CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A PATIENT-TEACHING GUIDELINE FOR
CATHETER CARE IN THE HOME
A graduate project submitted in partial
satisfaction of the requirements
for the degree of
Master of Public Health
by
Peggy Joyce Streid
August, 1981
The Graduate Project of Peggy Joyce Streid is approved:
.P. H.
Krishnamurty,
Co-Chairperson
California State University, Northridge
ii
ACKNOiiTLEDGEMENTS
I am deeply grateful to my committee
Co-Chairpersons, Dr. G.B. Krishnamurty and Mary Parker,
for their valuable guidance and supportive attitude.
I would also like to thank my committee member and
field training supervisor, Ruth Geagea, who was a
constant source of encouragement throughout the project.
I wish to thank the entire staff of National
In-Home Health Services for their gracious cooperation
and helpfulness.
Sincere appreciation to
Cheryl Yamashita for typing the teaching guideline
and handouts, and to Cathy Cabrera who translated the
teaching tools into Spanish.
The contribution of my family and friends has
been especially meaningful to me.
In particular, I
would like to express gratitude to my mother,
Norma Streid, for her patience and understanding, and
to my friends,
Charlotte Laubach and Jacky Clutter,
for the laughter we shared.
iii
TABLE OF CONTENTS
Page
APPROVAL .
• • •
ii
ACKNOWLEDGEMENTS
iii
LIST OF TABLES
vi
ABSTRACT • • •
viii
Chapter
1.
2.
1
INTRODUCTION
Background of the Problem •
1
Statement of the Problem
4
Purpose of the Study
5
Definition of Terms • •
5
Limitations of the Study
7
REVIEW OF THE LITERATURE
9
Patient-Teaching as a Function
of Nursing Practice . • • • .
11
Nurses' Perception of
Teaching • • • • . • .
19
Factors Interfering with
Patient-Teaching • • •
22
The Use of Teaching
Guidelines
. • •
29
The Place of Documentation
in Nursing
31
Current Practices in Organizing
and Documenting PatientTeaching . • • • • . . • • •
36
iv
Chapter
3.
Page
METHODOLOGY . • .
.
•
45
Identification of the
Problem • . • . •
Target Group
4.
5.
• • • .
45
• • • • • •
Establishment of Project Goals
and Objectives
••.•
47
Planning of the Project • • .
48
Implementation of the Project
52
Evaluation of the Project •
53
RESULTS .
.
. .
.
56
Findings: Nurses'
Questionnaire . .
56
Findings:
71
Chart Review •
SUMMARY, CONCLUSIONS AND
RECOMMENDATIONS
. • •
Summary .
73
• • .
73
Conclusions • • •
75
Recommendations •
76
BIBLIOGRAPHY •
APPENDICES
78
. .. . . . .
.
APPENDIX A
NEEDS ASSESSMENT SURVEY
APPENDIX B
CATHETER CARE TEACHING
GUIDE
.
APPENDIX
47
c
APPENDIX D
APPENDIX E
. .
PATIENT-TEACHING TOOLS
(ENGLISH)
. . .
PATIENT-TEACHING TOOLS
(SPANISH)
. . .
CATHETER CARE TEACHING
GUIDE EVALUATION . .
.. . .
v
85
86
. . .
. . .
. . .
...
88
91
98
105
LIST OF TABLES
Page
Table
1.
Evaluation of Published Teaching
Guidelines . . . • • • • • • .
. . .
38
Guideline's Effect on PatientTeaching • . • . • • • • . •
57
Guideline's Effect on Patient
Behavior • • • •
58
Type of Patient to Benefit from
Guideline • . • . . • • • • •
59
5.
Additional Functions of Guideline
60
6.
Teaching Methods Most Frequently
Used by Nurses • . • • • • • •
61
Does the Guideline Require
Significant Time to Use?
62
Should the Patient Be Given a List
of the Learning Objectives?
63
Topics for Future Teaching
Guidelines • • • • • • .
64
Number of Visits Required to Teach
Information • • • • • . • • • .
65
Number of Visits Required to Evaluate
Patient Learning . • .
• • • . •
66
12.
Frequency of Guideline's Use
67
13.
Degree to Which Patient Must Correctly
Perform Objective • • • . •
68
Number of Times Objective Must be
Performed Correctly . • • •
69
2.
3.
4.
7.
8.
9.
10.
11.
14.
vi
Table
15.
16.
Page
Nurses' Background in Teaching
Techniques •
• • • •
70
Desire for Additional Training in
Patient-Teaching • • • . • •
71
vii
ABSTRACT
A PATIENT-TEACHING GUIDELINE
FOR CATHETER CARE IN THE HOME
by
Peggy Joyce Streid
Master of Public Health
The purpose of this study was to develop,
implement and evaluate a teaching guideline to
facilitate and document the patient-teaching of home
health nurses in the area of indwelling catheter care.
The guideline was designed to make the nurses' educational efforts more organized and systematic.
An
additional function of the form was to serve as a rapid
and convenient method of recording the patient-teaching
that occurs.
Essential features incorporated into the design
of the catheter care teaching guideline included:
1) an outline of the content to be taught, 2)
viii
learning
objectives to be attained by the patient, and 3) an
evaluation of the patient's learning.
Space was also
provided for notating the teaching methods utilized,
patient learning barriers, the date that teaching is
performed and the signature of the nurse-teacher.
Following a period of the teaching guideline's
use, a questionnaire was developed in order for the
staff nurses to evaluate the content, clarity and efficacy of the guide.
In addition, a review of catheter
patients' charts was performed to determine whether the
teaching-documentation form was being utilized according
to procedure.
The results of the nurses' evaluation indicated
that the teaching guideline generally enhances the
quality of the nurses' instructional efforts and is an
effective method of organizing the teaching of catheter
care.
The guide was given a favorable assessment in
terms of both the clarity of its format and the comprehensiveness of the content.
A majority also reported
that use of the guideline does not require a significant
amount of extra time.
The chart review disclosed that
the form is rarely filed in the permanent medical record.
Therefore, the teaching guide does not meet the objective
of providing documentation of the teaching performed in
the area of catheter care.
ix
Chapter 1
INTRODUCTION
Background of the Problem
An essential component of health care is the
education of the patient and others concerned with the
patient's well-being.
Patient education has existed for
many years on an informal basis within the health care
delivery system, but only recently has it begun to emerge
in a formalized and structured manner.
Health care
agencies_have been focusing increased attention on the
necessity of documentation when providing patient education.
The 1975 Joint Commission on Accreditation of
Hospitals required that the criteria for patient care
standards include "demonstrated knowledge of the patient
concerning health status, level of functioning, and
self-care after discharge" (48:25).
The Patient's Bill
of Rights includes a reference to the ethical and legal
requirements of meeting the educational needs of
patients (42:3).
A local health care agency explicitly
states as agency policy their patients' right "to be
taught about the illness so that the patient can help
himself, and the family can understand and help the
patient" (35:9).
These statements acknowledge that the
1
2
patient is entitled to the opportunity to participate in
educational activities so that sufficient knowledge and
appropriate skills may be acquired in order to properly
manage the disease.
Patients themselves are beginning
to accept responsibility for their own health care.
Crucial to the progress of any patient from dependent
care receiver to knowledgeable participant in care is
the patient-teaching process.
Patient-teaching is an integral part of nursing
practice as today's nurses revise their professional
role to shift from "traditional mother-surrogate activities
to more educative nurturing ones" (26:28).
This
growing emphasis on the nurse as a teacher is reflected
in the 1973 American Nursing Association Standards of
Practice which lists teaching as a function of the nurse
(42:13).
Highly competent nursing care of necessity
incorporates the use of patient-teaching to meet the
assessed individual needs of the patient, the family,
and the community (25:17).
Along with this increasing
focus on the role of the nurse as a teacher comes a
widespread awareness by nurses of the effectiveness of
educating patients.
In a 1980 survey of registered
nurses, over 97 percent responded that the well-informed
patient has an easier recovery period than the poorlyinformed patient (48:25).
Also, the same survey
3
revealed that more than three-quarters of the nurses
indicated that from 20 to 100 percent of the care they
give patients involved patient education.
Clearly then,
health teaching by nurses is regarded as a major nursing
function that is incorporated into daily patient care.
Nursing practice standards, growing consumer
pressure, and legal requirements combine to make the
documentation of patient-teaching a necessity.
Yet only
recently has an awareness developed that patient education must be a planned and evaluated function as are
other aspects of medical treatment.
Despite nurses
responsibility to plan strategies and be held accountable
for their actions (47:47), systematic plans for the
patient-teaching process are rare.
Studies reveal that
only 65 percent of nurses feel that their background and
education have adequately prepared them to teach (48:27).
Statistics such as these,
coupled with the lack of
patient-teaching plans, underscore the acute need today
for formalized teaching systems.
This need can be met
by health educators who, by virtue of their specialized
background in organizing health instruction, are able to
apply professional skills in the development of guidelines for the facilitati0n and documentation of the
patient-teaching process.
Thus, the specialized knowl-
edge of various health professionals can be applied in
4
a manner which contributes maximally to quality care for
each patient.
Statement of the Problem
With the growth of both institutional requirements and consumer pressure for quality assurance in
patient education, nurses today are faced with the tasks
of organizing and documenting the teaching of patients.
Although widely recognized as an integral part of nursing
practice, few tools exist to both structure and record
the patient-teaching process.
The Director of Education
for a local home health agency, aware of the lack of
systematic teaching by agency nurses, expressed the need
for a teaching guideline.
By standardizing the content
taught in a given subject and documenting the process in
the patient's chart, the guideline would help assure
agency administration of quality care being given in the
area of patient-teaching.
Home health agencies provide a coordinated
program of interdisciplinary skilled health care to
patients at home.
The need for substantial patient-
teaching is particularly acute in the home care setting.
As home health agencies care for patients on a part-time
basis only, a high degree of patient or caregiver
involvement in the patient's care is necessitated.
The
5
emphasis on educating the patient or caregiver about
living with illness or injury is perhaps greater than
with hospitalized patients who have round-the-clock
professional nursing care.
The nature of home health
care and the necessity for the participation and independent functioning of the patient requires the formalization of the patient-teaching process in home health
nursing.
Purpose of the Study
The purpose of this study was to develop, implement and evaluate a teaching guideline on indwelling
urinary catheter care for use by staff nurses at a home
health agency.
The teaching guideline was designed to
standardize the content taught by the nurses and to
document the teaching process for agency records.
This
study will describe the formalization of the patientteaching process into-a written guideline and the results
of the guideline's evaluation.
Definition of Terms
Caregiver
Family member or paid attendant who takes daily
personal care of the patient.
6
Documentation
The supplying of a written record as proof or
support of things said; the furnishing of a written paper
providing evidence or information.
Foley/Indwelling Catheter
A type of urinary catheter designed to remain in
the bladder for long periods of time.
Long-term cathe-
terization is necessitated by chronic cases of urinary
retention or incontinence.
Home Health Agency
A community agency (voluntary or private) which
provides a coordinated program of physician-ordered
skilled health care for patients who are confined to the
home and in need of skilled services on a part-time,
intermittent basis.
Home Health Nurse
A Registered Nurse or Licensed Vocational Nurse
who works for a recognized home health agency and provides nursing care in the patient's home; commonly known
as a visiting nurse.
For the purpose of this study, home
health nurse will be used interchangeably with staff
nurse.
7
Patient Education
Health experiences designed to influence learning
which occurs as a person receives preventive, diagnostic,
therapeutic and/or rehabilitative services.
Patient-Teaching
Communication between nurse and patient which is
especially structured and sequenced to produce learning
by the patient.
Patient-teaching includes both formal
instruction and informal teaching.
Urinary Catheter
A thin, hollow tube used to empty the bladder of
urine.
The catheter is inserted into the bladder via
the urethra.
Limitations of the Study
The teaching guideline employed in this study
was designed to meet the specific needs and requirements
of the nursing staff and administration of one home
health agency.
The results of the evaluation may or may
not be valid for other health agencies.
The Investigator assumes that the nurses using
the patient-teaching guideline are aware of proper
catheter care and possess some knowledge of basic
teaching methods.
The purpose of the guide is to assist
8
the nursing staff in teaching more systematically.
While
an inservice education program on learning theory and
educational methodology would be valuable, it is not
within the scope of this study.
