Patient teaching is designed to improve understanding of one's health condition and management (Institute of Medicine [IOM], 2012; Robert Wood Johnson Foundation [RWJF], n.d.). A substantial body of evidence supports that patients who are engaged in their care are more likely to adhere to the prescribed plan following discharge from the acute care setting and may experience better outcomes (RWJF, n.d.). The IOM (2012) report, Best Care at Lower Cost, summarizes steps needed to improve discharge teaching. When teaching occurs, clinicians supply information based on their scientific expertise. Patients contribute perceptions regarding the suitability, or lack thereof, of the care advocated. If the plan is not developed collaboratively, tailored to individual preferences, and clearly understood, patients may not follow all or some of the recommendations, placing them at risk for potential complications (IOM, 2012; RWJF, n.d.).
Nursing has long emphasized the importance of patient education targeted at individual needs and preferences (Dahlke, Baumbusch, Affleck, & Kwon, 2012). Patient teaching should be provided in a comprehensive manner throughout the patient stay, culminating at the time of hospital discharge. To provide effective teaching, it is essential to assess patients' life goals to identify facilitators and barriers to change. Factors such as health literacy, self-efficacy, and financial constraints are also important considerations (Londoño & Schulz, 2015; Zhang, Dindoff, Arnold, Lane, & Swartzman, 2015). Teaching then can be structured in ways that reduce barriers. Although optimal, this goal can be difficult to achieve (Kuntz, et al., 2014; Mulder, van Belzen, Lokhorst, & van Woerkum, 2015), especially for novice nursing students.
To address these concerns, three evidence-based interactive video modules were developed that presented examples of effective and ineffective patient education for patients with complex chronic conditions who were preparing for their transition to self-care at home. This article describes the development, implementation, and evaluation of this innovative teaching strategy.
Nursing students often are not afforded the opportunity to develop and deliver patient education in the acute care environment, especially at the sophomore level. Student experience generally is restricted to limited observation of teaching behaviors and theory-based assignments. Simulated patients are used extensively to teach assessment and communication skills in graduate education (Clayton et al., 2012; Rosenzweig, Clifton, & Arnold, 2007) and some undergraduate programs (Dearmon et al., 2013; Miles, Mabey, Leggett, & Stansfield, 2014; Owen & Ward-Smith, 2014). Videos often are used in undergraduate nursing education to teach nursing skills (Kelly, Lyng, McGrath, & Cannon, 2009). Videos can be used in successive terms, making them less costly than simulation or paid patient actors. The authors reasoned that examples of effective and ineffective teaching could be filmed and then postconference sessions could be conducted to enable discussion for fostering critical thinking skills.
The videos developed for this project were modeled after Tanner's clinical judgment model (Tanner, 2006). From a review of nursing research that comprised more than 200 studies, Tanner proposed that five factors influence nurses' clinical judgement: what the nurse brings to the situation, knowing patients or engaging with patients to learn their concerns, the context in which the situation occurs, patterns of reasoning, and reflection used to tailor perceptions and improve clinical outcomes. Tanner's clinical judgement model, developed from these general conclusions, includes four phases: noticing (context and expectations), interpreting (analytic and intuitive reasoning), responding (actions), and reflection (analysis and revision as needed) (Tanner, 2006). Content of the videos and discussion points were structured to reflect these phases, with the goal of illustrating how nursing judgement informs critical thinking. Critical thinking, an essential nursing skill, is learned over time and describes the manner in which nurses come to understand the problems and concerns of patients to promote optimal outcomes (Thompson, Aitken, Doran, & Dowding, 2013; Thompson & Stapley, 2011).
Three health conditions (asthma, diabetes, and heart failure) were chosen. These topics were chosen because each represented a common health condition with frequent readmissions that required comprehensive knowledge for optimal self-management (Elixhauser & Steiner, 2013). Each module included two sections; one portrayed effective patient teaching and one portrayed ineffective teaching. The modules were developed from a literature review that identified key concepts essential to promote optimal self-management. Clearly defined learning objectives focused on problems commonly experienced following discharge. To address the barrier of inadequate health literacy, scripts used for effective patient teaching were developed using common, nonmedical words at a fifth to sixth grade reading level (Centers for Disease Control and Prevention, 2010; Weiss, 2007). Discussion was interspersed throughout the module at key points, guided by Tanner's clinical judgement model. To promote critical thinking, steps used in the gather, analyze, and summarize (GAS) technique used in simulation debriefing (Phrampus & O'Donnell, 2013) were incorporated in the modules.
