Teaching Essential Skills to Family Caregivers

Nurses can use teachable moments to help the transition

from hospital to home care.

Editors note: This is part two of a three-part series, Supporting Family Caregivers, in collaboration with the AARP Foundation and funded by the Jacob and Valeria Langeloth Foundation. The series is part of an initiative, Professional Partners
Supporting Diverse Family Caregivers Across Settings, and builds on the work addressed in AJNs September 2008 State
of the Science report, Professional Partners Supporting Family Caregivers (available at http://bit.ly/o9GZOD). Each article in the series has an accompanying video; the second video can be accessed at http://links.lww.com/AJN/A26.

The single biggest problem in

communication is the illusion
that it has occurred.
George Bernard Shaw

ose Johns, 81, is admitted

to the cardiac floor with
an acute exacerbation of
congestive heart failure. Her ability to perform self-care is limited,
and during her baseline assessment she displays mild cognitive
impairment, expressed primarily
as short-term memory impairment.
Her husband of 60 years, Robert,
will be assisting her when shes
dischargeduntil she gets back
on her feet, he says. The nurse is
at the bedside administering her
morning medications. (This is not
a real case; its a composite based
on the authors experience.)
Mr. and Mrs. Johns, says
the nurse, I have the medications Mrs. Johns will be taking
at home. Mr. Johns, youre going to be giving your wife her
daily pills at home, is that right?
Mr. Johns says yes. This is one
of her heart medications that she
needs to take every day, the nurse
continues. Most people prefer
to take it in the morning because
it makes them go to the bathroom
for a good part of the morning. If
she takes it early, it wont keep
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her up at night. Its called Lasix

or furosemide.
Mr. Johns says, Oh, I dont
know which one that is, but she
doesnt like taking the ones that
make her have to go to the bathroom. So on days were going out,
she generally doesnt take those
pills.
NONCOMPLIANT OR ILL INFORMED?

The preceding scenario reveals

that Mr. and Ms. Johns have deficits in whats known as health
literacydefined by the Health
Resources and Services Administration (HRSA) as the degree to
which individuals have the capacity to obtain, process, and understand basic health information
needed to make appropriate health
decisions and services needed to
prevent or treat illnessin this
case as it relates to understanding
the purposes and importance of
her medications. (Go to http://1.
usa.gov/a3xzIQ for more from
HRSA on health literacy.) Its
highly likely that at several points
in Ms. Johnss encounters with
health care professionals, her
medication list was reviewed and
confirmed. Its just as likely that
during her hospital stay no one explored with her and her husband
how the adverse effects related to

the use of diuretics might affect

the quality of her life. Even if the
option of taking her pills at alternative times had been discussed,
it may not have been done at the
couples level of understanding.
Are the Johnses noncompliant,
or do they merely lack the knowledge necessary to relate cause and
effect?
Discovering this deficit at this
point in the course of Ms. Johnss
hospitalization enables the nurse
to relay the information to the rest
of the patients health care team,
including the pharmacist and physician, with the goals of developing
a plan that incorporates the patient
and caregiver into the decisionmaking process and, ultimately, improving outcomes in the patient.
THE CRUCIAL ROLE OF THE CAREGIVER

Informal (unpaid) caregivers provide the majority of assistance frail

older people receive. (See the first
article in this series, The Hospital Nurses Assessment of Family
Caregiver Needs, October.) According to a report from the National Alliance for Caregiving, in
collaboration with AARP, nearly
one-third of American households
report that at least one person has
provided unpaid assistance to an
older adult family member or loved
ajnonline.com

Photo by Ed Eckstein.

By Cynthia J. Nigolian, MSN, GCNS-BC, and

Karin L. Miller, MSW, LICSW

one. The burden on these caregivers grows dramatically when their

loved ones are hospitalized. Family caregivers can provide vital information to the health care team
and emotional and practical support to the hospitalized patient. In
turn, hospitalization is an opportunity for the team to provide intensive education, addressing the
needs of the older adult and preparing both the patient and the
caregiver for a safe discharge.
Outcomes are better when hospital staff find time to collaborate
with caregivers on discharge planning. Caregivers report that they
feel more in control when they have
adequate information and less
stressed when they believe theyre
adequately prepared to manage
2, 3
care at home. This is important
because a caregivers lack of confidence contributes to an increased
risk of error as well as readmis4-9
sion. The more a person knows
about a role before performing it,
the better she or he does. Just as
patients tend to be more satisfied
and adhere to treatment when
they take greater roles in health
ajn@wolterskluwer.com

10
care decision making, so families involved in discharge planning have a better understanding
of the meaning and importance
11
of continuity of care.
But how is this accomplished?
Its our contention that patient education is a basic component of
disease and symptom management
and should begin at admission and
extend throughout the hospital
stay. In this second article in the
Supporting Family Caregivers series, we focus on incorporating
proven principles of adult learning into daily practice interactions
as a vital role of the bedside nurse
in supporting and educating the
family caregiver.

