Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Patient and Family Education After Myocardial Infarction Nanette K. Wenger To cite this article: Nanette K. Wenger (1975) Patient and Family Education After Myocardial Infarction, Postgraduate Medicine, 57:7, 129-134, DOI: 10.1080/00325481.1975.11714080 To link to this article: https://doi.org/10.1080/00325481.1975.11714080
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Patient and Family Education After Myocardial lnfarction A program of public education is the ideal approach to prevention of coronary atherosclerotic heart disease, particularly efforts at coronary risk-factor modification. Recognition of early warning signs of heart attack should be taught so that they are promptly, appropriately heeded. The apparently healthy individual, however, has far less motivation to learn about prevention and management of disease than does the patient with clinical evidence of illness. Therefore, it is the primary physician's responsibility to institute a program of education for patient and family. The program should be designed to provide suffi.cient information about the disease and its management to enable patients to assume sorne responsibility for their own health care. Patients who understand their disease and its management have increased ability and motivation to cooperate in health care regimens. Motivation and opportunity for education tend to be optimal during the crisis episode-most often hospitalization for acute myocardial infarction (Ml). Incidentally, this is often the first identification of the illness to the patient. For this reason, an in-hospital educational program is often the cornerstone for all patient teaching efforts. Although the patient and family are most "vulnerable" to teaching efforts during hospitalization, physician-patient contact rarely averages more than 10 to 20 minutes per day. Thus, the educational programming responsibility best rests with other health care personnel with
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
Patient education must be an integral part of medical care. A defined core curriculum is necessary. The educational program on myocardial infarction can be started early in hospitalization, with repetition of information and no contradiction. The family must be included in the educational process. NANEnE K. WENGER, MD Emory University School of Medicine
Atlanta
whom patient and family are in contact during the remaining 23% hours. The Educational Program
The program outlined in this article is equally applicable to all patients with symptomatic coronary atherosclerotic heart disease, eg, anginal syndromes or more prolonged pain of myocardial ischemia. The concepts and much of the program material derive from the educational program which has been a part of the cardiac rehabilitation effort at Grady Memorial Hospital and Emory University School of Medicine since 1967. The short-term goals of the in-hospital educational program are to decrease
129
······················································································ ······················································································
Because patient and family education for a chronic disease must be a long-term process, the continuity of the educational program is important.
the feelings of helplessness, aid in restoring selfesteem, increase the patient's confidence in a successful outcome, and enhance his ability to cope. The educational program can offer the patient information thar will provide realistic reassurance of concerns regarding such factors as family role, sex, recreation, and job. The design of the program involves the compilation of a core curriculum specifying the information to be taught at each stage of the illness. The MI patient should be presented, at a minimum, the basic concepts of normal heart funcrion so he can understand how myocardial infarction alters them. Without this background information, he will have difficulty in understanding how obstruction of a coronary artery can cause the pain he experiences and how disturbances of cardiac rhythm and impaired pumping function can produce symptoms. An oftenheard criticism of earlier efforts of physicians at patient-family education was that authoritarian orders or directions were given, which the patient perceived were without apparent reason. An informational, explanatory approach was what the patients desired. Teaching Life-Style Modification
Since most intervention in management of coronary disease entails modification of !ife-style, the teaching emphasis should provide insight into those !ife-style factors that alter the risk of heart attack and into the value of change in !ife-style. Information should be provided about prescribed dietary alterations-changes in calories, fat, and sodium, if warranted, together with the
130
rationale for the dietary prescnpttOn and the objectives. This should be coupled with specifie inquiries about food preferences and eating habits so that a reasonable diet with enough familiar foods to encourage compliance can be constructed. Furthermore, the means of dietary adherence (eg, changes in food buying, guidetines for restaurant eating) should also be presented. Physical activity should be discussed, and reasons for initial restriction presented, including a reminder that these restrictions are temporary. The concept of a gradually progressive increase in physical activity and the benefits of a prescribed, individually tailored physical activity program after hospitalization, designed to enhance cardiac function, should be presented. The patient should be referred to an appropriate community program where he can implement these recommendations for physical activity. Cessation of smoking should be advised, the reasons for the recommendation outlined, and the patient referred to an appropriate antismoking program within the hospital or community. Risk-factor modification and control of associated disease (eg, diabetes, hypertension) should be emphasized, again relating this approach to what is known about coronary disease and providing detailed, specifie suggestions for implementation of recommendations. Ali medications the patient is to take should be carefully reviewed-name, purpose, dosage, expected response, and any adverse response or side effects which should be reported. ln ali the teaching efforts, the emphasis should be on prescription rather than proscription. The correct response to new or recurrent coronary symptoms subsequent to hospitalization should also be discussed, as the individual with MI is at increased risk for recurrent MI. Only if the appropriate response to chest painseeking immediate medical care-is taught can we hope to make inroads on the problem of prehospital sudden cardiac death. Scheduling and Timing