This study will not include the effect of the
teaching guideline on the patients themselves except
insofar as the nurses report any change in their patients'
knowledge, attitudes, or behavior as part of the nurses'
assessment of the document's strengths and weaknesses.
Chapter 2
REVIEW OF THE LITERATURE
This chapter will examine the literature pertinent to the design and development of a teaching plan to
guide and document the patient-teaching performed by
nurses.
Specific areas of review will include
1) patient-teaching as a function of nursing practice,
2) nurses' perceptions of teaching, 3)
factors inter-
fering with patient-teaching, 4) the use of teaching
guidelines, 5) the place of documentation in nursing,
and 6) current practices in organizing and documenting
patient-teaching.
The nursing profession has for many years viewed
patient-teaching as an essential function of its practice.
From nursing curricula in the early 1900's to
present-day standards and nurse practice acts, nursing's
role in patient education has increasingly been emphasized as a therapy for which nurses are accountable.
Several nursing leaders regard the nurse as the most
appropriate member of the health team to assume the
major responsibility for teaching activities.
Assisting
patients to develop their optimal health potential can
be a difficult task for nurses accustomed to giving only
9
10
essential physical care, but it is particularly critical
for homebound or chronically ill patients.
While studies of nurses' perceptions of teaching
indicate some discrepancies in acceptance of the teaching
role, there has been a generally positive shift in both
performance and preparation.
However,
ineffective
patient-teaching continues to be practiced by some staff
nurses for several reasons, including:
lack of adminis-
trative support, physician dominance, and nurses'
inadequate teaching skills.
Fortunately, the use of
teaching guidelines can increase a nurses' ability to
provide effective instruction by standardizing the
teaching content and defining learning outcomes.
Adequate documentation systems are a necessity
for quality assurance in nursing as they provide written
proof of all aspects of nursing care received by patients.
As
a vital component of nursing service, patient-
teaching must also be documented in the medical record.
Teaching-documentation facilitates communication between
members of the health team and aids continuity in the
teaching learning process.
It is recommended that
existing forms be revised or new documentation tools be
developed in order to adequately document educational
activities.
11
Few guidelines to facilitate and document
patient-teaching have been published in the nursing
literature.
The majority of those that exist are at
least partially inadequate in fulfilling the purposes
of outlining the teaching content, defining behavioral
objectives, evaluating patient learning, and documenting
the teaching that is performed.
The paucity of satis-
factory teaching guidelines emphasizes the need within
professional nursing for planned, systematic approaches
to patient education.
as a Function
of Nursing_£ractice
Patient-Teachin~
Theoretically, the nursing profession has long
been committed to the belief that patient-teaching is
both the function and responsibility of its members.
Nursing literature has for many years described the role
of the nurse as a teacher.
In 1918, the National League
of Nursing Education published a curriculum which
expressed the need to prepare nurses for their teaching
duties and decried nurses' training that neglected
"preventive and educational factors" (33:88).
The 1950
curriculum stressed the necessity for inclusion of
teaching-learning principles as well as teaching skills
in all nursing curricula (42:2).
The American Nurses'
Association Standards of Nursing Practice, published in
12
1973, identified several characteristics nurses must
possess in order to provide a high quality of nursing
care.
Teaching activities are clearly listed as a func-
tion of nursing practice, and patient education is integrated into the body of the standards.
It is stated
that these standards are intended for application to
nursing practice in any setting.
Nursing actions ... employ teaching-learning
opportunities for the client; the client and family
are kept informed about and/or are provided with
the information needed to make decisions and
choices; teaching-learning principles are incorporated into the plan of care and objectives for
learning stated in behavioral terms (2:2).
The nurse's responsibility for patient education
is further emphasized in nurse practice acts which
include teaching as an explicit part of nursing service.
Nurse practice acts establish the legal definition of
nursing by state law and declare in broad terms what a
nurse may do in that state (6:22).
Recently, thirty
nurse practice acts have been revised to expand the
scope of practice for registered nurses.
For example,
the New York State Nurse Practice Act updated its definition of professional nursing to include, "diagnosing
and treating human response of actual or potential health
problems through such services as case-finding, health
counseling, and provision of care" (23:19).
California
is also among the states that have broadened the scope
13
of nursing to make the teaching-supportive aspects of
care central to the nursing role (11:75).
As
a conse-
quence, patient education is making "the transition from
being a nice humane thing for which [a nurse] is not
accountable to a therapy for which practice laws hold
[a nurse] responsible" (40:19).
Nurses are professionals who must be held
accountable for meeting professional standards.
Redman
views as essential to the nursing profession the
establishment of patient education as a therapeutic service
with adequate standards of care.
The creation of
a core of nurses able to practice patient education
according to those standards is also considered crucial
(39:1366).
Standards should define as malpractice not only
the omission of teaching when it could reasonably
be expected to be therapeutic but also the production of incapacitating confusion or the forcing of
values on the patient when it could reasonably
have been avoided (42:236).
The role and responsibility of the nurse in
patient-teaching is further emphasized by nursing
leaders and nursing educators throughout the literature.
The profession of nursing is characterized as an educative process and an educative instrument (42:2).
The
nurse is a natural teacher with an established aura of
trust (37:27) who "must not only be recognized but also
held accountable for patient-teaching activities just as
14
she is for carrying out doctors' orders" (16:4).
Orem
lists teaching as one of the five helping behaviors
nurses need to use in order to guide individuals toward
self-care (19:11).
Redman expands on the importance of
teaching within nursing practice:
"Perhaps i t is most
useful to nursing practitioners to view all interaction
with patients as contributing to the broad process and
objectives of teaching-learning" (42:10).
The teaching
function, according to Bille, should be described in the
nurse's job description and should therefore also be
included as one aspect of periodic performance appraisal
(33:94).
Several nursing leaders go beyond the acceptance
of patient education as a legitimate nursing activity to
declare that the nurse is the single most appropriate
member of the health team to assume the major responsibility for the teaching of patients.
"As knowledgeable
health providers who understand the personal and cultural
background of the patient, primary nurses are in an ideal
position to educate the patient" (13:9).
Palm comments
that the nurse 1) knows the treatment plan; 2) knows the
patient's level of acceptance of the health problem;
3) has more frequent and consistent opportunities than
other health personnel for contact with the patient and
family; and 4) can assess the patient's learning on a
15
daily basis (34:675).
As Dachelet states:
A significant part of nursing's organized
effort to increase its status is based on defining
its unique role/ describing and demarcating that
area of expertise/ skill and knowledge over which
i t would be acknowledged as the authority and/ perhaps/ most critically, establishing the legitimacy
of that role in the eyes of the public and physicians (9 :32).
The formation of the American Association of
Diabetes Educators and the American Association of
Nephrology Nurses and Technicians, nursing specialty
groups highly concerned with the teaching aspect of
their practices, is cited by nursing leaders as additional evidence of the profession's growing acceptance
of its teaching function.
Attempts to remove this
function from the nurse and designate another health
professional, the patient educator, as the one responsible are denounced by nursing educators who ask/
Are we not going to increase the confusion and
overlapping of roles and responsibilities by introducing yet one more person to the patient already
confused and assaulted by a complex health care
delivery system (43:261)?
The nursing profession does, however, seem to
have the primary responsibility for all aspects of
patient education in the nation's hospitals.
Results of
a 1975 survey revealed that the health team members most
frequently involved in teaching patients are nurses, who
were involved twice as often as physicians (30:78).
Nurses are found on over 90 percent of the patient
16
education policy-setting committees.
The majority of
the hospitals also named nursing as the department
responsible for the coordination of patient education
programs.
The relationship of patient-teaching to the
nursing process further supports the role of teaching
in nursing practice.
Teaching and nursing both involve
a helping relationship which seeks to develop independence
in the subject (42:2).
The statement that "Every
person who receives health care has some need to learn, "
(42:6) reflects the similarity and interaction of the
teaching and nursing processes.
The nursing process, the dominant nursing
modality today, is a systematic, problem-solving approach
to assessing the patient's situation.
It identifies
all the significant steps taken during patient care
"with attention to their rationale, their sequence, and
relative importance in helping the patient reach specified and attainable health goals" (3:4).
The general
steps in the nursing process include assessing the
problem, planning nursing actions, implementing the plan,
and evaluating the results.
Redman sees the teaching
process as parallel to this nursing process.
The process
of teaching includes assessment of the learner's readiness and need to learn, setting objectives,
17
teaching-learning activities, and evaluation (42:24).
Thus, each process has an assessment, diagnosis and
intervention phase.
For this reason, Redman feels that
teaching can easily be performed in the same amount of
time that the nursing process is already taking.
If at
any time during care, the ongoing nursing assessment
indicates a learning problem for which teaching is relevant, a more refined assessment of need and readiness is
then made, and the problem is resolved through the
teaching process (42:25).
With practice, the nurse-
teacher can become very sensitive to expressions of
learning readiness that occur during daily nursing care.
In this manner, teaching is integrated into the nurse's
other care-giving functions.
The general goal of health teaching is to assist
individuals in developing their optimal health potential.
Specifically, teaching aids patients to:
1.
Make rational decisions about health;
2.
Participate effectively in care and cure;
3.
Adjust to the realities of the health
situation; and
4.
Feel satisfaction in working toward health
(42:60).
It is the task of the nurse-teacher to stimulate
people to assume responsibility for their own health and
18
to "ensure that the patient understands what the doctor
has told him, for only if this is done can she carry out
her nursing role" (19:13).
The literature repeatedly
affirms that "the highest level of care is self-care and
that is a more difficult challenge for health profess ionals than providing the care themselves" ( 26:29) .
As
Redman explains:
One must be very secure to give up the satisfaction that comes from giving services and begin
to derive i t from teaching. The latter, which
involves guiding patients through slow, fumbling.
half-hearted efforts to do something for themselves, can be trying and fatiguing to the nurse ...
This is a kind of nursing very different from just
giving essential physical care and following a
physician's orders (42:14).
Winslow notes that a double standard exists
within the health care setting in that nurses and physicians are expected to have years of training before
caring for patients, yet often patients are expected to
care for themselves without any understanding of basic
self-care (51:213).
In a mutually supportive and inter-
active relationship, both the nurse and patient assume
responsibility for movement toward the goal of independence.
By means of teaching, the nurse relinquishes
control to the patient.
The development of a certain degree of independence
in the homebound or chronically ill patient is
particularly critical due to the fact that this type of
19
patient often must function with minimal medical supervision for long periods of time.
The teaching of
patients with chronic illness needs to include some new
factual knowledge and skills but mostly should deal with
reintegration of the medical regimen into the patient's
life (39:1365).
This approach is reinforced by studies
indicating that patients are particularly concerned with
receiving information that enables them to plan realistically for their immediate and long-range lives and are
least concerned about the various small details of
treatment (51:220).
Fortunately, patients having the
responsibility for self-care at home seem to be more
highly motivated to remember what they have learned, and
have a higher retention for teaching performed in the
nonstressful home environment (33:83).
Nurses' Perceptibn of Teaching
While a certain amount of confusion continues to
exist regarding patient-teaching as a nursing function,
studies of nurses' perceptions of the subject indicate
a generally positive shift in attitude toward both performance and preparation.
A 1961 study revealed that
the majority of medical-surgical nurses accepted teaching
about the toxic symptoms of medications and the symptoms
of disease complications as their responsibility but did
20
not believe they were responsible for teaching about the
purpose of medications or special diets (23:20).
addition,
In
teaching and preparation for home care was
evaluated at that time as being less well-accomplished
than any other aspect of nursing care.
A survey con-
ducted in 1965 found that of the 1500 American Nursing
Association members polled, one-third felt they had no
preparation for the teaching they were doing,
20 percent
believed they were adequately prepared to teach,
and
most held generally unclear concepts of teaching (7:7).
Increasingly, however, nursing practitioners are
accepting teaching as a vital nursing responsibility.
Palm's 1971 study revealed that nearly sixty percent of
the nurses surveyed assigned top priority to teaching
responses when ranking responses of physical care, supportive emotional care, patient-teaching and liaison
activities in written descriptions of nursing care situations (34:673).
An additional thirty percent of the
nurses ranked the teaching response second in importance.
Significantly, though, the nurses tended not to select
teaching responses for patients who did not overtly
express learning needs.
A recent survey of nurses
reported that 95 percent replied affirmatively to the
question,
"Have you ever seen a registered nurse perform
health teaching or counseling?" (38:17)
21
In 1980, Sutherland conducted a study which not
only disclosed that over forty percent of the nurses
polled would like increased responsibility for patientteaching, but found that a full two-thirds perceived
their background and/or education as being adequate
preparation for it (48:27).