THE ROLE OF THE NURSE IN

PATIENT EDUCATION

The National Center for Ethics in

Health Care has stated that communicating effectively is an important aspect of showing respect
12
to patients. Certainly that notion applies to the caregiver as
well. As with involving the patient and caregiver in planning,
effective communication is linked

to greater satisfaction with care

11, 13
and improved adherence. Providing the patient and family with
the information they need to actively participate in promoting the
patients health and healthful behaviors has long been one of the
primary roles of the nurse, and
the value of patient education by
nurses is supported by decades of
4, 14, 15
As early as 1918
research.
the National League of Nursing
Education released its Standard
Curriculum for Schools of Nurs
ing, which articulated the need
to prepare nurses for the task of
teaching the public and called on
nurses to arouse strong incentives
as a means of forming good hy16
gienic habits. This critical aspect
of health care is woven into the fabric of Healthy People 2020 from
the U.S. Department of Health
and Human Services, which focuses on changing health behavior
and advocates patient and consumer education as a key inter6, 15
ventional strategy. Tied firmly
to this is the need for effective discharge planning.
An argument could be made
that any member of the health care
team, including the physical therapist, the respiratory therapist, the
pharmacist, the social worker, the
care coordinator, the certified diabetes or cardiac educator, the transitions coach, or the physician,
could take the lead in teaching
the plan of care that the team has
devised for the medically complex
older adult. Indeed, each member
of such an interdisciplinary team
provides crucial elements in the
in-depth assessment of patient
and caregiver needs and communicates related findings and instruc4, 7, 9, 10, 15, 17
However, its the
tions.
nurse who features most directly
and consistently in the patientcentered relationship. Also, its the
role and responsibility of the nurse
to coordinate communication
among the different practitioners
and pull together the plan for discharge needs. The bedside nurse,
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53

therefore, remains the gatekeeper

charged with educating the patient and family caregiver and
15
preparing them for discharge.
MEETING CHALLENGES

Barriers to complete assessment

and communication are plentiful in the health care environment. To communicate effectively,
its important for all health care
providersand perhaps nurses
in particular, given their importance in this areato be acutely
aware of the challenges and to be
prepared when they arise.
Cultural differences. Differences can be found in beliefs about
social interaction, communication
styles, and views on health and
healing, as well as end-of-life issues. The patients cultural practices must be taken into account
to provide successful discharge
11, 18
Acknowledging the
teaching.
importance of ethnicity or culture
and asking the patient or caregiver to provide this information
both help when planning for dis18, 19
charge.
All staff should be mindful of a
familys level of acculturation, the
extent to which various members
have adapted to what one might
consider the prevailing or mainstream culture. There can be discrepancies between a patients or
caregivers traditional cultural values and her or his actual practice
or behavior once an elderly loved
20
one becomes ill. Even caregivers

whove grown up in this country

can experience conflicts between
their own upbringing and more
modern values and may struggle
in their efforts to be the conduit
for communication between hospital staff and the patient.
According to a draft of a report
on research conducted by Lake
Research Partners for the AARP
Public Policy Institute, African
American patients and caregivers
believe they arent given adequate
hospital teaching, especially concerning the physically demanding
aspects of caregiving, such as bathing, transferring, and dressing, and
want more hands-on training; Latinos report that the teaching they
receive at discharge is confusing
and overwhelming (permission to
cite the report granted by Michael
Perry of Lake Research Partners,
September 14, 2011). In a survey
study of racial and ethnic differences in patients perceptions of
bias and cultural competence in
health care, Johnson and colleagues
reported that African American,
Hispanic, and Asian respondents
were more likely than white respondents to perceive that medical staff judge them unfairly and
treat them with disrespect. Moreover, respondents from all three
groups report that aspects of their
culture, including the way they
speak, are looked upon unfavor19
ably.
Nonverbal signals. Nonverbal
communication and affect vary