Because physical and mental readiness is necessary for learning, the scheduling and timing of this core curriculum are important. Early in
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
Photo: Jay Walter
the course of the illness, when fear, pain, and fatigue are signihcant components, only simple, brief information can be transmitted. In the coronary care unit (CCU), an explanation of the equipment and procedures is reassuring, decreases the likelihood that the patient will misinterpret staff actions or comments, and helps the patient to adjust to a life-threatening situation. During recovery the patient is ready to assimilate more detailed information. A positive staff attitude is of major importance in this phase, helping the patient to maintain his self-esteem while he makes reasonable, realistic plans for resuming or altering his life-style. W e have found that the core curriculum is best presented in a group setting, a format that provides for economy of the instructor's time and, equally important, gives the patient an opportunity to interact and share with a peer group confronting similar problems. Such an experience apparently reinforces learning. Similarly, we have noted lessened anxiety in a group educational setting, as a peer group with similar problems seems to facilitate adaptation to stress
Vol. 57
-
No. 7 * June 1975
-
POSTGRADUATE MEDICINE
and decrease frustration. In addition, the opportunity to function as a group member and help others is supportive of the patient's selfesteem. Classes or groups that combine inpatients and outpatients may make use of the reinforcing effect of the recovered patient, one who has returned to the mainstream of life. Individual patient-family insquction for particular details and problems must supplement the group presentations. Continuity of the Program
Because patient and family education for a chronic disease must be a long-term process, the continuity of the educational program is important. The format of progression of learning should be standardized, initially in the CCU and then during the remainder of the hospital stay. This should be correlated with the longterm care educational efforts in the physician's office, hospital clinic, or industrial medical facility. Although continuity of an educational program for the large patient population with coronary disease over a long period may appear as an insurmountable task, preplanning the pro-
························································································ ························································································
The needs of the patient are a major determinant of the effectiveness of an educational program; information must be designed to solve relevant problems. gram and entering patient educational data in the patient's record have proved to be great facilitators. A predefined content is important, as noted above, in the educational program for the coronary patient. A display method for this educational program should be provided in the patient record. It should detail the information presented to the patient at each stage of the illness, identify the teacher and the teacher's assessment of patient learning, and specify areas of information which apparently need repetition or reinforcement. The display document has proved most valuable for the varied health care personnel caring for and teaching the patient, in helping to eliminate any conBicting information being given to the patient, in helping to eliminate unnecessary repetition, and in assuring that the appropriate, necessary repetition and reinforcement are provided. Repetition and satisfaction reinforce learning. Therefore, throughout the educational process, the satisfaction derived from the achievement of both short- and long-term goals is an important cornpanent of the learning process. Equally important is the relatively intangible concept of staff attitude in transmitting the expectation that the combined efforts of health care team and patient will succeed. It is an attitude of realistic optimism that tells patient and family that the staff are concerned with them as individuals, that they respect them, and that they are conferring responsibility in the teaching.
132
The Physician's Rote
The physician's task in a program of patient and family education is to define the educational curriculum, specifying the information to be presented at each stage of the illness (in the ecu, during the remainder of hospitalization, after discharge from the hospital) and periodically reviewing the content to assure accuracy. Although hospital educational programs are often fairly highly structured, being conducted by various members of the health care team (their responsibilities are discussed below), an excellent educational program can be implemented, albeit in a less formai and structured manner, in the primary physician's office. The office nurse or other office staff and personnel should be involved in a program of patient education, the structure and content of which the physician has predefined. The physician's waiting room should be an educational facility. In many communities, pamphlets are available from the local hospital, based on their teaching program. The physician can simply, effectively design instructional booklets, and many prepared educational materials are available from volunteer health agencies (the American Heart Association is a major source for the coronary patient). Reinforcement by audiovisual techniques is extremely effective. Sorne physicians now have in the waiting room or another room in the office a library of tape cassettes for patient education. The single-concept module approach is used to delineate the physician's instructions or provide information to patients with a specifie problem. That is, the physician presents on a cassette a single concept of information, the basis for the recommendations, and the means of implementation of these. The patient may listen to the tape before discussion or consultation with the physician and may be instructed to re-review it during subsequent office visits. Thus, the physician prescribes education as part of the therapeutic regimen. The cassettes may be supplemented by tape-slide series; a signal on the tape cassette automatically triggers slide changes to correspond with the text and pro-
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
vide illustrative material. This approach has been found to be equally effective in industrial medical facilities.