Theater arts students were engaged to play the roles of nurse, patient, and family member. This choice had dual benefits; the students credited the film in their portfolio, and their acting expertise provided realistic portrayals.
The modules were presented to 216 sophomore nursing students during clinical postconference. Students were enrolled in a university-affiliated baccalaureate nursing program offered on two campuses in southwestern Pennsylvania. Both traditional students (high school graduates) and accelerated second-degree students (bachelor's degree in a field other than nursing) were included in the audience.
Equipment and Filming
The project was funded with an Innovations in Teaching Grant through university funds. Equipment was purchased for module development (computer and video camera) and student viewing (tablets, pocket projectors, and speakers). The number of tablets and projectors was determined by the number of clinical facilities and ability to share equipment. Equipment was selected for portability, quality, and ease of use. Filming was accomplished over 2 days by a faculty member (A.M.B.) who had previous experience filming and editing videos for skills laboratory instruction.
A training manual was developed that included core curriculum points, a lesson plan, a script that summarized evidence-based teaching points, and a discussion model. Many faculty had used the GAS technique in high-fidelity patient simulation debriefing, making it easy to use this strategy. Briefly, the GAS technique involves actively listening, asking clarifying questions, and requesting additional information as needed (gather); interpreting what is shared (analyze); and asking learners to share their understanding, sometimes referred to as teachback (synthesize) (Phrampus & O'Donnell, 2013). Using a pictorial technology guide, feasibility of training was tested with one faculty member who had no prior experience using the technology. The faculty member was able to master the equipment in less than 5 minutes with minimal input.
Prior to each video presentation, students were asked to write key points regarding evidence-based guidelines for discharge management, teaching strategies, and common reasons for readmission on three 3×5 index cards. In postconference, students were instructed to share their cards with a peer and were given 5 minutes to discuss the information. This process was used to assist students to access information and sort and filter this information for key points.
Structure and Scheduling of Sessions
The presentation process required faculty to start and stop the video, giving students the opportunity to discuss their assessment of the teaching provided and patient and family responses. The format allowed students to practice critical thinking and reasoning, exploring what they would do in these situations. Students were asked to develop a rationale for their choices and explore the interrelationships of knowledge, culture, and reward systems from the perspective of the patient and family. Discussions were guided by faculty but were student driven.
Following course completion, 20 students and 10 faculty were randomly selected to participate in two focus groups. Both groups (faculty and student) were led by a faculty member not associated with the project. This evaluation method was chosen because it seemed the best choice to elicit rich evaluation data. With this method, discussion can be open ended, and probes can be used to provide rich, extensive, and illuminating information (Jayasekara, 2012). Responses were tape-recorded, transcribed verbatim, and analyzed into themes. Student themes included visual illustration, role modeling, and practical utility. The faculty themes included positive teaching strategy and ease of use. Institutional review board approval was obtained, and all of the participants provided informed consent.
Student Focus Group
Visual Illustration. Students shared that the videos presented information that was “not new” but that was “very helpful in illustrating how to provide patient teaching” as the nurse actors “showed the worst way to say it and the best way.” One student commented that although this information was presented in lecture, the videos “actually showed how to do [patient teaching].” The videos illustrated how important it was to not “overlook patient response,” “realize the patient does not understand what you are trying to tell them,” and allow the “patient time to talk.”
Students also reported that they better understood the family “had a direct influence on the patient” and the importance of “making sure they are on board.” Students also thought “how to begin” was illustrated well by showing the nurse “sitting down, not rushing, and taking time to talk with patient and family.” Students noted that the video illustrated “subtle aspects of teaching” such as “how to walk in, begin a conversation with the family,” and “determine the patient's baseline level—what they knew before—in order to tailor education.”
Role Modeling. Students related the videos provided “good examples of how to talk to patients because we are all new at this.” As one student remarked, “I'm still learning, and it gave me a good idea of how to approach patients” by “showing the process” with examples, which took the “intimidation out of approaching patients to teach them.”
