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Chapter 1
Overview of Education in
Health Care
Historical Foundations of the
Nurse Educator Role
• Health education has long been
considered a standard care-giving role
of the nurse.
• Patient teaching is recognized as an
independent nursing function.
• Nursing practice has expanded to
include education in the broad concepts
of health and illness.
Historical Foundations (cont’d)
Organizations and Agencies Promulgating
Standards and Mandates:
– first observed health teaching as an
important function within the scope of
nursing practice
– responsible for identifying course content
for curriculum on principles of teaching and
Historical Foundations (cont’d)
2. ANA
- responsible for establishing standards and
qualifications for practice, including patient
3. ICN
- endorses health education as an essential
component of nursing care delivery
Historical Foundations (cont’d)
4. State Nurse Practice Acts
- universally includes teaching within the scope
of nursing practice
- accreditation mandates require evidence of
patient education to improve outcomes
6. AHA
- Patient’s Bill of Rights ensures that clients
receive complete and current information
Historical Foundations (cont’d)
7. Pew Health Professions Commission
- puts forth a set of health profession
competencies for the 21st century
- over one-half of recommendations pertain to
importance of patient and staff education
Current Mandates for
Nurse as Educator
Institute of Medicine 2001
 focuses more broadly on how the health system
can be reinvented to foster innovation and improve
the delivery of care.
 Six Aims for Improvement
 Ten Rules for Redesign
Joint Commission:
Patient and Family Education
 The organization provides education that
supports patient and family participation in
care decisions and care processes.
 Education and training help meet patients’
ongoing health needs.
 Education methods consider the patient’s and
family’s values and preferences and allow
sufficient interaction among the patient,
family, and staff for learning to occur.
Current Mandates for
Nurse as Educator
Healthy People 2020 (USDHHS)
Federal initiatives outlined:
To increase the quality & years of healthy life
To eliminate health disparities among different
segments of the population
*Requires the nurse as educator to use theory
and evidenced based strategies to promote
desirable health behavior.
Trends Affecting Health Care
Social, economic, and political forces
that affect a nurse’s role in teaching:
• growth of managed care
• increased attention to health and well-being of
everyone in society
• cost containment measures to control
healthcare expenses
• concern for continuing education as vehicle to
prevent malpractice and incompetence
Trends (cont’d)
• expanding scope and depth of nurses’
practice responsibilities
• consumers demanding more knowledge and
skills for self-care
• demographic trends influencing type and
amount of health care needed
• recognition of lifestyle related diseases which
are largely preventable
• health literacy increasingly required
• advocacy for self-help groups
Purpose, Benefits, and Goals of
Patient, Staff and Student Education
Purpose: to increase the competence and
confidence of patients to manage their
own self-care and of staff and students to
deliver high-quality care
Benefits of education to patients:
- increases consumer satisfaction
- improves quality of life
- ensures continuity of care
Purpose, Benefits and Goals (cont’d)
- reduces incidence of illness complications
- increases compliance with treatment
- decreases anxiety
- maximizes independence
Benefits of education to staff:
- enhances job satisfaction
- improves therapeutic relationships
- increases autonomy in practice
- improves knowledge and skills
Purpose, Benefits and Goals (cont’d)
Benefits of preceptor education for
nursing students
• prepared clinical preceptors
• continuity of teaching/learning from
classroom curriculum
• evaluation and improvement of student
clinical skills
Purpose, Benefits, and Goals (cont’d)
Goal: to increase self-care responsibility
of clients and to improve the quality of
care delivered by nurses
The Education Process
Definition of Terms
Education Process: a systematic, sequential,
planned course of action on the part of both
the teacher and learner to achieve the
outcomes of teaching and learning
Teaching/Instruction: a deliberate intervention
that involves sharing information and
experiences to meet the intended learner
The Education Process (cont’d)
Learning: a change in behavior
(knowledge, skills, and attitudes) that can
be observed and measured, and can
occur at any time or in any place as a
result of exposure to environmental
The Education Process (cont’d)
Patient Education: the process of helping
clients learn health-related behaviors to
achieve the goal of optimal health and
independence in self-care
Staff Education: the process of helping
nurses acquire knowledge, attitudes,
and skills to improve the delivery of
quality care to the consumer
A useful paradigm to assist nurses to organize
and carry out the education process.
