time
Since the self-paced response time of the control group was also measured, these data are in Table 3 for comparison among the groups. The total self-paced response time was calculated by adding all response times to the five questions. The data show that the three groups did not differ significantly from each other in the total self-paced response time, X2(2) = 4.98, ? > .05. A chi-square test was used for this analysis because variance of the three groups were significantly different*, /w(14) - 18.218, ? < .05. 30 The median was used as a measure of central tendency because of the number of extreme values. The common median of the total response time was 12.25 seconds. The self-paced response time to any one question ranged from 0.5 to 48 seconds. Some patients took as long as 40 to 48 seconds to recall drug information such as name, purpose, and frequency of drug administration.
The findings of the present study support the hypothesis that elderly patients who are instructed at a slow pace will have greater gain from the pretest to the posttest score than those instructed at a normal pace and those receiving no instruction. Furthermore, the gain score of the group receiving instruction at a normal pace did not differ significantly from that of the group who did not receive any instruction Thus, we conclude that elderly patients learn more when the speech rate used for instruction is slowed.
NUMBER OF ELDERLY PATIENTS IN EACH MEDICATION
ACCORDING TO SELF-PACED RESPONSE TIMES
The data also show that elderly patients who are instructed at a slow pace make fewer errors in responding to questions during the instruction than those elderly instructed at the usual rate. This further emphasizes the importance of slowing the pace of instruction for the elderly. The results of our present study agree with those of other investigators, who found that elderly persons are at a disadvantage with insufficient study time.19'"0 The present results also agree with Panicucci and associates," who found that slow speech created a difference in the aged patient's ability to integrate information and to respond appropriately.
Our study revealed that, regardless of the pace of instruction, elderly patients have difficulty recalling drug information within 1.5 minutes after receiving it. When response errors to each question were examined, recalling the name of the drug was the most difficult learning task. Less than one fourth of the patients in the experimental groups were able to recall the names of their drugs 1.5 minutes after receiving the information. The high response errors in recalling drug names may be explained partly by complexity of drug names, and the fact that with age the decline in recall is greater than the decline in recognition of learned material.15'17 Although the average number of letters in each drug name was seven to eight, six patients had a prescription for hydrochlorothiazide (19 letters). It should be noted that all five questions that measured response errors were recall items, whereas the posttest consisted of both recall and recognition items. In the posttest, the patients had more difficulty in recalling the names of their drugs than recognizing the drug names.
Fortunately, when taking a prescribed medication at home the patients usually need to recognize rather than recall information on the drug container label. Nevertheless, this finding emphasizes the importance of written instructions in addition to verbal information for the elderly. Written information not only gives an opportunity to review information, but also encourages recognition of learned material.
Our study showed that pacing of medication instruction had no significant effect on the self-paced response time. Canestrari21 reported that older persons used significantly more time under self-paced learning conditions than did younger persons. Our data showed the importance of recognizing a wide individual variation in self-paced response time among the elderly.
Caution should be taken in generalizing the results of this study. In addition to the uniqueness of the sample and setting, the sample size was limited to 45. Additional studies need to be done to validate the results of this study with another population. In future studies, the levels of the speed of instruction could be increased to determine the appropriate speed of instruction for the elderly. How slowly should the instruction be delivered to the elderly? Future studies should be directed to answer this question.
In summary, the findings of this study showed that slow-paced instruction benefits elderly patients in their learning. The patients in the slow-paced group had not only greater gain from the pretest to the posttest score, but also made fewer errors during the medication instruction. As evident in the literature and in our study, speed of instruction is a major variable influencing learning in the elderly. In providing drug information to elderly patients, it is important that nurses not only deliver their instruction at a slow pace, but also provide sufficient time for patients to respond to questions.
The authors wish to thank the thesis committee members, Dr. Mary Bn>is and Dt. Alice Dan for their assistance during various phases of the study.
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KNOWLEDGE OF MEDICATION GAINED BY ELDERLY PATIENTS
FREQUENCY OF RESPONSE ERRORS BY ELDERLY PATIENTS
NUMBER OF ELDERLY PATIENTS IN EACH MEDICATION
ACCORDING TO SELF-PACED RESPONSE TIMES