“There is nothing so powerful as an idea whose time has come.”
Teaching patients. Two words guaranteed to evoke a yawn in any audience of health professionals. For physicians, there is little or no reimbursement for the time spent educating patients. If you compare the reimbursement rate for 60 minutes of educating a patient about the meaning of a new diagnosis of acute coronary syndrome versus 60 minutes performing an angioplasty and stent insertion on that same patient, you will quickly see why any session in a medical meeting entitled “patient education” plays to an empty room, but a session on new stents is standing-room only.
Nurses, who have traditionally been identified as the professionals most interested and adept at educating patients, experience a different set of imperatives. Hospitalization provides an important window of opportunity for patients to learn about their illness and its meaning for their future, and nurses are charged with educating patients about their disease, medications, procedures, and required lifestyle changes. Unfortunately, as lengths of stay in the hospital have decreased, the turnover both within intensive care units and in general units has increased significantly. Nurses usually have little time to assess each patient’s unique discharge needs or to meet the patient’s family members who will be charged with providing the physical care and emotional support following hospitalization, much less to provide that individualized education. Quickly the bed is empty and a new patient is admitted.
Most nurses have seen (and perhaps participated in) “wheelchair-discharge teaching.” Here is an only slightly fictionalized account of a case we observed recently. A 72-year-old surgical patient spent 24 hours in the surgical intensive care unit and was discharged to the intermediate care unit as soon as she was successfully extubated. She was told on morning rounds of the third postoperative day that she could go home. The nurse heard about the anticipated discharge 1 hour later when the desk clerk identified a family member walking down the corridor to the patient’s room. A volunteer arrived soon thereafter with a wheelchair, and the nurse found himself reviewing all the discharge medications (a bag of 8 different vials), along with wound care instructions and recommendations for physical activity, as the patient sat by the nurses’ station in the wheelchair, with the family member standing by. The patient had an appointment to return to the surgical clinic in 1 week, but seemed very confused about what to do in the interim. The family member, a son who lived 50 miles away from the patient, was trying to get time off of work to stay with his mother, but was not sure how long he would be able to assist. This case exemplifies the challenges that persist for nurses who are caring for patients in a fast-track system of care where discharge comes early in the hospital course and unexpectedly, and family members are minimally prepared to assume the responsibilities of care.
The Changing Faces of Patients
Education of patients has always been important—in reducing anxiety and uncertainty, maximizing adherence, and providing a context for self-care. However, 2 forces make education of patients in the hospital more important than ever: the rapid aging of our population and the increase in chronic diseases.
The statistics are compelling. Today, 1 out of every 10 persons in the world is aged 60 years or older. By 2050, it will be 1 out of 5 (an achievement we’ve already reached in the United States). By 2150, it will be 1 out of 3 in the world. The people that gerontologists call “the oldest old” (>80 years) is the fastest growing segment of the population in all high-income nations. They currently make up 11% of the 60+ age group in the world and will grow to 19% by 2050. The number of centenarians (≥100 years) is projected to increase 15-fold in the world from approximately 145000 in 1999 to 2.2 million by 2050.11
The aging of the population has occurred because of advances in healthcare, with an attendant decrease in mortality, combined with decreasing birthrates in many countries. The growth in numbers of older people in society is expected to accelerate even more in the next several decades because of the large cohorts from the US baby boom after the Second World War that will turn 65. With increasing life expectancy, this large population will join the “oldest old” in unprecedented numbers. Although this is good news for all of us, because it means that our anticipated survival is increasing along with everyone else’s, it means that the patients in our hospitals are more likely to be elderly, and many will be in the category of the oldest old.
Combined with the aging of the world’s population, we are seeing a dramatic increase in chronic diseases. In 2005, all chronic diseases accounted for 72% of the total global burden of disease in the population aged 30 years and older. The cause of death has changed drastically in many countries from infectious to chronic disease. In fact, in 2005 injuries accounted for less than 10% of all deaths, and communicable, maternal, and perinatal causes explained another 30% of global deaths. The remaining 60% of the deaths worldwide were attributed to chronic illnesses, with heart disease being the No. 1 killer.22
Most chronic diseases do not result in sudden death. Rather, they are likely to cause people to become progressively ill and debilitated. Once diagnosed, the goal of care is to delay the onset of signs and symptoms and promote longer, healthier lives. This goal is achievable, but the key is education of patients. In fact, without education of patients, the goal of optimizing survival and minimizing signs and symptoms will never be achieved.
Patients with chronic illness play an important role in managing their own conditions on a day-to-day basis. They must understand their disease and various pharmacological and nonpharmacological treatments. They must be able to anticipate the progression of the disease and be able to sort through various signs and symptoms to know which ones can be ignored and which ones require prompt attention and treatment. Often, patients must adjust their own behavior related to diet, activity, and risk factors to maximize their health. They are called upon to deal with complex situations and determine which is the best course given the constraints of their disease. None of this is easy, and all of it requires large and repeated doses of education and counseling, the basis for all disease management programs. The education and counseling must start in the intensive care unit and continue through outpatient care.
What Do Patients Want?
Patients definitely want more than wheelchair-discharge teaching. When asked, patients want explicit explanations about what they can expect while in the hospital and once they return home. For example, patients with left ventricular dysfunction have the highest risk of sudden death in the first month following an acute myocardial infarction.33 Family members therefore are eager for information about what to do in case of an emergency at home, a topic that is rarely covered in the hospital.44
Another important message from research on patients’ education is that patients and their families have very different needs and want something more than “canned” education. Issues that are highly salient for some have no relevance for others.55,66 Nurses need the time to explore with patients their particular concerns and then provide the information in a way that is meaningful.
Nurses in the United States, in particular, are often challenged by the huge influx of clients of various cultures into virtually all healthcare systems and the dearth of educational materials written at appropriate readability levels and/or in languages other than English. A wonderful example of these dilemmas is provided by the Hmong population who arrived in the United States in the 1970s from Laos. The collision of their culture with that of Western medicine is poignantly described by Fadiman77 as she chronicles the lack of communication between the parents and the physicians and nurses who cared for a young girl who was born with severe epilepsy. Ultimately the lack of communication and effective “patient education” led to tragedy. Every physician and nurse will relate to the frustration of the caregivers in the very challenging care of this Hmong child.
The problems of scarcity of time and cultural differences that are difficult to bridge are major impediments to providing optimal care in today’s healthcare system. Nurses and physicians are highly motivated to educate and counsel patients. Many have chosen their careers primarily because of these teaching opportunities. Yet, the problems of scarcity of time and cultural differences that are difficult to bridge are major ones. The lack of reimbursement (“what isn’t reimbursed, isn’t valued”) is a major stumbling block in many healthcare settings and should be addressed in every forum. As the population ages and chronic disease increasingly becomes the focus of hospitalization, we must solve the problems that have haunted patients’ education for decades. Many patients know what information they need. Many nurses and physicians are eager to give them that information.
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The statements and opinions contained in this editorial are solely those of the Editors.