··················································································· ···················································································
Role of Allied Health Care Personnel
A variety of health care personnel may implement the educational curriculum in the hospital setting. Nurses, dietitians, social workers, occupational and physical therapists, vocational rehabilitation counselors, and even hospital volunteers may be recruited to participate in the educational program. lt is important that ail individuals participating be familiar with the total program, the materials and methods, and the interrelationships of teaching and that the aforementioned communication format in the patient record be used to the fullest extent. Audiovisual presentations using such media as tapes, slides, or television can provide the necessary repetition in a more interesting form. Locally prepared audiovisual presentations and pamphlets are often far superior to the nationally marketed ones. Familiar persons (hospital health care personnel) are portrayed in familiar settings, and use of local language is possible. The patients portrayed can be prototypes of the population served. Ancillary Methods
Because the needs of the patient are a major determinant of the effectiveness of an educational program, the information must be designed to solve common, relevant problems. For example, group discussions might concern accomplishing prescribed dietary alterations on a limited income; access to and time and facilities for programs of physical activity; access to health care; payment for health care and medications; availability and interest of family for support; job problems with limited education, skills, and experience, now compounded by physical impairment; and community attitudes toward persons with heart disease. Patient self-tests often reinforce learning. We have found a take-home patient educational booklet to be valuable. lt contains a review of ali the educational material presented, but also includes questions that commonly arise on re-
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
.. The physician and the health care .. team must consider both the informational and the behavioral .. objectives in the evaluative stage .. of the educational program. turn home from the hospital. The patient is instructed to have his physician fill in the blanks regarding specifie home and community activities, eg, when he can resume sexual activity, when he can drive a car, when he can go to church, when he can grocery shop. Writing in this information reinforces its importance and accuracy, allows for individual variation in instructions, and permits supplementation by specifie, individual instruction of general information given in group classes or group discussions. Furthermore, these specifie patient-family instructions help to minimize the homecoming conflicts and frustrations deriving from vague or ambiguous directions and recommendations. Readiness for Learning
The necessity for both physical and mental readiness for learning deserves reemphasis, particularly in the setting of acute or relatively acute illness. Fear, pain, shock, anxiety, and depression ali decrease the ability to learn. Despite this, the positive attitude presented by a teaching program-the concept of learning for a living -often decreases the patient's anxiety and depression. Being instructed to begin an educational program designed to help care for the patient when he returns home is reassuring to the family of a patient in the ecu. Equally reassuring to the ecu patient is receiving even the most preliminary, simple information about activities designed to prepare him for his retuen home, during the stage of the illness when he still fears for his survival. Nevertheless, sim-
133
plicity and brevity of information are necessary early in the course of the illness to avoid fatiguing the patient. The information must be presented with the realization that repetition is generally necessary, because often the information is retained only transiently. Many patients are too anxious to hear what is said; sorne hear and rapidly forget. Objectives
Finally, differentiating between the content, or informational, objectives and the behavioral objectives is important for the entire educational program. New knowledge does not always resuit in the desired alteration of behavior. Information is satisfactorily transmitted to many patients; nevertheless, it does not always affect their behavior, ie, their adherence to recommendations. Effective learning requires participation. This is, perhaps, an advantage of group classes, in that patient participation in discussion may be an important component in the learning process-not only in learning content but also in beginning behavioral change. The physician and the health care team must consider both the informational and the behavioral objectives in the evaluative stage of the educational program. Effort must be made to determine if the content-the information-is being transmitted satisfactorily. This is easily ascertained either by a self-test for the patient or by direct questioning and evaluation of the responses by health care personnel. One must theo determine whether this new information changes behavior, that is, improves patient and family adherence to recommendations for continuing health care. ln the clinic, the physician's office, or the industrial facility, efforts must be directed toward determining whether the patient who understands the reasons for cessation of smoking has indeed quit; whether the patient who understands the need for weight reduction or alteration of dietary fat has undertaken these efforts, as measured by decrease in body weight or serum lipid levels or both; whether the patient who understands the rationale for participation in a cardiac conditioning program has attended exercise classes and