Online Help with Cultural Competency

Ethnogeriatrics and Cultural Competence for Nursing Practice
(from the Hartford Institute for Geriatric Nursing)
http://bit.ly/rpaTzu
Culture Clues (from Patient and Family Education Services of
the University of Washington Medical Center in Seattle)
http://depts.washington.edu/pfes/CultureClues.htm
Culture, Language, and Health Literacy (from the Health Resources
and Services Administration, U.S. Department of Health and
Human Services) www.hrsa.gov/culturalcompetence/index.html
54

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widely among cultures. For example, nodding of the head in some

Asian American cultures doesnt
necessarily signify understanding
but can be a sign of politeness.
Likewise, some Asian Americans
might say yes to a question as a
means of avoiding conflict. In contrast, some Latino Americans
may nod their heads not to signify agreement, but as a sign that
theyre listening. (For more detailed information on this complex topic, see Culture Clues from
Patient and Family Education Services of the University of Washington Medical Center in Seattle:
http://depts.washington.edu/pfes/
CultureClues.htm.) We believe
its safe to say that with all cultures, and especially with regard
to older adults, the use of respectful communication, such as calling the patient and caregiver by
their titlesMr., Mrs., Ms., and
Miss, as appropriategoes a long
way toward establishing trust and
mutual respect.
Language differences. Despite
access to interpreter phone lines
being a mandated standard of
hospital practice, language differences can become a barrier when
an interpreter isnt immediately
available. Although the use of family members as interpreters may
seem efficient, it should be considered a last resort because of
patient-privacy concerns and the
providers inability to assess the
accuracy of the interpretation or
the interpreters understanding
18, 19
of medical terminology. When
a patient or caregiver isnt proficient in English, its important to
speak slowly and avoid the use of
colloquialisms and slang.
Although its unrealistic to expect nursing staff to be proficient
in working with every population,
its important to apply a level of
awareness and sensitivity to all pa18
tients and their families. For this
reason we have provided supportive Web sites that can be used by
hospital staff to practice providing
ajnonline.com

Teach Back
Key principles of the educational technique.
Effective patient communication requires adherence to a number
of principles, such as using plain language, creating a shamefree environment, slowing down, breaking information into short
statements, using chunk and check (presenting small pieces of
information at one time and checking to see whether theyve
been understood), focusing on the two or three most important
concepts, and checking for understanding using teach back.
Teach back is an educational technique in which the provider
asks the patient or caregiver to demonstrate or repeat what she
or he believes are the points to take away from the session. It
should never be considered (or treated like) a test or quiz; its a
way for the clinician to gauge the effectiveness of the education.
Teach back can help to overcome a number of barriers to understanding,12 including
a low level of functional literacy (the ability to read and comprehend written materials) or health literacy (understanding
the health- and health carerelated issues, including dosing
or other number-related information).
cognitive impairment.
limited proficiency with English (an interpreter may be necessary).
Asking questions in nonshaming ways. People often feel uncomfortable admitting they dont understand. Questioning should
be done in a nonshaming way, using open-ended questions. Asking a patient or caregiver, Do you understand? or Do you have
any questions? puts the person on the spot and elicits one-word
answers, which wont reveal the depth of the persons understanding. Here we have adapted sample questions from the Iowa Health
Systems Health Literacy Collaborative to the scenario presented
in this article.
Weve talked a lot today about your wifes condition. I want
to be sure I explained everything clearly. What changes in
Mrs. Johnss condition will you call the physician about?
On days that you and Mrs. Johns go out, what will you do
about taking the Lasix?
Starting with the first thing in the morning, what will your
daily routine look like?

culturally competent care to all

patients and families; see Online
Help with Cultural Competency.
Functional and health care
literacy. Functional literacy refers
to ones ability to comprehend
written material. But in health care,
when considering the skills necessary for safe medication management, assessing for the ability to
comprehend number- or mathrelated health care information
ajn@wolterskluwer.com

(also sometimes called numeracy),

such as dosing instructions or interpreting blood glucose values,
21
becomes of equal importance.
Socioeconomic status, anxiety,
cognitive capacity, the ability to
concentrate, memory, and sleep
deprivation can all influence func4, 15, 21
tional literacy.
According to the National Patient Safety Foundation, the 90
million people in the United States