Dennis discovered a corre-
lation between nursing education and performance:
as
education increases, nurses are more interested in providing a teaching function (17:22).
Sixty-seven percent
of the nurses who responded to a hospital-based survey
felt that they did have opportunities to teach patients
and all the respondents believed patient-teaching to be
a legitimate responsibility of nurses (31:4).
Still, there is evidence that nurses do not
fully comprehend their teaching role.
According to
Johnson and Pachano's 1981 survey of hospital nurses,
nurses did recognize some degree of self-involvement in
all areas of patient education, especially in relation
to teaching about medications.
However, in nearly all
areas, nurses perceived themselves performing as much
as four times more patient-teaching than the patients
perceived the nurses doing (27:50).
Sutherland's study
was also one that revealed certain conflicting results
regarding nurses' perceptions of teaching.
Although
seven out of ten nurses indicated that patient education
22
involved between 20 and 100 percent of the care they give
patients, only 42 percent said that the nurse is the
staff member who actually instructs the patient on care
after discharge.
Similarly, nine out of ten nurses felt
that it is the private physician who should tell patients
about their condition (48:25).
Obviously, a diversity
exists among nurses regarding their teaching function.
Factors Interferjng with
Patient-Teaching
A number of factors have been identified which
affect the nurse's teaching role:
1.
staffing.
Lack of time, heavy workload( and inadequate
Present-day staffing patterns and assignments
emphasize a task-oriented role for nurses which "will
leave little time for the bedside teaching of patients
until nurses themselves become convinced that patient
education is an important task that must be carried on
continuously" (7:8).
However, it has been suggested
that these time-related interferences in teaching are
more likely to be rationalizations for nurses' inadequate
teaching skills (42:16).
2.
Physician dominance.
Some nurses will not
accept responsibility for teaching because of a patriarchal belief that only physicians should impart
23
information to a patient (7:8).
Realistically, however,
another person is often needed to help interpret what
the doctor says into simpler language.
Yet because the
nurse's relationship with the physician has traditionally
been dependent, even serving as an intermediary may seem
too independent an action for many nurses (42:15).
The
absence of a clearly defined role and responsibility for
teaching between the two professions is the basis for
the problem.
Physicians control the prerogative to
share information in such areas as diagnosis or prognosis
but have made limited use of education in their daily
practice ( 42:236) .
The nurse, whose license includes
health teaching, is then placed at a disadvantage.
Often
the nurse is expected to perform follow-up or independent
teaching even though the doctor has failed to initiate
the prerequisite teaching.
Unfortunately, the "cult of
secrecy-only the physician can tell you" philosophy
continues to be advocated by some schools of nursing
(51:218).
3.
mechanism.
Withholding information as a controlling
The belief that sharing knowledge with the
patient decreases the nurse's power is another factor
affecting the nurse's teaching role.
The nurse-patient
relationship depends upon a differential in skills and
knowledge; teaching is an especially sensitive area of
24
practice because it attempts to alter that differential.
While it is reasonable and functional to expect the nurse
to conceal some information,
"withholding information or
educational-supportive therapy can be as devastating to
the client as withholding other treatment such as drugs"
(42:235).
4.
Patient reticence.
By failing to take the
initiative and request information from the nurse, the
patient must accept at least partial blame for inadequate
teaching.
As mentioned, nurses tend not to perform
informal teaching except for needs specifically expressed
by patients (34:676).
This problem is compounded by
the finding that patients may not perceive or utilize
the nurse as a source of information (51:215).
Yet, a
group of hospitalized patients cited "giving a poor
explanation" as the most unsatisfactory aspect of their
care (42:15).
This situation improves, says Winslow,
when nurses clarify their role as teacher and the
patient's as student; the appropriate psychologic set is
produced and learning will increase (51:219).
5.
Lack of institutional support.
A crucial
factor affecting the teaching behavior of nurses is the
lack of support for patient education by nursing service
administration.
A 1962 survey of ninety nursing super-
visors revealed that they did not expect their nurses to
25
to teach.
Teaching duties, considered low priority com-
pared to the high priority of administrative duties, were
neither rewarded nor encouraged (42:16).
The literature
provides many examples that administrative support for
patient-teaching has increased over the years.
This may
in part be due to the 1974 American Hospital Association
statement on the role and responsibilities of hospitals
and other health care institutions in personal and community health education, which states:
A significant corporate commitment, including
staff and financial resources, is essential if
hospitals and other health care institutions are
to fulfill their leadership role in health education. This commitment involves the acceptance and
implementation of health education as an integral
component of health care, the designation of
specific responsibility for organizing and implementing health education programs, and continuing
evaluation (1:1).
Apparently, however, not all health care agencies
have administrators supportive of educational programs.
Sutherland found that over forty percent of the hospital
nurses in her 1980 study reported that "very little" or
"almost nothing" is done for patients to help them understand what is wrong with them (48:25).
Administrative
commitment to patient-teaching is a critical resource
whose absence will undermine the most enthusiastic
nursing efforts.
A philosophy of patient education
"reflects institutional values, attitudes and priorities,
which are in turn reflected in the behavior of the
26
nursing staff in patient education" (14:56).
Redman
suggests that the lack of preparation for teaching in
basic nursing education may have produced administrators
who are unable to provide knowledgeable teaching supervision to their staff nurses (42:16).
Nursing administration needs to assist the nurse
to acquire the knowledge and skills necessary to teach
patients.
The motivation of a staff to perform expected
duties consistently and competently appears to be
a process that involves the initiation of action,
the sustaining of activity and the regulating of
patterns of activity (36:43).
Consequently, the nurse must be not only encouraged
but supported and rewarded for deliberately setting
a time priority for patient-teaching.
6.
Nurses' inadeg_uate teaching_ skills.
Schweer
states,
It would be safe to say that there is no
professional school of nursing that does not have
the concept of health teaching as one of the curriculum objectives, and that there is no hospital or
public health agency that does not have health
teaching as a major goal of patient care (45:681).
Yet studies reveal that many nurses cannot provide proper patient education because of their lack of
knowledge concerning basic teaching-learning principles
and
methodology.
Nurses vary in their preparation,
experience and exposure to patient-teaching; unfortunately,
"teaching is a special kind of skill that many
27
staff nurses do not have" (42:219).
Failure to develop
the necessary educational skills and attitudes results in
ineffective patient-teaching.
Observations reveal the
following problems when nurses untrained in educational
principles, methodology and evaluation attempt to teach:
1.
Telling patients what the nurse thinks they
should know rather than what the patient is ready or
willing to learn;
2.
Failing to individualize educational efforts
in consideration of the patient's personal background,
attitude and motivation;
3.
Failing to assess the patient's knowledge
before beginning an educational effort; and
4.
Providing education on an incidental, acci-
dental or ad hoc basis, rather than in a carefully evaluated manner (13:3).
Freedman lists additional mistakes commonly made
in many patient-teaching situations.
1.
Teaching information that is not relevant
to the patient;
2.
Uncertainty regarding what the patient should
be able to do with the information taught;
3.
Poorly introducing the teaching content so
the patient is unsure of what is to be learned;
28
4.
Presenting the information unclearly without
clearcut guidelines for the patient to follow;
5.
Presenting too much information and using
too few handouts;
6.
Using handouts which are poorly labeled,
disorganized, incomplete or irrelevant;
7.
Not using enough examples or practice; and
8.
When teaching a skill, not telling the
patient how to determine if the skill is being performed
correctly (22:x).
Nurses are discovering that it is not the "what"
of patient-teaching but the "how" - the process used that is the critical key to the success of educational
efforts.
"Today the teacher is less a dispenser of
information - factual material - than a programmer and
designer of many kinds of learning experiences" (42:114).
Thus, in order to fulfill their basic responsibility
for teaching patients, all nurses should obtain some
degree of proficiency in and appreciation for the
teaching process.
McWeeney suggests that nurses accom-
plish the following to assure quality education to their
patients:
1.
Develop their own skills for effective
teaching;
2.
Be continually alert for opportunities to
29
teach;
3.
Communicate teaching plans for consistency
and continuity of teaching; and
4.
Document what is taught, how it is taught,
and the patient's response and level of understanding
during and after the teaching session (33:87).
If all health professionals were better prepared
as educators, suggests Chaisson, or if the member of the
health care team who is best prepared as an educator was
given the primary responsibility for teaching the patient,
the public could perhaps be guided towards an improved
health status and thereby reduce the patient's health
care bill (13:5).
Nurses must recognize their need for
adequate knowledge and skills of patient-teaching as
one having great implications for their nursing practice.
The Use of Teaching Guidelines
Research shows that structured teaching, that is,
the use of specific written teaching guidelines,
effective than unstructured teaching (51:219).
is more
Many
health agencies are now developing these teaching guides
for subject areas commonly taught by staff nurses.
The
purpose of a teaching guideline is to increase a nurse's
ability to effectively provide instruction to patients.
This is accomplished by standardizing the teaching
30
content and defining the behavioral objectives to be
attained by the learner.
Guidelines can enhance the teaching of patients
by providing nurses with clear direction for their educational efforts.
Gusfa points out,
"We can no longer
assume that each registered nurse has at her disposal
the available resources and knowledge to teach each of
her patients properly" (25:17).
A nurse may avoid
teaching patients completely due to uncertainty about
what to teach:
"Gross errors in health teaching can now
exist, probably more by omission than commission" ( 40:20).
Nurses who do not have access to pre-planned teaching
guidelines are forced to rely on their intuition and past
experience in order to determine the proper teaching
content.
The lack of standardized content can result
in conflicting information being presented by numerous
well-meaning staff nurses; this in turn creates frustration in the patient-learner (7:8).
Written guidelines
solve this dilemma by clearly outlining the teaching
process and providing some common understanding among
staff as to what basic behaviors patients should learn.
If nurse-teachers force themselves to identify
in precise terms the behavior to be attained, they
will have a clearer notion of the content, sequence
of content, and the teaching methods that are most
likely to be successful (42:23).
31
Redman comments that with clearly defined objectives,
learners are provided the means to evaluate their own
progress during instruction and are often able to learn
by themselves (42:64).
Many nurses will function more effectively if
teaching guidelines are made available.
Studies indicate
that nursing personnel prefer structured teaching because
it is more consistent, less difficult, less frustrating
and seems to require less time to accomplish (51:219).
Nurses are not expected to remember the entire written
plan but to use it to guide them while they are teaching
to see that content is not omitted and to focus on the
objectives if the discussion rambles (42:167).
Use of
these teaching guidelines does not, however, absolve the
nurse from the responsibility of comprehending the
material in some depth and being a skilled teacher.
Written teaching guidelines, then, are a significant aid
to professional nurses in performance of their teaching
function.
The Place of Documentation
in Nursing
Documentation, the act of providing written
proof of care rendered, is an essential component of
professional nursing and a necessity for the assurance
of high quality care.
The notion that "care is good
32
because we say it is" is outmoded and unprofessional; in
reality/ documentation is the only proof nurses have that
patients were cared for properly (18:164).
A well-
documented record of services is crucial because assumptions and expectations are not totally reliable as evaluation of the quality of care actually received by
patients.
"Assumptions that nursing care was given
cannot be tolerated.
If the care was not documented then
... it was not done" {4:4).
Documentation forms the basis for quality assurance programs which measure adherence to the standards
of nursing care.
The American Nurses
1
Association
standards of practice are based on the premise that the
individual nurse is responsible and accountable to the
patient for the quality of nursing care given.
Nursing must control its practice in order to
guarantee the quality of its service to the public.
Behind that guarantee are the standards of the profession which provide assurance that service of a
high quality will be provided (3:4).
The information documented in the patient
1
S
chart serves
as a means to determine if nursing practice meets acceptable standards.
A properly documented nursing record should
reveal every aspect of care provided.
documented record:
A correctly
33
1.
Provides the data needed to plan the
patient's care and insure continuity of care;
2.
Provides a way for the health team members
to communicate;
3.
Furnishes written evidence of why the
patient received the nursing care provided, the
patient's response to that care, and revisions in the
care plan;
4.
Provides a way to review, study, and evalu-
ate patient care in preparation for an audit;
5.
Furnishes a legal record that can be used
to protect the patient, nurse, and health care agency;
and
6.
