1.7 The Teaching-Learning Process

This section applies the teaching-learning process to content previously discussed in this chapter. The teaching/learning process follows the same steps of the nursing process, including Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation, but in the following manner:

• Assessment: Data is collected about the client, including strengths and barriers to learning.

• Diagnosis: Learning need(s) are identified collaboratively by the nurse and the client. Educational nursing diagnoses are established, such as “Readiness for Enhanced Learning.”

• Outcome Identification: Nursing goals and expected outcomes are identified. Goals are broad, general statements. “SMART” outcome criteria are established as learning objectives, with SMART standing for Specific, Measurable, Achievable, Realistic, and within a specific Time frame. Client-focused goals that are responsive to nursing interventions will provide a basis for evaluation later in this process.

• Planning: A teaching plan is created by an RN that establishes content to be taught and teaching methods based on the three domains of learning (cognitive, affective, and psychomotor), along with materials to be used based on the individual client’s needs.

• Implementation: Implementation refers to actually teaching the client and providing reinforcement as needed.

• Evaluation: Data is gathered and analyzed to determine if the client acquired the knowledge, skills, and information they needed based on the outcome criteria that were set. This is often accomplished by having the client teach back the information they are learning or completing a return demonstration of a skill they are learning. The teaching plan is modified through adjustments in goals or materials taught if teaching goals are not met or partially met. The teaching plan is modified if the client does not meet the outcome criteria in the time frames specified.

A comparison of the nursing process and the teaching process is provided in Table 1.7a.

Table 1.7a Comparison of the Nursing Process and the Teaching Process

Each step of the teaching-learning process is further described in the following subsections.

Learner Assessment

During the learner assessment, the nurse assesses the following data:

• Is the client ready to learn? In what stage of change theory is the learner (i.e., precontemplation, contemplation, preparation, action, or maintenance)?
• What is the client’s motivation for learning?
• What is the client’s knowledge level? What topics do they desire to learn more about?
• What are the client’s strengths for learning?
• What barriers or challenges are present and how can they be addressed?
• What is the client’s preferred learning style?
• What cultural considerations should be incorporated?
• Is the environment appropriate for learning?

Sample questions for the nurse to ask the client (and for the nurse to consider) during the learner assessment are as follows:

• Health status: What is your current health condition or diagnosis? How long have you had this condition? Have you received any previous education regarding this condition? Are you currently tired or in pain? Do you have any concerns about hearing, vision, ambulation, or fine motor skills?
• Learning needs and goals: What do you already know about your condition and how to manage your condition? Are you interested in learning more about this health condition? Are there any specific skills you would like to learn more about during this teaching session? What are your goals in managing this health care condition? (Consider: Does the client appear motivated to learn?)
• Financial: Do you have access to health insurance? Do you have financial concerns about your medical care, such as obtaining your medications, purchasing foods to support your diet, accessing health care, etc.? Do you have access to transportation? What form of transportation do you have? Is your transportation reliable?
• Learning style: How do you learn best? Do you like visual aids, computer technology, hands-on demonstrations, or written handouts? Do you like to learn in groups or individually? What is the highest level of education you completed? (Consider: How old is the client and what is their developmental level?)
• Health literacy: How comfortable are you with medical terminology and understanding health care information? In your own words, what is your health condition and how is it treated? It is common for clients not to have a good understanding of their health condition or treatment, so if this is a concern for you, please let me know. (Consider: What are the client’s written and verbal language skills? Does the client prefer written or spoken information? Is an interpreter needed?)
• Social support: Is there anyone you would like to be with you at this teaching session? Do you have family, friends, or church or social groups that support you?
• Lifestyle, culture, and habits: What is your daily health routine? What cultural or religious practices are incorporated in your health routine? Do you prefer to have a member of the same sex doing the teaching, if possible? What is your occupation? What is your level of education (i.e., junior high school, high school, college)? Are you currently using any holistic remedies such as herbs to assist with your health condition? Some open-ended cultural assessment questions include the following:
  • Who is considered family for you?
  • What beliefs, values, and cultural practices surround major life events in your family or culture?
  • In what language are you most comfortable speaking and reading?
• Barriers to learning: Do you have any physical, sensory, or cognitive concerns to learning today? What challenges have you had with your health treatment plan? (Consider: Are there visitors in the room? Are cell phone notifications off during the teaching session? Is a language interpreter needed? Is the client anxious regarding a new diagnosis and treatment plan?)
• Strengths to learning: Do you feel like you have support from family or friends?
• Medication plan: What medications are you taking and what is the purpose of each? What medications do you have questions about? Do you use a pill reminder, pill organizer, or do family members assist?
• Self-care: How confident are you in managing this health care condition? What self-care practices do you currently use for this condition?
• Follow-up and reinforcement: How often would you like a follow-up session? Would you like another in-person, phone call, or telehealth visit to review these concepts?