134
whether his exercise tolerance has improved on objective treadmill testing; and whether blood pressure control is achieved by taking medications appropriately and regularly. Program evaluation must also concern itself with the cost/effectiveness ratio of this educational approach and with the availability of, or possibilities for training or retraining of, the professional personnel needed. Conclusion
The patient and his family are extremely important components of the health care team. They are the only individuals consistently in contact with the patient, they have the greatest and closest concern for his health care, and they are the ones who indeed appear to know most about him. Weed 1 has said, "The most powerfui of ali medical and paramedical personnel is the patient-highly motivated, not costing anything--even willing to pay-and there is one for every member of the population." Therefore, as an advance in effective delivery of preventive and therapeutic health services to coronary patients, educational programs must be designed to enable them to fulfill an optimal role as participants of the health care team. Address reprint requests to Nanette K. Wenger, MD, Grady Memorial Hospital, 69 Butler St SE, Atlanta, GA 30303.
REFERENCE 1. Weed LL: A Touchstone for Medical Education. Harvard Medical Alumni Bulletin, Nov-Dec, 1974, pp 13-18
BIBLIOGRAPHY Baden CA: Teaching the coronary patient and his family. Nurs Clin North Am 7:563-571, 1972 Griffith GC: Sexuality and the cardiac patient. Heart and Lung 2:70-73, 1973 Rosenberg SG: Patient education leads to better care for heart patients. HSMHA Health Rep 86:793-802, 1971 W enger NK, Mount ZF: An educational algorithm for myocardial infarction Cardiovasc Nurs 10:11, MayJun 1974 Woodwark GM, Gauthier MR: Hospital education program following myocardial infarction. Can Med Assac J 106:665-667, 1972
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Patient and Family Education After Myocardial Infarction Nanette K. Wenger To cite this article: Nanette K. Wenger (1975) Patient and Family Education After Myocardial Infarction, Postgraduate Medicine, 57:7, 129-134, DOI: 10.1080/00325481.1975.11714080 To link to this article: https://doi.org/10.1080/00325481.1975.11714080
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
Patient and Family Education After Myocardial lnfarction A program of public education is the ideal approach to prevention of coronary atherosclerotic heart disease, particularly efforts at coronary risk-factor modification. Recognition of early warning signs of heart attack should be taught so that they are promptly, appropriately heeded. The apparently healthy individual, however, has far less motivation to learn about prevention and management of disease than does the patient with clinical evidence of illness. Therefore, it is the primary physician's responsibility to institute a program of education for patient and family. The program should be designed to provide suffi.cient information about the disease and its management to enable patients to assume sorne responsibility for their own health care. Patients who understand their disease and its management have increased ability and motivation to cooperate in health care regimens. Motivation and opportunity for education tend to be optimal during the crisis episode-most often hospitalization for acute myocardial infarction (Ml). Incidentally, this is often the first identification of the illness to the patient. For this reason, an in-hospital educational program is often the cornerstone for all patient teaching efforts. Although the patient and family are most "vulnerable" to teaching efforts during hospitalization, physician-patient contact rarely averages more than 10 to 20 minutes per day. Thus, the educational programming responsibility best rests with other health care personnel with
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
Patient education must be an integral part of medical care. A defined core curriculum is necessary. The educational program on myocardial infarction can be started early in hospitalization, with repetition of information and no contradiction. The family must be included in the educational process. NANEnE K. WENGER, MD Emory University School of Medicine
Atlanta
whom patient and family are in contact during the remaining 23% hours. The Educational Program
The program outlined in this article is equally applicable to all patients with symptomatic coronary atherosclerotic heart disease, eg, anginal syndromes or more prolonged pain of myocardial ischemia. The concepts and much of the program material derive from the educational program which has been a part of the cardiac rehabilitation effort at Grady Memorial Hospital and Emory University School of Medicine since 1967. The short-term goals of the in-hospital educational program are to decrease
129
······················································································ ······················································································
Because patient and family education for a chronic disease must be a long-term process, the continuity of the educational program is important.