Supplies data for use in research and educa-
tion (18:25).
A nursing audit is a retrospective evaluation of
nursing care based upon the documentation of that care
in the patient's medical record in order to improve
patient care systematically over time (5:2).
If the
documentation is poor, an audit may show deficiencies
in care where actually there were none.
poirits out,
As McNeill
"No one can really determine what's been done
for a patient, how well it's been done, and what should
be done in the future, until he examines the documentation" ( 18 : 9) .
34
As
an integral part of nursing practice, patient-
teaching must also be reflected in nursing documentation.
The necessity for recording educational activities is
noted in the American Hospital Association's statement
on their role in health education:
"In order to improve
health and health care services, ongoing systems of
health education must be planned, implemented and documented" (1:1).
In addition, the Joint Commission on
Accreditation of Hospitals Manual requires that the
medical record of each patient includes information
documenting "patient disposition and any pertinent
instructions given to the patient and/or family for
follow-up care" (28:68).
Documentation of patient-teaching has two
purposes:
1.
To communicate to each nurse where the
patient is in the learning process; and
2.
To reflect the learning accomplished by the
patient during health care (15:72).
By facilitating communication between members
of the health team, documentation proves to be a principal aid in attaining continuity, assurance of which in
teaching is as necessary as in other phases of nursing
care.
To meet a patient's learning needs, nurses must
keep abreast of what the patient is learning; this is
35
accomplished through adequate documentation.
When a
convenient system of teaching-documentation is utilized,
it helps to guarantee that teaching will occur and
"avoids leaving patient-teaching undone because everyone
thought someone else was going to do it" (51:218).
Although it is often claimed that patient education activities are not documented, a 1975 study found
that 67.5 percent of the hospitals surveyed made speclii~
provisions for documenting educational activities
somewhere in the medical record (30:80).
While the
majority carry out documentation on nursing progress
notes or discharge planning sheets, nearly 20 percent
use a separate sheet for recording patient education.
In preference to creating new forms, Lee suggests that
the nursing staff evaluate current tools such as patient
history forms and care plans to determine how they could
be used or changed for the purpose of documenting educational activities (30:82).
Blount agrees that the
record system must be revised as quality documentation
cannot be easily accomplished with traditional charting
forms (10:9).
Documentation, however, is an integral
component of problem-oriented medical records (POMR), a
system of charting which provides for the efficient
organization of pertinent information within the
patient's chart (52:13).
A distinctive feature of POMR
36
is the requirement for not only identifying the plan for
patient education but also clearly documenting it in the
medical record.
In order to be successful, any teachingdocumentation system should be immediately accessible
to the nursing staff and should make the recording of
teaching activities both easy and separate from nursing
progress notes.
In this manner, the documentation
system used will further promote proper documentation
of the teaching function of nurses.
Current Practices in Organizing and
Documenting Patient-Teaching
Although teaching by nurses is emphasized as a
priority for which nurses should be held accountable,
only a handful of guidelines that facilitate and document patient-teaching are published in the literature.
These teaching guides have been developed for various
health care agencies in order to formalize and record
the teaching of staff nurses.
However, when evaluated
for certain necessary features, the majority are shown
to be basically inadequate in fulfilling their purposes.
Seven of the most suitable teaching guidelines
were evaluated using the following criteria:
1.
Teaching content outlined (42:163)
2.
Behavioral
~bjectives
defined (53:3)
37
41-.
3.
Patient learning evaluated (42:200)
4.
Teaching adequately documented (33:82)
5.
Clarity of format (53:ix)
In addition, the presence of other less crucial but
desirable features was noted.
1.
Are the patient's possible barriers to
learning noted? (53:6)
2.
Is space available for additional comments
on the teaching process by the nurse? (12:38)
3.
Is the patient given a copy of the learning
objectives? (42:64)
4.
Is the guideline permanently filed in the
patient's medical record? (12:37)
5.
Is both the teaching guide and teaching
documentation contained within a single sheet of paper
that is kept separate from nursing progress notes? (10:9)
The overall results of the evaluation (Table 1)
reveal that six of the seven teaching plans do outline
the specific content to be taught by the nurse.
The
same number also provide an area for the nurse to evaluate the patient's learning, either by an indepth written
summary or by simply checking off the patient's demonstration of knowledge.
Because any accurate evaluation
of learning is dependent ·upon the patient's ability to
meet the stated objectives of the teaching plan, the
Table 1
Evaluation of Publisred Teaching Guidelines
'IEAOUNG GUIDELINES
EVALUATIVE CRI'IERIA
X = yes
- = no
Vi~
0
~~
~~
t;:lO
t;:l~
~~ -w
~@
~§
..
!":t:l
1-'~
- -
1.0
M
uH -
'N~
OJ:;t)
.........
I
s~
w
@
Content outlined
X
X
X
X
X
-
X
Objectives defined
X
X
X
X
-
-
-
Learning evaluated
X
X
X
X
X
X
-
Teaching documented
X
X
X
X
X
-
Clarity of format
X
X
X
-
-
-
X
Space for barriers
X
X
-
X
-
Space for comments
X
X
-
-
X
-
-
Copy to patient
X
-
-
-
-
X
-
Permanently filed
X
X
-
-
X
X
X
Single page
X
X
X
-
X
X
Separate from nursing notes
X
X
X
X
X
X
X
I
I
I
_I
w
co
39
validity of the evaluation plans of two guidelines is
questionable as they fail to define learning objectives.
A serious lack of knowledge concerning basic teaching
principles is evidenced by the designers of these particular
teaching plans.
Five of the guidelines adequately document the
teaching that takes place by requiring the nurseteacher's signature and the date of teaching to be noted
on the form.
Finally, only slightly more than half of
the guidelines utilized an orderly, easy-to-read format.
Only three of the seven guides made provision
for assessing any barriers patients may have which
affect their learning abilities.
Less than half allow
space for any explanatory notes or additional comments
by the nurse,
a necessity for communicating useful infor-
mation not called for elsewhere.
The policy of only
two of the agencies required that patients be given a
copy of their learning objectivesi five specifically
mention that the teaching guide is to be permanently
filed in the patient's medical record.
Significantly,
while it is often suggested in the literature that staff
nurses modify existing tools to document and guide
patient-teaching, all seven forms were newly created by
the agencies.
Each teaching guideline was designed to
keep the teaching documentation separate from nursing
40
progress notes, and five managed to confine the teaching
guideline to a single page.
An examination of the characteristics of the
individual guidelines reveals that only three forms meet
all the major criteria and have most of the other
desirable features.
The teaching forms of Whitehouse
(50:1229), Zander (53:233), and Gulko (23:23) all have
simple, methodical formats which would take a minimal
amount of time for a nurse to become familiar with.
The
uncomplicated designs place the learning objectives and
related content in close proximity to each other for
easy reference by the nurse.
Whitehouse's form has the
additional advantage of an area on the back of the sheet
for nursing assessntent.
Here the nurse documents impor-
tant information such as learning barriers, learning
progress, and the patient's attitude toward teaching.
As Whitehouse's teaching guide was developed for use
within several different nursing units, only basic
content topics such as anatomy and risk factors are
listed on the form.
The nurse is responsible for filling
in the objectives appropriate to the particular medical
subject.
Both Zander and Whitehouse include additional
sheets detailing the specific content in order to standardize the information that is taught.
Zander's
41
teaching guide (53:233) has a large space at the bottom
for nurses to write in their evaluation of teaching,
including the patient's overall ability to meet the
objectives, the most appropriate teaching methods, and
the nurse's plan to correct any learning deficiencies.
While certainly helpful,
this written summary is more
time-consuming than a simpler checklist format.
Gulko's sample teaching plan (23:23)
is one of
the most workable and efficient available in the literature.
Gulko divides the sheet into several columns:
objectives,
related content, teaching resources, learning
evaluation and teaching documentation.
This teaching
guide has a very general format so that i t can be modified for any type of health content area.
The other four guidelines evaluated fail to meet
all the basic five criteria.
McCulloch (32:66) developed
a patient-teaching record specifically for use with
coronary patients.
It is the only teaching plan which
pre- and post tests the patient's knowledge, yet learning
objectives are not listed anywhere within the teaching
guide.
Although the teaching content is outlined on a
separate page, the teaching record itself is still
rather complicated in appearance due to an excessive
number of items to be recorded.
Also, there is a lack of
correlation between the sequence of content to be
42
covered and its location on the teaching record.
Another generally unsatisfactory method of
organizing and documenting patient-teaching is found in
Shuler's "Home Instruction Sheet" ( 4 7: 48) .
This is a
general form designed to record discharge teaching for
all types of patients and, because it is used for many
different diagnoses, neither specific teaching content
nor learning objectives are defined.
Making the formula-
tion of these critical areas the responsibility of individual nurses, who may or may not be knowledgeable about
basic teaching principles, can result in ineffective
teaching.
Similar to McCulloch's teaching record, this
sheet is confusing to use due to the large amount of
information to be completed regarding medications, referrals, activities, and so on.
Shuler's format requires
a great deal of information to be recorded within a
relatively small amount of space.
Gusfa (25:19)
formulated a patient-teaching
program which outlines nursing goals, teaching objectives, content, teaching tools and an evaluation plan,
all in a concise, efficient manner.
However, it is
unsuccessful in fulfilling one of Gusfa's purposes:
as
a reference in the documentation of teaching it is useless as it lacks any area to record the date and teacher.
Similarly, the final teaching guideline to be reviewed,
43
Fouts'
"Teaching Square" for prenatal instruction (21:13),
is also inadequate as an aid for patient-teaching.
It
merely lists the areas of teaching content to be covered,
and leaves a space for the nurse to initial when each
topic is completed.
An educational philosophy equating
"telling" with teaching is reflected by this format
because Fouts also neglects to define or evaluate
learning outcomes.
These deficiencies result in a totally
unsatisfactory teaching guideline.
The Investigator found i t remarkable to note
that, despite the major weaknesses of several of the
teaching guidelines, not one author reported any problems occurring with their guidelines during implementation.
In addition, only Fouts mentioned a single, albeit
insignificant revision to her teaching plan after introduction to various nursing units.
None of the other
authors revealed any need for modifications.
This situ-
ation may indicate an unwillingness on the part of the
designers to admit the existence of difficulties or a
lack of awareness of the basic components of an effective
guideline for patient-teaching.
In summary, this survey of published teaching
guidelines reveals that, of the few that exist, the
majority do succeed in organizing the content to be
taught and documenting the teaching that occurs.
Yet
p •
44
only slightly more than half defined the all-important
learning outcomes to be attained by the patient-learner.
The generally unsatisfactory quality of published teaching
guidelines has negative implications for the function of
teaching within nursing practice.
Formal teaching plans
can assist nurses to maintain their professional standards in teaching by providing 1) that objectives are
set, 2) documentation that teaching has occurred, and
3) evidence that the patient has understood and benefited from the teaching (33:82).
The scarcity of ade-
quate teaching guidelines emphasizes the need within
professional nursing for planned, systematic approaches
to patient education.
Chapter 3
METHODOLOGY
This chapter presents the methodology utilized
in the design, development and evaluation of a teaching
guideline and documentation form.
passed the following steps:
The process encom-
1) identification of the
problem, 2) target group, 3) establishment of project
goals and objectives,
4) planning of the project,
5) implementation, and 6) evaluation.
Identification of the Problem
During the Investigator's field training at a
home health agency, the Director of Education expressed
the need for a method of standardizing the patientteaching performed by staff nurses.
This concern
resulted in part from a recent agency survey which
revealed that over 20 percent of the home care patients
felt that they could have used additional information
about their illnesses.
Believing that the nurses' edu-
cational function would be improved through the use of
a guide to both organize and record their teaching
activities, the Director requested the development of a
teaching guideline and documentation form.
45
46
In order to be effective, an educational program
must be based on the needs, problems and interests of
those for whom the program is designed.
Therefore, the
first step was to assess the specific needs of the
agency in relation to the teaching guideline.
Inter-
views with several key staff members, including the
Director of Nursing and Associate Director of Nursing,
elicited suggestions for subjects that represented
problem areas for patient-teaching.
In addition, their
requirements for the format of the guideline were specified.
The meetings also served to introduce the general
concept of a teaching guideline to the agency decisionmakers whose support of the project was crucial for its
successful implementation.
Next, it was necessary to allow the home health
nurses, the personnel who would be using the guide, to
determine which health topic they felt was most in need
of a consistent approach to patient-teaching.