Practical Utility. The “stop and ask questions format” was judged to work well. Faculty “stopped the video a lot, which helped with learning.” Several students observed that the “bad nurse” was “obvious, but this was comical and helped keep interest.” One shared that “postconference can be a little dry,” but the videos were “an example of a great conference.”
Faculty Focus Group
Positive Teaching Strategy. Faculty uniformly described the videos as a “positive teaching strategy” including “interactions that showed [students] how to react” and be an “active listener” and “empathetic” toward patient concerns. One faculty member noted students were “more comfortable” teaching patients after watching the videos. A second faculty member reported observing students “using communication techniques illustrated in the videos” during high-fidelity simulation and interacting “more frequently” with families during clinical experiences.
Ease of Use. Faculty described the education level as “perfect” with “appropriate content” for teaching patients with chronic disease. The video length (8 to 10 minutes) was viewed as “perfect”; each video was “long enough to keep students' attention, but not too long to be boring.” No concerns were expressed regarding technical problems.
Technology. Trial use of the equipment is important to confirm its usability. Potential challenges (e.g., sound quality, viewing quality, and resistance to breakage) were tested before final purchase decisions. Sharing the equipment was challenging due to the number of faculty and facilities. To avoid problems, a detailed schedule and checklist was developed to facilitate transfer and ensure all cords, chargers, and equipment were included. The health condition illustrated in the videos did not always correlate with presentation in the lecture, a problem that could be minimized by more preplanning. However, the teaching technique crossed boundaries specific to conditions selected.
Uniform Instruction. The authors' nursing program involves education on two campuses and numerous clinical facilities with different learning opportunities. A secondary goal was to promote uniform instruction for all students, regardless of clinical teaching opportunities. The interactive video modules allowed for uniform instruction for a large number of students in a small group format. Through these modules, all of the students shared the experience of patient education for the selected disease processes. Video representation was able to bring clarity to concepts central to patient education.
Acceptance. Overall, the modules were well received by nursing faculty and students. By involving students from the theater arts, a collaborative partnership was fostered that hopefully will continue with future projects. Theater arts students also were exposed to the art of being a standard patient, something that most of them reported they did not know existed.
Placement. Clinical groups were limited to a maximum of eight students per faculty member, and each clinical day ended with a conference to reinforce didactic and clinical instruction. The postconference venue was an ideal format. Room scheduling was not required, as the equipment was highly adaptable, and postconference rooms could serve as the viewing site. The setting, immediately following clinical, and small student groups promoted lively discussion. It was therefore easy to link what was viewed to what took place in the care of patients that day.
Nursing students rarely are afforded the opportunity to provide discharge teaching in the acute care environment. An innovative educational method that was cost effective, reproducible, uniform, and interactive was needed. In response, three evidence-based interactive video modules were developed that presented effective and ineffective patient education for patients with complex chronic conditions preparing for transition to self-care at home. Students viewed the modules during post-conference using portable technology. Twenty students and 10 faculty were randomly selected to evaluate the project in two focus groups. Students commented positively on the format and illustration of effective teaching. Faculty rated the teaching strategy positively and the technology as easy to use. The project supported the benefits of this teaching–learning strategy. Future studies are needed to evaluate ability to transfer skills learned to the clinical setting.
