Educating Patients: Understanding Barriers, Learning Styles, and Teaching Techniques
Linda Beagley, MS, BSN, RN, CPAN
Health care delivery and education has become a challenge for providers.
Linda Beagley, M
cator, Swedish Cov
Conflict of intere
nant Hospital, 51
e-mail address: lbe
� 2011 by Ame 1089-9472/$36.
Journal of PeriAnesth
Nurses and other professionals are challenged daily to assure that the
patient has the necessary information to make informed decisions.
Patients and their families are given a multitude of information about
their health and commonly must make important decisions from these
facts. Obstacles that prevent easy delivery of health care information
include literacy, culture, language, and physiological barriers. It is up
to the nurse to assess and evaluate the patient’s learning needs and read-
iness to learn because everyone learns differently. This article will
examine how each of these barriers impact care delivery along with
teaching and learning strategies will be examined.
Keywords: patient education, barriers, culture, literacy, perianesthesia nursing.
� 2011 by American Society of PeriAnesthesia Nurses
EDUCATING PATIENTSHAS become a challenge for health care providers because the patient
length of stay has decreased and the need to deliver
complex information has increased. A new version
of the melting pot society requires special efforts
by health care professionals to ensure that the pa-
tient understands the information given to him or
her. Barriers that inhibit patient education are liter- acy, language, culture, and physiological obstacles.
Assessing and evaluating the learning needs of
the patient are essential before planning and im-
plementation of an educational plan. Presenting
a well-formulated plan will increase the likelihood
of a successful recovery for the patient. In this
article, barriers will be dissected and strategies
examined to determine what will best suit the edu- cational needs of the patient.
S, BSN, RN, CPAN, is a PACU Clinical Edu-
enant Hospital, Chicago, IL.
st: None to report.
ondence to Linda Beagley, Swedish Cove-
40 N. California Ave, Chicago, IL 60625;
rican Society of PeriAnesthesia Nurses
esia Nursing, Vol 26, No 5 (October), 2011: pp 331-337
To effectively educate patients, health care pro-
viders must have an understanding of the princi-
ples of adult learning. Malcolm Knowles, who
began to study adult learners in the 1960s, is
known as the father of adult learning principles be-
cause of his extensive writing on adult education. The term andragogy, the art and science of teach-
ing adults, is synonymous with that of Knowles.
He deduced that adults learn differently than chil-
dren. His studies determined five assumptions on
learning: self-concept, experience, readiness to
learn, orientation to learning, and motivation to
learn.1 According to Knowles, as a person ma-
tures, his self-concept moves from one of being a dependent personality towards one of being
a self-directed human being. Humans accumulate
a growing reservoir of knowledge, followed by
a readiness to learn, which increasingly is oriented
towards developmental tasks related to social roles
with immediate application of their new knowl-
edge. Knowles’ final assumption reflects the moti-
vation of learning as moving from external to internal.1,2 Table 1 compares and summarizes
Knowles’ assumption regarding the adult (andra-
gogy) and the child (pedagogy) learner.
Table 1. Assumptions Differences of Pedagogy and Andragogy1,2
Assumptions Pedagogy Andragogy
Self-concept Dependency Self-directed
Experience Happens to learner Rich resource
Readiness Biologic and academic development Evolving social and life roles
Orientation to learning Logical; directed by teacher Life centered; task/problem centered
Motivation External approval of teacher Internal drive; life goals
332 LINDA BEAGLEY
Literacy is defined as ‘‘an individual’s ability to
read, write and speak in English and compute
and solve problems at levels of proficiency neces-
sary to function on the job and in society, to
achieve one’s goals, and to develop one’s knowl-
edge and potential.’’3 Illiteracy does not discrimi- nate; it can be found in all populations, and
a person’s grade level is not an accurate gauge
for reading ability.4 Having any level of illiteracy
can cause a number of problems with activities
of daily living, such as analyzing a transportation
schedule, following directions, understanding rec-
ipes, and completing job applications. Low liter-
acy is described as those people who have the ability to read, write, and understand information
only at the seventh grade reading level. According
to the US Department of Health and Human Ser-
vices (DHHS),3 demographics does play a role in
literacy; certain groups demographically have
a higher prevalence of low literacy. Table 2 out-
lines this population.