the feelings of helplessness, aid in restoring selfesteem, increase the patient's confidence in a successful outcome, and enhance his ability to cope. The educational program can offer the patient information thar will provide realistic reassurance of concerns regarding such factors as family role, sex, recreation, and job. The design of the program involves the compilation of a core curriculum specifying the information to be taught at each stage of the illness. The MI patient should be presented, at a minimum, the basic concepts of normal heart funcrion so he can understand how myocardial infarction alters them. Without this background information, he will have difficulty in understanding how obstruction of a coronary artery can cause the pain he experiences and how disturbances of cardiac rhythm and impaired pumping function can produce symptoms. An oftenheard criticism of earlier efforts of physicians at patient-family education was that authoritarian orders or directions were given, which the patient perceived were without apparent reason. An informational, explanatory approach was what the patients desired. Teaching Life-Style Modification
Since most intervention in management of coronary disease entails modification of !ife-style, the teaching emphasis should provide insight into those !ife-style factors that alter the risk of heart attack and into the value of change in !ife-style. Information should be provided about prescribed dietary alterations-changes in calories, fat, and sodium, if warranted, together with the
130
rationale for the dietary prescnpttOn and the objectives. This should be coupled with specifie inquiries about food preferences and eating habits so that a reasonable diet with enough familiar foods to encourage compliance can be constructed. Furthermore, the means of dietary adherence (eg, changes in food buying, guidetines for restaurant eating) should also be presented. Physical activity should be discussed, and reasons for initial restriction presented, including a reminder that these restrictions are temporary. The concept of a gradually progressive increase in physical activity and the benefits of a prescribed, individually tailored physical activity program after hospitalization, designed to enhance cardiac function, should be presented. The patient should be referred to an appropriate community program where he can implement these recommendations for physical activity. Cessation of smoking should be advised, the reasons for the recommendation outlined, and the patient referred to an appropriate antismoking program within the hospital or community. Risk-factor modification and control of associated disease (eg, diabetes, hypertension) should be emphasized, again relating this approach to what is known about coronary disease and providing detailed, specifie suggestions for implementation of recommendations. Ali medications the patient is to take should be carefully reviewed-name, purpose, dosage, expected response, and any adverse response or side effects which should be reported. ln ali the teaching efforts, the emphasis should be on prescription rather than proscription. The correct response to new or recurrent coronary symptoms subsequent to hospitalization should also be discussed, as the individual with MI is at increased risk for recurrent MI. Only if the appropriate response to chest painseeking immediate medical care-is taught can we hope to make inroads on the problem of prehospital sudden cardiac death. Scheduling and Timing
Because physical and mental readiness is necessary for learning, the scheduling and timing of this core curriculum are important. Early in
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
Photo: Jay Walter
the course of the illness, when fear, pain, and fatigue are signihcant components, only simple, brief information can be transmitted. In the coronary care unit (CCU), an explanation of the equipment and procedures is reassuring, decreases the likelihood that the patient will misinterpret staff actions or comments, and helps the patient to adjust to a life-threatening situation. During recovery the patient is ready to assimilate more detailed information. A positive staff attitude is of major importance in this phase, helping the patient to maintain his self-esteem while he makes reasonable, realistic plans for resuming or altering his life-style. W e have found that the core curriculum is best presented in a group setting, a format that provides for economy of the instructor's time and, equally important, gives the patient an opportunity to interact and share with a peer group confronting similar problems. Such an experience apparently reinforces learning. Similarly, we have noted lessened anxiety in a group educational setting, as a peer group with similar problems seems to facilitate adaptation to stress
Vol. 57
-
No. 7 * June 1975
-
POSTGRADUATE MEDICINE
and decrease frustration. In addition, the opportunity to function as a group member and help others is supportive of the patient's selfesteem. Classes or groups that combine inpatients and outpatients may make use of the reinforcing effect of the recovered patient, one who has returned to the mainstream of life. Individual patient-family insquction for particular details and problems must supplement the group presentations. Continuity of the Program
Because patient and family education for a chronic disease must be a long-term process, the continuity of the educational program is important. The format of progression of learning should be standardized, initially in the CCU and then during the remainder of the hospital stay. This should be correlated with the longterm care educational efforts in the physician's office, hospital clinic, or industrial medical facility. Although continuity of an educational program for the large patient population with coronary disease over a long period may appear as an insurmountable task, preplanning the pro-