- Centers for Disease Control and Prevention. (2010). Simply put: A guide for creating easy-to-understand materials (3rd ed.). Retrieved from: http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
- Clayton, J.M., Butow, P.N., Waters, A., Laidsaar-Powell, R.C., O'Brien, A., Boyle, R. & Tattersall, M.H.N. (2012). Evaluation of a novel individualized communications-skills training intervention to improve doctors' confidence and skills in end-of-life communication. Palliative Medicine, 27, 236–243. doi:10.1177/0269216312449683 [CrossRef]
- Dahlke, S., Baumbusch, J., Affleck, F. & Kwon, J.Y. (2012). The clinical instructor role in nursing education: A structured literature review. Journal of Nursing Education, 51, 692–696. doi:10.3928/01484834-20121022-01 [CrossRef]
- Dearmon, V., Graves, R.J., Hayden, S., Mulekar, M.S., Lawrence, S.M., Jones, L. & Farmer, J.E. (2013). Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. Journal of Nursing Education, 52, 29–38. doi:10.3928/01484834-20121212-02 [CrossRef]
- Elixhauser, A. & Steiner, C. (2013). Readmissions to U.S. hospitals by diagnosis, 2010 (Agency for Healthcare Research and Quality Statistical Brief #153). Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf
- Institute of Medicine. (2012). Best care at lower cost: The path to continuously learning health care in America. Retrieved from http://iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx
- Jayasekara, R.S. (2012). Focus groups in nursing research: Methodological perspectives. Nursing Outlook, 60, 411–416. doi:10.1016/j.outlook.2012.02.001 [CrossRef]
- Kelly, M., Lyng, C., McGrath, M. & Cannon, G. (2009). A multi-method study to determine the effectiveness of, and student attitudes to, online instructional videos for teaching clinical nursing skills. Nurse Education Today, 29, 292–300. doi:10.1016/j.nedt.2008.09.004 [CrossRef]
- Kuntz, J.L., Safford, M.M., Singh, J.A., Phansalkar, S., Slight, S.P., Her, Q.L. & Hornbrook, M.C. (2014). Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings. Patient Education and Counseling, 97, 310–326. doi:10.1016/j.pec.2014.08.021 [CrossRef]
- Londoño, A.M. & Schulz, P.J. (2015). Influences of health literacy, judgment skills, and empowerment on asthma self-management practices. Patient Education & Counseling, 98, 908–917. doi:10.1016/j.pec.2015.03.003 [CrossRef]
- Miles, L. W., Mabey, L., Leggett, S. & Stansfield, K. (2014). Teaching communication and therapeutic relationship skills to baccalaureate nursing students: A peer mentorship simulation approach. Journal of Psychosocial Nursing & Mental Health Services, 52(10), 34–41. doi:10.3928/02793695-20140829-01 [CrossRef]
- Mulder, B.C., van Belzen, M., Lokhorst, A.M. & van Woerkum, C. (2015). Quality assessment of practice nurse communication with type 2 diabetes patients. Patient Education & Counseling, 98(2), 156–161. doi:10.1016/j.pec.2014.11.006 [CrossRef]
- Owen, A.M. & Ward-Smith, P. (2014). Collaborative learning in nursing simulation: Near-peer teaching using standardized patients. Journal of Nursing Education, 52, 170–173. doi:10.3928/01484834-20140219-04 [CrossRef]
- Phrampus, P.E. & O'Donnell, J.M. (2013). Debriefing using a structured and supported approach. In Levine, A.I., DeMarie, S.Jr., , Schwartz, A.D. & Sim, A.J., (Eds.), The comprehensive textbook of healthcare simulation (pp. 73–84). New York, NY: Springer. doi:10.1007/978-1-4614-5993-4_6 [CrossRef]
- Robert Wood Johnson Foundation. (n.d.) The chronic care model: Model elements. Retrieved from http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18
- Rosenzweig, M., Clifton, M. & Arnold, R. (2007). Development of communication skills workshop for oncology advanced practice nursing students. Journal of Cancer Education, 22, 149–153. doi:10.1007/BF03174327 [CrossRef]
- Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.
- Thompson, C., Aitken, L., Doran, D. & Dowding, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50, 1720–1726. doi:10.1016/j.ijnurstu.2013.05.003 [CrossRef]
- Thompson, C. & Stapley, S. (2011). Do educational interventions improve nurses' clinical decision making and judgement? A systematic review. International Journal of Nursing Studies, 48, 881–893. doi:10.1016/j.ijnurstu.2010.12.005 [CrossRef]
- Weiss, B.D. (2007). American Medical Association Foundation and American Medical Association. Health literacy and patient safety: Help patients understand, manual for clinicians (2nd ed.). Retrieved from: https://psnet.ahrq.gov/resources/resource/5839/health-literacy-and-patient-safety-help-patients-understand-manual-for-clinicians-2nd-ed
- Zhang, K.M., Dindoff, K., Arnold, J.M.O., Lane, J. & Swartzman, L.C. (2015). What matters to patients with heart failure? The influence of non-health-related goals on patient adherence to self-care management. Patient Education and Counselling, 98, 927–934. doi:10.1016/j.pec.2015.04.011 [CrossRef]