Of the
topics suggested from the previous staff interviews
(Appendix A) , the nurses identified catheter care as
the subject in greatest need of a teaching guideline.
This result was not particularly surprising to the
Investigator because problems concerning patient compliance with indwelling catheter care were frequently
discussed by nurses during patient care conferences.
47
It was subsequently found that 25 percent of the agency's
patients have indwelling catheters, a significant proportion of the patient census.
Improper self-care by
catheter patients or their caregivers can result in
bladder infections or other serious complications.
Yet
despite the prevalence and the potential hazards of
indwelling urinary catheters in the elderly population,
few guidelines or teaching materials exist to aid
nurses' educational efforts in this area.
Target Group
The target group for the project is comprised
of nurses employed by a home health agency serving the
San Fernando and Santa Clarita Valleys.
The partici-
pants, eleven Registered Nurses and one Licensed Vocational Nurse, are responsible for providing care to a
predominantly elderly group of patients with indwelling
Foley catheters.
Establishment of Project Goals
and Objectives
The Investigator's goal for the project was to
develop and implement a patient-teaching guideline and
documentation tool to facilitate and record the teaching
of home health nurses in the area of catheter care.
48
The objectives were:
1.
To document the patient-teaching process for
the agency's records; and
2.
To increase the nurses' ability to effec-
tively present information on catheter care to patients.
The sub-objectives were:
1.
To standardize the content taught, define
learning objectives, and provide for an evaluation of
patient learning by nurses;
2.
To encourage the nurses to differentiate
between teaching methods and evaluate the effectiveness
of each method for individual patients; and
3.
To encourage the nurses to identify the
patient's barriers to meeting learning objectives and
assess methods to overcome these learning difficulties.
The staff nurses' goal for participation in the
project was to promote the intelligent compliance of
their catheter patients with standard medical procedure.
Planning of the Project
The first step involved in planning the catheter
care teaching guideline was to define the learning
objectives to be attained by the patient upon completion
of the nurse's teaching.
As mentioned in the literature
review, many of the mistakes commonly made in
49
patient-teaching result directly from a failure to
specify what the patient should be able to do with the
information taught.
In addition, nurses avoid teaching
irrelevant information when provided with realistic
learning objectives which serve to focus their teaching
efforts.
Defining the expected behavioral outcomes of
instruction also aids the nurse-teacher in assessing
the patient's level of knowledge before beginning the
teaching program so that the instruction is tailored to
the individual.
The patient learning objectives for
the catheter care teaching guide were formulated with
the assistance of several key staff nurses whose input
was specifically requested.
At this stage, as in all
phases of the planning process, the Investigator
involved the nursing staff in the project in order to
adapt the teaching guideline to their particular needs
and to sustain their interest and commitment to its
success.
In addition to using the staff's recommendations,
the agency's nursing procedure manual and other nursing
textbooks were consulted for the determination of
learning objectives and related content of the teaching
guideline.
The teaching content to be included in the
guide was selected on the basis of its relationship to
the objectives.
Outlining the content provides a
50
consistent and comprehensive approach to patient-teaching
by ensuring that useful information is not omitted by
the nurse-teacher.
The content and objectives were
sequenced so that basic information is taught before the
more complex material.
It was necessary to include several other sections in the teaching guideline in addition to the content and objectives:
1.
Date of the teaching performed and the
signature of the nurse-teacher;
2.
Evaluation of patient learning through
attainment of learning objectives;
3.
Teaching methods utilized and an assessment
of the most effective methods for the individual patient;
and
4.
Patient learning barriers and the nurse's
suggestions for overcoming the difficulties.
After the content of the teaching guideline and
documentation form was specified, an appropriate format
had to be determined, based on the needs of the agency.
Discussions with agency administrators and nurses
revealed the need to confine the form to a single page,
front and back, for acceptability to a staff already
burdened with excessive paperwork.
The nurses expressed
their preference for a teaching system that was neither
51
too time-consuming nor complicated.
ity
Therefore, simplic-
of use became the major criterion for format design.
Following some modifications, the Director of Education
approved a suggested format, and the catheter care
teaching guideline was produced (Appendix B) .
Although they are not the focus of this project,
several patient handouts on catheter care were also
developed by the Investigator to reinforce the verbal
information taught by the nurse.
These handouts detail
the information patients need in order to meet several
of the learning objectives (Appendix C) .
Because a
significant proportion of patients' caregivers are
Spanish-speaking, the teaching tools were also translated into Spanish (Appendix D) .
Several of the nursing staff, including the
Director of Nursing and the agency's nursing education
consultant, made a final check of the accuracy and
suitability of the information contained in the
teaching guide and patient handouts.
When the process
was completed, the catheter care teaching plan was
prepared for implementation.
52
Implementation of the Project
Following completion, the catheter care guideline and teaching aids were formally presented to the
nursing personnel during their staff meeting.
At this
time, the purpose and goals of the teaching plan were
reviewed and the nurses were instructed in the guideline's use.
The staff was given the opportunity to
examine the content and format in detail and to ask
questions.
The teaching guideline was introduced to the
nurses as a positive but minor change in their teaching
activities.
It was stressed that use of the guideline
would not institute any major modification
in how they
taught catheter care, but would merely serve to make
their educational efforts more organized and systematic.
The documentation form would also serve as a rapid and
convenient method of recording the teaching that occurs.
In addition, it was emphasized that the staff would be
asked to evaluate the guideline following a period of
use to determine if any revisions were necessary.
With
this approach, it was hoped to maximize staff acceptance
of the project.
Use of the teaching guideline began immediately
with all new and ongoing catheter patients.
The evalua-
tion nurses started a teaching-documentation form for
53
each new catheter patient and checked off those content
areas that are covered during the visit.
A copy of the
guideline is placed in the patient's chart to document
that teaching was initiated; the original is given to
the primary care nurse who continues using it for
instruction until the patient is discharged.
Following each visit to a catheter patient, the
nurse documents both the teaching and learning that has
taken place as well as the teaching approach used.
When
the teaching plan is completed, a general evaluation of
the patient's learning is made by the nurse, along with
an assessment of the most appropriate teaching methods
to use with the patient and suggestions for overcoming
any barriers to learning.
It was the Investigator's
understanding that, upon discharge, the patient's
completed teaching form would be filed in the permanent
medical record.
Evaluation of the Project
The major purpose of evaluation is to determine
if the project's objectives are being met.
For the
catheter care teaching guideline, this was accomplished
with a written evaluation by staff nurses and a chart
review by the Investigator.
54
A questionnaire was developed in order for the
nurses to evaluate the content, clarity and efficacy of
the ·teaching guideline (Appendix E) .
This written evalu-
ation also was designed to provide information concerning
the guideline's usage, the nurses' attitude regarding
their teaching role, and suggestions for revision of the
form.
Before being administered, the questionnaire was
pre-tested with a staff nurse who validated that the
questions were neither ambiguous nor confusing.
Four months following implementation, the questionnaire was distributed to the nursing personnel.
Many of the questions were of the multiple-choice,
objective format but several were open-ended in order to
elicit a maximum amount of information from the respondents.
A copy of the teaching guideline was attached
to each questionnaire and it was emphasized that the
questions pertained only to the documentation form and
not to the patient handouts that were developed.
The Investigator felt that the nurses might
return a more thoughtful analysis if given additional
time to respond.
Therefore, the staff was asked to
return the questionnaire at their convenience within a
number of days in the stamped, self-addressed envelope
included.
Anonymity was preserved for the individual
nurses completing the evaluation.
55
The other phase of the evaluation process consisted of a review of all the agency's catheter
patient's charts.
This examination, occurring at
approximately the same time as the questionnaire's
administration, was performed so that the Investigator
could determine whether the teaching-documentation form
was being utilized according to established procedure.
It was hoped that information gathered from the review
would also have provided data for guideline revisions.
Chapter 4
RESULTS
The purpose of this project was to design,
develop and evaluate a catheter care teaching guideline
to facilitate and document the patient-teaching of home
health nurses.
A questionnaire and chart review were the
methods employed in the evaluation of the guideline.
Findings:
Nurses
1
Questionnaire
Eleven questionnaires were distributed to the
target group (one nurse was on sick leave), and ten
questionnaires were completed and returned.
The infor-
mation gathered from the questionnaire was utilized in
the evaluation of the teaching guideline.
The nurses
1
assessment of the teaching guide was
based on use with approximately 45 catheter patients,
according to the nurses
1
estimate.
During the four
months of implementation, each staff nurse had an
average of six patients although the range was from one
to twelve patients.
The results of the evaluation are generally
positive in regards to the efficacy of the teaching
guideline.
Seventy percent of the nurses stated that
56
57
organizing the material into a guideline definitely
enhanced their patient-teaching (Table 2) .
One nurse
commented that the guideline "is a visual reminder of
steps to a goal in catheter care."
Another descri'bed
it as making patient-teaching "more thorough, organized,
and individualized."
A nurse also wrote that an advan-
tage of using the guide is that "when you don't feel
like teaching because of the family's resistance or
apathy, it forces you to try anyway."
One stated that
the guideline "is a good check for the nurse to go by;
it also leaves a permanent record in the patient's
chart."
Table 2
Guideline's Effect on
Patient-Teaching
Response
Number
Percentage
Positive effect
7
70%
No effect
1
10%
Undecided
2
20%
10
100%
Total
Half of the respondents reported a positive
change in the patient/caregiver's behavior as a result
of the utilization of the teaching guide (Table 3}.
58
One nurse observed that patients/caregivers use "better
technique in maintaining a patent
catheter" while
another felt that several patients/caregivers have been
"much more confident" about catheter care.
Twenty per-
cent were unsure if any behavioral change had occurred.
Table 3
Guideline's Effect on
Patient Behavior
Response
Number
Percentage
Positive effect
5
50%
No effect
1
10%
Undecided
2
20%
Unable to assess
2
20%
10
100%
Total
Six out of ten nurses felt that the teaching
guideline was more effective with new catheter patients/
caregivers (Table 4).
Twenty percent stated that it
was equally o£ value with either new or long-term
patients.
59
Table 4
Type of Patient to Benefit
from Guideline
Response
Number
Percentage
New patient/caregiver
6
60%
Long-term patient/caregiver
0
0
Either type
2
20%
Unable to assess
2
20%
10
100%
Total
Two of the objectives for the project concerned the nurses identifying the most appropriate
teaching methods for different patients as well as
recognizing learning barriers which can exist in patients.
The nurses were asked to rate the degree to which the
teaching guideline made them more aware of these tasks
(Table 5).
The majority responded that the guideline
did an average to good job in increasing their awareness of 1) the different teaching methods they use,
2) the effectiveness of each teaching method for individual patients, 3) patient learning barriers, and
4) methods of overcoming learning difficulties.
60
Table 5
Additional Functions of Guideline
Degree To Which Guide
Increased The :::;Jurses'
Awareness Of:
Poor
Average
Good
Total
Number/Percentage
Different teaching
methods
0
4/44%
5/56%
9/100%
Effectiveness of each
method with patients
0
2/22%
7/78%
9/100%
5/56%
3/33%
9/100%
3/33%
6/67%
9/100%
Patient learning
barriers
1/11%
Methods of over coming barriers
0
The nurses revealed in the questionnaire that
they do utilize a number of teaching methods in their
educational efforts (Table 6).
Several different tech-
niques were mentioned and the majority of the nurses
listed at least two.
The most commonly used method
was demonstration, followed by verbal explanations.
61
Table 6
Teaching Methods Most Frequently
Used By Nurses
Number
Response
Demonstrations
Percentage
10
44%
Verbal explanations
5
22%
Written materials
4
17%
Return demonstrations
4
17%
23
100%
Total
Eighty percent of the respondents felt that the
learning objectives listed in the guideline were appropriate, necessary and thorough.
One nurse, however,
stated that the objectives for the content area of
"Special Considerations" needed clarification but did
not specify exactly how it should be clarified.
Another complained that although the objectives appear
necessary,
"when you look at the chart, it looks so
detailed that you think it can never be finished."
Regarding the comprehensiveness of the guideline's content, nine out of ten nurses felt that no
additional information on catheter care needs to be
included.
One nurse suggested, however, that irrigation
procedures be listed as a content area.
62
In assessing the teaching guide for clarity,
eighty percent stated that the format could not be made
any easier to use.