The answers to these questions will help the nurse formulate an individualized teaching plan. Before implementing the teaching plan, the environment must also be assessed for barriers that can impact learning. For example, the nurse must consider the following factors:

• Is the room well-lit?
• Is there comfortable seating?
• Is the temperature acceptable?
• Are there supplies and/or teaching tools like handouts and visual aids available?
• Is an individual or a group of clients being taught? Are family members or other support persons available to participate in the teaching if requested by the client?

Diagnosis

After performing an assessment that includes a learner assessment, the nurse selects appropriate nursing diagnoses from a current care-planning resource based on the client’s specific needs.​ Nursing diagnoses for teaching plans are a little different from nursing diagnoses for care plans. Most nursing diagnoses for teaching plans will begin with “Readiness for enhanced…” or “Deficient knowledge…” as these diagnoses reflect the need for teaching from a motivational or lack of understanding standpoint. However, these are not the only types of nursing diagnoses applicable to a teaching plan.

See Table 1.7b for common examples of NANDA nursing diagnoses related to health teaching.

Table 1.7b NANDA Nursing Diagnoses Related to Health Teaching^[1]

Knowledge deficit can also be used as a related factor of a nursing diagnosis, for example, “Ineffective health maintenance behaviors related to deficient knowledge.”

Outcome Identification

During the outcome identification step of the teaching-learning process, the nurse applies Bloom’s Taxonomy and develops SMART outcomes. The teaching plan should include expected outcomes from the cognitive, affective, and psychomotor domains.

Cognitive Domain

The cognitive domain includes expected outcomes related to the knowledge part of learning. An example of a SMART outcome for this domain would be the following:

• The client will accurately list three signs of hypoglycemia to the nurse by the end of the teaching session. 

Affective Domain

The affective domain includes expected outcomes related to thoughts and feelings related to the teaching topic(s). An example of a SMART outcome for this domain would be the following:

• The client will express two emotions related to the new diagnosis of diabetes to the nurse by the end of the teaching session.

Psychomotor Domain

The psychomotor domain includes expected outcomes related to a skill that requires both mental and motor activity. An example of a SMART outcome for this domain would be the following:

• The client will demonstrate with 100% accuracy how to use a glucometer to measure their blood glucose before discharge from the hospital.

Planning

Registered nurses create individualized teaching plans based on the client assessment. The teaching plan includes the following:​

• Expected outcomes/learning objectives based on the three domains of learning
• Teaching content
• Related teaching tools such as handouts, videos, and websites
• Recommendations for significant other/family/caregiver involvement​

Implementation

During implementation, the standards, theories, and principles of teaching previously discussed in this chapter should be applied.​ An active learning environment should be established to maximize learner participation. Teaching materials and teaching methods should be used to encourage client participation and understanding. A trusting relationship should be created with the client, and efforts to learn should be reinforced. A variety of teaching methods and teaching tools should be implemented to address multiple intelligences and learning styles. Finally, questions should be asked frequently throughout the session to verify learner understanding of content.

Evaluation

Health teaching is not complete until the previously established outcomes are evaluated and documented.​ Were outcomes met, partially met, or not met? What teaching needs to be readdressed, and are modifications to the teaching plan required? Was the nursing diagnosis of deficient knowledge correct? Was the learner ready to learn? Were the teaching methods appropriate for the learner’s style?