Introduction
Patient education is an integral part of every health care interaction. It is one of the most powerful tools that a health care provider can use to influence positive changes in health and wellness for patients. Whether the patient requires a diagnostic study, lifestyle changes, or a medication, the provider can offer the necessary education to the patient. Effective patient education provides patients with the information they need to make informed decisions regarding their health. Proper teaching must go beyond simple instructions, such as how to take a medication correctly. Patient education allows us to address disease prevention, safety, nutrition, and physical activity. It also serves to manage expectations for procedures or future visits. Perhaps most importantly, the process of patient education creates an environment that facilitates relationship-building, increases patient trust, and builds rapport between the patient and provider. Patients have an expectation that they will be fully informed about their health and treatment plans. The challenge then becomes how to teach effectively.
Barriers to patient education
If the process of educating patients were simple and straightforward, it is likely that the prevalence of some of the most common health problems, such as heart disease and type 2 diabetes, would decrease. Patients would take our simple instructions and implement them to improve their health. Nevertheless, many barriers can stand in the way of effective patient education and its ability to motivate patients to change. A variety of factors can adversely affect the communication between a physician assistant (PA) and her or his patient. Age, gender, socioeconomic status, ability to learn, provider skill, and a patient’s environment are just a few of the potential hurdles in the patient-provider interaction. In addition, simply arming patients with knowledge is not enough to create meaningful change. The provider must assess the patient’s motivation and ability to implement changes. This chapter is designed to help PAs understand some common reasons patient education fails to translate into positive health behavior change.
Barriers to patient education can be simplified into two categories: communication barriers and implementation barriers. An interaction with an elderly patient can illustrate both types of barriers. An older man with hearing loss may struggle to hear the provider but smile and nod anyway, indicating to the PA that he understands her message. Unfortunately, the patient will not be able to act on the PA’s advice because he never heard the advice. An implementation barrier exists when the patient hears and understands the instructions but faces obstacles that may prevent him from implementing these instructions. Common implementation barriers include the inability to afford recommended medications, lack of transportation to and from appointments, or the lack of vision or dexterity needed to carry out treatment recommendations. In most patient interactions, both communication and implementation barriers are present. They must be managed through negotiations between the patient and the provider. To successfully overcome these problems, a deeper understanding of these barriers is essential.
Patient barriers
Most patients want to avoid the discomfort and costs associated with chronic disease, yet providers struggle to get patients to follow their advice on how to prevent or effectively manage these disorders. Motivation is a determining factor in the successful implementation of patient education and a health care plan. Some patients receive the teaching that is provided and implement it successfully; however, many do not. It is common for providers to seek innovative ways to inspire and motivate patients. In the past, fear tactics were used as the primary tool to motivate patients. Fear works for some people, but for many, it isn’t enough to inspire action. Fear can lead patients to develop attitudes of denial, avoidance, or hopelessness, none of which help them move forward.
Motivation is an intrinsic quality that is difficult to influence. The Stages of Change model developed by Feldman allows the provider to assess where the patient is in his or her willingness to implement a change in behavior. PAs can use this tool to identify which patients are ready and motivated to make a change, and which patients need more information and encouragement. Feldman’s six Stages of Change are: precontemplation, contemplation, preparation, action, maintenance, and relapse. These stages can be applied in any situation during which a provider is asking a patient to make a behavioral change. Smoking cessation counseling is used as an example here.
A patient in the precontemplation stage is aware that smoking is bad for him or her but will either dismiss the concern or deny it. This patient might resist change by using an example of someone he or she knows who smoked his or her whole life and never became unwell. This patient is not motivated or willing to make a change yet.
In the contemplation stage , the patient is more aware of the problem, may begin to articulate a desire to quit smoking, and understands some of the benefits of doing so. This patient will weigh the desire to change against the perceived benefits of continuing to smoke. A patient in the contemplation stage might make a few attempts at change, but these efforts are often inconsistent and short-lived.
During the preparation stage , the patient is ready to commit to making a change. In this stage, the patient who smokes is willing to set a quit date. The patient has not yet implemented any changes but exhibits a willingness to do so. Patients in this stage are usually open to help from their PA.
Patients in the action stage are actively engaged in executing behavioral change. The patient has reached his or her pre-established quit date and is using a provider-recommended plan of action to avoid smoking. This stage requires daily effort to maintain the change. The PA can be a significant encouragement to patients in this stage.