One person recommended less detail
on the page and larger type print.
Eighty-nine percent of the respondents reported
that the guideline does not require a significant amount
of extra time to use (Table 7) .
One nurse felt that the
guide was time-consuming and described that as the major
problem with the form.
Although stating that it did not
require a great deal of time to use, another person said
that the guide did necessitate significant effort and
thought.
Table 7
Does The Guideline Require Significant
Time To Use?
Response
Number
Percentage
Yes
8
89%
No
1
11%
Total
9
100%
The nurses were evenly divided on the question
of whether the patient/caregiver should be given a list
of the learning objectives that they are expected to
63
meet (Table 8).
One person commented that "it would be
a good idea in some cases when the caregiver is not too
swift."
But another wrote that the list of objectives
would be "too much information for them to sift through
on top of the responsibility of care."
Table 8
Should Patient Be Given A List
Of Learning Objectives?
Response
Number
Percentage
Yes
3
33.3%
No
3
33.3%
Undecided
3
33.3%
Total
9
100.0%
The result that seventy percent of the nurses
suggested topics for additional teaching guidelines
indicates a generally high degree of staff acceptance
of the teaching plan concept (Table 9).
Most often
mentioned was the need for diabetes and cardiac rehabilitation guidelines.
A variety of subjects was suggested
and many nurses offered more than one topic.
64
Table 9
Topics For Future Teaching Guidelines
Number
Topic
Percentage
Diabetes
3
25.0%
Cardiac rehabilitation
2
16.9%
Colostomy care
l
8.3%
Bladder training
l
8.3%
Decubiti ( beds.ores)
l
8.3%
Medication side effects
l
8.3%
Non-English speaking
caregivers
l
8.3%
Respiratory care
l
8.3%
Restorative nursing
l
8.3%
12
100.0%
Total
Several of the questions in the nurses' evaluation provided information pertaining to the general
method in which the teaching guide was used in daily
practice.
Most nurses reported needing two to four
visits to teach the necessary information or catheter
care (Table 10) .
65
Table 10
Number Of Visits
Reauired To
.
Teach Information
~
Response
Number
Percentage
1 - 2
1
14%
2
-
3
3
43%
3
-
4
2
29%
4 - 5
0
0
-
1
14%
7
100%
5
6
Total
Two-thirds of the respondents said that two to
four visits were required for the nurse to evaluate
the patient/caregiver's attainment of the learning
objectives (Table 11).
One nurse, however, reported
that an average of ten to eleven visits was necessary.
66
Table 11
Number Of Visits Required To
Evaluate Patient Learning
Response
Number
Percentage
1 - 2
1
16.7%
2 - 3
2
33.3%
3 -
2
33.3%
10 - 11
1
16.7%
Total
6
100.0%
4
All of the nurses stated that they teach the
caregivers more often than they teach the actual
patient.
One person explained that most patients are
unable to do their own catheter care and thus caregiverteaching is a necessity.
Eighty-six percent of the nurses stated that
they utilize the teaching guide only during the first
few visits to a catheter patient (Table 12).
Only one
person said that the guideline is used during most
visits.
67
Table 12
Frequency Of Guideline's Use
Response
Number
Percentage
First few visits
6
86%
Most visits
1
14%
Every visit
0
0
Until every objective
met
0
0
Total
7
100%
Eight out of nine members of the target group
reported that they continue to reinforce their teaching
even after the patient/caregiver has met the objectives.
Two nursesdid comment that they only reinforce their
teaching "a couple times" or "briefly."
The nursing staff appears to have similar standards for the evaluation of patient learning when using
the teaching guide.
Nearly nine out of ten felt that
the patient/caregiver must meet the stated criteria to
a degree of at least 75 percent before the nurse will
regard the objective as having been met (Table 13).
68
Table 13
Degree To Which Patient Must Correctly
Perform Objective
Response
Number
Percentage
100 percent
4
44.5%
Over 75 percent
4
44.5%
1
11.0%
50
-
75 percent
Under 50 percent
0
Total
9
0
100.0%
The majority of the nurses require the behavioral objective to be performed a minimum of two times
before documenting it on the form (Table 14).
One nurse
commented that the first time is "so I know it - the
second time so they know they know it."
69
Table 14
Number Of Times Objective Must
Be Performed Correctly
Response
Number
Percentage
Once
3
43%
Twice or more
4
57%
Other
0
0
Total
7
100%
Three questions specifically related to the
teaching function of nurses.
All of the staff perceive
patient education as a crucial responsibility of horne
health nursing.
Patient-teaching was described as "the
most valuable tool we have."
Other comments on the
subject included, "Since we are allowed to see a patient
only a short time, teaching the caregiver to continue
what work has been accomplished is of great relevance."
70
Table 15
Nurses' Background In Teaching Techniques
Response
Number
Percentage
Quite a lot
8
80%
Some
2
20%
Little
0
0
Total
10
100%
This commitment to teaching patients may be
due in part to the fairly extensive background in
teaching techniques that the majority of the nurses
claim to have (Table 15).
Perhaps, however, their
enthusiasm for patient education is a result of working
in the home care setting which places a large amount
of responsibility on the nurse for developing independence in the patient.
For this reason, it was not
surprising that six out of ten staff nurses stated they
would like additional training in patient-teaching
(Table 16) .
71
Table 16
Desire For Additional Training
In Patient-Teaching
Response
Number
Percentage
Yes
6
67%
No
2
22%
Undecided
1
11%
Total
9
100%
Findings:
Chart Review
The purpose of the chart review was to determine
if the teaching-documentation form was being utilized
according to procedure.
It was the Investigator's
understanding that agency policy in regards to the
guideline involved 1) the evaluation nurse placing a
copy of the guide in the patient's chart following
initiation of teaching during the first home visit, and
2) the primary nurse filing the completed teaching form
in the permanent medical record upon discharge of the
patient.
The review disclosed that staff nurses are following this procedure only 25 percent of the time.
Of
the forty catheter patients' charts examined, approximately ten contained either the form or a copy.
It was
72
noted that most of the forms had been filed by the
evaluation nurses rather than the nurses performing
primary care.
The majority of the guidelines were
filed during the first several weeks of implementation;
the compliance rate decreased greatly thereafter.
The Investigator had hoped that the data from
the chart review would reinforce the nurses' subjective
evaluation as well as provide additional information
for guideline revisions.
The small number of forms
filed in the permanent medical record, though, precluded
a more comprehensive examination.
Chapter 5
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Summary
The nursing profession has for many years viewed
patient-teaching as a fundamental responsibility and
function of its members.
Ineffectual teaching continues
to be practiced for a number of reasons, however,
including the lack of planned, systematic approaches to
educating patients.
The use of teaching guidelines can
increase a nurse's ability to provide effective instruction by clearly structuring the teaching process for
the nurse-teacher.
The purpose of this study was to develop,
imple-
ment and evaluate a teaching guideline to facilitate
and document the
patient-teaching of home health nurses
in the area of indwelling catheter care.
The guideline
was designed to make the nurses' educational efforts
more organized and systematic.
An additional function
of the form was to serve as a rapid and convenient
method of recording the patient-teaching that occurs.
73
74
Essential features incorporated into the design
of the catheter care teaching guideline included:
1) an outline of the content to be taught,
2)
learning
objectives to be attained by the patient, and 3) an
evaluation of the patient's learning.
Space was also
provided for notating the teaching methods utilized,
patient learning barriers, the date that teaching is
performed and the signature of the nurse-teacher.
Following a period of the teaching guideline's
use, a questionnaire was developed in order for the
staff nurses to evaluate the content, clarity and efficacy of the guide.
In addition,
a review of catheter
patients' charts was performed to determine whether the
teaching-documentation form was being utilized according
to procedure.
The results of the nurses' evaluation indicated
that the teaching guideline generally enhances the
quality of the nurses' instructional efforts and is an
effective method of organizing the teaching of catheter
care.
The guide was given a favorable assessment in
terms of both the clarity of its format and the comprehensiveness of the content.
A majority also reported
that use of the guideline does not require a significant
amount of extra time.
In addition, the nurses suggested
a number of topics for future teaching guidelines.
75
The chart review disclosed that staff nurses
are following the procedure of filing the documentation
form in the patient's chart only a small percentage of
the time.
Therefore, the teaching guide does not meet
the objective of providing a permanent record of the
teaching performed in the area of catheter care.
Conclusions
The conclusions to be reached from the study are:
1.
This study has established that the
teaching guideline can be an effective and minimally
time-consuming method of enhancing patient-teaching in
the area of catheter care.
Although originally developed
for home health nurses, the guideline could be successfully utilized by professional nurses in a variety of
health care settings.
2.
The general failure of the nurses to file
the teaching guideline in the permanent medical record
may be primarily attributed to the error of the Investigator in not placing adequate emphasis on the guideline's
equally important function as documentation of teaching.
It is necessary that new procedures be fully clarified
for the staff and periodically reinforced by administration to ensure correct use.
76
3.
The number of topics for additional teaching
guidelines suggested by the nurses would seem to indicate
the staff's willingness to continue utilizing such guidelines in the future as well as their growing acceptance
of planned, systematic approaches to patient education.
In addition, the diversity of the suggested topics
reflects the need of teaching plans for a wide range of
health-related areas.
4.
The home health nurses employed in this
study demonstrated a high level of commitment to their
teaching role.
The very nature of home health nursing
requires this emphasis on educating patients concerning
self-care.
Assuming that this target group is repre-
sentative of other nurses working in the home care
setting, it may be concluded that home health nurses
would be an appropriate and valuable population to
utilize in future studies regarding the educational
function within professional nursing.
Recommendations
On the basis of the project findings,
the fol-
lowing recorrmendations are made:
1.
Systems to document the patient-teaching
performed by nurses need to be implemented by health
care agencies.
The procedure for documentation should
77
be explicitly stated and reinforced by nursing administration
for maximum effectiveness.
2.
Standardized teaching plans should be formu-
lated for additional topics in order to facilitate the
patient-teaching function of professional nurses in
various health care settings.
3.
Because the teaching efforts of home health
nurses tend to be directed towards caregivers rather
than patients, special educational programs and teaching
aids need to be developed for this target group.
4.
Should this project be replicated, it is
suggested that the impact of the teaching guideline's
use on the health behavior of the patient and its effect
on the teaching abilities of nurses be objectively
evaluated.
5.
It is recommended that home health agencies
employ health education specialists who can apply
professional skills in the development of educational
programs for both staff and patients.
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78
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34.
Palm, Mary L.
"Recognizing Opportunities for
Informal Patient Teaching." Nursing Clinics
of North America, Vol. 6 No. 4 (Dec. 1971),
669-78.
35.
Patient Handbook and Community Resource Guide.
National In-Home Health Services, 1980.
36.
Payne, Juana.
"Promoting Written Care Plans."
Supervisor Nurse, Vol. 9 No. 8 (Aug. 1978),
43-7.
37.
Pyle, Nancy.
"Health Education for the Aging."
Journal of Gerontological Nursing, Vol. 5
No. 3 (June 1979), 24-9.
38.
Rabin, Lynne.
"The Image of the Nurse: A
Comparison Between the General Public and
Registered Nurses." Unpublished master's
thesis, UCLA, 1977.
39.
Redman, Barbara K.
"Curriculum in Patient
Education." American Journal of Nursing,
Vol. 78 No.8 (Aug. 1978), 1363-66.
40.
"Guidelines for Quality of Care in
Patient Education." Canadian Nurse, Vol. 71
No. 2 (Feb., 1975), 19-21.
41.
"Patient Education as a Function of
Nursing Practice." Nursino Clinics of North
America, Vol. 6 No.4 (Dec. 1971), 573-80.
83
42.
The Process of Patient Teaching in
Nursing. 3rd ed., St. Louis: C.V. Mosby Co.,
1976.
43.
Reed-Ash, Carol.
"Patient Education." Cancer
Nursing, Vol. 3 No. 4 (Aug. 1980), 261.
44.
Schell, Pamela L.
"POMR - Not Just Another Way
to Chart." Nursing Outlook, Vol. 20 No. 8
(Aug. 1972), 510-14.
45.
Schweer, Jean E.
"Teaching Students to Teach
Health Care to Others." Nursinq Clinics of
North America, Vol. 6 No.4 (Dec. 1971),
679-690.
46.
Shaw, Jane S.
"New Hospital Commitment:
Teaching Patients How to Live with Illness
and Injury." Modern Hospital, Vol. 121
No. 11 (Oct. 1973), 99-102.