························································································ ························································································
The needs of the patient are a major determinant of the effectiveness of an educational program; information must be designed to solve relevant problems. gram and entering patient educational data in the patient's record have proved to be great facilitators. A predefined content is important, as noted above, in the educational program for the coronary patient. A display method for this educational program should be provided in the patient record. It should detail the information presented to the patient at each stage of the illness, identify the teacher and the teacher's assessment of patient learning, and specify areas of information which apparently need repetition or reinforcement. The display document has proved most valuable for the varied health care personnel caring for and teaching the patient, in helping to eliminate any conBicting information being given to the patient, in helping to eliminate unnecessary repetition, and in assuring that the appropriate, necessary repetition and reinforcement are provided. Repetition and satisfaction reinforce learning. Therefore, throughout the educational process, the satisfaction derived from the achievement of both short- and long-term goals is an important cornpanent of the learning process. Equally important is the relatively intangible concept of staff attitude in transmitting the expectation that the combined efforts of health care team and patient will succeed. It is an attitude of realistic optimism that tells patient and family that the staff are concerned with them as individuals, that they respect them, and that they are conferring responsibility in the teaching.
132
The Physician's Rote
The physician's task in a program of patient and family education is to define the educational curriculum, specifying the information to be presented at each stage of the illness (in the ecu, during the remainder of hospitalization, after discharge from the hospital) and periodically reviewing the content to assure accuracy. Although hospital educational programs are often fairly highly structured, being conducted by various members of the health care team (their responsibilities are discussed below), an excellent educational program can be implemented, albeit in a less formai and structured manner, in the primary physician's office. The office nurse or other office staff and personnel should be involved in a program of patient education, the structure and content of which the physician has predefined. The physician's waiting room should be an educational facility. In many communities, pamphlets are available from the local hospital, based on their teaching program. The physician can simply, effectively design instructional booklets, and many prepared educational materials are available from volunteer health agencies (the American Heart Association is a major source for the coronary patient). Reinforcement by audiovisual techniques is extremely effective. Sorne physicians now have in the waiting room or another room in the office a library of tape cassettes for patient education. The single-concept module approach is used to delineate the physician's instructions or provide information to patients with a specifie problem. That is, the physician presents on a cassette a single concept of information, the basis for the recommendations, and the means of implementation of these. The patient may listen to the tape before discussion or consultation with the physician and may be instructed to re-review it during subsequent office visits. Thus, the physician prescribes education as part of the therapeutic regimen. The cassettes may be supplemented by tape-slide series; a signal on the tape cassette automatically triggers slide changes to correspond with the text and pro-
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
vide illustrative material. This approach has been found to be equally effective in industrial medical facilities.
··················································································· ···················································································
Role of Allied Health Care Personnel
A variety of health care personnel may implement the educational curriculum in the hospital setting. Nurses, dietitians, social workers, occupational and physical therapists, vocational rehabilitation counselors, and even hospital volunteers may be recruited to participate in the educational program. lt is important that ail individuals participating be familiar with the total program, the materials and methods, and the interrelationships of teaching and that the aforementioned communication format in the patient record be used to the fullest extent. Audiovisual presentations using such media as tapes, slides, or television can provide the necessary repetition in a more interesting form. Locally prepared audiovisual presentations and pamphlets are often far superior to the nationally marketed ones. Familiar persons (hospital health care personnel) are portrayed in familiar settings, and use of local language is possible. The patients portrayed can be prototypes of the population served. Ancillary Methods
Because the needs of the patient are a major determinant of the effectiveness of an educational program, the information must be designed to solve common, relevant problems. For example, group discussions might concern accomplishing prescribed dietary alterations on a limited income; access to and time and facilities for programs of physical activity; access to health care; payment for health care and medications; availability and interest of family for support; job problems with limited education, skills, and experience, now compounded by physical impairment; and community attitudes toward persons with heart disease. Patient self-tests often reinforce learning. We have found a take-home patient educational booklet to be valuable. lt contains a review of ali the educational material presented, but also includes questions that commonly arise on re-