Analyze the learner
State objectives
Select instructional methods and materials
Use teaching materials
Require learner performance
Evaluate/revise the teaching/learning process
Role of the Nurse As Educator
• Nurses act in the role of educator for a
diverse audience of learners—patients
and their family members, nursing
students, nursing staff, and other
agency personnel.
• Despite the varied levels of basic
nursing school preparation, legal and
accreditation mandates have made the
educator role integral to all nurses.
Role of Nurse As Educator (cont’d)
• Nurses function in the role of educator as:
- the giver of information
- the assessor of needs
- the evaluator of learning
- the reviser of appropriate methodology
• The partnership philosophy stresses the
participatory nature of the teaching and
learning process.
Barriers to Teaching
Barriers to teaching are those factors
impeding the nurse’s ability to optimally
deliver educational services.
Major barriers include:
• lack of time to teach
• inadequate preparation of nurses to assume the
role of educator with confidence and competence
• personal characteristics
• low-priority status given to teaching
Barriers to Education (cont’d)
• environments not conducive to the reachinglearning process
• absence of 3rd party reimbursement
• doubt that patient education effectively
changes outcomes
• inadequate documentation system to allow
for efficiency and ease of recording the
quality and quantity of teaching efforts
Obstacles to Learning
Obstacles to learning are those factors that
negatively impact on the learner’s ability
to attend to and process information.
Major obstacles include:
• limited time due to rapid discharge from care
• stress of acute and chronic illness, anxiety,
sensory deficits, and low literacy
• functional health illiteracy
Obstacles (cont’d)
• lack of privacy or social isolation of health-care
• situational and personal variations in readiness
to learn, motivation and compliance, and
learning styles
• extent of behavioral changes (in number and
complexity) required
Obstacles (cont’d)
• lack of support and positive reinforcement from
providers and/or significant others
• denial of learning needs, resentment of
authority and locus of control issues
• complexity, inaccessibility, and fragmentation,
of the healthcare system
Questions (cont’d)
• What are the common mistakes made in the
teaching of others?
• How can teaching and learning best be
What other questions might you ask?
Chapter 3
Applying Learning Theories to
Healthcare Practice
• Learning: a relatively permanent change
in mental processing, emotional
functioning, and behavior as a result of
• Learning Theory: a coherent framework
of integrated constructs and principles
that describe, explain, or predict how
people learn
• Provides information and techniques to
guide teaching and learning
• Can be employed individually or in
• Can be applied in a variety of settings
as well as for personal growth and
interpersonal relations
Application Questions to Keep in Mind
• How does learning occur?
• What kinds of experiences facilitate or
hinder the process?
• What held ensure that learning
becomes permanent?
• Concepts: stimulus conditions,
reinforcement, response, drive
• To change behavior, change the
stimulus conditions in the environment
and the reinforcement after a response
Behaviorist Dynamics
• Motivation: drives to be reduced,
• Educator: active role; manipulates
environmental stimuli and
reinforcements to direct change
• Transfer: practice and provide similarity
in stimulus conditions and responses
with a new situation
Respondent Conditioning
• Learning occurs as the organism
responds to stimulus conditions and
forms associations
• A neutral stimulus is paired with an
unconditioned stimulus–unconditioned
response connection until the neutral
stimulus becomes a conditioned
stimulus that elicits the conditioned
Operant Conditioning
• Learning occurs as the organism
responds to stimuli in the environment
and is reinforced for making a particular
• A reinforcer is applied after a response
strengthens the probability that the
response will be performed again under
similar conditions.
