How to Teach Your Most Difficult Patients

By Lara Alspaugh RN, BSN

Education is a fundamental responsibility of nursing practice. We teach patients and their families. But, not all teaching situations are ideal. We've all taken care of the patients who argue with every sliver of information they're provided and will outright defy efforts to provide learning, and we've all battled inhospitable learning environments. Below, you'll find two common scenarios of educational challenges that practicing nurses face as well as approaches to handling those situations suggested by nursing experts from around the country.

Meet the Experts:

Cory B. Sevin RN, MSN, NP

Sevin lives in Colorado and is a director with the Institute for Healthcare Improvement.

Barbara Boushon, RN, BSN

Boushon lives in Wisconsin and works as an independent health care consultant.

Mrs. Smith is a 56-year-old woman with a new diagnosis of breast cancer. She is scheduled for a mastectomy and is in her surgeon's office to go over her treatment plan. The office nurse plans to review the exercises Mrs. Smith will need to do after her mastectomy and information about expectations and changes after surgery. When the nurse attempts to provide Mrs. Smith with information, Mrs. Smith continually interrupts and talks over the nurse. The nurse is concerned Mrs. Smith is not getting all the information she needs.

Sevin: Mrs. Smith is interrupting the nurse because she is not able to hear what she has to say at this time. As important as the information is that the nurse has to impart, she will need to meet the more immediate needs of Mrs. Smith. It is likely that Mrs. Smith is experiencing anxiety, may be grieving and is afraid.

Boushon: The nurse can check if there is someone with her who could be another set of ears and eyes during the learning, as she seems unable to process at this time. Use a technique called teach-back. Ask the patient specifically what you have told [her] by topic. Then listen for gaps in learning and understanding. This allows the nurse a chance to fill the gaps and re-teach the patient [what she] did not grasp the first time around. If Mrs. Smith is not able to calm down or process, try to reschedule (if time allows, before the procedure) and send her home with some written materials, web-sites, links, etc. as well as a follow-up contact number when she is ready to learn.

Mr. Gonzales is a 19-year-old college student who has a history of diabetes mellitus, juvenile onset, who recently moved out of his family's home. When he first arrived in the ER, Mr. Gonzales was suffering from a decreased level of consciousness, confusion and lethargy. His blood sugar measured 68. The next day, Julia, his nurse, attempts to provide Mr. Gonzales with information about nutrition, exercise and diabetes to help him better control his disease now that he's living on his own. Mr. Gonzales is argumentative and obstinate. He tells Julia he already knows everything there is to know about diabetes and doesn't need her help.

Sevin: For reasons that need to be discovered, Mr. Gonzales is not ready to either take care of himself or listen to what the nurse knows he needs to know in order to take care of himself. A good strategy would be to talk with Mr. Gonzales and find out what happened that led to his blood sugar getting dangerously low and how he is taking care of himself now that he is out on his own. In the process of the discussion, the nurse will most likely learn (and can probe for) what he knows already, what he does for self-management and perhaps the behaviors that are high risk for him. The nurse can then learn his strengths and support his strengths and self-care and his gaps in knowledge, behaviors and self-management.

Boushon: The nurse should first check Mr. Gonzales' blood sugar and other vital signs for physiologic issues or barriers to learning. The irritability and obstinacy may actually indicate a blood sugar issue. Next, assess his readiness to learn by perhaps a checklist or pre-test (if willing) to show Mr. Gonzales his own gaps. Take some time to get to know him as a person (vs. as a patient) to help establish rapport. After some rapport is established, ask him to tell the story of how he ended up in the ER. This may help establish some need for change or learning. Then try to identify a topic that is mutually beneficial-on the nurse's list of "must-teach" and Mr. Gonzales' list of "would-like-to-learn." Use this list to do short, but focused segments that are interactive and stress the teach-back I suggested with Mrs. Smith.

This is the first half of a two-part series on nursing education. Check back next month for new scenarios and opinions from two new experts.

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