Low literacy and low health literacy are related but
not interchangeable. Health literacy is defined in
Healthy People 2010 as ‘‘the degree to which indi-
viduals have the capacity to obtain, process, and
understand basic health information and services
needed to make appropriate health decisions.’’5
Low health literacy is content specific. An individ-
Table 2. Demographics of Low Literacy3
Fewer years of education
Lower cognitive ability
Some racial or ethnic groups from the South or
Low income status
ual may be able to read and write in certain con-
texts but struggle to comprehend the unfamiliar
vocabulary and concepts found in health-related
materials or instructions.5 According to the US Department of Education, which conducts a na-
tionwide survey of adult Americans to evaluate lit-
eracy skills,5 an estimated nearly one half of
Americans (90 million) have difficulty understand-
ing and acting on health information. These stud-
ies have linked low health literacy with delayed
diagnosis, poor disease management skills, and
higher health care costs. These same individuals demonstrate a limited understanding of their dis-
ease processes resulting in worse health care out-
comes.6 Unnecessary health care costs ranging
from $106 to $238 billion are attributed to limited
Factors associated with health literacy are depen-
dent on the skills, preferences, and expectations of health information providers. At times, health
care professionals may be oblivious to the effect
of limited health literacy on patients and the health
care system. In one study7 of 240 health care pro-
viders and students, researchers found fewer than
12% of participants were aware of their degree of
limited health literacy. Twenty-five percent were
found to have a common misconception that health literacy could be determined by race, eth-
nicity, culture, age, or socioeconomic status.7 To
heighten matters, responders inaccurately be-
lieved that patients with a higher level of education
were not at risk for having limited health literacy
(7.4%). In health care, nurses comprise the largest
group of providers and are responsible for ensur-
ing patient education. The researchers recom- mend health literacy education for nurses during
the education process.
Cutilli8 completed a systematic review of the liter-
ature for the purpose of analyzing and evaluating
the research on health literacy and the elderly.
EDUCATING PATIENTS 333
Age becomes an important demographic marker
with an inverse relationship to health literacy.
Cutilli found that as the patient’s age increases,
the health literacy level decreases. This is an
important element because of the aging popula- tion in the United States and the projected trend
of aging. By 2030, it is estimated that 20% of the
population will be 65 years and older.9 The
Federal Interagency Forum on Aging9 reports older
Americans are proportionately more likely to have
below basic health literacy than other age groups.
Thirty-nine percent of people aged 75 years or
older have below average health literacy skills compared to 23% of people aged 65 to 74 years
and 13% of people aged 50 to 64 years.
Language and Culture Barrier
The United States has been known as a melting pot
of diversity over the last 100 plus years. Some
changes, however, have occurred from those early years. Ethnicities are found in large urban neigh-
borhoods, as well as the suburbs and rural areas
of the country. The diversity now existing across
the country has presented many challenges for
health care providers. In 2001, DHHS published
national standards on culturally and linguistically
appropriate services. These DHHS standards10 re-
quired health care institutions to demonstrate cul- tural competency while caring for patients in
a manner responsive to their beliefs, interpersonal
styles, attitudes, language, and behaviors of the in-
dividual and required that care be provided in
a manner that demonstrates respect for individual
dignity, personal preference, and cultural differ-
Health care providers must be knowledgeable of
cultural competencies. Nurses should have aware-
ness of biases and prejudices by examining gener-
alizations they might use routinely about cultures
other than their own. Any biases must be con-
fronted. A commitment to learn more about the
cultures that have been generalized in the past
must be made.11 Second, core cultural values need to be examined and understood about the
varying populations that frequent the institution.
Cultures have several core values on which all
other values are based.12 This foundation is a start-
ing point for health care providers in understand-
ing different cultures.