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
.. The physician and the health care .. team must consider both the informational and the behavioral .. objectives in the evaluative stage .. of the educational program. turn home from the hospital. The patient is instructed to have his physician fill in the blanks regarding specifie home and community activities, eg, when he can resume sexual activity, when he can drive a car, when he can go to church, when he can grocery shop. Writing in this information reinforces its importance and accuracy, allows for individual variation in instructions, and permits supplementation by specifie, individual instruction of general information given in group classes or group discussions. Furthermore, these specifie patient-family instructions help to minimize the homecoming conflicts and frustrations deriving from vague or ambiguous directions and recommendations. Readiness for Learning
The necessity for both physical and mental readiness for learning deserves reemphasis, particularly in the setting of acute or relatively acute illness. Fear, pain, shock, anxiety, and depression ali decrease the ability to learn. Despite this, the positive attitude presented by a teaching program-the concept of learning for a living -often decreases the patient's anxiety and depression. Being instructed to begin an educational program designed to help care for the patient when he returns home is reassuring to the family of a patient in the ecu. Equally reassuring to the ecu patient is receiving even the most preliminary, simple information about activities designed to prepare him for his retuen home, during the stage of the illness when he still fears for his survival. Nevertheless, sim-
133
plicity and brevity of information are necessary early in the course of the illness to avoid fatiguing the patient. The information must be presented with the realization that repetition is generally necessary, because often the information is retained only transiently. Many patients are too anxious to hear what is said; sorne hear and rapidly forget. Objectives
Finally, differentiating between the content, or informational, objectives and the behavioral objectives is important for the entire educational program. New knowledge does not always resuit in the desired alteration of behavior. Information is satisfactorily transmitted to many patients; nevertheless, it does not always affect their behavior, ie, their adherence to recommendations. Effective learning requires participation. This is, perhaps, an advantage of group classes, in that patient participation in discussion may be an important component in the learning process-not only in learning content but also in beginning behavioral change. The physician and the health care team must consider both the informational and the behavioral objectives in the evaluative stage of the educational program. Effort must be made to determine if the content-the information-is being transmitted satisfactorily. This is easily ascertained either by a self-test for the patient or by direct questioning and evaluation of the responses by health care personnel. One must theo determine whether this new information changes behavior, that is, improves patient and family adherence to recommendations for continuing health care. ln the clinic, the physician's office, or the industrial facility, efforts must be directed toward determining whether the patient who understands the reasons for cessation of smoking has indeed quit; whether the patient who understands the need for weight reduction or alteration of dietary fat has undertaken these efforts, as measured by decrease in body weight or serum lipid levels or both; whether the patient who understands the rationale for participation in a cardiac conditioning program has attended exercise classes and
134
whether his exercise tolerance has improved on objective treadmill testing; and whether blood pressure control is achieved by taking medications appropriately and regularly. Program evaluation must also concern itself with the cost/effectiveness ratio of this educational approach and with the availability of, or possibilities for training or retraining of, the professional personnel needed. Conclusion
The patient and his family are extremely important components of the health care team. They are the only individuals consistently in contact with the patient, they have the greatest and closest concern for his health care, and they are the ones who indeed appear to know most about him. Weed 1 has said, "The most powerfui of ali medical and paramedical personnel is the patient-highly motivated, not costing anything--even willing to pay-and there is one for every member of the population." Therefore, as an advance in effective delivery of preventive and therapeutic health services to coronary patients, educational programs must be designed to enable them to fulfill an optimal role as participants of the health care team. Address reprint requests to Nanette K. Wenger, MD, Grady Memorial Hospital, 69 Butler St SE, Atlanta, GA 30303.
REFERENCE 1. Weed LL: A Touchstone for Medical Education. Harvard Medical Alumni Bulletin, Nov-Dec, 1974, pp 13-18
BIBLIOGRAPHY Baden CA: Teaching the coronary patient and his family. Nurs Clin North Am 7:563-571, 1972 Griffith GC: Sexuality and the cardiac patient. Heart and Lung 2:70-73, 1973 Rosenberg SG: Patient education leads to better care for heart patients. HSMHA Health Rep 86:793-802, 1971 W enger NK, Mount ZF: An educational algorithm for myocardial infarction Cardiovasc Nurs 10:11, MayJun 1974 Woodwark GM, Gauthier MR: Hospital education program following myocardial infarction. Can Med Assac J 106:665-667, 1972
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
