Description #
This unit teaches community health nurses to teach clients how to self-administer intravenous therapy while at home.
Learning Objectives #
1. Applies principles of adult learning to all teaching related to home infusion.
2. Applies knowledge learned from module while teaching clients to self-administer intravenous therapy at home.
3. Demonstrates and coaches clients to safely learn self-administration of intravenous therapy at home.
4. Adapts teaching and coaching techniques to specific client needs.
Introduction #
Purpose
Review the concept of adult “readiness to learn” to increase client leaning outcomes and nurse teaching satisfaction.
Objectives
This learning unit is intended to give nurses the opportunity to:
1. Define “readiness to learn.”
2. Review four components of the readiness to learn model including:
a. Physical readiness
b. Emotional readiness
c. Experiential readiness
d. Knowledge readiness.
3. Identify the readiness to learn principles in case study examples.
4. Apply knowledge gained from this unit while teaching clients to self-administer IV medications by gravity.
Background
Learners in each situation have different ways of learning. This is influenced by their roles, context and who they are in the moment, the history of their personal journey, their cultural beliefs and practices, their education level, and their past experiences that have shaped the way that they learn. As nurses we connect with each individual to understand who they are so that we acknowledge their uniqueness and tailor each learning situation to that understanding and connection. Nurses use knowledge from many domains in order to teach clients in the community. Carper (1978) was the first to identify nurses’ knowledge as fitting into four patterns or “ways of knowing”. These patterns include: empirics, ethics, personal knowing, and aesthetics. Empirical knowledge is the based in the science of nursing. Why we choose one wound care product over another is empirical knowledge. Ethical knowledge is based in our code of ethics and guides us through our beliefs and values. Personal knowing is the understanding of oneself and others as they interact in the nurse-client relationship. Aesthetic knowledge is used in assessing each situation and finding the meaning in the moment, also known as the art of nursing.
Each pattern is essential to nursing practice and utilizing each pattern of knowing promotes integrated and appropriate nursing care. It is important to acknowledge and articulate this as the essence of nursing knowledge. As we learn to articulate what we do, we increase the awareness of other team members and the public of the nurses contributions to patient care in general and self-care by patients in particular.
How many times have you been asked to “teach her how to do that?” Nurses require complex skill sets and knowledge bases to meet the learning needs of a diverse client population. The acuity and complexity of clients’ needs in the community is growing exponentially and will continue along this trajectory. This unit will assist the nurse to assess learning needs and readiness to learn in each situation, and identify methods to meet those needs.
After learning needs are identified the nurse must determine the client’s readiness to learn. Readiness to learn is the time when a learner demonstrates an interest in learning the information necessary to maintain optimal health. The four components of readiness to learn include: 1) physical readiness; 2) experiential readiness; 3) emotional readiness; and 4) knowledge readiness; all of which should be assessed prior to teaching. Case studies will be used to demonstrate this process.
Physical Readiness
Case One
Olga Kryciak is a 72-year-old woman of Ukrainian decent. She has lived in the community for 50 years. She lives independently and is active in her community and church. Olga was discharged from Richmond Hospital with an order for home IV antibiotics by gravity as therapy for her infective cystitis.
On your first visit, Olga tells you that she is excited and scared to learn the new skill but is looking forward to gaining her independence again. Having worked as an LPN for decades, she is familiar with the rationale for requiring intravenous medication but has never been taught the skill herself. Olga explains that she has seen the skill performed numerous times and is confident she will have no problems learning the task.
With verbal coaching, prepares a clean work area and washes her hands. She opens the IV tubing and is careful not to touch the end of the tubing to the floor. With little difficulty Olga prepares the primary IV bag and tubing. Olga is keen to move on and learn step two. While accessing the medication bag, she accidentally touches the spike of the secondary IV tubing. Olga is disappointed with herself when she does not get the task right the first try. Olga’s error has caused her to become frustrated.
As the nurse you know that you need to identify Olga’s strengths, re-teach the area Olga is having difficulty with. Adult learners often need information to be repeated to them in different ways. If they can associate the information in different ways, they will likely have an easier time remembering the information or skill. As tasks get more complex, it is important that the nurse encourages client learning by identifying success. Pointing out what Olga had done well is a method of positive reinforcement and will likely help her feel good about her accomplishment and encourage her to learn more.