Changing Behavior Using Operant
• To increase behavior
– positive reinforcement
– negative reinforcement (escape or
avoidance conditioning)
• To decrease behavior
– nonreinforcement
– punishment
Advantages of Behaviorism
• Highly structured situations
• Skills training in which steps and
sequences can be clearly delineated
Disadvantages of Behaviorism
• Instruction is mechanistic
• Minimizes student involvement in
• Inappropriate for complex mental
processes, problem-solving, and critical
• Concepts: cognition, gestalt, perception,
developmental stage, informationprocessing, memory, social
constructivism, social cognition,
• To change behavior, work with the
developmental stage and change
cognitions, goals, expectations,
equilibrium, and ways of processing
Cognitive Dynamics
• Motivation: goals, expectations,
disequilibrium, cultural and group values
• Educator: organize experiences and
make them meaningful; encourage
insight and reorganization within learner
• Transfer: focus on internal processes
and provide common patterns with a
new situation
Gestalt Perspective
• Perception and the patterning of stimuli
(gestalt) are the keys to learning, with
each learner perceiving, interpreting,
and reorganizing experiences in her/his
own way
• Learning occurs through the
reorganization of elements to form new
insights and understanding
Information-Processing Perspective
• The way individuals perceive, process, store,
and retrieve information from experiences
determines how learning occurs and what is
• Organizing information and making it
meaningful aids the attention and storage
process; learning occurs through guidance,
feedback, and assessing and correcting
• Focus on describing the way information is
tracked, the sequence of mental operations,
and the results of operations.
Cognitive Development Perspective
• Learning depends on the stage of
cognitive functioning, with qualitative,
sequential changes in perception,
language, and thought occurring as
children and adults interact with the
• Recognize the developmental stage and
provide appropriate experiences to
encourage discovery.
Social Constructivist Perspective
• A person’s knowledge may not
necessarily reflect reality, but through
collaboration and negotiation, new
understanding is acquired.
• Learning is development
• Assimilation, accommodation, &
construction are part of learning
Social Constructivist Perspective ( cont)
• Learning is heavily influenced by the
culture and occurs as a social process
in interaction with others.
• A learner constructs new knowledge by
building on internal representations of
existing knowledge thru personal
interpretation of experience.
Social Cognition Perspective
• An individual’s perceptions, beliefs, and
social judgments are affected strongly
by social interaction, communication,
groups, and the social situation.
• Individuals formulate causal
explanations to account for behavior
that have significant consequences for
their attitudes and actions (attribution
• Concepts: role modeling, vicarious
reinforcement, self-system, selfregulation
• To change behavior, utilize effective
role models who are perceived to be
rewarded, and work with the social
situation and the learner’s internal selfregulating mechanisms
Social Learning Dynamics
• Motivation: compelling role models
perceived to be rewarded, self-system
regulating behavior, self-efficacy
• Educator: model behavior and
demonstrate benefits; encourage active
learner to regulate and reproduce
• Transfer: similarity of setting, feedback,
self-efficacy, social influences
• Use of intellectual development gives
teacher ↑ professional & personal
• ↑ satisfaction in relationship with learner
• ↑ Increased use of a variety of instructional
strategies → teacher creativity
• ↑ learner satisfaction as move into
improved cognitive ability & look forward to
more challenging/ stimulating life
• ↑ Critical thinking in learner
↑ time & energy by teacher to become
knowledgeable about different
Students stressed if looking for certainty
or absolute answers
• Concepts: stage of personality
development, conscious and
unconscious motivations, ego-strength,
emotional conflicts, defense
• To change behavior, work to make
unconscious motivations conscious,
build ego-strength, and resolve
emotional conflicts
Psychodynamic Dynamics
• Motivation: libido, life force, death wish,
pleasure principle, reality principle, conscious
and unconscious conflicts, developmental
stage, defenses
• Educator: reflective interpreter; listen and
pose questions to stimulate insights
• Transfer: remove barriers such as resistance,
transference reactions, and emotional
• Learning occurs on the basis of a
person’s motivation, derived from
needs, the desire to grow in positive
ways, self-concept, and subjective
• Learning is facilitated by caring
facilitators and a nurturing environment
that encourage spontaneity, creativity,
emotional expression, and positive
Humanist Dynamics
• Education motivates student to develop their
potential & progress to self-actualization
• Motivation: needs, desire to grow, selfconcept
• Educator: act as facilitator who respects
learner’s uniqueness and provides freedom
to feel, express, and grow creatively
• Transfer: positive or negative feelings and
choices as well as freedom to learn, promote,
or inhibit transfer
• Focuses on honesty, Integrity, manners, respect for
others, & accepting responsibility for self-development
• Students engage in all aspects of learning
experiences—teachable moments
• Appropriate for learning critical thinking, problem
solving, & different points of view.
• Direction by faculty is necessary to
ensure all domains of learning are
adequately addressed.