A challenging aspect is the ability to communicate
effectively to the patient whose native language is
not English. Thoroughly assessing the patient’s
comprehension and the need for a translator is vi-
tal. Every attempt must be made to provide a qual- ified translator whether the translator is physically
present or available via a telephone translation
line. Family members as translators may not be
able to translate important terms needed in obtain-
ing informed consent or education. Furthermore,
caregivers must provide written education mate-
rials for the patient to take home. Many concepts
are not easily translated, and it is imperative to have a fluent translator translate the written
word into the targeted language.11
An estimated 40 different languages are spoken by
the patients who use the services at one Midwest
community hospital. Managing multiple languages
and cultures has proven to be a challenge. The hos-
pital intranet offers resources for many of the cul- tures including common practices, values, and
beliefs. Another unique attribute for this hospital
is the diverse nursing population. In the surgical
arena, every effort is made to pair similar culture/
language of the patient to the health care provider.
This luxury of a diverse nursing population is not
common for many facilities, creating a need to
rely on telephone language lines or hospital- employed interpreters.
Madeleine Leininger’s theory of cultural care diver-
sity and universality defines culture as a guide
whereby the individual’s thinking, aswell as his de-
cisions and actions, is patterned and usually passed
on from one generation to another.12 A person
uses culture as a framework in viewing the world, including health and the need for health care. Be-
cause patients can feel a sense of losing control,
they have a tendency to hold onto family beliefs
when they become ill. Successful teaching plans
are congruent with patient and family values.4
Nursing care that incorporates cultural values
and practices can be positively related to patient
satisfaction, and patient compliance to treatment will be greater. Conflict will result if nursing care
is in discord with the patient’s belief systems.
Knowing one’s patient is important for delivery of
care. A recent Swahili refugee was admitted to
have a cholecystectomy. She had been treated
with tribal medicine, which resulted in several
334 LINDA BEAGLEY
healed burn scars on her abdomen. Arousing from
anesthesia, the patient relayed through her inter-
preter that she wanted to see what was removed
during surgery. The nurse tried to explain that
the patient’s gallbladder had been removed and sent to pathology. The patient continued to insist
that she needed to see the gallbladder. For this pa-
tient, it was imperative to visualize the gallbladder
to confirm that she was healed from her illness.
The nurse recognized the needs of the patient,
contacted the surgeon, and between the two of
them, they were able to have the patient see her
gallbladder through pictures taken during surgery.
Another example of the importance of cultural
awareness is demonstrated in the story below.
The diabetic educator consults with patients
who have gestational diabetes frequently in the
clinic. A Muslim patient and her husband were
scheduled for education. In this patient’s culture,
the educator was not permitted to address the patient directly and was to speak only to the
husband. To acknowledge the patient’s cultural
beliefs, the educator instructed the husband,
who then instructed the patient in her presence.
The educator used several different teaching tech-
niques to quantify that the patient could safely ad-
minister insulin to herself.
In the American culture, the patient is the key deci-
sionmaker in health care.13 Thepatientmay consult
with other family members, but ultimately, the pa-
tient makes the final decision.14 Traditionally, Amer-
ican families have been defined as having a mother,
father, and child/children. Familial hierarchy can be
different for some cultures. How is the ‘‘family’’ de-
fined for this patient? Is it the immediate nuclear family or the family that may include extended fam-
ilymembers, close friends, or neighbors? Identifying
who is thehealth care decisionmaker for thepatient
is important.4,13 For some cultures, the decision
maker is the head of the household or the entire
extended family. All key players must be involved
in any decisions because they will either reinforce
or block health care behaviors.
The nurse must be aware of both verbal and non-
verbal communication behaviors. There are vast
differences in culturally defined communication
behaviors. Before discussion of personal informa-
tion, it is important to understand cultural prac-
tices related to nonverbal communication during
conversation, communication practices related to
the opposite gender, and cultural practices of so-
cial conversation.4 Gender-specific topics could
be taboo for some cultures. For some, direct eye
contact is a sign of disrespect. Be aware of cultures in which disagreement is perceived as impolite-
ness. The patient may be agreeing with what the
health provider is saying purely out of civility
rather than out of agreement.13,15
Physical and Environmental Barriers
Physiological factors play a role in how the patient is
able toprocess health information. As a person ages,
visual clarity and auditory acuity will decrease, mak-
ing it difficult for the person to receive information.