As part of your assessment, you learn that Olga does not have any hearing or cognitive impairments. However, she seems to be having difficulty following your instructions as the teaching session proceeds. As the nurse you know that older adults learn new information by making connections to knowledge already stored in their memory, so you check the pace of your lesson. Older adults learn new information by making connections to knowledge already stored in their memory. It often takes older adults more time to search through their memory and make connections with new knowledge. The nurse may have to allow more time for older adults to learn new skills and new knowledge.
On your third visit you had planned to teach Olga how to run the IV medication. Olga tells you that her arthritis has flared up in her knuckles and that she is in a lot of pain. You decide to change the teaching plan with Olga today and ask Olga to describe the task while you follow her instruction, postponing the hands-on learning until Olga’s pain is better controlled.
As the nurse, you know that making this adjustment, and adapting your teaching plan around Olga’s barriers to learning uses your knowledge from the domain of personal knowing by understanding Olga’s strengths and need to accomplish goals.
Case Two
Jennifer Tapping is a 36-year-old English-speaking Caucasian woman. She is a stay at home mom who lives in a small house with her husband and two children aged 4, and 7. The 4-year old stays home with her during the day and the other child attends school. To make ends meet, her husband works two jobs and is often not home. Jennifer is requiring home intravenous therapy for cellulitis to her left leg.
When you meet Jennifer, she is at home with her four year old. The child is watching a blaring TV. Jennifer invites you into a cluttered living room with little space to sit. You wonder if this situation will be conducive for Jennifer’s learning. As the nurse, you know that each client can learn in a different environment. So you ask Jennifer “tell me what type of learning situation you are best able to concentrate in?” Asking Jennifer this question, acknowledges her ability to participate in developing the teaching plan. Doing this used your knowledge within the aesthetics of nursing that shows your understanding of the situation.
Jennifer grows tearful and explains to you that she is overwhelmed with the amount of chores that she is behind with and believes she is failing as a mother. She does not think she will be able to learn the skill. As the visiting nurse, you want to create a positive learning environment. So you ask her to identify her support systems, strengths, and barriers. Stress often hinders critical thinking and problem solving. By identifying her learning barriers, you can plan the teaching session around these issues. You can help build Jennifer’s confidence by acknowledging her identified strengths and use them as motivators.
Experiential Readiness
Case 1
Mrs. Tehrani is a 54-year-old woman from the Middle East. She lives with her son in a small condominium. Mrs. Tehrani has been discharged from the hospital with home intravenous therapy for meningitis. On your first entry into the home, you meet Mrs. Tehrani and her son, Amjad. You recognize that you are unfamiliar with the Tehranis’ customs. Culture is a determinant that has a profound impact on a client’s health and can determine how clients make health related choices. A cultural assessment includes determinants such as the client’s behaviours, physical and social environments, and understanding verbal and nonverbal messages within the context of the client’s culture. You realize that it is important to have an awareness of these because cultural factors may influence how a client participates in learning and should be factored into the teaching plan.
Along with assessing the Tehranis’ cultural practices, you also reflect on your own culture. This is important because it will decrease the chance of development of an ethnocentric attitude. By being self aware, the nurse will likely develop a teaching plan that best fits and/or acknowledges the client’s needs.
On your second visit you begin by teaching the family to flush the line. As you begin the lesson, the family explains to you that they are finding it difficult adjusting to this new health issue. You use open-ended questions to encourage the family to identify how they have coped with difficulties in the past. Having the family identify how they have coped in the past will increase the awareness of its own strengths. Once strengths have been identified, nurses and clients should further explore how strengths can be utilized to promote learning. Clients should also be encouraged to identify their barriers to learning; teaching lessons can then be created that address these learning barriers.
Emotional Readiness
You are about to go visit a client in his home for the first time. You learn that Mr. Smith is a 69 year-old, English speaking Caucasian man. He has just been discharged from the hospital for community-acquired pneumonia. Aside from hypertension and gout, he was in good health prior to the pneumonia. This was Mr. Smith’s first experience being hospitalized.
