15Effective teaching is unquestionably essential to the provision of safe home infusion therapy. Patient education is one of the four aspects of care that impact patient outcomes as described in the Gorski Model for Safe Home Infusion Therapy (Chapter 1). Experienced nurses who are new to home care often enter the world of home infusion therapy confident in their own ability to administer intravenous (IV) medications and care for vascular access devices (VADs). Quickly, it becomes apparent that technical skills in infusion therapy procedures are important, but equally important is the nurse’s skill in educating the patient to perform those same infusion procedures. In the majority of cases, home infusion therapy procedures are taught to and performed by patients and/or their caregivers. For example, most patients will learn to infuse their own IV antibiotics and parenteral nutrition (PN). It is important to recognize that when patients are not effectively taught, the risk for complications such as infection or adverse drug reactions is increased.
In the context of patient education, home care nurses must always assess the appropriateness of the skill being taught. Home care clinicians become very comfortable teaching patients and caregivers skills normally performed by nurses in any other health care setting. There is not a specific listing of every home infusion procedure amenable to teaching. Sometimes, issues such as insurance coverage or geographic location (e.g., rural extremes) drive decisions and push for a high level of patient participation. However, nurses must always exercise professional judgment and critical thinking skills, weigh the risks versus the benefits, and act as a patient advocate when teaching home infusion skills. For real-life situations, consider the following:
16■ Is it in the patient’s best interest to have him or her discontinue and remove the port needle after a chemotherapy infusion? Is this a simple task or does it require assessment of response to the infusion therapy, of the port site, and for potential therapy/VAD-related complications?
■ Is it appropriate for a patient or a caregiver to perform site care on a peripherally inserted central catheter (PICC) and change the stabilization device? What is the risk for PICC dislodgement? Is the patient/caregiver capable of adhering to aseptic technique with this more complex procedure?
■ Is it appropriate to change administration methods (e.g., elastomeric device to gravity) without a home visit, even if the patient was independent with the previous method? What are the implications should the infusion run in too fast?
When effective teaching strategies are used with each home visit, home care is more cost-effective because fewer home visits are needed to achieve patient independence in infusion care. Most commercial insurers authorize a limited number of home visits at the start of care to teach home infusion therapy. Each visit must be used judiciously to teach patients. Some patients may require an additional visit(s) to learn infusion procedures. The home care nurse must be prepared to clearly articulate progress in patient education and describe clear rationale outlining the need for additional visits, particularly when requesting coverage or authorization of additional visits from the patient’s insurer.
After reading this chapter, the reader will be able to:
■ Identify factors that affect the patient’s readiness to learn
■ Develop a plan for patient education
■ Employ effective teaching strategies
■ Evaluate the effectiveness of the teaching plan
17ASSESSMENT: READINESS TO LEARN
Teaching infusion therapy requires that the patient learn multistep procedures, concepts such as aseptic technique, some math skills such as counting drops or reading an infusion pump, and understanding relationships such as the importance of hand hygiene in reducing infection risk. The patient’s or caregiver’s readiness and ability to learn home infusion therapy are influenced by a number of factors such as current stressors, sensory deficits, and functional abilities. Past experiences with health care may positively or negatively shape attitudes toward learning. Additional factors that impact the teaching–learning process include age, developmental and cognitive level, culture and language, and health literacy (Gorski et al., 2016, p. S25). Some areas to guide assessment include:
■ Presence of stresses that affect readiness/ability to learn such as:
Fear and anxiety over learning home infusion therapy
Coping with a new medical diagnosis and treatment and implications such as inability to eat normally and dependence on PN
Pain or weakness/fatigue from a stressful hospitalization/surgery
■ Sensory deficits that impact ability; for older adults, sensory decline is a natural occurrence of the aging process.
A loss of elasticity in the lens of the eye results in visual changes including delayed recovery from glare, decreased ability to adapt to light, decrease in color discrimination, and difficulty in seeing small print, especially under poor lighting conditions. Furthermore, there is an increased incidence of eye diseases including glaucoma/cataracts and macular degeneration (Cacchione, 2005).
Age-associated changes in hearing include decreased ability to hear high-frequency sounds (e.g., alarms on an infusion pump), less ability to hear in the context of background noise, and difficulty hearing high-pitched sounds such as s, z, sh, and ch (Cacchione, 2005).
■ Functional limitations such as issues with coordination, dexterity, and steadiness of hand/fingers that would affect the ability to perform infusion procedures
■ Past experiences that impact learning home infusion therapy such as:
Positive experience: The patient with diabetes who has self-administered insulin may be less anxious about learning home infusion due to comfort with syringes.
18Negative experience: The patient who was recently hospitalized with a catheter-related bloodstream infection (CR-BSI). The caregiver who administered the PN is now afraid to perform newly prescribed home IV antibiotic infusions because he or she believes he or she caused the infection.
■ Developmental and/or age-related considerations, for example:
Middle-aged adults may have many work and family obligations that affect timing of medication doses.
Pediatric implications: For infants, toddlers, and young children, teaching will be aimed primarily at the parent, while older children and teenagers will likely want to participate in their infusion administration.
Presence of memory or cognitive issues that may make teaching more challenging or could preclude the ability to learn procedures. If present, is there a willing/available caregiver and if not, is it possible/realistic for the home care nurse to administer all infusions? Normal changes in cognition associated with aging include reduced processing speed, tendency to be distracted, and reduced capacity to process and remember new information at the same time (U.S. Department of Health and Human Services, n.d.-a).
Culturally pertinent implications related to learning such as religious preferences, involvement of family/caregiver in care, attitudes toward medications and health care practices, and need for language interpretation services.
■ Health literacy:
Health literacy refers to the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (U.S. Department of Health and Human Services, n.d.-b).
Fast Facts in a Nutshell
Health literacy includes basic ability to read, knowledge of health topics, and number skills. The American Nurses Association’s (ANA) Professional Performance Standard on Communication addresses the importance of assessing language and literacy needs of patients in learning how to best communicate (ANA, 2014, p. 67).
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