with low levels of literacy (according to 1993 statistics) may be at

risk for poor health outcomes related to some level of functional
illiteracy (see http://bit.ly/p7tMFH
for statistics on literacy from the
National Patient Safety Foundation). Additionally, 66% of U.S.
adults ages 60 and over have inadequate or marginal literacy skills.
In epidemiologic studies, Weiss
notes that people with limited functional literacy come from all segments of society, and most are
22
white, native-born Americans.
Given this, it should be assumed
that patients education and literacy levels vary widely and that
their reading level is lower than
their education level. As noted by
Donaldson and colleagues, in a
health care system in which standard written materials are generally
the source of health care information, its clear that adjusting education to meet individual levels of
both functional and health liter15
acy is imperative. Assessing the
patients literacy level requires a
gentle and considerate approach.
The Newest Vital Sign. One
quick tool thats available free of
charge from Pfizer is called the
Newest Vital Sign (http://bit.ly/
pFQj72). Its available in Spanish
and English. Developed by Weiss
and colleagues, it consists of a nutritional label (for ice cream) and
related questions that allow the
provider to quantify a patients
ability to understand and apply
words and numbers in real-life
situations. The tool has been
found to be reliable in comparison with more rigorous literacy
22-24
instruments, and the time involved in administration is said
to offset the time spent clarifying
confusion over a diagnosis or
23
medications.
Teach back. Another method of
assessing literacy is teach back
(also sometimes referred to as
the interactive communication
loop), a style of communication
that confirms that any information
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55

or education provided has been

21
understood by the learner. Teach
back involves asking learners (in a
nonshaming way) to repeat back,
using their own words, what they
think they need to know or demonstrate what they think they should
do. Teach back isnt a test but is
rather an opportunity for the provider to check how well a concept
was understood. Too often the use
of teach back is left to the last
minute on the day of discharge,
which doesnt readily lead to assim4, 15, 21
ilation of knowledge of a skill.
The National Quality Forum has
identified teach back as one of 50
essential safe practices in health
care and recommends that it be incorporated into daily practices in
health care. (For more on this educational technique, see Teach
12
Back. )
Sensory limitations. Sensory
limitations in the caregivers, such
as vision and hearing loss, can affect not only the practitioners
ability to communicate with and
educate them, but also the caregivers ability to carry out the role
of caregiver, especially in the area
of instrumental activities of daily
25
living (IADLs). Its of the utmost
importance that when the provider
recognizes that a sensory deficit
exists, appropriate modifications
are made and supportive interventions are used in the home to assist as needed with IADLs. Raina
and colleagues found that in
community-dwelling older adults,
sensory limitations affected the
ability to do heavy chores, shop
for groceries, and perform house26
work. And although impaired
vision can severely limit the caregivers ability to read the small
print on medication labels and accurately dispense medications, both
visual and hearing impairment can
26-29
compound the situation.
Vision. All printed health education material and visual aids must
be readable and understandable.
Its recommended that, to accommodate deficits in either vision
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or literacy, they be written at the

fifth-grade level and printed in a
large font (14 points or larger); in
addition, the contrast of black on
4, 6, 15, 21, 28, 29
white should be high.
Inexpensive handheld magnifiers
can be given to patients and caregivers to aid in reading labels and
28
printed materials. Instructions
must be both written and verbal
and in the persons primary lan30
guage. Pictorial representations
of information (such as a picture
of a sunrise or a moon on a medication list to indicate when a medication should be taken) can be
provided to support the written
word.
Hearing. When a hearing deficit is present, the adults ability
to interact can be improved by
changing peoples placement in
the room or moving to a room
29
that has less background noise.
Additionally, amplified hearing
devices, such as the Pocketalker
devices from Williams Sound, can
27
be extremely helpful. Since the
loss of hearing will affect the caregiver beyond the patients hospital
stay, if its possible, the caregiver
should be given a device to use at
home.
THE CAREGIVERS COGNITIVE AND
HEALTH STATUS

Cognitive appraisal and assessment for general health status and

functional ability can be conducted
using observation during interactions with the caregiver, especially
when teach back is employed. An
inability on the part of the caregiver to stay focused and attentive
could be the result of medications,
pain, or an overall poor health status. An obviously low energy level
suggests that education should be
29
staggered to avoid fatigue. Because these variables can wax and
wane, its important to provide
education when the adult caregiver is in the most advantageous
15, 29
condition.
Repeated attempts resulting in
failed retention or acquisition of

skills required to provide care, despite the use of the approaches

mentioned above, signal the need
for a new approach and that more
support in the home for both the
caregiver and patient should be
considered by the health care
team.
TEACHABLE MOMENTS