Upon your first home visit Mr. Smith appears sad, lonely, and uninterested in the conversation. When asked what he would like to learn first, he tells you that he doesn’t want to learn anything, and states that you are supposed to do it. As the nurse, you know that it is important to collaborate with the client to identify mutually agreeable learning goals. This helps to increase learner autonomy and promotes self-directed learning.
Adult learners need to know why they should learn certain information and how it will directly benefit their life. Mr. Smith’s mood and behavior makes the nurse feel that further assessment of possible barriers to learning is needed. Since Mr. Smith does not recognize a personal need to learn how to self-administer his medications, you ask Mr. Smith a little bit more about his reasons for reluctance to participate in the teaching session. By further exploring the reasons that Mr. Smith does not want to participate in the learning, you are not only gaining a better understanding of his barriers to learning but also building trust by trying to better understand Mr. Smith.
Mr. Smith states that he has been in the hospital for three weeks, and that during that time the nurses provided all care for him. He says there is no way he can do it himself without causing harm. You notice that Mr. Smith is wringing his hands, and has a quivering voice. You can’t identify what is going on exactly, but he seems generally uneasy about something. You wonder if the thought of having to administer his own IV is causing him anxiety. He did state earlier that he is worried about causing himself harm. When you ask him if he is feeling scared or anxious, he says no.
As the nurse, you realize that it is important to look for behavioral cues of anxiety in Mr. Smith because many people are reluctant to disclose that they are indeed feeling anxious. To a degree, anxiety can serve as a motivator to learn. When anxiety levels become too high a client’s readiness to learn will be negatively influenced. It is the nurse’s responsibility to assess for anxiety before and during teaching sessions. Behavioral anxiety cues such as fiddling with hands, inability to concentrate, and shakiness are often signs that anxiety needs to be addressed. Mr. Smith’s fear of causing self-harm is a common contributor to anxiety among clients.
To add to his current challenges, Mr. Smith tells you that he has been unable to find his right hearing aid since coming home from the hospital. He says that wearing only one makes it even harder to hear, which is why today he is wearing neither. You realize that his apparent disinterest during the teaching session may also be a result of his inability to hear. With the Mr. Smith’s permission, you go take a look in his bathroom and find his missing hearing aid. After returning them to Mr. Smith and confirming that he can hear you, you try to explore his strengths and barriers to learning. Depression and sensory impairments are common barriers to learning among the older adult population. Increased stressors during times of illness and hospitalization can increase the risk of anxiety and depression. It is essential that nurses assess clients for sensory impairments such as healing loss and poor vision.
You decide to start the demonstration, as your time is limited. While priming the tubing you learn that Mr. Smith has a small dog, Dexter, who has been staying with his sister for the past month. Mr. Smith’s love for Dexter is apparent by the smile on his face, which you have not seen before. He expresses how sad and lonely he is without him. He also misses their morning walk to the park and local coffee shop. Using your “personal and aesthetic ways of knowing”, you decide to use Mr. Smith’s dog as a source of motivation. Although right now, Mr. Smith is unable to imagine he will be strong enough to take care of Dexter, you try to reinforce that he will soon be back to his old self. You explain that by learning how to self-administer the IV antibiotics, he will slowly begin to resume his pre illness activities and lifestyle. Using this intervention shows that you understand that adults often need support to counteract the barriers to learning
During times of illness it may be hard for adults, like Mr. Smith to identify motivating factors for learning. Motivation can be described as clients’ ability to take action. Clients’ are best motivated when they see value in the outcome of the learning. As discussed earlier, clients’ barriers to learning must first be identified and discussed, as they can have profound negative effect on motivation. Teaching involves assessing the level of motivation and presence of barriers. By building a relationship with Mr. Smith, the nurse was able to identify that Dexter could be utilized as a source of motivation for him to learn, heal, and get back to his usual routine.
You now notice Mr. Smith’s fatigue from the long discussion. You run the IV for the first time while verbally explaining the steps. Before leaving you provide him with learning materials to review before your next visit and invite his participation at the next visit. He says that he would be willing to try flushing. You provide him with positive feedback for his willingness to learn. Providing Mr. Smith with positive feedback about his willingness to learn will increase his self-confidence and keep him engaged in the learning process.