Many times, a patient may refuse to wear corrective
devices. Altered mental capacity because of patho- logic disease processes, such as Alzheimer disease,
or pharmacologic interventions, such as medica-
tions, can create a barrier for effective teaching.
Increased agingmay causedecline in cognitive capa-
bilities in processing information, memory, and
comprehending abstractions.16 As the adult ages,
the ability to reason and process information occurs
at a slower rate and reaction or response time in- creases significantly after the age 65. Managing
multiple messages simultaneously is harder to do.
Short-term memory loss and the quantity of new
information may limit the length of the teaching
session and amount of information given. The
capacity to draw conclusions from inference
decreases in the older adult. Vague terms of
‘‘adequate,’’ ‘‘several times a day,’’ and ‘‘often’’ can have multiple meanings. Directions should be spe-
cific to time and order with quantities defined.
Physical conditions can limit mobility and the pa-
tient’s ability to sit and be receptive to learning.
Many times, patients seek out health care be-
cause of pain or not feeling well. Uncontrolled
pain will block the patient’s ability to receive in- formation. Anticipation, anxiety, and fear are all
contributing factors in diminishing reception of
knowledge. In the perianesthesia area, pain and
anxiety are obstacles that must be identified
and controlled for the patient to comprehend
Because of busy schedules, environmental barriers are challenging at times. Poor lighting, noise levels,
and room temperatures can inhibit the learning
Table 3. Learning Styles With Teaching Strategies
Learn Styles Teaching Strategies
Visual Visual material
Handouts—easy to read
Variety of technology—computers,
overhead, video, TV, Internet
Auditory Rephrase key points
Vary speed, volume, and pitch
Write down key points
Positioned to hear the message clearly
Use multimedia—tapes, music
Kinesthetic Frequent breaks to move around
Learner writes own notes
Provide tactile activities
EDUCATING PATIENTS 335
process. These barriers are difficult to control be-
cause of capped thermostats and controlled light-
ing. Noise levels are under careful consideration
because of the complaints of patients who have
not been able to rest because of noise while hospi- talized. Hospitals have responded by instituting
quiet times during the day. Physical space for the
health care professional to share information
with the patient that is private, quiet, and with
minimal distractions can be at a premium,
although necessary for effective learning. Lastly,
time to devote to adequate teaching is a large bar-
rier in today’s health care environment. Profes- sionals are asked to do more with less, including
time. Patients’ length of stay has shortened be-
cause of many factors, giving the nurse less time
with the patient to accomplish important teaching
Besides understanding barriers that impact the re-
ception of education, the nurse must be aware of
how an individual learns. Learning patterns are de-
veloped as a child and the ‘‘learner’’ discovers what
works best for his or her individual learning style. Assessment of the patient is essential for effective
teaching, which may require more than one learn-
ing style for comprehension. Learning patterns in-
clude visual, auditory, and kinesthetic.17 A visual
learner prefers to see what he or she is learning.
Pictures and images help the learner understand
ideas and information better than an explanation.
The auditory learner needs to hear the message or instructions being given. This type of learner
wants to be talked through a process rather than
reading about it first. The kinesthetic learner
does not like lecture or discussion, preferring the
movement of the skill or task. Demonstration
and return demonstration works best with kines-
Once the learning style is established, the nurse
adapts the teaching materials to the preferred
style. For the visual learner, the nurse will havema-
terials for the patient to read or watch. The infor-
mation should be well organized, interesting,
appealing, and easy to read. With today’s advance-
ment of technology, there are many choices to of-
fer the visual learner, including computers, live video feeds, close circuit television, photography,
and the Internet.