Because time is limited during a

hospital stay, its crucial for the
nurse to seize every possible opportunity to communicate, making use of what can be termed
teachable moments. Teachable
moments can be formal or informal, spontaneous or structured;
they can occur during almost any
15
interaction with a caregiver :
while administering medications,
conducting assessments, preparing
the patient for testing, or transferring the patient from the bed
to a chair. All team members can
take advantage of teachable moments that arise and pay attention
to the way in which the caregiver
relates to the information provided. In this way the team may
be able to gauge the caregivers
level of health literacy and modify approaches and the content of
4, 15, 29
information as necessary.
The need to know. Adults are
more apt to be motivated to learn
when they need the information.
Although that may seem obvious,
its important to convey why information or a skill is necessary
or what the benefits will be to the
patient or caregiver. The readiness to learn is driven by real life,
and information thats provided
when its pertinent is more easily
4, 10, 15, 29, 31
assimilated.
Example: revisiting the John
ses. Consider the Johnses again,
and Mr. Johnss assertion that his
wife doesnt always take her medications. The nurses approach to
medication management and related education can now change
to meet Mr. Johns where he is,
based on recognition of his lack
of knowledge.
ajnonline.com

The nurse then says, Mr.

Johns, your wife has whats called
congestive heart failure, which
means that her heart muscle is
weaker than normal. The Lasix
the furosemideshe takes helps
to ease the work of the heart by
decreasing fluids in the body, and
that makes it easier for her to
breathe and walk, which is why
its so important that she take the
Lasix every day, even though decreasing the fluids in the body
makes her have to go to the bathroom.
In this way, the nurse has
helped to connect the dots for the
caregiver, from pathophysiology
to hospitalization to the need for
medication adherence. If this
teachable moment had passed, as
often happens on a busy medical
unit, critical information might
have been missed, yet it only took
a few moments at the bedside.
Motivation. No matter how
dynamic we are as teachers, a
caregivers motivation to learn
comes from internal desires,
such as improving the quality
of or satisfaction with ones life.
When peopleand particularly
those with chronic health care
conditionsare forced to choose
between health-related needs and
the desire to have a life, they might
choose the latter, at the cost of
their precarious health. In such
situations, its imperative to work
with patients and caregivers alike
to find safe alternatives that will
help them keep their lifestyle while
maintaining function and health
4, 10, 15, 29, 31
When
as much as possible.
we impose our will on them, negating their beliefs or desires, we
lose them, and any change in learning or behavior has ceased. In such
instances, compromise is needed,
and health care providers must be
flexible.
Example: keeping up with the
Johnses. Including the patient
and family in the discussions and
decision making allows them to
take part in finding solutions that
ajn@wolterskluwer.com

are agreeable to them and that

theyll be more apt to apply to
their home care and health care
4
management. Once again consider the Johnses.
Mr. Johns, the nurse asks,
when you and Mrs. Johns go
out, what time of day is that usually? Mr. Johns says that once a
week they go grocery shopping,
usually about 11 am, and once a
week they like to meet friends
for lunch at noon. In both cases,
theyre home by 2 pm. Checking
with the pharmacist on your team,
you learn that the onset of action
of oral furosemide (and consequently, the onset of the need to
urinate) is around 30 minutes,
but the duration of action is up
to six hours. Sharing this with
the couple opens the door to discussing at what time Ms. Johns
might be comfortable taking the
medication.
Perhaps you can bring it with
you and take it right after lunch,
if you intend to be home within
30 minutes? How long is the
drive? The Johnses agree to try
this approach.
THE GRAND ILLUSION

Theres a tendency in health care

to underestimate patients and
caregivers need for information
and overestimate providers effec21
tiveness in conveying information.
Keeping in mind the quotation at
the top of this articleThe single biggest problem in communication is the illusion that it has
occurredwill go a long way
toward improving caregivers
(and patients) satisfaction with
care, reducing their stress, and
improving outcomes in the loved
ones they care for. The demands
placed on a care provider in the
hospital setting are daunting. However, our patients caregivers have
asked for support, and regulatory
agencies are demanding that it be
a priority of care. And the truth
is, teaching the caregiver as well
as the patient is within the scope

of nursing practice, and can be

incorporated into any patient- and
family-centered plan of care and
shouldered by the nurse with the
support of an interdisciplinary
team.
Keywords: caregiver, communication, cultural competency, discharge planning,
family caregiver, familycentered nursing, health care
literacy, patient-centered
nursing, patient education

Cynthia J. Nigolian is the clinical admin

istrator of the Nurses Improving Care
for Healthsystem Elders (NICHE) pro
gram at the New York University School
of Nursing in New York City. Karin L.
Miller is a geriatric social worker at the
Mercer Island Senior Health Center, a
department of Overlake Hospital in
Bellevue, WA. Contact author: Cynthia
J. Nigolian, cjn2@nyu.edu. The authors
have disclosed no potential conflicts of
interest, financial or otherwise.

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