You leave feeling satisfied that you were able to collaborate with Mr. Smith and reduce barriers to learning. You are hopeful that future teaching sessions with Mr. Smith will be successful.
Knowledge Readiness
This is your second visit to Mrs. Kwan’s home. She is being treated for an infected diabetic foot ulcer. On your last visit Mrs. Kwan successfully flushed and connected the IV with assistance.
Mrs. Kwan is a married 47-year-old woman who moved to Canada 7 years ago with her husband. She has conversational English and comprehends most information. She has had diabetes since she was a child. She states that since coming to Canada, she has not been able to keep her diabetes under control. She voluntarily explains that her son was diagnosed with cancer 10 years ago and passed away the year before they moved to Canada. Through her tears, she explains to you how hard these years have been and how much she misses her son.
As the nurse you know that adults bring past feelings and experiences to new learning. It is important to assess relevant past experiences, how they could potentially impact learning, and not to assume that Mrs. Kwan’s experience will negatively affect her learning. Although the memories of her son’s chemotherapy could make it harder for her to learn, there is still a possibility for successful learning.
When you enter the house Mrs. Kwan invites you into her kitchen to commence the teaching session. You immediately notice the piles of diabetes pamphlets and brochures as well as numerous appointment reminders for her endocrinologist and podiatrist. You ask her about them and she says that they are “garbage” and says you can “throw them out.” You notice an appointment reminder dated for tomorrow at 8am. You ask her if she was aware of the appointment, and she says no.
You are concerned that she may be struggling to process and comprehend the health information she has been given. You remember that poor health literacy levels are more common among the older adult, ESL clients, and individuals living with a chronic illness. You recall health literacy can have a profound affect on a client’s understanding of disease processes and their capacity for health promotion. As the nurse, you know that health literacy is a client’s capacity to obtain, process, and comprehend information in order to make appropriate health related decisions. Health literacy also involves a client’s ability to seek out, read, and understand health related materials on his or her own.
It is important to recognize that low health literacy does not always equate to low intelligence. Nurses need to assess health literacy and tailor the teaching plan to meet the unique needs of the client. In the case of low health literacy, establishing a shame free environment, providing clear purposeful instruction and reinforcing the spoken word are all beneficial strategies that can be used to promote learning.
Mrs. Kwan states that she is ready to learn how to prime the IV tubing today. Before laying out the supplies you ask her if she reviewed the written information you left with her last week. She says no, stating that she doesn’t find it useful. You decide it is best to verbally talk her through the steps. Mrs. Kwan appears distracted as you are talking. She is fiddling around with the equipment you have laid out on the table. You stop for a moment to try to assess what is going on. Based on your experience with Mrs. Kwan, you suspect that Mrs. Kwan is a “kinesthetic learner” or that she learns by doing. As the nurse you know that assessing clients’ preferred learning style is a fundamental component of teaching done by the nurse. Identifying Mrs. Kwan’s preferred style of learning through discussion and observation will allow the nurse to modify the teaching plan and choose appropriate teaching methods to best suit the client.
You have realized that Mrs. Kwan is a kinesthetic learner. She says she likes to be as hands on as possible. You continue the lesson by allowing her to be more hands on, ensuring that she is supervised. When she is about to flush her PICC line, she begins to cry and says that it reminded her of how much her son used to hate his chemotherapy treatments. You console Mrs. Kwan and give her the opportunity to express her feelings. After some discussion, she is able to focus again and continue on with the lesson. As the nurse, you realize that Mrs. Kwan’s experience with her son’s illness will likely both benefit and hinder her learning. The familiarity with the equipment will make her learning easier, but the sad memories could create anxiety and thus negatively affect her learning abilities.
You reviewed today the importance of assessing for health literacy and acting as a client advocate for those in need. You also reviewed that preferred learning styles are unique to each client. After trying to teach using written material and spoken word, you realized that Mrs. Kwan learned best by doing. By providing Mrs. Kwan with the opportunity to talk about memories that came up for her during the teaching, in a safe environment, trust was established and the therapeutic relationship was strengthened. Your experience reinforced your learning those clients’ past experiences and knowledge can affect their learning and ability to cope with and manage self-care.