47.
Shuler, Cynthia.
"Documenting Patient Teaching." v
Supervisor Nurse, Vol. 10 No. 6 (June 1979),
43-9.
48.
Sutherland, Mary S.
"Education in the Medical
Care Setting: Perceptions of Selected
Registered Nurses." Health Education,
Vol. 11 No. 1 (Jan. 1980), 25-7.
49.
Valadez, Ana M. and Karen B. Heusinkveld.
"Teaching Nursing Students to Teach
Patients." Journal of Nursing Education,
Vol. 16 No. 4 (April 1977), 10-14.
50.
Whitehouse, Rebecca.
"Forms that Facilitate
Patient Teaching." American Journal of
Nursing, Vol. 79 No.7 (July 1979), 1227-9.
51.
Winslow, Elizabeth H.
"The Role of the Nurse
in Patient Education. 11 Nursinq Clinics of
North America, Vol. 11 No. 2 (June 1976),
213-222.
52.
Wray, Janet G.
"Problem-Oriented Recording in
Community Nursing - A New Experience in
Education." Journal of Practical Nursing,
Vol. 16 No. 9 (Nov. 1977), 12-15.
v'
v
84
53.
Zander, Karen S., ed.
Patient-Teaching.
1978.
Practical Manual for
St. Louis:
C.V. Mosby Co.,
APPENDICES
85
p •
APPENDIX A
NEEDS ASSESSMENT SURVEY
86
87
In order to help the staff at National In-Home Health Services
with family and patient education, I have been asked to develop
alternate methods of teaching patients and families. The topics
need to be determined by the staff members who best know their
patients' needs.
The following topics were suggested during interviews with
several of the staff. Please check off the three topics you
feel to be in greatest need of a consistent approach to patient
teaching, and rate them as your first, second or third choices.
If there are specific sub-topics within a general topic area that
you would like to see covered, write them in the space provided.
Please feel free to add any topics that are not listed.
Thank you for your time and input!
Priority
(1-2-3)
Topic
(choose 3)
Catheter care
Symptom control
for terminally ill
Diabetes
Energy conservation
techniques
Ostomies
Medication usage
Hygiene for bedconfined
C'VA's
Care of the
terminally ill
Community resources
Correct exercise
techniques
Parkinsori s disease
Arthritis
Family education
Gait training
Possible sub-topic(s)
APPENDIX B
CATHETER CARE TEACHING GUIDE
88
NATIONAL IN-HOME HEALTH SERVICES
CATHETER CARE TEACHING GUIDE
Patient Name
Pt. Number
How long has -patient had catheter?
Teaching
Learner Difficulties
Method(s)*
(barriers to meeting objective)*
~
CONTENT / OBJECTIVE
I
ObJectl.ve
Met (date)
Teaching (date)
Initiated
Reinforced
Introduction to catheter care.
Anatomy/physiology of urinary tract.
A.
Obj: To identify the pathway of urine
through the urinary tract and the
general function of the kidneys, ureters,
bladder, urethra.
B.
Purpose and function of catheter.
Obj: To briefly explain what a catheter
is, where it goes and how it works in
relation to the urinary tract.
c.
Catheter equipment
Obj: (1) To briefly explain the function
of the catheter tip, balloon, tubing and
bags; and (2) to demonstrate the correct
set-up of catheter equipment.
II Basic catheter procedures
A. Equipment maintenance
Obj: (1) To demonstrate the proper
technique for optimum maintenance of
catheter equipment; and (2) to contrast
cleaning and sterilization procedures.
B.
Patient hygiene
Obj: To state methods of personal care
to be performed for maintenance of
proper hygiene.
c.
Drainage routines
Obj: TO demonstrate correct technique
for emptying catheter bags using established drainage schedule.
Teaching Methods *= Verbal instruction
Handout
Demonstration
Supervision/return demo
Learner Difficulties :
Hard of hearing
Short attention span
Poor vision
11
Gorked ..
R.N.
Nurse(s)
R.N.
(X)
1.0
CATHETER CARE TEACHING GUIDE
Objective
Met (date)
CONTENT / OBJECTIVE
II
Teaching (date)
Initiated
Reinforced
Teaching
Method(s)*
Learner Difficulties
(barriers to meeting objective)•
Basic catheter procedures cont.
D. Leg bag attachment
Obj: To demonstrate correct technique
for attachment of leg bag.
III Special considerations
A. Avoidance and warning signs of
infection or complications.
Obj: (1) To repeat warning signs and
methods of avoiding infection or
complications; and (2) to state
circumstances under which the doctor
or nurse should be immediately
notified.
B.
Medications affecting bladder
and/or urine
Obj. To state any medication the
patient is taking which can affect
the bladder and/or urine and its
effect.
c.
Possible problems with catheters
Obj: Using the given diagram, patient/
caregiver will be able to identify
methods of coping with various problems
associated with retention catheters.
TEACHING EVALUATION
1.
In general, how well did the patient meet the objectives?
2.
Circle the
A.
3.
~
1.
Poor
2.
Fair
3.
Average
4.
Good
5.
Excellent
effective and cross out the least effective teaching method(s) to use with this patient:
Verbal instruction
B.
Handouts
C.
Demonstration
D.
Supervision of return demonstration
What suggestions do you have for overcoming this learner's difficulties? (ex.: Larger print handouts; more time; etc.)
1..0
0
APPENDIX C
PATIENT-TEACHING TOOLS
(ENGLISH)
91
92
HOW THE URINARY SYSTEM WORKS
, KIDNEYS : Organs that
filter out waste products
and excess water from
the blood. The liquid
is called urine.
BLADDER: Muscular bag
where urine is stored - _
before leaving the
body.
URETHRA: Passageway
for urine leading from the bladder to the outside of the body.
___ - -URETERS: Hollow tubes
connecting the kidneys
with the bladder.
Urine flows through the
ureters down to the
bladder.
93
MALE SYSTEM
BLADDER - - - - _____ _
(where urine is stored)
URETHRA-_
(tube thro~gh­
which urine
leaves body)
(SIDE VIEW)
Your catheter is a thin, hollow tube made
of rubber or plastic which is designed to
empty your bladder of urine.
The catheter is inserted through the
urethra into the bladder (see picture).
Urine, stored in the bladder, flows into
a small hole near the tip of the catheter
and goes down the tube.
You have what is called a "Foley" catheter,
a type which is made to stay in the body
for long periods of time. The catheter is
kept in place by a tiny "balloon" inflated
near the catheter's tip. The balloon is
larger than the bladder's opening and
prevents the catheter from slipping out.
94
FEMALE SYSTEM
o---BLADDER
(whe~e
urine is stored)
'
o------
(where catheter
goes)
VAGINA
(birth canal)
*·-----RECTUM
(bowel movements)
URETHRA-
(tube
through
which
urine
leaves body)
(SIDE VIEW)
(VIEW FROM UNDERNEATH)
Your catheter is a thin, hollow tube made
of rubber or plastic which is designed to
empty your bladder of urine.
The catheter is inserted through the
urethra into the bladder (see picture).
Urine, stored in the bladder, flows into
a small hole near the tip of the catheter
and goes down the tube.
URETHRA~-
You have what is called a "Foley" catheter,
a type which is made to stay in the body
for long periods of time. The catheter is
kept in place by a tiny "balloon" inflated
near the catheter's tip. This balloon is
larger than the bladder's opening and
prevents the catheter from slipping out.
95
CATHETER DRAINAGE
,This section is for inflating the small balloon near
,'the catheter's tip so that the catheter will not slip
/
~,'::_of .-yt"o'\.ur--b-l_a_d_d_e_r_._ _ _ _ _ _ __
·The catheter is a thin, flexible,
hollow tube with a "V" shaped end.
The long, clear drai~age
tube is connected to the
eiUf""of the catheter.
tube is attached to
the night drainage
bag.
If you are able to be up,
you can use this leg drainage
~ which is strapped to
your leg. The leg bag
holds less urine and must
be emptied more often but
is more convenient when
you are moving about. The
opening connects directly
with the catheter (no drainage tube is
necessary). Empty the bag by removing
the green cap at the bottom. After using
the bag, clean the upper opening with
alcohol, replace the green cap and hang
in a dry, airy place.
The night drainage bag
attaches to your bed.
It holds a large amount
of urine and does not
have to be emptied as
-..:.. ..
often. The bag is
drained by removing
the lower tube from
its pocket and opening
the valve. When emptied, close the
valve and put the tube back in its pocket
to protect it from germs.
IMPORTANT! !
l)
To prevent urine from flowing back up
into the bladder and possibly starting
an infection, always keep drainage
bag at or below the level of your
bladder (see above). It is also
important to coil up the tubing and
position it at a level between the
bladder and bag. The tube should
never hang in a "U" shaped loop below
~rainage bag.
Keep drainage bag at or below the level
of your bladder.
2) Empty bag frequently - always drain before
urine fills up bag.
3) Change bags on schedule - every 10-14 days.
4) Keep the tubing coiled up at a level between the bladder and the drainage bag.
5) Avoid letting either the bag or tubing
touch the ground to prevent picking up
germs.
6) Keep the tubing free of kinks and place
it over your leg - never sit or lie on it.
7) Always wash off the ends of the catheter,
tubing and bags with alcohol before
connecting.
8) Keep the green plastic caps from the leg
bag and drainage tubing in alcohol when
not in use.
PROBLEM
WHAT TO DO
WUO TO CALL
CATHETER SLIPS OUT
Place towel under you to absorb urine. Do not try to put the
catheter back in. Contact nurse, especially if catheter's
"balloon" comes out broken or still inflated.
Nurse. Emergency Room - (only if
catheter is out and you have not
passed urine for over 8 hours) •
PLUGGED UP CATHETER
Check for any kinks in tubing or broken connections first.
Nurse. Emergency Room - (only if
no urine in bag for over 8 hours
and you have pain or swelling in
h1adder area).
BLADDER SPASMS
Placing warm towels over stomach area sometimes relieves the
spasms. Nurse may put in a smaller catheter. Also doctor
can prescribe medication to help you.
Nurse.
BLOOD IN URINE
Slight bleeding may occur if catheter was recently changed or
pulled upon. Passing an occasional blood clot is also normal.
Nurse will determine if the bleeding problem is serious.
Nurse, doctor, or emergency room
immediately if bleeding is heavy
or urine is a dark pinklsh color.
CONNECTION BREAKS
BETWEEN CATHETER
& DRAINAGE TUBING
Clean both ends of tubing with alcohol (to prevent infection)
and put back together.
Nurse - only if you have a
problem reconnecting tubing.
CATHETER LEAKING
Place a towel under you to absorb the urine. This is not an
emergency so you can wait until office hours to contact
nurse. She can try different methods to stop the leaking.
Nurse.
DRAINAGE BAG LEAKING
Throw away leaky bag and connect a new drainage bag to tubing.
Remember to clean the opening at top of the bag with alcohol
before attaching it to tubing.
Nurse - only if you have a
problem connecting a new bag.
STRONG URINE SMELL
Try following suggestions in section called "Ways to Avoid
Infections" as these methods can also help reduce odor.
If irritation is around urethral opening, make sure you are
washing and drying the area frequently ~~wice a day). If
irritation increases, contact nurse. For skin irritations
from the catheter being taped to your leg, try changing the
spot where catheter is taped from leg to leg.
IRRITATED SKIN
CHANGE IN COLOR OF
URINE
----------------------------------------------------------------Nurse to determine if you have
Check section on "Blood in Urine" first. Urine turns a
dark yellow when highly concentrated. Drinklng more fluids will
prevent this. Also, some medications can change the normal color
of the urine. Your nurse can tell you if any of your medications
might be affecting your urine.
an infection.
NursP.
--------------------
Nurse
1.0
0)
97
WAYS
TO AVOID URINARY INFECTIONS
*
Drink plenty of liquids for a steady flow of urine.
*
*
Change drainage bags often (every 10-14 days).
Always keep drainage bag at or below level of the bladder so that urine is
draining downhill.
Prevent any kinks in the tubing and never sit or lie on tubing to avoid slowing
the flow of urine.
Always clean the opening at the top of drainage bag with alcohol before
connecting to catheter.
Drink cranberry juice at least once a day, if possible.
Other orders from doctor:
* Frequently wash and dry around catheter at urinary opening (twice a day).