When the patient reaches the maintenance stage , the implemented behavioral change has become a habit. The patient may not need to use daily strategies to feel like he or she is able to maintain a smoke-free life. During this stage, the change begins to feel more integrated into normal life. The final stage is relapse, which is exactly as it sounds. This is when the patient begins to smoke again after a period of success. Not all patients will relapse. Feldman’s model, however, encourages both patients and providers to anticipate and plan for what will happen if relapse occurs.
PAs who take the time to assess where a patient is in terms of willingness to change can tailor the message to the patient in a way that encourages him or her to move toward the action and maintenance stages. For example, if a patient is solidly in the precontemplation stage, the provider should not see the task as impossible and avoid a conversation with the patient about smoking cessation. It would also be premature for the provider to attempt to engage the patient in a plan of action for smoking cessation because the patient is not yet ready for this step. Instead, the PA should engage the patient in a conversation targeted at moving the patient from the precontemplation stage to the contemplation stage. The provider should use the time to understand the patient’s concerns and correct any misperceptions the patient might have. The provider should always encourage the patient to let the provider know when he or she might want to talk about making a change. Similar provider strategies exist for each stage, which are designed to increase and encourage patient readiness for change ( Table 16.1 ).
| Stage of Change | Patient Characteristics | Provider Strategies |
|---|---|---|
| Precontemplation |
|
|
| Contemplation |
|
|
| Preparation and determination |
|
|
| Action |
|
|
| Maintenance |
|
|
Patients give many reasons for their previous failed attempts to change behavior or their current unwillingness to attempt change. Common reasons include lack of time, lack of family support, level of difficulty, cost, time of high stress, and lack of resources. If two similar patients want to start an exercise program, both of whom are in the preparation stage but have similar barriers such as stressful jobs, lack of time, and no gym access, why is one successful and the other unsuccessful? Patients have belief systems that influence their faith in their ability to overcome obstacles. These barrier-beliefs create rationalizations and excuses that undermine a patient’s ability to succeed. Ultimately, if these rationalizations and excuses are not managed by the health care provider and the patient together, the patient will give up on change. Barrier beliefs are created by the patient’s past experiences and perceptions and can be divided into three distinct categories: attributions, self-efficacy, and negative outcome expectations. For a provider to successfully encourage patients to adhere to treatment plans, these three elements should be considered.
Attributions are the reasons a patient uses to explain lack of success in implementing a change or a strategy. It is human nature to ascribe meaning and reasoning to an undesirable behavior or outcome. These attributions can be factual, interpreted, or even implausible. For example, if a patient is asked to take a medication for hypertension every day, he or she may use the following attributions to explain why he or she is unable to do so. Factual: “I cannot afford the medication.” Interpreted: “Taking medication every day will be too many chemicals for my body to handle.” Implausible (or misinformed): “Lowering my blood pressure will make my heart have to work harder to get blood to my feet, so it will wear out my heart if I take this medication.” The type of attribution deployed by the patient will direct the PA’s response.
Self-efficacy is the patient’s belief that he or she is capable of completing an action or meeting a goal. Self-efficacy is often the decisive factor in determining success or failure. If one patient believes he or she can exercise on a regular basis, then that patient will overcome a busy schedule and lack of gym membership. If the patient does not believe he or she is capable of exercising on a regular basis, however, the barriers will prevent the patient from achieving his or her goal. Many factors influence a person’s self-efficacy: previous failures or successes, other people’s failures or successes, other people’s opinions regarding their ability to succeed, low self-esteem, and knowledge about the steps needed to achieve the goal.
Negative outcome experiences are beliefs that implementing change will precipitate an undesirable outcome. These outcomes could be social, physical, or monetary. For example, dieters may have one of the following reasons for not dieting. Social: “My family won’t eat the healthy food I make, and it is important that we eat the same foods.” Physical: “I feel tired in the afternoons when I eat healthy so I have to eat more.” Monetary: “Healthy food is really expensive, and the food spoils so quickly. I can’t afford to do this.”
Health care providers must consider all these dynamics when counseling their patients. If the provider does not account for a patient’s willingness to change and the patient’s belief in his or her ability to make a change, the provider cannot tailor the message to the patient to give the greatest opportunity for long-term success. Without tailored education, the patient is less likely to succeed ( Fig. 16.1 ).
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