For the auditory learner, the nurse should rephrase
important points and questions in several different
ways to communicate the intended message. Vary-
ing the speed, volume, and pitch helps create an
interesting aural texture. An environment where the patient and family can hear the message is im-
portant while encouraging the patient to write key
elements. A quiet space, preferably with the ability
to close the door along with minimal distractions,
assists the teacher to maximum the learning for an
auditory learner. To assist the auditory learner, in-
corporate multimedia of sounds, music, or speech.
Kinesthetic learners prefer frequent breaks so that
they can move around. The nurse should encour-
age the patient to take notes while providing tacti-
cal and hands-on activities. Providing samples
will allow the kinesthetic learner to practice
what he or she is learning, verifying comprehen-
sion through return demonstration. Table 3 sum-
maries learning styles with teaching strategies.
In the perianesthesia arena, more than one type of
teaching strategy may be necessary to successfully
deliver the message and establish comprehension.
For example, the follow-up telephone call was indi-
cating negative outcomes for several patients who
were to remove their urinary catheter at home. The
patient teaching before going home for this patient population had become labor intensive, yet urinary
catheters were still being removed without deflat-
ing the catheter balloon, causing harm to the
patient and unhappy surgeons. Brainstorming,
336 LINDA BEAGLEY
a group of nurses looked to see how those in the
unit could improve the education process and out-
comes. The result was to continue to demonstrate
to the patient and significant other how to deflate
the balloon and remove the catheter. A return dem- onstration was verified by both the patient and the
family member, each practicing using the syringe
and inserting it into the catheter port (without re-
moving the catheter). The department also devel-
oped a step-by-step handout with pictures for the
patient to take home. All three learning styles
were instituted to ensure a positive change of no
longer having patients remove the urinary device with the balloon intact.
Teaching methodologies are multiple, and not all will work in the perianesthesia setting. The most
commonmethod is lecture, inwhich the presenter
gives information to the learner and learning is pas-
sive. Discussion allows for participation and for
the ability of the learner to ask and answer ques-
tions and share feelings. Demonstration is a useful
technique using both psychomotor and social
skills of the learner. In health care, demonstration with return demonstration is commonly used
when a new technique or skill is to be learned by
the patient. An example of demonstration was the
urinary catheter instructions and patient demon-
stration previously mentioned.
Another common method of teaching is the use of
printed instructions. Printed health care informa- tion should avoid technical language: use short
simple sentences and write at a level that most pa-
tients will understand.4 The recommendation for
written instructions is that they be at the fifth
grade level. Avoidance of glossy paper and small
fonts also assists the learner.
The Internet can be a friend or foe when obtaining health care information. Hospitals are setting up
Web sites for patients to obtain information. In
one pre-surgical testing department, the nurse
gives the scheduled surgical patient a Web site
where he or she can learn more about anesthesia
before coming to the hospital. Health care profes- sionals also need to establish that the patient is ob-
taining reliable information on the Internet and
steer the patient to government and academic sites
that are proven to be more trustworthy.19 Inpa-
tients can watch health-related stations on their
televisions.11 On the obstetric unit, patients can
access the television to learn about a variety of is-
sues related to the mother and care of the new baby. The disadvantage of watching a television
station or already-taped segment is the inability
to ask and have questions answered immediately.
The nurse must be diligent in following up with
the patient to answer questions and reinforce the
teachings from the video.
For effective delivery of health information and ed-
ucation, the nurse must be aware of the barriers that can impede the patient’s ability and readiness
to learn. Awareness of the potential barriers of lit-
eracy, culture, language, and physiological factors
will help the nurse determine what tools he or
she may need to assist in the delivery of informa-
tion. Awareness of one’s biases and prejudices
and overcoming them will assist in the education
process. The nurse assesses the patient’s under- standing by looking at both verbal and nonverbal
cues that the patient is displaying. Using more
than one way of delivering the message will pro-
mote the patient’s learning. A family member pres-
ent during key moments will assist and help the
patient to remember the information. The astute
nurse will be more successful in overcoming bar-
riers if she or he is aware of patient’s needs and areas where additional assistance is needed.
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