Neuropsychology and Learning
• Brain and nervous system information
• Neurological conditions, mental health
issues, and learning disabilities
• Relationship between stress and
• Integration of learning theories
Generalizations about Learning
• Learning is a function of developmental
• Brain processing is different for each learner
• Learning is active, multifaceted and complex
• Stress can interfere with or stimulate learning
• stimulus conditions and configuration of
• social and cultural influences
• role models, experts, and guides
• reinforcements
• feedback
developmental stage
thoughts and reasoning
ways of processing information
memory storage
conscious and unconscious motivation
subjective feelings
How to promote change
• Relate to what learner knows and is
familiar with
• Keep experiences simple, organized,
and meaningful
• Motivate learner (deprivation, goals,
disequilibrium, needs, tension)
• May need incentives and rewards, but
not always
How to promote change
• Experiences must be at the appropriate
developmental level
• Make learning pleasurable, not painful
• Demonstrate by guidance and attractive
role models
How to make learning relatively
• Relate experiences to learner
• Reinforce behavior
• Rehearse and practice in variety of
• Have learner perform and give
constructive feedback
• Make sure interference does not occur
before, during, or after learning
How to make learning relatively
permanent (cont’d)
• Promote transfer
• Have learner mediate and act on
experience in some way (visualize,
memory devices, discuss, talk, discuss,
write, motor movement)
State of the Research Evidence
• Tests and modifies theories, methods,
and assumptions
• Challenges conventional wisdom and
• Interdisciplinary focus is beneficial
• Lack of resources is hindrance
Questions to Consider
• In what ways do the learning theories
• In what ways are they similar?
• How can the learning theories be used
in combination to change behavior and
enhance learning?
• Why are some theories more effective
with certain individuals than with
Chapter 4
Determinants of Learning
Educator’s Role in Learning
The educator plays a crucial role in the
learning process by:
• assessing problems or deficits
• providing information in unique ways
• identifying progress made
• giving feedback
• reinforcing learning
• evaluating learners’ abilities
The Educator’s Unique Position
The educator is vital in giving support,
encouragement, and direction during the
process of learning.
The educator assists in identifying optimal
learning approaches and activities that can
both support and challenge the learner.
Assessment of the learner includes attending to the
three determinants of learning:
* Learning Needs
(WHAT the learner needs to
* Readiness to Learn
(WHEN the learner is receptive to
* Learning Style
(HOW the learner best learns)
Haggard, 1989
Assessment of Learning Needs
Identify the learner
Choose the right setting
Collect data about, and from, the learner
Involve members of the healthcare team
Prioritize needs
Determine the availability of educational
• Assess demands of the organization
• Take time-management issues into account
Needs are prioritized based on the
following criteria:
Mandatory: Needs that must be learned
for survival when the learner’s life or
safety is threatened
Desirable: Needs that are not life-dependent but
are related to well-being
Possible: Needs for information that are “nice to know” but not
essential or required because they are not directly related to
daily activities or the particular situation of the learner
Methods to Assess Learning Needs
Informal conversations
Structured interviews
Focus groups
Self-administered questionnaires
Patient charts
Assessing Learning Needs of
Nursing Staff
Written job descriptions
Formal and informal requests
Quality assurance reports
Chart audits
Rules and regulations
Knox Four-Step approach
Take TIME to take a PEEK at
the four types of Readiness to
The Four Types of Readiness to
Learn Are:
P = Physical readiness
E = Emotional readiness
E = Experiential readiness
K = Knowledge readiness
The Components of Each Type of Readiness
1. Physical readiness
– measures of ability
– complexity of task
– health status
– gender
– anxiety level
– support system
The Components of Each Type of Readiness
2. Emotional readiness
Anxiety level
Support system
risk-taking behavior
frame of mind
developmental stage
The Components of Each Type of Readiness
3. Experiential readiness
– level of aspiration
– past coping mechanisms
– cultural background
– locus of control
– orientation
The Components of Each Type of Readiness
4. Knowledge readiness
– present knowledge base
– cognitive ability
– learning disabilities
Learning Styles
Six Learning Style Principles
• Both the teacher’ style prefers to teach and the
learner’s style prefers to learn can be identified.
