How to Teach Your Most Difficult Patients, Part 2

By Lara Alspaugh RN, BSN

Last month on, two nursing experts weighed in on two common patient scenarios. In both cases, the hypothetical situations presented unique problems when it came to one of the most important roles in nursing-patient education. This week, we have two new experts and two new scenarios.

Meet the Experts:

Kathryn Peppe, RN, MS

Peppe recently retired from the Ohio Department of Health where she was the Chief of the Division of Family and Community Health Services. She now works as an independent Maternal and Child Health Consultant.

Virginia Crowe RN, MS, Ed.D.

Crowe is Principal of Hamilton Consulting, LLC a quality management and organizational learning consulting practice based in Michigan.

Ruby Chester is a 22 year old primigravada who is 26 weeks and has been admitted for pre-term labor. Ruby's husband Chad has been with her from the time of her admission. Ruby is being given Mag Sulfate and has been placed on bed rest. The nursing staff has been attempting to educate Ruby on the risks and complications of pre-term labor for both her and the baby; however, Chad has been disruptive to the learning process. Chad continually answers for Ruby when the nurse asks for feedback and provides time for question and answer.

Peppe: The nurse should tell Chad that while it is very important for him to master the information, it is even more critical for Ruby to have complete mastery of it since she will be the one who needs to recognize the danger signs and symptoms of complications as they develop. The nurse could refocus Chad's attention away from himself and his own knowledge by enlisting Chad's help in coaching his wife after the nurse gives both of them instruction. The nurse should give both of them the chance to ask questions and seek clarification to the information provided and should allow Chad to respond and then say it is Ruby's turn to respond.

Crowe: This interaction could be based on several issues, however, anxiety for both new parents is the most likely contributor, if not the only cause. Depending on the energy or tension in the room when Chad answers for Ruby, it might be a useful strategy for the nurse to use gentle humor by overtly thanking Chad with a genuine smile and then asking Ruby (using her name) what she thinks. This might give some insight, by the observed reaction of both Chad and Ruby, into the pattern of communication in the relationship. [This new insight into their relationship] should help the nurse choose additional educational approaches.

In addition, I would suggest using time when the nurse is alone with Ruby during her daily care, as an opportunity to have a conversation with Ruby regarding her concerns and understanding of the risks and complications. In addition, the nurse could use the need for quiet time for the patient as an opportunity to take Chad aside and have a private time with him. Addressing Chad's concerns and fears in a more private place might allow him to express his anxiety and create a better opportunity for learning for both of them.

Bob Carter is a 68-year-old man who was admitted two days ago after complaining of chest pain and nausea. An MI, or heart attack, was confirmed and an angioplasty was performed immediately. Bob is 50 pounds overweight, admittedly sedentary and is a partner at a high-profile law firm. To recover and continue to stay healthy, Mr. Carter needs to make several life-style changes. The nursing staff repeatedly tries to provide Mr. Carter with the information he needs to make those changes but he refuses to engage with the nurses. He appears to be listening when the information is presented but will not engage in conversation or inquire on his own when provided time to ask questions.

Peppe: The nurse should acknowledge to Mr. Carter that lifestyle changes are hard, and that his life doesn't have to totally change at once. Since Mr. Carter has been uncommunicative, the nurse should begin by asking him a question and then using the ensuing silence by simply waiting expectantly and patiently for him to respond, no matter how long it takes for him to break the silence. The nurse could ask him to select one or two changes that he knows he can make successfully as the initial question and use his eventual response as a base upon which to build his treatment plan. Once he has helped to identify initial lifestyle changes that he feels he can make successfully, the nurse can help him see the possibilities of adjusting the treatment plan as he gains experience and confidence in his own abilities.

Crowe: There might be several reasons for this situation to occur. It might be just as simple as a preference for a visual learning style and introverted temperament. More likely, however, these changes are life-long changes, which will need to take place over a period of time. The current situation is most likely of greatest concern to Mr. Carter. I can remember teaching people about what was going to happen to them when they [were about to undergo] an angioplasty; when they were concerned with what was happening at the moment; and what the helicopter [they would be transported to the hospital] would look like.

I suggest addressing this situation in a short-term and long-term approach. Ask the patient what his current greatest concerns are and help to clarify for him what he needs to know about signs, symptoms and events in the next month. I would also then develop a learning plan or package for him with resources he would need for the next stage of his recovery and healing.

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