*
*
*
*
IMPORTANT:
Diabetics and persons who have had surgery, chemotherapy or radiation
to the general area of the bladder run a high risk of urinary infections
and mus~ take great care to avoid infection by following the-above
guidelines.
WARNING SIGNS OF URINARY HIFECIION CNoTIFY NuRsE)
Cloudy urine
Foul-smelling urine
Much sediment in urine
Pain or tenderness around kidneys
Bladder spasms
Burning or itching around catheter
Catheter suddenly leaking
Nausea/vomiting
Chills or fever
Pain or cramps in bladder area
EMERGENCIES !
CONTACT
X
X
X
X
DOCTOR~
NuRSE OR EMERGENCY RooM IMMEDIATELY IF YOU HAVE:
SEVERE PAIN IN BLADDER AREA,
No URINE IN DRAINAGE BAG FOR 8 HOURS OR MORE,
REDDISH OR DARK PINK URINE.
FEVER OF 101 DEGREES OR HIGHER,
APPENDIX D
PATIENT-TEACHING TOOLS
(SPANISH}
98
99
COMO IRABAJA EL SISTEMA URINARIO
RINONES: Son los organos
•'que ayudan a filtrar y
elminar los productos y
exceso de agua de la
sangre.
El liquido es llamado
la orina.
__ URETRA: Los tubos hue cos que
conectan los rinones con la
vesicula.
El flujo de la orina que pasa
por el uretra hacia abajo de
la vesicula.
VESICULA:
muscular donde
la orina antes
del cuerpo.
URETRA: El canal por donde pasa la orina
por la vesicula antes
de salir fuera del
cuerpo
--- -- --
--
100
EL SISTEMA DEL HOMBRE
VESICULA
(Donde se junta la orina(
' ...
- - RECTO - AND
(Eliminacio'n)
URETRA- - - - ____ _
(Tubo donde la orina
deja el cuerpo)
(VISTA DE LADO)
La Zenda es un tubo hueco y delgado que es heche de
o
goma
de plastico que fue desiffada para la
eliminaci6n de la orina.
La Zenda es insertada por la uretra bacia la vesicula
(Vea dibujo). La orina se junta en la vesicula, el
flujo pasa por el ablljero pequefio cercas de la
punta de la zonda y pasa por el tubo.
Tiene lo que se llama una zenda de "Foley"
es hecha de una clase de tipo para mantenerse
en el cuerpo por periodos largos.
La Zenda es mantenida en su lugar por medic
de un "globe" pequefio, inflado cercas del
punto de la zenda. El globe es mas grande
que la abierta de la vesicula y previene que
la zenda se salga.
101
EL SISTEMA DE LA MUJER
VESICULA
(Donde se junta la orina)
..
0
-URETRA
(Por donde la
zonda va)
···-LA VAGINA
Canal de Luz
(Nacimiento)
VISTA DE POR DEBAJO
/
VISTA DE LADO
/
/
URETRA
(Tubo" por donde la orina sale del cuerpo)
La Zonda es un tubo hueco y delgado que es hecha
de goma o" de plastjco que fue desinada para la
eliminacion de la orina.
La Zonda es insertada por la uretra hacia la
vesicula (Vea dibujo). La orina se junta en
la vesicula, el flujo pasa por el abujero
pequeno cercas de la punta de la zonda y pasa
por el tubo.
Tiene lo que se llama una zonda de "Foley"
es hecha de una clase de tipo para mantenerse
en el cuerpo por periodos largos. La Zonda
es mantenida en su lugar por medio de un
"globo", pequeiio, inflado cercas del punto
de la zonda.
El globo es mas grande que la abierta de la
vesicula y previene que la zonda se salga.
PROBLEMA
QUE HACER
AQUIEN LLAMAR
LA ZONDA SE SALE
Poner toallas debajo de uno para absorber
la orina. No trate de volver a meter la
zonda. Comuniquese con la enfermera,
especialmente si el globo de la zonda
sale roto o todavia inflado.
Enfermera. Cuarto de emergencia.
(Solamente que la zonda se haiga
salido y ud. no ha podido orinar
por mas de 8 horas.
l.A ZONDA SE ENCUENTRE
TAPADA
Examine el tubo para ver que no se haiga
doblado o la conecton se haiga roto
primero.
Enfermera. Cuarto de emergencia.
(Solamente si no hay la orina en
la bolsa por mas de 8 horas y ud.
tenga dolor oeste inflamado en
el area de la ve!'icula.
DOLORES EN LA VESICULA
Coloque toallas calientes en el area del
estomago para ayudar el dolor. La ~nfermera
puede poner otra zonda mas pequefia.
Enfermera
SANGRE EN LA ORINA
Un poco de sangre puede ocurrir si la zonda
fue recientemente cambiads
jslada.
Pasando un coagulo ocasionalmente es
tambien normal. La enfermera determinara
st es un problema serio al estar sangrando.
Enfermera, doctor o cuatro de emergencia
immedi.atAmente si esta sangrando bastante
si la orina esta de un color de rosa
obscuro.
CONECION SE ROMPE POR
MEDIO DE LA ZONDA Y LA
TUBACION DE DRENA.JE
Ltmptar los lados del tubd' con alcohol
(para prevenir infecion) y poner de
vuelta junto.
Enfermera. Solamente st tiene algun
problema al reconectar la tubacion.
LA ZONDA ESTE GOTEANnO
Poner una toalla debajo de uno para absorber la
orina. Esto no es niguna emergencia asi que
puede esperar hasta que la oficina abra para
llamar a la enfermera. Ella puede intentar
diferentes metodos para parar que este goteando.
Enfermera
o
I
1-'
0
N
PROBLEMA
QUE HACER
AQUIEN LLAMAR
LA BOLSA DE DRENAJE
ESTE GOTEANDO
Tire la bolsa y conecte una nueva bolsa rle drenaje
a la tubacion. Rec•terde q•te ti.ene que 1 i.mpi:u lo
de arriba de la bolsa ('On alcohol antes rle conectar
la tubacion.
Enfermera. Solnmente si tiene
problema conectando la nueva
bols'l.
T..A OlHNA TENGA OLOR
Trate de seguir los consejos en la seccion llamada
"M:meras de prevenir infeciones", que tambien
estos metodos pueden ayudar a reducir el nlor.
Enfermera determinara si tiene
infecion.
PtEL IRRtTADA
Si hay i rri tacion al r.erledor de la abi.erta de la
uretra. Este segura (o) que esta lavando y
secando el area frequentemente (Dos veees al
dta). Si l.a irritacton Aumenta. Comuniquese
con la enfermera. Puede que la irritacion sea
por J.a cinta adhesivea que detiene 1:1 zonda
a la pier.na. Trate de camblar el lu'gar donde
la zonda es pegada a la pierna.
Enfermera
CAMBIO DE COJJOR EN
LA ORINA
Revise la secciO'n en "Sangre en la ori.na",
primero. La orina cnmbta a un amartllrJ
obscuro cuando eAts concentrada. Tomando
mas liquidos pre,•iene e!'lto.
Tambien, algunas medicinas pueden camb:lar
el color normal de J.a orina. Su enfermera
le puede decir si alguna de sus medicinas
pueden afectar la orina.
F.nfermera
FUERTE
1-'
0
w
104
MANERAS DE PREVENIR INFECIONES URINARIAS
*
*
*
*
*
*
*
*
Tomar bastante liquidos para llevar un flujoseguido en la orina.
Frequentemente lave y seque alrededor de la zonda a la abierta del urinario.
(2 veces al dia).
Cambie sequido la bolsa de drenaje (cada lD-14 dias).
Siempre mantega la bolsa de drenaje a un nivel, o bajo el nivel de la vesicula
para que la orina corra bacia abajo.
Prevenga que la tubacion se doble y nunca se siente o acueste encima del tube,
para que no prevenga que el flujode la orina sea lenta.
Siempre limpie la abierta que se encuentre arriaba de la bolsa de drenaje con
alcohol. Antes de conectar la zonda.
Tome jugo de arandano (cranberry juice), por lo menos una vez al dia, si es
possible.
Algunas otras ordenes que senale el medico.
IMPORTANTE:
o
Diabeticos y personas que han tenido cirujia, quimioterapia
radiacion en el are~ general de la vesicula corren gran riesgo
a las infeciones urinarias y deben tomar cuidado para prevenir
infeciones, siquiendo los consejos anteriores que hemos mencionado.
SIGNOS DE ADVERTENCIA DE INFECIONES URINARIAS (NOTIFIQUE A LA ENFERMERA)
La orina nublada
La orina que tenda mal olor
Que la orina contenga bastante sedimentacion
Dolor o molestia alrededor de
los rinones
Dolor en la vesicula
Quemazon 0 comezon alrededor de la zonda
La zonda comienze a gotear
Nausea/vomito
Descalofrio
o
fiebre
Dolor o calambres en el area de la vesicula
EMERGENCIAS
(ONTACTE AL
X
X
X
X
DOCTOR~
ENFERMERA 0 AL CUARTO DE EMERGENCIA Sl ES QUE TIENE UNO
DoLOR ABUNDANTE EN EL AREA DE LA VESICULA
QuE EN LA BOLSA DE DRENAJE NO HAIGA LA ORINA POR 8 HORAS 0 MAS
QuE LA ORINA SEA DE COLOR ROJO 6 DE COLOR DE ROSA OBSCURO
FIEBRE DE 101 GRADOS 6 MAS ALTO
APPENDIX E
CATHETER CARE TEACHING
GUIDE EVALUATION
105
106
04-07-81
CATHETER CARE TEACHING GUIDE EVALUATION
I need your input in order to make the catheter care teaching
guideline as useful as possible to the nursing staff at National
In-Home Health Services. Your responses to the following questions
will help me to make any necessary changes.
Thank you very much for your time.
Please return this evaluation to me in the attached envelope
no later than Friday, April 10, 1981.
1.
Approximately how ~catheter patients have you used the
teaching guideline with?
2.
Have you noted any changes in your patient's/caregiver's
behavior as a result of the teaching guide? If so, what
have you observed?
3.
Has organizing the material on catheter care into the teaching
guide made any difference in your teaching? If so, how?
4.
Is the teaching quide ~ effective with:
New catheter patients or their caregivers.
Long-term catheter patients or their caregivers.
Either, makes no difference.
5.
Do you find yourself teaching catheter care more often to the
patients themselves or to the caregivers?
6.
On the average, how many visits do you need to teach the information
on catheter care?
7.
Approximately how~ visits are required for the patient/caregiver to cover all the objectives?
1
107
8.
Look over the patient-teaching objectives listed on the guide.
Are any of the objectives unnecessary, incomplete, confusing
or overly difficult for the patient? (Please list & describe
desired changes).
9.
What other information or material on catheter care needs to be
included in the teaching guide?
10. Does·the use of the teaching quideline require a significant
amount of extra time?
11. Could the format of the guideline be modified in any way to
make it easier to use? If so, how?
12. Do you think the patient/caregiver should be given a list of
the catheter care objectives that they are expected to meet?
Yes
No
Comments_________________________
------~
13. For you to consider a patient/caregiver as having met a given
objective, he must meet the stated criteria to the following
degree:
50-75% ________under SO%
100% -------- over 75%
14. How many times must an alert patient/caregiver perform an
objective correctly before you mark it on the form?
Once _________Twice or more -------- Other (please
describe)
15. How often do you use the teaching quideline when seeing
catheter patients?
First few visits
Most visits
Every visit
Until patient/caregiver
meets every objective
16. After the patient/caregiver meets an objective, do you continue
to reinforce your teaching?
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17. What teaching method(s) do you use the most?
18. Using the scale below, rate the degree to which the teaching
guideline has helped you become more aware of:
(1
= Poor
(a)
(b)
(c)
(d)
2 = Average
3 = Good)
the different teaching methods you use every day
(verbal, demonstration, etc.)
the effectiveness of each teaching method for
different patients/ caregivers
the barriers to learning which can exist in patients
methods of overcoming learning difficulties in
patient/caregivers
19. How much background have you had in teaching techniques from
your inservice training and other experiences?
Quite a lot
Some
Little
20. Would you like more training in teaching techniques?
Yes
No
21. In your opinion, how important is patient-teaching in general
in the role of the home health nurse?
22. What other patient-teaching guidelines would assist you in
your nursing care?
(List the conditions or problems).
Any further comments you may have on the catheter care teaching
guide would be greatly appreciated:
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