• Educators need to guard against relying on
teaching methods and tools which match their
own preferred learning styles.
• Educators are most helpful when they assist
learners in identifying and learning through the
their own style preferences.
Six Learning Style Principles
• Learners should have the opportunity to
learn through their preferred style.
• Learners should be encouraged to
diversify their style preferences.
• Educators can develop specific learning
activities that reinforce each modality or
Learning Style Models and Instruments
• Brain Preference Indicator
(Right-Brain, Left-Brain, and Whole-Brain)
• Embedded Figures Test (EFT)
• Environmental Preference Survey
(EPS) (Dunn and Dunn Learning Style Inventory)
• Myers-Briggs Type Indicator (MBTI)
Right-Brain/Left-Brain and
Whole-Brain Thinking
• Brain Preference Indicator
• Right hemisphere—emotional, visual–spatial,
nonverbal hemisphere
Thinking processes using the right brain are
intuitive, subjective, relational, holistic, and
time free
• Left hemisphere—vocal and analytical side
Thinking process using reality-based and
logical thinking with verbalization
Right-Brain/Left-Brain and
Whole-Brain Thinking
• No correct or wrong side of the brain
• Each hemisphere gathers in the same
sensory information but handles the
information in different ways
• Knowledge of one’s own brain
hemispherical performance can help
educators identify the strengths and
weaknesses of various teaching
Examples of Right-Brain/Left-Brain and
Whole-Brain Thinking
Left Brain
• Prefers talking and writing
• Recognizes/remembers
• Solves problems by
breaking them into parts
• Conscious of time and
Right Brain
• Prefers drawing and
manipulating objects
• Recognizes/remembers
• Solves problems by looking
at the whole, looks for
patterns, uses hunches
• Not conscious of time and
Whole brain—combining both sides of the brain
Environment Preference Survey
Myers-Briggs Type Indicator
Extraversion (E)
Sensing (S)
Introversion (I)
Intuition (N)
Thinking (T)
Feeling (F)
Judgment (J)
Perception (P)
Kolb Learning Style Inventory
Concrete experience
Active experimentation
Abstract conceptualization
Reflective observation
Gardner’s Eight Types of
(#8 identified in 1999--naturalistic)
Linguistic intelligence
Musical intelligence
Spatial intelligence
LogicalĞmathematical intelligence
Bodily kinesthetic intelligence
Interpersonal intelligence
Intrapersonal intelligence
Generational Styles- Silents
born 1925-1942 >61 years old
This group is not clueless about technology; the fastest
growing group of Internet users
Older adults may need technology training.
Let your students dictate the pace; don’t rush things.
Be polite, say “please” and “thank you”.
Use proper grammar at all times
Avoid all off-color language or humor.
Even if you’re using computers for training, provide
plenty of opportunity for personal
***interaction: Older learners like to interact with people,
not machines.
Generational Styles-Baby Boomers
born 1943-1960
43-60 years old
Show them that you care, Be nice
Fairness is important.
Tell them they are important.
Know their names.
Give them a chance to talk-they want to show you what they
 Dialogue and participation is key.
 Don’t be authoritarian; don’t boss them around.
 Be democratic--Treat them as “equals”
 Acknowledge what they know; ask them lots of questions so
they can demonstrate what they know
 Treat them as though they’re young, even if they aren’t
 Avoid “sir” and ma’am”, which they may take as an insult
 Respect their experience
Older people
Do’s and Don’ts
– All printed material should be clear, easy to read,
large enough font.
– Provide a summary of topics and goals.
– Be pleasant, personal but not too intimate.
– Don’t put them on the spot. Give them time to prepare.
– If you’re a 20-something trainer…
– Get coaching from someone older to understand the
mindset of this generation.
– Invite someone with a little more gray hair to be a
guest presenter in your class, to help with credibility.
– Show respect for age and experience.
Generational Styles- Gen Xers
born 1961- 1981
Can multitask well
Used to change
Want to get job done
Visual & dynamic
State of art technology & know how to use it
Only read when they have to!
Generational Styles- Gen Y
born 1981- 2003
Accept authority & follows rules
Balance work & personal life
Direct & Vocal
Socially aware & involved
Team player
Technology expected
Active-let them move around
Frequent and instantaneous feedback
ARE readers—provide backup info